Design
A longitudinal cohort survey study was carried out in a single institution. Nursing students underwent a redesigned curriculum with extensive elements of community care.
A model for influencing perceptions
To influence students’ perceptions, a psychological model was chosen, describing how individuals respond to stimuli (here, the curriculum-redesign), namely affective and/or cognitive. Affective responses are fluctuating positive or negative emotions varying in intensity, and cognitive responses are ideas about how attractive a specific object (e.g., community care) is seen to be [32]. This perspective of affective and cognitive responses fits in well with the DAGMAR model - Defining Advertising Goals for Measured Advertising Results, a model for marketing and communication [33]. This model explains how individuals perform in decisions about purchases in four steps, which, in this example, is a process that begins with (1) the awareness about the possibility of a career in community care, moves to (2) an understanding what the career brings with it, then (3) to the belief about the career being the right choice, and (4) ends with a practical action: making the career choice. During this process, people progress through three successive phases: cognitive (thinking), affective (feeling), and conative (doing). Therefore, the approach of implementing a more community-care-oriented curriculum implies that students will have increased knowledge about this area (cognitive), possibly leading to a growing appeal, due to a sense of the field’s attractive aspects (affective), and subsequently a choice for a future career in this area (conative).
Participants and method of data collection
Nursing students from one University of Applied Sciences in a larger city in the Netherlands took part in the study. Longitudinal data collection took place four times from a single cohort of students in the full-time programme between October 2014 and May 2018 (the duration of the Dutch bachelor of science nursing programme is four years). Students in other educational pathways and/or specific programmes, and students that underwent only a part of the intervention due to enrolment in year two were excluded. The students were approached during allocated class time and, if not present, individually by email, in order to increase response rate. Data on students’ perceptions and placement preferences were collected with a questionnaire (see below).
Ethical considerations
The Ethical Review Board of the Open University of The Netherlands approved the study (reference U2014/07279/HVM). Students received information about the research project via the digital learning environment of the university. A letter was published about the purpose of the project, highlighting ethical aspects such as confidentiality of the information, and who would have access to the data. It was also emphasised that non-participation would in no way impact their studies. This was repeated during the data collection in the student groups, and verbal informed consent was given by all respondents.
Instrument
For the survey, the Scale on Community Care Perceptions (SCOPE), a valid and reliable instrument (Cronbach’s α = .892), was used [34,35]. SCOPE measures students’ perceptions of community care, placement preferences and underlying assumptions in 35 items. The first part of the instrument consists of items on potentially influential demographics. Students’ perceptions are measured in thirty-three items in three subscales: (1) the affective component of community care perception, (2) perception of a placement in community care, and (3) of community nursing as a profession. Items range from 1 (negative adjective) to 10 (positive adjective). The placement and profession subscales are aspects of cognitive components of students’ perceptions of community care. These two scales contain the extra option ‘I don’t know’, as it is relevant to gain an insight on aspects that students think they lack knowledge.
Finally, the student chooses a preferred area for a current placement from six healthcare areas: medical rehabilitation, mental healthcare, care for mentally disabled, community care, elderly care, and the general hospital. Then three aspects from the earlier profession scale that primarily determine the preference for the chosen area are selected. As this questionnaire measures the affective and cognitive component of perceptions [36], it is well aligned with the aforementioned DAGMAR-model.
The intervention: curriculum-redesign
The renewed curriculum, designed with the purpose to stimulate a positive interest in community care, contained an approach based on three elements: (1) influence of lecturers, (2) students’ experiences in the practice of the profession during placements and (3) new theoretical themes in the in-school curriculum.
With regard to the first element, the intervention focused on communication of lecturers to students about different areas. In a workshop to prepare curriculum redesign, reflecting on their own perceptions, many lecturers noticed they implicitly or explicitly advocated their own professional history (often related to hospital care) as a reference point. Therefore, new lecturers were recruited with a lot of expertise and/or experience in community nursing, acting as role models. Guest-lectures performed by community nurses were organised with challenging patient cases from the daily professional practice.
Second, management representatives from school and community-care organisations collaborated to ensure that a placement in the field was considered a positive experience for students. Mentors with a suitable level of education, i.e., a bachelor’s degree, are crucial in ensuring that students meet their learning needs [15, 37, 38]. However, as a result of labour market shortages, good mentors are not available everywhere.
Third, a new in-school curriculum was implemented. To understand the structure of this curriculum-redesign, an image, by and large, of the 4-year curriculum, is needed. Year 1 and 2 include general/broad theory about all types of patients in different contexts. In year 2, all students choose a one semester/ 20 week minor-programme (30 EC) for year 3, based on a specific theme or healthcare area (e.g., health technology, mental health, community care). The other 20 weeks in year 3, and the first 30 weeks in year 4 contain two different placements, with the placement in year 4 in a, by the student, preferred healthcare area. As a consequence, students have the opportunity to create an individual pathway in their study in the last two years of their study, based on their own interests and mostly relating directly to their career preferences.
The first purpose of the new programme [see A in Figure 1] was to broaden students views on the nursing profession, convincing them that nursing is more than hospital care. To get a sense of how/ which patient cases in the lessons were presented, all course materials were analysed. It appeared that, although many of these cases did not refer to a specific healthcare area, more than 60 of 110 cases took place in the hospital, compared to only four in community care. This imbalance, being an aspect of the ‘hidden curriculum’, was corrected by adding more patient cases in community care. By this time, a new more ‘community-oriented’ national Dutch profile for bachelor nursing education was developed [3]. Five themes from this profile were integrated in the broad theory programme of the curriculum: (1) fostering patient self-management, (2) shared decision-making, (3) collaboration with the patients’ social system, (4) healthcare technology, and (5) allocation of care.
In year 1 and 2 [period A in Figure 1], the specific elements in the new curriculum were:
- An introduction week at the start of year 1, presenting a broad picture of the profession with extra attention for community nursing [C, Figure 1].
- A ‘Community Care Week’ in year 2, intentionally planned shortly before students’ minor-choice for year 3. All students visited a nursing team working in people’s own homes. Where possible, they participated in the caregiving. The week further consists of assignments on analysing patient cases, a digital game, and ‘speed dates’ showing the diversity of community nursing, with nurses from palliative care, a technical team, and children home care [D, Figure 1].
[Figure 1]
The second purpose of the curriculum redesign was to create a ‘paved way’ in the direction of a future career in community care, by offering a challenging in-depth programme in year 3 and 4 [period B in Figure 1]:
- A minor ‘Complex Community Care’, with theory on challenging topics on community nursing: population-based prevention, multimorbidity, interprofessional collaboration, professional leadership, and system-based communication [E, Figure 1].
- A practice placement in the fourth year, where the student works on all competencies required for the independent role of the community nurse. During this placement, a complex patient case is selected by the student for analysing the caregiving in the final assignment [F, Figure 1].
- A graduation paper, being a case study of the selected patient. In short, the student uses clinical reasoning in analysing health problems and chooses substantiated evidence-based interventions for patient care [G, Figure 1].
Planning of data collection
Four moments of data collection between 2014 and 2018 [T0, T1, T2 and T3, Figure 1] were carefully planned to measure the effect of specific interventions. T0 and T3 were planned as close as possible to the beginning and the end of the educational programme. T1 was planned shortly after the community care week in year 2 (intervention D), and T2 at three-quarters of the third year when all third-year students by that time had experienced a placement and (at least a part of) the minor-programme of their choice.
Data analysis
Descriptive statistics were used to summarise student characteristics. The five negatively formulated items in the affective component scale of the SCOPE scale were recoded. Dimension scores were calculated by adding up all items and dividing them by the number of items, in the total scale and subscales, in order to give equal weight to each scale [39]. The normality of the data distribution was assessed, showing that assumptions for using parametric statistics were fulfilled. The student information system (SIS) was used for data on students’ factual placements. Students' placements preferences at cohort level from T0 to T3 (percentage, n) were analysed using contingency tables. To examine whether and how students’ placement preferences for community care and the hospital fluctuate during their study, students’ preferences were analysed at the individual level and visualised in schemes [see Appendix 1 for the visualisation schemes of placement preferences with regard to the other four healthcare areas].
To analyse students’ perceptions of community care, first, descriptive statistics (mean, SD) were used at the four time points at the level of total scale, subscale and item. Second, the development of students’ perceptions, i.e., the effect of time (T0-T3) on perceptions, was analysed using linear mixed model techniques (LMMs). This technique is specifically suitable for analysing a repeatedly measured continuous dependant variable (perceptions/ total scale), when (1) the observations over time are not independent of each other and (2) missing data occur from students not participating at all four time points due to drop out [39, 40, 41]. The data were analysed using IBM SPSS® version 25 (IBM Corporation, Armonk, NY).