Conceptual Framework for the Baccalaureate Program

Prologue
Given the rapidly evolving nature of the health care system, practitioners of the future must be prepared to anticipate and create change. Nursing education should enable graduates to embrace the concept of professionalism and to be prepared to redefine their roles within the health care delivery system as societal needs emerge. The curriculum of the College of Nursing is designed to educate a caring, professional nurse who is skilled in effective communication and able to collaborate inter- and intra-professionally in order to provide research and theory-based practice in working with diverse populations to maximize their health throughout their lifespans.

Professional Role
The curriculum is designed to imbue in its graduates a sense of professionalism and professional behaviors. This commitment is reflected in the core values recognized by this College. Students are introduced to the concept of professionalism in their first nursing course and this thread is woven throughout subsequent nursing courses and emphasizes the following characteristics of a profession:

• practice guided by a body of knowledge
• focus on matters of human urgency and significance
• a code of ethics
• shared values
• autonomy and accountability in practice (Berger & Williams, 1999).

Nursing, as an applied science, uses knowledge to solve problems within a practice setting. Nursing research and theory development by nursing scholars and clinicians continue to refine the unique body of knowledge that is the basis for nursing practice (Berger & Williams, 1999).

Nursing focuses on the human condition, quality of life and quality of care issues, and cost-effective health care delivery systems. Each of these would qualify as matters of human urgency and significance. Nursing also focuses on the support of client involvement in self-care, as well as the improvement of adaptation and coping with chronic conditions (Berger & Williams, 1999).

In the present health care delivery system, situations arise where there is a choice between various courses of actions. Nurses must confront complex questions and often even the most justifiable course of action may have undesirable consequences. Nursing's code of ethics (ANA, 1985) assists its members in critically dealing with such conflicts in ethically justifiable ways.

All professions have values or beliefs that influence practice and are considered important to the discipline. For members of a profession to have shared values, there must be a consensus between those who educate and those who employ members of the discipline. Having faculty with joint appointments to clinical and educational settings and engaging collaborative efforts between nursing educators and nursing service representatives in designing internship programs for nursing students are means to the development of shared values (Berger & Williams, 1999).

Professional autonomy for nurses means self-directed clinical practice. Professional accountability means that nurses are directly responsible to their clients for the quality of the nursing care provided. Control implies authority to determine roles, functions, and responsibilities of its members. Nursing must continue its efforts to assure control over personnel and material resources necessary to support nursing practice. Shared governance and participative management are two means which not only will enable nurses to deliver quality health care but also will provide control over professional practice (Berger & Williams, 1999).

Nursing is an evolving profession. The growth of professionalism in nursing has been influenced by higher and more specialized education and by increased autonomy in practice. Increased levels of research activity, accountability, and responsibility have contributed to enhance nursing’s status as a profession (Craven & Hirnle, 2000).

Nursing students are expected to demonstrate leadership skills in managing care for diverse populations in a variety of health care settings.

Pathways to Health
The goal of nursing care for clients is the attainment of health, in the broadest sense of that term. However, the College of Nursing has chosen the concept "pathways to health" to represent its goal for nursing care. We feel that this idea, "pathways to health," implies an even broader view of health. After all, health is more than just the absence of disease or illness. It includes elements of psychosocial and functional as well as physiological dimensions. It also allows for individual variations, not only in the pathway chosen (or the means by which the client reaches his goal of high-level wellness), but also in the destination (or what optimal health means to that client). Definitions of terms like health and illness are very dynamic; they vary among individuals and cultures and change over time. Furthermore, individuals define these terms in relation to their own values.

Good health, or wellness, is a state of well-being where the individual's self-esteem is maintained and he is able to interact effectively with family and community. Health is holistic in nature; it is the full expression of a person's physical, emotional, social, and spiritual potential. It is a dynamic state in which the individual continuously adapts to changes in both the internal and the external environment in order to maintain a sense of well-being. Components of the internal environment can be described as genetic, psychological, intellectual, and spiritual. The external environment relates to the physical environment itself, as well as social relationships, and economic variables (Potter & Perry, 1997).

Dunn's theory of high-level wellness is oriented toward maximizing the health potential of an individual and, as such, is consistent with a "pathway to health." The individual must maintain a continuum of balance and purposeful direction within the environment. The individual would progress to a higher level of functioning to arrive at his fullest potential. It focuses on elements of awareness, education, and growth (Dunn, 1997). This model can be applied to risk reduction and health promotion - important elements of preventative care. This model also can be applied to family and community as well as individual health.

Dunn's model seems consistent with the concept of optimal health. Optimal health is defined as the best health possible for a given individual at a given point in time. It is a person's potential for health (Berger & Williams, 1999). When dealing with chronic health problems, nurses would need to make careful and thoughtful assessments in order to give this term "optimal health" more specific meaning in each individual case. Optimal health can be achieved when interfering factors are either eliminated or modified. An important task of nursing is to promote optimal health for clients through a collaborative nurse-client relationship across acute, sub-acute, and community settings.

Lifespan
Nurses care for the very youngest and the very oldest and all in between. Professional nurses must have the knowledge and ability to assess and plan for the different needs that are relevant at each stage of the life cycle. Lifespan is the physical, psychological, emotional, social, spiritual, and cognitive stages of individuals' growth and development. Children and elders are our most vulnerable populations. Age-appropriate assessments and interventions will lead to more positive outcomes in their care. Targeted prevention strategies based on the developmental needs of a given group of clients can be initiated. Nursing students will be introduced to growth and developmental characteristics in the nursing assessment and health promotion course. With increasing complexity, nursing students will assess and plan care with individuals and groups of all ages and stages of development.

Diversity
Diversity is all those characteristics that make each person unique. Diversity is more than cultural difference. Human diversity encompasses all that includes the differences in males and females; young and old; urban and rural; levels and types of education; socioeconomic levels; religious and spiritual choices; regional, ethnic and racial difference. Awareness of these differences between self and one's own experiences and those of others is the cornerstone of a college education. The ability to appreciate these differences and to use this understanding to enhance one's effectiveness as a professional nurse is essential to providing individualized and non-judgmental care.

Health Care Delivery System
The health care delivery system includes the provision of health care services for individuals, families, and groups in a variety of settings. With the realities of population growth, dwindling resources, and health care cost inflation, pressures have been placed on professional nurses to maximize their efficiency and effectiveness in this rapidly changing health care environment. This encourages better utilization of resources for health care and increased efficiency by focusing on health practices and procedures that can be aimed at groups with common problems.

The changes in the health care delivery system have provided the impetus to the community perspective on health. Community health is the composite of the health status of individuals, families, and groups within the population and the ability of these individuals to implement health-related activities. Nursing's role in community health emphasizes health maintenance, promotion, and restoration as well as disease prevention through a collaborative relationship with other health care professionals and the community. This community perspective can be applied in a variety of settings such as homes, clinics, industries, and schools as well as acute, sub-acute, and long-term care settings.

Regardless of the setting, the current health care delivery system emphasizes health maintenance and promotion, health teaching, family nursing, and the managed care environment. Interdisciplinary cooperation and recognition of contributions of various disciplines in a variety of settings is essential in today's health care environment. Nursing students at all levels are given opportunities to provide health care for individuals, families, and groups in various health care settings. Students are encouraged to work collaboratively with other disciplines during the provision of these health care services.

Caring
Caring is a value central to nursing practice. Caring nurses strive to enhance the dignity and integrity of individuals, families, and groups within the health care delivery system. Potter and Perry (1997) describe the universal aspect of care as a human trait that helps nurses recognize the specific cultural expectations that should be incorporated into professional practice. Caring from a moral perspective inspires in humans the desire to dedicate themselves to the well-being of others (Potter & Perry, 1997). Caring provides an organizing framework for professional education, research, and theory development (Swanson, 1991).

Throughout the curriculum, the concept of caring is emphasized as a value central to professional practice. Students are expected to exhibit caring behaviors while interacting with individuals, families, and groups in various health care settings. Also, caring, commitment, and respect for the dignity of humans are emphasized as essential components of effective interpersonal interactions.

Communication
Communication is the foundation of professional nursing practice and, as such, is an essential skill. Communication can be defined as the transfer of meaning from the sender to the receiver. Professional nursing practice requires effective communication with clients, other health care professionals, families, groups, and communities. Professional nurses must possess skills in presentation, writing, conflict resolution and assertiveness, negotiation, and therapeutic communication with individuals, groups, and families. Nursing students will be introduced to communication theory, process, and skills with emphasis on self-awareness, effective communication, and presentation skills. Upon this foundation, students will develop therapeutic communication skills and begin to incorporate factors that influence communication into their nursing practice. Throughout the curriculum, students will use these communication skills to provide nursing care and to participate in health care delivery in increasingly complex clinical situations.

Collaboration
The ability to collaborate is an essential characteristic of a professional nurse. Collaboration can be defined as a process in which two or more people work together, jointly influencing one another, for the attainment of a goal. Williamson's (1981) model of mutual interactions is consistent with this idea of collaboration as an approach to professional nursing practice. This model limits client dependency and professional dominance and maximizes client participation. In this model, terms like "discuss" replace "inform," "enable/empower" replace "allow," "persuade" replaces "prescribe," and "negotiate/bargain" replace "tell." This model identifies an approach to problem-solving that builds on societal values and public and professional interests in the health care encounter (Williamson, 1981).

Collaboration implies partnership, equality, mutual accountability, and democratic decision-making processes. A collaborative approach to nursing and health care recognizes clients' rights to make decisions regarding their health care and emphasizes their role as equal and active participants.

Nurses not only collaborate with the client and the client's family but they must also be able to work well with their nursing peers and with those in positions of authority. They must be able to interact effectively with other professionals who make up the multidisciplinary health care team. They must do so in a way that fosters collegiality, coalition, and congruence of purpose. In short, professional nurses must have competence in both intra- and interprofessional collaboration. Today's nurses must develop skills that would allow them to form and maintain community and clinical partnerships with the goal of identifying creative solutions to complex societal problems. There is a strong need for nursing's collaborative practice with social policy-makers (Berger & Williams, 1999). Nurses must assume an active role in the development of health policy that will assure the highest quality of health care.

Nursing students will be introduced to the concept of collaboration early in the curriculum and will have many opportunities to develop their skills of collaboration during their clinical experiences. Exposure to service-learning projects during the curriculum will further strengthen their ability to collaborate in effective change in the health care delivery system upon graduation.

The College views service-learning as a mechanism through which we can instill in our students a renewed commitment to community. Through service-learning, faculty will be able to transmit important professional values to the students and provide important services to the community. Clinical nursing courses are structured to provide students with opportunities to participate in community partnerships. One of the aims of these community partnerships is to improve the health of the community through education, research, and service. These experiences will provide for students' academic, civic, and career development. Service-learning will broaden students' knowledge about larger social issues and increase their ability to effect change.

Service-learning is not just charitable volunteerism and it is more than experiential learning. It is a paradigm for rethinking the partnership between student, faculty, institution of higher education, and the communities within these individuals reside. Service-learning espouses that students learn best by engaging in activities that are personally meaningful and which will have a positive impact on others (Osborne, Penticuff, & Norman, 1997).

Service-leaning recognizes that communities are learning environments. It involves students in the public world where ideas like social obligation and communal problem-solving have a chance to grow. Service-learning prepares students for the demands and challenges of public life and citizenship. It makes classroom learning more meaningful for the students through their community involvement. Students become partners with community agencies. They become collaborators and engage in community efforts to solve problems. The community benefits from this partnership by the contribution to its improved welfare. Once the problem is solved, then the students examine the lessons they learned through critical inquiry in the classroom and through self-reflection (Pickeral & Peters, 1997).

Evidence-based Practice
Theory is a creative and rigorous structuring of ideas that project a tentative, purposeful, and systematic view of phenomena (Chinn & Kramer, 1999, p. 51). Theory is an intellectual tool which explains our world (Kim, 1983). Theories guide actions and influence how nurses act in the practice setting. Nursing practice theory is that which guides the nurse's action in attaining nursing goals while caring for individuals, families, and groups. This organized, systematic approach allows for health care needs to be met in a variety of health care settings.

Students will be introduced to nursing, developmental, and learning theories early in the curriculum. Emphasis will be placed on a basic understanding of these theories and their relevance to nursing practice. Later, students will have opportunities to apply various theoretical constructs to selected practice situations. Theory is strongly emphasized as a framework for professional practice.

Students must become informed of current research findings and develop their own sense of inquiry to foster research utilization in order to implement best practices and achieve positive health care outcomes across settings.

Critical Thinking
Critical thinking can be defined as the process of using information to reason, make inferences, and form a mental picture of what is happening in a given situation (Potter & Perry, 1997). In nursing practice, the critical thinking process is reflective, reasoned thinking about nursing problems without a single solution and is focused on deciding what to believe and do (Kataoka-Yahero & Saylor, 1994). Critical thinking allows individuals to think for themselves and to take actions after problems are clearly understood (Potter & Perry, 1997).

Critical thinking skills are essential in today's rapidly changing health care environment. Nurses must challenge ways of providing nursing care and provide scientifically supported evidence for improving client outcomes. By thinking critically, nurses are given opportunities to learn and to positively influence professional practice. To be effective, nurses must be able to analyze, synthesize, and apply knowledge to selected clinical situations.

Both in the classroom and in the clinical settings, students are given opportunities to learn and use critical thinking skills. They are expected to apply information and theory from the sciences, humanities, and nursing to think about resolution of nursing problems. Critical thinking skills also are enhanced through the use of the nursing process in all client care situations.

References
American Nurses Association (1985). Code for nurses with interpretive statements. Kansas City, MO: Author.

Berger, K.J., & Williams, M.B. (1999). Fundamentals of nursing: Collaborating for optimal health (3rd ed.), Stamford, CT: Appleton & Lange.

Chinn, P.L., & Kramer, M.K. (1999). Theory and nursing: Integrated knowledge development (5th ed.). St. Louis: Mosby, Inc.

Craven, R.F., & Hirnle, C.J. (2000). Fundamentals of nursing: Human health and function (3rd ed.), Philadelphia: Lippincott-Raven Publishers.

Dunn, H.L. (1997). What high level wellness means, High Values, 9:1.

Kataoka-Yahiro, M., & Saylor, C. (1994). A critical thinking model for nursing judgment. Journal of Nursing Education, 33(8), 351.

Kim, H.S. (2000). The nature of theoretical thinking in nursing (2nd ed.). New York, NY: Springer Publishing Co.

Osborne, R.E., Penticuff, J., & Norman, J. (1997). Reality-based service learning: A paradigm for sustaining momentum. In Cooperative Education Association's Expanding boundaries: Building civic responsibility within higher education, (Vol. II, Spring, 20-25). Columbia, MD: Author.

Pickeral, T., & Peters, K. (1997). Colleges of the community. In Cooperative Education Association's Expanding boundaries: Building civic responsibility within higher education, (Vol. II, Spring 53-58).

Potter, P.A., & Perry, A.G. (1997). Fundamentals of nursing: Concepts, process, and practice. St. Louis: C.V. Mosby Co.

Swanson, K. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161.

Williamson, J.A. (1981). Mutual interactions: A model for nursing practice. Nursing Outlook, 29:104-107.

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