The short answer is yes. But if the curriculum in these programs is not “concept-based” how does that work?

Important Truths to Get Started

1. Concepts are the building blocks of nursing practice; therefore, nursing students must understand and use concepts in the same way a nurse in practice understands and uses concepts.
2. You do not need a concept-based curriculum to teach concepts. A traditional-based curriculum can also teach concepts in a formal, deliberate manner – no need to transition to a concept-based curriculum. You can reach the goal of teaching concepts without the headache of a curriculum revision!
3. Teaching concepts is not new in nursing education – they appeared in the nursing education literature in the 1960s with Faye Abdellah’s 21 nursing problems theory, and probably before that. My first introduction was in my Master’s in Nursing program in 1980 with the book Thinking with Concepts published in 1970. I was already an ADN and BSN educated nurse but had not learned about the idea of nurses using concepts; what an eye-opener!
4. Concepts are the focus of the NCLEX (explained below). Many candidates fail NCLEX because they perform poorly on questions related to basic concepts used across care environments.

NCLEX and Concepts

All pre-licensure nursing programs must teach concepts because the NCLEX-RN and NCLEX-PN are based on knowledge of concepts. Searching these two test plans, the word “concept” only appears twice. In both test plans the word is found on the first page of Appendix B: Item Writing Tips. The test plans state, “The following tips are designed to provide nurse educators with information on writing NCLEX-style items.”  This statement clearly states these steps are used to write “NCLEX-style” items.

Steps 1 and 2 in the NCSBN’s tips use the term concept as follows:

Step 1. Select a nursing concept for focus of the item or case study (test plan category or integrated process).

Note: The nursing concept is identified if writing a test item or used in a case study type question.

Step 2. Use the concept to build the client data (clinical scenario/exhibits) and stem.

If the NCSBN is suggesting faculty develop test items based on nursing concepts, then it follows that the NCLEX is based on concepts. The NCSBN conducts a practice analysis every 3 years as evidence for content tested on the NCLEX representing current nursing practice. The NCLEX tests entry-level practice; therefore, nursing students must learn nursing concepts to achieve success on the NCLEX as well as for use in practice.

A Couple of Examples how Nurses and Nursing Students Use Concepts

The following examples apply to ALL nursing programs; it does not matter if the curriculum is a concept-based or a traditional program. Consider this:

All Students Learn Basic Psychomotor Skills

Students learn the steps of a psychomotor skill and each step requires knowledge of a concept. Consider the following abbreviated skills checklist. As the nurse performs a skill, the nurse makes necessary revisions depending on the individual patient’s situation. To make a good decision, the nurse relies on an awareness of the concept associated with each step and uses knowledge of the concept to base decisions as illustrated in the following table.

Indwelling Cather Insertion — Female Steps in the Procedure	Concept Represented	Can this step in the procedure be changed for the individual patient situation (context)?	Can this step in the procedure NOT Be changed? Why?
Check the PCP order.	Safety		X
Prior to starting, explain to the patient what is going to happen and why they need to be catheterized. Assess patients understanding and answer any questions they may have.	Teaching and Learning	X
Collect supplies, it is helpful to bring a second catheter in case of contamination of the first catheter.	Infection		X
Raise the bed to an appropriate working height and position yourself on the opposite side of your dominant hand.	Comfort (nurse)		X
Keep in mind that it may be necessary to obtain additional help with the catheterization.	Collaboration	X
Place the patient in supine position with the knees flexed and separated and feet flat on the bed, about 60 cm apart. If this position is uncomfortable, instruct the patient either to flex only one knee and keep the other leg flat on the bed, or to spread her legs as far apart as possible. A lateral position may also be used for elderly or disabled patients.	Comfort	X
Cover the patient only exposing the necessary areas.	Self (Culture)		X
With the thumb, middle and index fingers of the non-dominant hand, separate the labia majora and labia minora. Pull slightly upward to locate the urinary meatus. Maintain this position to avoid contamination during the procedure. With your dominant hand, cleanse the urinary meatus, using forceps and chlorhexidine-soaked cotton balls. Use each cotton ball for a single downward stroke only. Place the drainage basin containing the catheter between the patient’s thighs. Pick up the catheter with your dominant hand.	Infection		X
Insert the lubricated tip of the catheter into the urinary meatus.	Comfort		X
Advance the catheter about 5-5.75 cm, until urine begins to flow then advance the catheter a further 1-2 cm.	Elimination		X
Attach the syringe with the sterile water and inflate the balloon. It is recommended to inflate the 5cc balloon with 7-10cc of sterile water, and to inflate the 30cc balloon with 30-35cc of sterile water. Gently pull back on the catheter until the balloon engages the bladder neck.	Safety		X

The thinking illustrated in the above table is used by all nurses – not just those who were educated in a concept-based curriculum.

Physical Assessment and Concepts

Now consider performing a physical assessment. The nurse listens to the patient’s abdomen and finds bowel sounds are absent in 3 quadrants. The nurse uses knowledge of the concept of elimination (bowel) to determine what further information to collect as follows:

I will conduct focused assessments based on my knowledge of the concept of bowel elimination:

• Check type of diet.
• Check fluid status.
• Review documentation about previous BMs.
• Review medications.
• Review any procedures that may interfere with bowel elimination.
• Talk with patient about pain; flatus.
• Etc.

The nurse understands all the attributes of the concept of bowel elimination and uses that knowledge to determine how to proceed.

The Type of Nursing Program Does Not Matter – Concepts are Used!

Just these two basic examples of how nurses use concepts demonstrates that the type of curriculum the nursing program uses does not matter. Students must have a deep understanding of concepts. Students may already have an understanding of some concepts such as bowel elimination, nutrition, and others such as professionalism. However, students must understand how these concepts are used in nursing to be able to apply these concepts as a nurse. To engage in the thinking required for clinical judgment, students must have a deep understanding of all the nursing concepts and how each concept is used in nursing – not their own individual understanding about each concept they bring to school from their non-nursing experiences. Concept knowledge is needed to engage in clinical judgment!

Why concepts are not just for a concept-based curriculum.

The overall difference between a concept-based nursing curriculum and a traditional nursing curriculum is the way the content is packaged at the course level for delivery to students. That’s it! With that in mind, let’s contrast a concept-based curriculum and a traditional nursing curriculum. Delivery of content in a concept-based curriculum is organized around concepts. Delivery of content in a traditional, body-systems curriculum is organized around body systems and diseases. Both curricula teach concepts and both can be very effective if carefully taught and consistently implemented in the way they were intended. However, I would like to suggest one easy change that can be made to a traditional nursing curriculum to better prepare students for the NCLEX and for practice.

One, easy change to enhance NCLEX results and new graduate performance in practice:

Incorporate concepts within the traditional nursing curriculum. It’s actually easier than you might think.

My point is that we can help all new graduates be successful on NCLEX and in practice (regardless of the type of program in which we teach) by focusing on teaching students for a deep understanding of nursing concepts – regardless of the organizational structure of the nursing curriculum. This can be done in a traditional nursing program. Read on……

I have worked with hundreds and hundreds of nursing programs around the United States over the last 40 years. The majority of those programs implement a traditional nursing curriculum. I taught for nearly 30 years in a traditional nursing curriculum. Occasionally, when consulting with a school, one of the faculty members at that school was one of my students. This has happened to me at schools close to where I taught but also at schools thousands of miles away. Recently one such graduate told me that, although he learned a lot in the nursing program (he was always very polite!), that when he graduated, he felt unorganized. All the courses were focused on a specialty area such as pediatrics, medical/surgical, maternal/newborn, etc. To him they were all siloed, distinct entities that were not connected. I apologized for failing him.

The nursing program this student completed did not demonstrate or make clear that the foundation of all nursing care, no matter what population is being served, is built on nursing concepts and not just the ones learned in the fundamentals course. Concepts are what ties all areas of nursing practice together!

The nurse uses clinical judgment to apply concepts as needed to the care of individual patients within that particular patient’s context. This means that a concept may be applied in one way with one patient, but in a different way with another patient depending on the context. Clinical judgment is required to determine how the concept will be applied within that individual patient’s situation. To accomplish this deep level of nursing care, the student must have a complete understanding of concepts and experience using the same concepts in many different patient-care environments. For example, perfusion issues happen in medical/surgical, maternal/newborn, pediatrics, and every other type of patient care environment. Students can better determine what actions to take for issues with perfusion with any type of patient if they have a deep, profound understanding of the concept of perfusion.

 Working with nursing programs for over 4 decades, I have learned application of knowledge of concepts within a nuanced, individual patient situation is one of the major weaknesses in a new graduate’s thinking. This is caused by a lack of an in-depth understanding of both concepts and clinical judgment. Students are unsure how to use clinical judgment to apply concept knowledge within an individual patient context. They also have difficulty transferring concept knowledge from one type of patient to another. This is where a deep understanding of concepts is so important.

Students graduating from a traditional nursing program may not have a complete understanding of concepts and how to apply them contextually. However, this can be corrected.

Important note at this point: I am not suggesting that a concept-based curriculum is superior to a traditional-based curriculum. As experienced faculty know, student success in a nursing program is not as much a factor of the type of curriculum as it is the amount of faculty investment and student investment. However, the graduate’s success on NCLEX and in practice is very much a factor of what was taught in the curriculum and how it was taught.

A Suggestion for Concept Success!

My suggestion is that all nursing programs include a resource that is totally dedicated to all the concepts used by a nurse. Typically, in a traditional nursing program, concepts are scattered across courses and presented in many different ways. For example, basic concepts are covered in a fundamentals type course. In fact, as I work with faculty across the country who teach in a traditional nursing program but are transitioning to a concept-based curriculum, the faculty always share that their fundamentals (foundations) course is based on concepts. That is absolutely correct! However, (1) the formal, structured approach to teaching about concepts ends upon completion of the fundamentals course, and (2) the concepts are not interconnected but taught separately. As students move through the nursing courses they learn advanced concepts in higher level adult health courses, evidence-based nursing may be taught in a research course, higher level psychosocial concepts are taught in a mental health course, leadership concepts are taught in a leadership course, and on and on. These additional concepts are taught in a less structured way, students may not realize they are learning concepts, and the manner in which they are taught is not consistent across courses. This contributes to the siloed approach. The concepts that tie together all these courses are not recognized as such so each course appears to be separate from the others.

Furthermore, students do not actively retrieve detailed knowledge of concepts previously learned. They are expected to use that information, but often do not actively retrieve it. Active retrieval of previous learning reinforces and consolidates what was learned.

To ensure all concepts are taught and are used in various courses as needed across a nursing curriculum, one book covering all nursing concepts is extremely helpful. This type of book is the “hub” that spokes out to, and connects, all other courses to demonstrate their interconnectedness. No more siloed nursing practice.

NCLEX note: This was the major shift in the NCLEX when it moved from separate patient care areas (mental health, pediatrics, med/surg, etc.) to the current exam based on client needs across care environments.

For a Fresh Look at Concepts

Think you’ve reviewed all nursing concept student textbooks? You might find a new, fresh look by contacting your F. A. Davis sales representative for the most practical approach available today for learning concepts using clinical judgment to apply concept knowledge within an individual patient context. Get your students ready for NCLEX, no matter what type of curriculum you have!

So how does teaching concepts in this manner help the new graduate in practice?

New graduates accept positions on a variety of care units in a variety of healthcare agencies. The new graduate may be familiar with much of the nursing care provided, but will, of course, learn more with additional experience. An in-depth knowledge of concepts can help the student expand their knowledge base as they grow in their nursing positions.

Some new graduates will accept a position on a care unit that they did not experience while in their nursing program. These new graduates should feel assured they have learned all the concepts needed to practice in that area. Their task will be to determine when and how to apply the various concepts to the care of that patient population. For example, a new graduate accepts a position on a renal transplant unit. They may have learned how to care for a patient with a renal transplant likely covered in a short amount of time in the theory portion of a course, but did not spend any clinical time on a transplant unit. Could this make the new graduate somewhat apprehensive in that area of practice that is new to them? The new graduate might review the nursing textbook about care of the patient with a kidney transplant, but they can further expand their sense of knowing by reviewing all the concepts that relate to the care of this type of patient.

The following table lists example nursing actions for a patient with a kidney transplant. The table also lists concepts that align with each nursing action and possible interconnected concepts. It would be helpful for the new graduate to review these concepts prior to implementing the transplant-specific nursing actions. As the new graduate reads about nursing care for the kidney transplant patient, they expand on that care by reviewing the related concept knowledge. This approach is the same as that used in the psychomotor skill example at the beginning of this blog.

Suggestion: This is the approach I suggest for a traditional nursing program. Students learn individual concepts in some manner across a traditional nursing program, but it would be extremely helpful for success on NCLEX and in practice to be able to use concept knowledge when learning about disease processes and learning how to care for patients with those disease processes.

Relationship Between Nursing Actions and Concepts

Nursing Actions	Concept Knowledge Needed to Safety Implement the Nursing Actions	Example Interconnected Concepts
Monitor for signs of hypovolemia	Perfusion Oxygenation	Acid-base balance Cognition; Stress and coping
Monitor for fever	Thermoregulation	Cognition; Comfort
Monitor urine output	Elimination	Fluid and electrolytes; Comfort; Acid-base balance
Ensure fluid and electrolyte balance	Fluid and electrolytes	Elimination; Perfusion
Manage pain	Comfort	Stress and coping; Self-care
Monitor for transplant rejection	Immunity	Infection; Inflammation; Comfort
Teach patient about medications and signs of rejection	Teaching and learning	Self-care; Safety; Health promotion
Monitor for infection	Tissue integrity Infection	Comfort; Mobility Inflammation

In addition to the concepts listed in the table, there are a number of other concepts to review for this patient:

• Nutrition
• Evidence-based nursing practice
• Collaboration
• Safety
• Family

A List of Important Facts about Nursing Concepts

• Concepts are the thread that ties together all of nursing practice.
• All nurses think using concepts.
• The NCLEX-RN and NCLEX-PN test items focus on concepts.
• You do not need a concept-based curriculum to teach concepts.
• All nursing students should have an in-depth understanding of all nursing concepts.
• Nursing students must learn to use clinical judgment to determine how to safely apply concept knowledge to make care decisions within an individual patient care context.
• Nursing programs should adopt a book that consistently presents all nursing concepts. Student will use this book throughout their nursing program to apply concept knowledge to a variety of patient care situations.

For questions and/or comments on this Blog please click on the “Contact” tab and send your message to Dr. Linda Caputi. I would love to hear from you!!