Description
The problem is the limited health education activities among nurses. Although they undergo health education courses during university studies, they lack the knowledge or implementation of the correct steps in the health education process.1. Program identificationTask 1: Analyzing Educational Needs Choose a specific subject area or field of study. Describe the process of analyzing educational needs for this subject area. Include factors such as changing societal demands, learner demographics, and emerging trends that can influence program identification.
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CHAPTER TWO
Step 1
Problem Identification and General
Needs Assessment
. . . building the foundation for meaningful objectives
Copyright 2016. Johns Hopkins University Press.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
Eric B. Bass, MD, MPH, and Belinda Y. Chen, MD
Medical instruction does not exist to provide individuals with an
opportunity of learning how to make a living, but in order to make
possible the protection of the health of the public.
—Rudolf Virchow
Definitions
12
Importance
12
Defining the Health Care Problem
12
General Needs Assessment
14
Current Approach
Ideal Approach
Differences between Current and Ideal Approaches
Obtaining Information about Needs
Finding and Synthesizing Available Information
Collecting New Information
14
16
18
18
19
22
Time and Effort
23
Conclusion
24
Questions
24
General References
25
Specific References
25
Many reasons may prompt someone to begin work on a medical curriculum. Indeed,
continuing developments in medical science and technology call for efforts to keep
medical education up to date, whether it be new knowledge to be disseminated (e.g.,
effectiveness of a new therapy for hepatitis C infection) or a new technique to be taught
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Account: ns224396.main.eds
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Curriculum Development for Medical Education
(e.g., a robotic-assisted minimally invasive surgical technique). Sometimes, educational
leaders issue a mandate to improve performance in selected areas, based on feedback
from learners, suboptimal scores on standardized examinations, or recommendations
from educational accrediting bodies. Other times, educators want to take advantage
of new learning technology (e.g., a new simulation center) or need to respond to new
national standards for competency-based training. Regardless of where one enters the
curriculum development paradigm, it is critical to take a step back and consider the responsibilities of a medical educator. Why is a new or revised curriculum worth the time
and effort needed to plan and implement it well? Since the ultimate purpose of medical
education is to improve the health of the public, what is the health problem or outcome
that needs to be addressed? What is the ideal role of a planned educational experience
in improving such health outcomes? This chapter offers guidance on how to define the
problem, determine the current and ideal approaches to the problem, and synthesize all
of the information in a general needs assessment that clarifies the gap the curriculum
will fill.
DEFINITIONS
The first step in designing a curriculum is to identify and characterize the health
care problem that will be addressed by the curriculum, how the problem is currently
being addressed, and how it ideally should be addressed. The difference between how
the health care problem is currently being addressed, in general, and how it should be
addressed is called a general needs assessment. Because the difference between the
current and ideal approaches can be considered part of the problem that the curriculum
will address, Step 1 can also simply be called problem identification.
IMPORTANCE
The better a problem is defined, the easier it will be to design an appropriate curriculum to address the problem. All of the other steps in the curriculum development
process depend on having a clear understanding of the problem (see Figure 1). Problem
identification (Step 1), along with targeted needs assessment (Step 2), is particularly
helpful in focusing a curriculum’s goals and objectives (Step 3), which in turn help to
focus the curriculum’s educational strategies and evaluation (Steps 4 and 6). Step 1 is
especially important in justifying dissemination of a successful curriculum because it
supports its generalizability. Steps 1 and 2 also provide a strong rationale that can help
the curriculum developer obtain support for curriculum implementation (Step 5).
DEFINING THE HEALTH CARE PROBLEM
The ultimate purpose of a curriculum in medical education is to equip learners to
address a problem that affects the health of the public or a given population. Frequently,
the problem of interest is complex. However, even the simplest health care issue may
be refractory to an educational intervention, if the problem has not been defined well.
A comprehensive definition of the problem should consider the epidemiology of the
problem, as well as the impact of the problem on patients, health care professionals,
medical educators, and society (Table 2.1).
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Step 1: Problem Identification and General Needs Assessment
Table 2.1.
13
Identification and Characterization of the Health Care Problem
Whom does it affect?
Patients
Health care professionals
Medical educators
Society
What does it affect?
Clinical outcomes
Quality of life
Quality of health care
Use of health care and other resources
Medical and nonmedical costs
Patient and provider satisfaction
Work and productivity
Societal function
What is the quantitative and qualitative importance of the effects?
In defining the problem of interest, it is important to explicitly identify whom the
problem affects. Does the problem affect people with a particular disease (e.g., frequent
disease exacerbations requiring hospitalization for patients with asthma), or does the
problem affect society at large (e.g., inadequate understanding of behaviors associated
with acquiring an emerging infectious disease)? Does the problem directly or indirectly
affect health professionals and their trainees (e.g., physicians inadequately prepared
to participate effectively as part of interprofessional teams)? Does the problem affect
health care organizations (e.g., a need to foster the practice of patient-centered care)?
The problem of interest may involve many different groups. The degree of impact has
implications for curriculum development because a problem that is perceived to affect
many people may be granted more attention and resources than one that applies to
only a small group. Educators will be able to choose the most appropriate target audience for a curriculum, formulate learning objectives, and develop curricular content
when they know the characteristics and behaviors of those affected by the health care
problem of interest.
Once those who are affected by the problem have been identified, it is important
to elaborate on how they are affected. What is the effect of the problem on clinical outcomes, quality of life, quality of health care, use of health care services, medical and
nonmedical costs, patient and provider satisfaction, work and productivity, and the
functioning of society? How common and how serious are these effects?
EXAMPLE: Partial Problem Identification for a Poverty in Health Care Curriculum. “Thirty-seven million
Americans live below the federal poverty threshold, representing 12.6% of the U.S. population. Even
more—nearly 90 million Americans—live below 200% of the federal poverty threshold, an income at
which many struggle to make ends meet. Given these realities, most physicians will work with low-income patients, regardless of their specialty or practice location. Countless studies have shown that
lower socioeconomic status (SES) is associated with unique challenges to health, higher disease burden
and poorer health outcomes” (1).
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Curriculum Development for Medical Education
GENERAL NEEDS ASSESSMENT (TABLE 2.2)
Current Approach
Having defined the nature of the health care problem, the next task is to assess current efforts to address the problem. The process of determining the current approach
to a problem is sometimes referred to as a “job analysis” because it is an assessment
of the “job” that is currently being done to deal with a problem (2). To determine the
current approach to a problem, the curriculum developer should ask what is being done
by each of the following:
a. Patients (including their families, significant others, and caregivers)
b. Health care professionals
c. Medical educators
d. Society (including community networks, health care payers, and policymakers)
Knowing what patients are doing and not doing with regard to a problem may influence decisions about curricular content. For example, are patients using noneffective
treatments or engaging in activities that exacerbate a problem, behaviors that need to
be reversed? Or, are patients predisposed to engage in activities that could alleviate the
problem, behaviors that need to be encouraged?
Knowing how health care professionals are currently addressing the problem is especially relevant because they are frequently the target audience for medical curricula.
In the general needs assessment, one of the challenges is in determining how health
care professionals vary in their approach to a problem. Many studies have demonstrated substantial variations in clinical practice within and between countries, in terms
of both use of recommended practices and use of ineffective or harmful practices (3).
EXAMPLE: Treatment of Diarrheal Illness among Private Practitioners in Nigeria. Ninety-one doctors in
Enugu, Nigeria, who had heard of oral rehydration therapy (ORT) and expressed belief in its efficacy were
interviewed using a structured questionnaire to determine their knowledge of, attitude toward, and
practice of treatment of diarrheal illness. Fifty percent said they would recommend salt-sugar solution
(SSS) over standardized oral rehydration solutions due to availability and cost-effectiveness. However,
only 55% knew how to prepare SSS correctly. Even though 76% of doctors believed that viral infections
were a common cause of diarrhea, antibiotics were commonly used. The study revealed a high rate of
inappropriate drug use and a deficiency in the knowledge and practice of ORT (4).
Most problems important enough to warrant a focused curriculum are encountered
in many different places, so it is wise to explore what other medical educators are currently doing to help patients and health care professionals address the problem. Much
can be learned from the previous work of educators who have tried to tackle the problem of interest. For example, curricular materials may exist already for medical trainees
and may be of great value in developing a curriculum for one’s own target audience.
The existence of multiple curricula may highlight the need for evaluation tools to help
educators determine which methods are most effective. This is particularly important
in medical education, where the number of things that could be taught is constantly
expanding while the time and resources available for education are finite. A dearth of
relevant curricula will reinforce the need for innovative curricular work.
EXAMPLE: Interprofessional Education. Reports from the World Health Organization and the Institute of
Medicine have called for greater interprofessional education (IPE) to improve health outcomes through
fostering the development of coordinated interprofessional teams that work together to promote quality,
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Step 1: Problem Identification and General Needs Assessment
Table 2.2.
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The General Needs Assessment
What is currently being done by the following?
Patients
Health care professionals
Medical educators
Society
What personal and environmental factors affect the problem?
Predisposing
Enabling
Reinforcing
What ideally should be done by the following?
Patients
Health care professionals
Medical educators
Society
What are the key differences between the current and ideal approaches?
safety, and systems improvement. Those developing curricula in interprofessional education should be
familiar with the guidelines and competencies established by various Interprofessional Health Collaboratives (5, 6). However, even within the guidelines, there is substantial room for variation. To assist other
curriculum developers, a paper published in Academic Medicine describes the development, implementation, and assessment of IPE curricula in three different institutions, along with a discussion of lessons
learned (7).
Curriculum developers should also consider what society is doing to address the
problem. This will help to improve understanding of the societal context of current efforts to address the problem, taking into consideration potential barriers and facilitators
that influence those efforts.
EXAMPLE: Impact of Societal Approach on Curricular Planning. In designing a curriculum to help health
care professionals reduce the spread of HIV infection in a given society, it is necessary to know how the
society handles the distribution of condoms and clean needles. As of 2010, 82 countries were reported
to have some program for needle/syringe exchange. However, 76 countries/territories reported IV drug
use activity but no needle/syringe exchange programs (8). If the distribution of clean needles is prohibited, an HIV infection prevention curriculum for health care professionals will need to address the most
appropriate options acceptable in that society.
To understand fully the current approach to addressing a health care problem, curriculum developers need to be familiar with the ecological perspective on human behavior. This perspective emphasizes multiple influences on behavior, including at the
individual, interpersonal, institutional, community, and public policy levels (9). Interventions are more likely to be successful if they address multiple levels of influence on
behavior. Most educational interventions will focus primarily on individual and/or interpersonal factors, but some may be part of larger interventions that also target collective
levels of influence.
When focusing on the individual and interpersonal levels of influence on behavior,
curriculum developers should consider the fundamental principles of modern theories
of human behavior change. While it is beyond the scope of this book to discuss specific
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Curriculum Development for Medical Education
theories in detail, three concepts are particularly important: 1) human behavior is mediated by what people know and think; 2) knowledge is necessary, but not sufficient, to
cause a change in behavior; and 3) behavior is influenced by individual beliefs, motivations, and skills, as well as by the environment (9).
In the light of these key concepts, curriculum developers need to consider multiple
types of factors that may aggravate or alleviate the problem of interest. Factors that can
influence the problem can be classified as predisposing factors, enabling factors, or
reinforcing factors (10). Predisposing factors refer to people’s knowledge, attitudes, and
beliefs that influence their motivation to change (or not to change) behaviors related to a
problem. Enabling factors generally refer to personal skills and societal or environmental forces that make a behavioral or environmental change possible. Reinforcing factors
refer to the rewards and punishments that encourage continuation or discontinuation
of a behavior.
EXAMPLE: Predisposing, Enabling, and Reinforcing Factors. In designing curricula for health professionals on the prevention of smoking-related illness, curriculum developers should be familiar with predisposing, enabling, and reinforcing factors that influence an individual’s smoking behavior. The 2008
U.S. Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence (11) summarizes available evidence to make recommendations for health professional interventions. One predisposing factor is an individual’s self-defined readiness to quit—so the guidelines recommend strategies
for assessing a patient’s readiness to quit and describe different interventions based on whether a patient is willing or unwilling to make a quit attempt. An enabling factor would be the availability and cost
of tobacco products and tobacco-cessation products. Reinforcing factors include the strength of physical and psychological addiction, personally defined benefits to smoking, personally defined motivators
for stopping or not starting, and personally defined barriers to cessation.
By considering all aspects of how a health care problem is addressed, one can
determine the most appropriate role for an educational intervention in addressing the
problem, keeping in mind that an educational intervention by itself usually cannot solve
all aspects of a complex health care problem.
Ideal Approach
After examination of the current approach to the problem, the next task is to determine the ideal approach to the problem. Determination of the ideal approach will require
careful consideration of the multiple levels of influence on behavior, as well as the same
fundamental concepts of human behavior change described in the preceding section.
The process of determining the ideal approach to a problem is sometimes referred to
as a “task analysis,” which can be viewed as an assessment of the specific “tasks” that
need to be performed to appropriately deal with the problem (2, 12). To determine the
ideal approach to a problem, the curriculum developer should ask what each of the following groups should do to deal most effectively with the problem:
a. Patients
b. Health care professionals
c. Medical educators
d. Society
To what extent should patients be involved in handling the problem themselves? In
many cases, the ideal approach will require education of patients and families affected
by or at risk of having the problem.
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Step 1: Problem Identification and General Needs Assessment
17
EXAMPLE: Role of Patients/Families. Parents of children discharged from a neonatal intensive care unit
(NICU) generally have not received any instruction about the developmental milestones that should be
expected of their children. To foster timely and appropriate developmental assessment of children discharged from a NICU, neonatologists need to address the role that parents play in observing a child’s
development (13).
Which health care professionals should deal with the problem, and what should
they be doing? Answering these questions can help the curriculum developer to target
learners and define the content of a curriculum appropriately. If more than one type of
health care professional typically encounters the problem, the curriculum developer
must decide what is most appropriate for each type of provider and whether the curriculum will be modified to meet the needs of each type of provider or will target just
one group of health care professionals.
EXAMPLE: Role of Health Care Professionals. A curriculum designed for physicians to practice developmental assessment of pediatric patients in a post-NICU follow-up clinic needed to accommodate
general pediatric residents, neurology residents, and neonatal and neurodevelopmental fellows. The
curriculum developers recognized that general pediatric physicians needed to know what to teach parents and which patients to refer for specialty evaluation. Neonatologists needed to learn the potential
developmental complications of various NICU interventions. Neurodevelopmental specialists needed to
learn not only how to formulate specific management plans but also how to teach key diagnostic assessment tools to referring pediatricians and neonatologists (13).
What role should medical educators have in addressing the problem? Determining
the ideal approach for medical educators involves identifying the appropriate target
audiences, the appropriate content, the best educational strategies, and the best evaluation methods to ensure effectiveness. Reviewing previously published curricula that
address the health care problem often uncovers elements of best practices that can be
used in new curricular efforts.
EXAMPLE: Identifying Appropriate Audiences and Content. Interns and residents have traditionally been
trained to be on “code teams,” but medical students can also be in clinical situations where improved
competence in basic resuscitation can make a difference in patient outcomes. Basic life support (BLS)
and advanced cardiovascular life support (ACLS) training can increase familiarity with cardiac protocols
but have been shown to be inadequate in achieving competency as defined by adherence to protocols.
Deliberative practice through simulation is an educational method that could potentially improve students’ achievement of competency in these critical skills, so a curriculum was created, implemented,
and evaluated with these outcomes in mind. (See Appendix A, Essential Resuscitation Skills for Medical
Students.)
EXAMPLE: Identifying Best Practices. Since publication of the Institute of Medicine’s report Unequal
Treatment (14), there has been increasing attention to addressing health care disparities in undergraduate medical education. A curriculum developer searching PubMed might learn of a validated cultural
assessment instrument, TACCT, that could be used in a needs assessment or post-curricular evaluation
to assess cultural competency (15–17). A consortium of 18 U.S. medical schools funded by the National
Heart, Lung, and Blood Institute to address health disparities through medical education has also collated and shared additional online curricular resources on this topic (18). Resources include tools for
measuring implicit bias, case studies for use in workshops and local curricula, validated assessment
tools, and sample curricular products. Curriculum developers tasked with developing approaches to
health care disparities within their local environments should be familiar with such resources.
Keep in mind, however, that educators may not be able to solve the problem by
themselves. When the objectives are to change the behavior of patients or health care
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Curriculum Development for Medical Education
professionals, educators should define their role relative to other interventions that may
be needed to stimulate and sustain behavioral change.
What role should society have in addressing the problem? While curriculum developers usually are not in the position to effect societal change, some of their targeted
learners may be, now or in the future. A curriculum, therefore, may choose to address
current societal factors that contribute to or alleviate a problem (such as advertisements, political forces, organizational factors, and government policies). Sometimes,
curriculum developers may want to target or collaborate with policymakers as part of a
comprehensive strategy for addressing a public health problem.
EXAMPLE: Social Action Influenced by a Curriculum. The Kellogg Health Scholars Program was a twoyear postdoctoral fellowship program that trained academic leaders, not only in community-based participatory research related to the social determinants of health, but also in the application of research to
effect policy changes (19).
EXAMPLE: Social Action Influenced by Curricula. Medical school faculty published 12 tips for teaching
social determinants of health in medical school, based on their review of the literature and their five-year
experience in developing and teaching a longitudinal course at their institution. Their description includes a table of sample cases and action-oriented activities to engage students in the subject matter.
These actions include looking at local data and discussing policy recommendations that could decrease
health disparities (20).
The ideal approach should serve as an important, but not rigid, guide to developing
a curriculum. One needs to be flexible in accommodating others’ views and the many
practical realities related to curriculum development. For this reason, it is useful to
be transparent about the basis for one’s “ideal” approach: individual opinion, consensus, the logical application of established theory, or scientific evidence. Obviously, one
should be more flexible in espousing an “ideal” approach based on individual opinion
than an “ideal” approach based on strong scientific evidence.
Differences between Current and Ideal Approaches
Having determined the current and ideal approaches to a problem, the curriculum
developer should identify the differences between the two approaches. The differences
identified by this general needs assessment should be the main target of any plans for
addressing the health care problem. As mentioned above, the differences between the
current and ideal approaches can be considered part of the problem that the curriculum
will address, which is why Step 1 is sometimes referred to, simply, as problem identification.
OBTAINING INFORMATION ABOUT NEEDS
Each curriculum has unique needs for information about the problem of interest. In
some cases, substantial information already exists and simply has to be identified. In
other cases, much information is available, but it needs to be systematically reviewed
and synthesized. Frequently, the information available is insufficient to guide a new curriculum, in which case new information must be collected. Depending on the availability
of relevant information, different methods can be used to identify and characterize a
health care problem and to determine the current and ideal approaches to that problem.
The most commonly used methods are listed in Table 2.3.
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Step 1: Problem Identification and General Needs Assessment
Table 2.3.
19
Methods for Obtaining the Necessary Information
Review of Available Information
Evidence-based reviews of educational and clinical topics
Published original studies
Clinical practice guidelines
Published recommendations on expected competencies
Reports by professional organizations or government agencies
Documents submitted to educational clearinghouses
Curriculum documents from other institutions
Patient education materials prepared by foundations or professional organizations
Patient support organizations
Public health statistics
Clinical registry data
Administrative claims data
Use of Consultants/Experts
Informal consultation
Formal consultation
Meetings of experts
Collection of New Information
Surveys of patients, practitioners, or experts
Focus group(s)
Nominal group technique
Liberating structures
Group judgment methods (Delphi method)
Daily diaries by patients and practitioners
Observation of tasks performed by practitioners
Time and motion studies
Critical incident reviews
Study of ideal performance cases or role-model practitioners
By carefully obtaining information about the need for a curriculum, educators will
demonstrate that they are using a scholarly approach to curriculum development. This
is an important component of educational scholarship, as defined by a consensus conference on educational scholarship that was sponsored by the Association of American
Medical Colleges (AAMC) (21). A scholarly approach is valuable because it will help
to convince learners and other educators that the curriculum is based on up-to-date
knowledge of the published literature and existing best practices.
Finding and Synthesizing Available Information
The curriculum developer should start with a well-focused review of information
that is already available. A review of the medical literature, including journal articles
and textbooks, is generally the most efficient method for gathering information about
a health care problem, what is currently being done to deal with it, and what should
be done to deal with it. A medical librarian can be extremely helpful in accessing the
medical and relevant nonmedical (e.g., educational) literature, as well as in accessing
databases that contain relevant but unpublished information. However, the curriculum
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Curriculum Development for Medical Education
developer should formulate specific questions to guide the search for relevant information. Without focused questions, the review will be inefficient and less useful.
The curriculum developer should look for published reviews as well as any original
studies about the topic. If a systematic review has been performed recently, it may be
possible to rely on that review, with just a quick look for new studies performed since
the review was completed. The Best Evidence in Medical Education (BEME) Collaboration is a good source of high-quality evidence-based reviews of topics in medical
education (22). Depending on the topic, other evidence-based medicine resources may
also contain valuable information, especially the Cochrane Collaboration, which produces evidence-based reviews on a wide variety of clinical topics (23). If a systematic
review of the topic has not yet been done, it will be necessary to search systematically
for relevant original studies. In such cases, the curriculum developer has an opportunity to make a scholarly contribution to the field by performing a systematic review of
the topic. A systematic review of a medical education topic should include a carefully
documented and comprehensive search for relevant studies, with explicitly defined
criteria for inclusion in the review, as well as a verifiable methodology for extracting and
synthesizing information from eligible studies (24). By examining historical and social
trends, the review may yield insights into future needs, in addition to current needs.
For many clinical topics, it is wise to look for pertinent clinical practice guidelines
because the guidelines may clearly delineate the ideal approach to a problem. In some
countries, practice guidelines can be accessed easily through a government health
agency, such as the Agency for Healthcare Research and Quality (AHRQ) in the United
States or the National Institute for Health and Care Excellence (NICE; formerly, the
National Institute for Health and Clinical Excellence) in the United Kingdom, each of
which sponsors a clearinghouse for practice guidelines (25, 26). With so many practice
guidelines available, curriculum developers are likely to find one or more guidelines for
a clinical problem of interest. Sometimes guidelines conflict in their recommendations.
When that happens, the curriculum developer should critically appraise the methods
used to develop the guidelines to determine which recommendations should be included in the ideal approach (27–29).
When designing a curriculum, educators need to be aware of any recommendations
or statements by accreditation agencies or professional organizations about the competencies expected of practitioners. For example, any curriculum for internal medicine
residents in the United States should take into consideration the core competencies set
by the Accreditation Council for Graduate Medical Education (ACGME), requirements
of the Internal Medicine Residency Review Committee, and the evaluation objectives
of the American Board of Internal Medicine (ABIM) (30, 31). Similarly, any curriculum
for medical students in the United States should take into consideration the accreditation standards of the Liaison Committee on Medical Education (LCME) and the core
entrustable professional activities (EPAs) that medical school graduates should be able
to perform when starting residency training, as defined by the AAMC (32, 33). Within
any clinical discipline, a corresponding professional society may issue a consensus
statement about core competencies that should guide training in that discipline. A good
example is the Society of Hospital Medicine, a national professional organization of
hospitalists, which commissioned a task force to prepare a framework for curriculum
development based on the core competencies in hospital medicine (34). Often, the
ideal approach to a problem will be based on this sort of authoritative s
