Theoretical Framing of the Curriculum

Original Editor - Stacy Schiurring based on the course by Larisa Hoffman

Top Contributors - Stacy Schiurring and Angeliki Chorti

Introduction

Curricula in healthcare programs are influenced by a variety of factors that can be organized into four domains:  future of healthcare workforce, capabilities of the graduate, teaching and learning approaches, and local culture (Lee, 2013).  These domains reference the why, who, how and where learning occurs.  

The first domain references the reason healthcare programs exist.  Healthcare education programs are designed to train a healthcare workforce to address societal needs.  To protect the public, standards are often created by regulatory bodies including licensing boards, educational program accreditation bodies, professional associations, and higher education commissions (Lee, 2013).  These educational standards and requirements must guide the curriculum.  The most common way to ensure alignment between the standards and the curriculum is by mapping the standards to course objectives.  Creating standards of education or competencies has the benefit of fostering quality improvement of the profession by increasing standardization of practice (Nieveen, 2012).  This guidance can create conflict with the culture of academic freedom which is valued by most Universities (Nieveen, 2012).  In a curricular review or development of a new curriculum, the leaders should identify standards that inform the curriculum from national licensing boards, accreditation bodies, professional associations and higher education commissions.  

The second domain references the program outcomes of the graduates in terms of knowledge, skills, and attitudes (Lee, 2013).  Program outcomes should reflect diverse behaviors observed in the practicing clinician, considering the multiple roles and responsibilities of the profession.  The World Health Organization’s Rehabilitation Competency Framework identified five competencies for rehabilitation providers:  clinical practice, professionalism, learning and development, management and leadership, and research.  The World Physiotherapist Education Framework identifies eight domains of physiotherapy competence:  assessment and intervention, ethical and professional practice, communication, evidence based practice, interprofessional teamwork, reflective practice and lifelong learning, quality improvement, and leadership and management.  Defining expectations in graduates guide curricular development including the conditions for the graduates to perform and opportunities for students to practice (Barrie, 2005) (Premalatha, 2019).  The graduate outcomes can guide the selection of summative assessments, formative assessments, and learning theories and instruction (Premalatha, 2019).  In a curricular review or development of a new curriculum, the leaders should consider how each program outcome will be developed and ultimately assessed.

The third domain references the teaching, learning and assessment approaches (Lee, 2013).  The types of instruction, activities, and assessments are guided by the learning theories selected for the curriculum.  The theories that will be described here are objectivism (including behavioralist and cognitivism), constructivism, and connectivism (Bates, 2018) (Boville, 2018).  The difference in these theories is primarily the level of teacher guidance relative to autonomy in the learner:

• Objectivism relies on direct instruction.  
• Constructivism emphasizes inquiry-based learning with faculty guidance.  
• Connectivism is when knowledge is generated through discussion amongst learners without guidance.

The learning theory emphasized in the curriculum may subtly influence the culture of the program.   A course that emphasizes direct instruction such as lecture or reading (using an objectivist approach) may promote a hierarchical structure where there is an authority who shares a specific correct answer with the learner.   Programs that utilize direct instruction (objectivism) emphasize a learning authority (instructor) and accuracy of the materials.  For content that emphasizes fact and recall of information, using lecture or reading as a way to transmit knowledge may be the most efficient way to teach content (Bates, 2018).  The learning mechanism is primarily through receiving information (listening or reading). The assessment method is typically a multiple choice or short answer question, where there is an answer that is most correct.  The limitation with this theoretical approach is that the teaching and learning does not promote critical thinking or affective learning.  This type of instruction has been criticized for being superficial and not promoting long term retention.  

In a similar way to direct instruction, experiential learning or apprentice learning can rely on observation of an expert, with an emphasis on learning by doing.  The difference is that the assessment method for experiential learning is usually in the psychomotor domain.  In both examples, a reference of correctness is established.  This can lead to rote memorization or practice of skills.  In circumstances which require rigid thinking and consistent performance, this is useful.  However, healthcare providers are often put into environments that are rapidly changing.  This suggests that a program that only uses teaching and learning materials with direct instruction (using objectivism theory) are incomplete.  

A course that emphasizes problem-based learning or case-based learning (Irby, 1994) may emphasize a process of discovery of knowledge, where there are several correct options rather than a single correct answer. This type of model uses a constructivist approach. (Bates, 2018).  Rather than observation or direct instruction, this type of learning relies on discovery learning and cultivation of thinking.  In higher education, these types of courses may be referred to as interactive seminars or tutorial sessions.  There is often a small group of students paired with a course instructor.    

Haward Barrows defined problem based in 1969 using these steps for students:

1. Clarify concepts and define the problem
2. Discuss the problem and identify solutions,
3. Create learning objectives and research solutions
4. Synthesize results and share the outcomes

This type of learning is useful for concepts that are multi-faceted with multiple solutions.  This learning strategy has been criticized for being time consuming, but the depth of learning and the length of retention is greater than direct instruction.  For courses with an emphasis on the attitudinal domain of learning, case-based learning might be particularly useful.  In case-based learning, the instructor selects a case to tell a story that creates empathy to the characters, provokes conflict and forces decisions (Herreid, 2004).  The role of the instructor is to guide decision making, model professional thinking, and provide feedback in a collaborative discussion (Irby, 1994).  The assessments used in a constructivist approach must allow for diversity of answers which might be best captured in a reflection, participation in discussion, or debate.  

Alternatively, for content that relies on subjective interpretation of information, an open forum may be the best learning environment (using a connectivism approach) (Bates, 2018).  In connectivism groups share their experience, passion or concern through discussion (Wenger, 2013).  Knowledge is generated amongst group members through experiential learning and discussion.  Communities of practice discussion forums use a connectivism approach to learning.   Rather than allowing for a diversity of answers, in the connectivism approach – the answer changes based on group discussion.  

Each learning theory has benefits and drawbacks, suggesting that incorporating different learning theories into a program will ensure that learning is efficient and accurate, promotes critical thinking, and allows for personal growth in the affective domain.  Identifying content that best matches the learning theory, and ensuring course materials including instruction, learning activities, and assessments are aligned to the learning theory; will promote a well rounded curriculum.  

The fourth domain that influences the curriculum is the local culture within the university and community  (Lee, 2013).   This includes cultural norms, institutional values, and expectations embedded in policies (Lee, 2013).  Institutional values can be identified in both the institution and program’s philosophy,  mission, and vision statements.   A philosophy statement defines the beliefs and values of a program.  Through a review of the mission and vision statement,  an institution’s priorities (Seeber, 2017), purpose, values, strategy, and standards (Schoen, 2019)(Cortes-Sanchez, 2017) (Ozdem, 2010) can be revealed.  All of these elements reflect an institution’s culture  (Ozdem, 2010).   The local culture should influence the curriculum.  An institution that focuses on scholarly inquiry should emphasize performance of research in the curriculum.  Likewise, an institution that focuses on social justice should incorporate a project with a community partner.   Ensuring the local culture is embedded into the curriculum, will differentiate the program and highlight the unique strengths inherent within the program.  

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