Integrating a Competency-Based Curriculum Through the Modernization of Teaching Strategies

Abstract

Background

Historically, lecture-based classrooms have been the pedagogy of choice for higher education. Nursing education has the opportunity to pivot from the use of lecture-only pedagogy to active learning platforms with the integration of competency-based education (CBE) while considering the learning needs of master's entry students.

Method

This scaffolded education innovation (SEI) used pre-class, in-class, and post-class activities grounded in CBE with spaced repetition techniques in an adult and geriatric nursing course.

Results

Students reported that active learning activities helped them learn and apply content and that having a variety of learning methods was useful for understanding the material.

Conclusion

Faculty can benefit from sharing experiences after leveraging modernized teaching strategies to build best practices for teaching today's nursing students.

Historically, lecture-based classrooms have been widely accepted as a favored pedagogy for higher education (^{Bradshaw & Hultquist, 2017}). While lectures can emphasize important points and deliver large volumes of content, educational researchers have demonstrated that lecture-only instruction leads to inadequate knowledge retention, overall course dissatisfaction, lower levels of student engagement, and decreased learning outcomes (^{Kay et al., 2019}). Still, lecture-only pedagogy remains a popular approach in higher education (^{Kay et al., 2019}). Nursing education has the opportunity, if not responsibility, to pivot from the use of lecture-only pedagogy to active learning platforms.

Students today have been using technology from an early age and often call upon higher education institutions to modernize their teaching strategies (^{Duncan et al., 2013}; ^{Ghezzi et al., 2021}). The timing of the updated framework of competency-based education (CBE) from the American Association of Colleges of Nurses (AACN) provides the opportunity for educators to revise their curriculum and update traditional teaching methods. A recent integrative review by Ghezzi et al. (²⁰²¹) describes active learning strategies as fundamental to teaching today's tech-savvy students because they place the student at the center of the learning process and increase their accountability and autonomy for mastering the material.

In the United States, prelicensure registered nursing programs include associate, baccalaureate, and entry-level master's degrees. As of 2022, there were 89 entry-level master's programs in the United States, compared to approximately 1,000 baccalaureate programs (^{AACN, 2023}; ^{nurse.org, 2023}). Students in entry-level master's programs hold a non-nursing baccalaureate degree and are awarded a master's degree in nursing upon completion (^{AACN, 2023}). Because these programs require a baccalaureate degree and varying prerequisite courses for admission, students who enter these programs come with a wide variety of work and life experience (^{Macdiarmid et al., 2021}; ^{Pellico et al., 2012}). These programs often have high grade point average requirements for entry; therefore, students are frequently described as mature learners with stronger reflective and decision-making skills (^{Downey & Asselin, 2015}). Additionally, research suggests that the age of the student may impact learning, with younger students excelling in game-based and technology-based activities while older students excel in reflective learning activities (^{Kulkarni et al., 2022}).

Much of the prelicensure registered nurse literature focuses on traditional baccalaureate education, leaving a gap in the research on entry-level (prelicensure) master's programs. Much of the entry-level master's literature focuses on program description, development, and integration of these programs into the colleges and not on educational teaching strategies applied to this level of learner (^{Jones et al., 2023}; ^{Mark et al., 2019, 2022}). Because of the diversity of these learners, it is important to understand their learning needs and implement diverse learning activities.

The purpose of this article is to help fill that gap and describe an educational innovation applied to entry-level master's students in a required adult and geriatric nursing course. Additionally, this article aims to support other educators in revising their curricula to meet the AACN The Essentials: Core Competencies for Professional Nursing Education standards with ideas for a variety of competency-based learning activities for a diverse population of students.

Recent literature discusses active and innovative teaching methods in one of three categories: inquiry-based learning activities, flipped classrooms, or simulation-based education (SBE; ^{Kay et al., 2019}; ^{Zhang et al., 2019}). Inquiry-based learning activities are student-centered active learning strategies that are integrated into lectures. They engage students in knowledge formation and deepen their conceptual understandings (^{Minner et al., 2010}). Examples include case studies, role-playing, quizzes/polls, and student-led presentations. Several authors have shown that these learning activities can lead to increased content retention and application of knowledge and are easily adaptable to large classrooms or online learning (^{Drinkwater et al., 2014}; ^{Kay et al., 2019}; ^{Roehl et al., 2013}; ^{Sarginson & McPherson, 2021}).

Flipped classrooms engage the students in prework, such as readings and recorded lectures, and class time is used exclusively for discussions, active learning activities, and debates (^{Betihavas et al., 2016}). Several large-scale reviews have demonstrated a positive impact on nursing students' critical thinking skills, knowledge retention, and clinical competence using flipped classrooms (^{Betihavas et al., 2016}; ^{Njie-Carr et al., 2017}; ^{Özbay & Çınar, 2021}; ^{Park & Suh, 2021}).

SBE represents an important component of clinical education, serving as a valuable augmentation to direct and indirect care within health care settings. SBE provides a safe environment for teaching nursing students to improve quality and safety, develop teamwork and technical skills, use critical thinking, and problem solve (^{Laack et al., 2017}), and ultimately, to prepare learners for practice in a variety of settings (^{Fey et al., 2022}). Additionally, SBE is a viable option for integrating CBE to meet the updated AACN Essentials (^{AACN, 2021}).

Method

This educational innovation was implemented in the summer of 2023 at a large, urban, midwestern U.S. college of nursing. Students in this entry-level master's program have a non-nursing baccalaureate degree and will receive a Master of Science in Nursing upon completion of the program. Sixty-five students of diverse educational backgrounds were enrolled in the course. During the summer semester, students completed a required 12-week adult and geriatric core nursing course. Students attended the course in a 4-hour time block once a week. Additionally, students were predominantly underrepresented racial and ethnic minority populations (74%). The Institutional Review Board determined that this study was exempt.

Spaced repetition combined with CBE was the framework for this education innovation. Spaced repetition is an established method in which the learner revisits material to be learned in regularly spaced-out sessions (^{Butler, 2010}; ^{Cepeda et al., 2006}; ^{Dunlosky, 2013}; ^{Kang, 2016}). Literature supports retention of material at a higher level when revisited during multiple spaced-out sessions (^{Butler, 2010}; ^{Cepeda et al., 2006}; ^{Dunlosky, 2013}; ^{Kang, 2016}). The AACN defines CBE as a system of instruction, assessment, feedback, self-reflection, and academic reporting (^{AACN, 2021}). It requires students to demonstrate that they have learned the knowledge, attitudes, motivations, self-perceptions, and skills expected of them as they progress through their education (^{AACN, 2021}). It is based on scaffolding student learning through introduction, reinforcement, and demonstration levels of content. Graduates must demonstrate competency in all the relevant domains and subcompetencies to meet program requirements and improve learning outcomes (^{Gravina, 2017}).

During the summer of 2023, faculty implemented a scaffolded education innovation (SEI) using pre-class, in-class, and post-class activities grounded in CBE with spaced repetition techniques in the 12-week adult and geriatric nursing course (Table A; available in the online version of this article). Based on the diverse learning needs of master's entry students, activities included a variety of technology-based, game-based, and reflective assignments. The activities were designed to scaffold their learning from introducing a concept through their demonstration of knowledge of that concept (CBE). The material was revisited in the following weeks to reinforce the learning (spaced repetition).

Table A

Competency-Based Education With Spaced Repetition Techniques

Pre-Class Activities	Scaffolded Learning Level
Readings via an online clinical learning platform	Introduction—CBE
High-quality video-based learning platform	Introduction—CBE
Completion of NCLEX practice questions	Introduction—CBE
In-Class Activities Scaffolded	Learning Level
5-minute warm-up with video-guided mediation activities	Introduction—CBE
Student-led presentations focused on the previous week's content	Revisit—spaced repetition
Instructor-led review of previous weeks, using NCLEX practice questions on a game-based learning platform	Revisit—spaced repetition
Didactic lecture	Reinforcement—CBE
Active learning 6 hours of SBE Inquiry-based learning strategies ○ Jigsaw activity ○ Drawing a visual representation ○ Weekly reflection with faculty feedback ○ Case studies	Demonstration—CBE
Course examinations Individual take Group retake	Demonstration—CBE and Revisit—spaced repetition
Post-Class Activities	Scaffolded Learning Level
Completion of NCLEX practice questions through an online learning platform, with a minimum score of 80%	Reinforcement—CBE
Group presentation preparation	Reinforcement—CBE
Practice comprehensive examinations via an online clinical learning platform	Reinforcement—CBE

Pre-class activities included 2 to 3 hours of prep work consisting of readings, high-quality videos, and practice questions. In-class activities included 4 hours of work: a meditation warm-up, a review of the previous week's content, a didactic lecture, active learning, and examinations. The active learning consisted of student-led presentations, SBE, and inquiry-based activities. Examinations were administered on 3 weeks of content and included an initial individual student take, immediately followed by a retake in a group. Post-class activities included 2 hours of work, including completion of practice NCLEX^® questions and preparation for student presentations.

The course was mapped to the AACN Essentials, specifically Domain 1: Knowledge for Nursing Practice, Domain 2: Person-Centered Care, Domain 5: Quality and Safety, Domain 6: Interprofessional Partnerships, and Domain 9: Professionalism. Grading for class activities was scaffolded based on achieving competence in the mapped AACN Essentials domains and occurred in various ways. Introductory work was awarded points based on completion only. As content was revisited or reinforced, grades were shifted to requiring achievement of a minimum score on quizzes or based on objectives and rubrics. Summative competency demonstration activities, such as course examinations, were graded using traditional alphanumeric methods.

Results

The SEI was evaluated using end-of-semester teaching evaluations. The response rate was 46%, with students reporting the most beneficial aspects of the course being active learning activities, which helped them apply course content and be exposed to different learning methods. Results from the teaching evaluations suggested that the students preferred the multiple types of learning methods. They felt that it helped them apply the material and forced them to make decisions and feel engaged. Students were asked, “What aspects of the course were most beneficial to you?”

One student responded, “The aspects that were most beneficial to me were the videos, the book, lecture, and simulation labs. I cannot emphasize enough how much I utilized the videos. If there was one thing that helped me the most in this course, this was it. Moreover, the weekly playlists due before class were extremely beneficial because they made me read the material and have an idea what was going on before lecture even started. Additionally, the book was thorough and told us in great detail about each disorder without us having to read a million pages. I liked how concise it was Furthermore, simulation labs helped solidify the information while also forcing us to think on the spot and be reactive. Lastly, I really did enjoy the case studies. I think these were a great way to tie all the information together.”

One student noted how important reflective activities were, stating, “I appreciate her effort to provide the opportunity for in-class reflection and review through the gaming platform and reflections.” Other students noted the variety of activities was highly beneficial; one student stated the most beneficial was “the diversity of instruction and learning content. I'm not a book person, PowerPoint [sic], or writing long notes. I'm a big audio learner, being able to rewatch lectures, extra Power-Points [sic], and the videos was very helpful for me.” Another student explained that the most beneficial parts of the course were the “interactive components and simulations.” Students also seemed to enjoy the mix of high SBE with low-fidelity case studies, stating:

“ Goes above and beyond to create interesting and interactive learning activities that keep students engaged and excited about the material. Whether it's case studies, simulations, or practice questions creativity in designing learning experiences has been both enjoyable and effective.”

Students were asked, “What aspects of the instruction were most beneficial to you?” Students again noted the variety and the technology as the most beneficial parts of the class, stating:

“ Implements other technologies, like gaming platforms and videos, that make the learning environment fun and engaging.”

“I loved having the gaming platforms and sim lab time.”

“ Gaming platforms, videos, study guides, and responses to questions in class and on Blackboard [Anthology].”

Conclusion

The use of modernized teaching strategies in nursing education has been shown to be cost-effective, time-saving, and effective in demonstrating improvements in competence with a high level of learner satisfaction (^{Hayden et al., 2014}). This SEI demonstrated a high level of self-reported learner satisfaction when combined with the use of spaced repetition and scaffolding student learning, aiding in knowledge acquisition. Further, students reported that these strategies enhanced their engagement in the course and helped facilitate a deeper understanding of the material, echoing other results from similar studies (^{Binoy, 2024}; ^{Ma et al., 2024}; ^{Mohseni et al., 2024}).

Lessons learned include limiting the number of platforms implemented into a course to three or fewer, as some student responses included frustration with the number of different platforms being used. Many of the platforms selected offered unique and engaging features; however, integrating the same or similar activities into the course's learning management system (LMS) would enhance accessibility and reduce student frustration. The game-based platform and the online clinical learning platform are the two external tools that faculty plan to continue using, as their unique features and learning experiences cannot be replicated within the LMS. Additionally, faculty need to learn how to use the different platforms efficiently, which can be a barrier. Faculty at this college of nursing are selected based on interest and expertise to teach this course; however, using graduate or teaching assistants may be an option to assist faculty with the technology platforms.

The aim of this SEI was to promote student learning through the modernization of teaching strategies with the use of inquiry-based learning activities, flipped classrooms, and SBE. The SEI led to self-reports of a high level of satisfaction and significantly increased reported knowledge among students. Faculty can benefit from sharing experiences after leveraging modernized teaching strategies to build best practices for teaching today's nursing students. It is useful to add to the literature on master's entry students who may have diverse learning preferences, as colleges of nursing are revising their curriculums to meet new AACN competencies.

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The authors thank Kevin Grandfield, Publications Manager for the University of Illinois Chicago Department of Biobehavioral Nursing Science, for editorial assistance.