Accepted Manuscript

Conceptualization of competency based curricula in pre-service nursing and

midwifery education: A grounded theory approach

Claudine Muraraneza, Gloria Ntombifikile Mtshali

PII: S1471-5953(16)30105-6
DOI: 10.1016/j.nepr.2017.09.018
Reference: YNEPR 2292

To appear in: Nurse Education in Practice

Received Date: 23 October 2016

Revised Date: 4 May 2017
Accepted Date: 28 September 2017

Please cite this article as: Muraraneza, C., Mtshali, G.N., Conceptualization of competency based
curricula in pre-service nursing and midwifery education: A grounded theory approach, Nurse Education
in Practice (2017), doi: 10.1016/j.nepr.2017.09.018.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
 ACCEPTED MANUSCRIPT

CONCEPTUALIZATION OF COMPETENCY BASED CURRICULA IN PRE-SERVICE

NURSING AND MIDWIFERY EDUCATION: A GROUNDED THEORY APPROACH

Claudine Muraraneza, RN, BsN, MSc NE, PhD Candidate1

PT
Gloria Ntombifikile Mtshali, RN/RM, MSc NE, PhD1

Authors’ Affiliation: Professor Mtshali, Senior academic leader, Muraraneza PhD candidate,

RI
1
School of Nursing and Public Health, University of KwaZulu-Natal, Howard College, Durban,
South Africa.

SC
Corresponding author: Claudine Muraraneza Email address:declau15@hotmail.com,
Cellphone number: +27619142939. Postal address: 4001 Durban, South Africa

U
Funding: This is a part of PhD project that was sponsored by the research office of the College
AN
of Health Sciences at University of KwaZulu-Natal.

Dr Donatilla Mukamana served as a contact person in a context where this study took place
M

Mr David Newman edited this manuscript

D
TE
C EP
AC
 ACCEPTED MANUSCRIPT
1

Abstract

In health professional education, the competency-based curriculum concept has been an

important driver of reform in the training of competent graduates for the 21st century. In African

countries, although there has been implementing it in pre-service nursing and midwifery

PT
education and the literature reports a lack of understanding of what is it on the part of the

RI
implementers. This article explores the meaning of competency based curriculum in pre-service

nursing and midwifery education in Rwanda. A grounded theory approach, following Corbin and

SC
Strauss, was used. Following ethical clearance by the university ethical committee, data was

collected from 17 participants through in-depth individual interviews of staff. Four categories

U
emerged: (a) transformation, (b) tool for primary health care philosophy, (c) technological
AN
approach to education, (d) and modular system. Competency-based curriculum is confirmed as
M

an appropriate educational tool in producing competent graduates for today and the future.

Key words: Competency-based curriculum, conceptualization, pre-service nursing/midwifery

D

education, grounded theory.

TE

Introduction

In health professional education, the concept of the competency-based curriculum (CBC) has
EP

been an important driver of reform in the training of competent graduates for the 21st century. Its
C

introduction brings education into line with the needs of the health sector in today’s
AC

technological environment. In recent decades, the implementation of CBCs has been a

predominant feature of education reform in African countries, but with many challenges that

hinder their successful implementation (Muraraneza et al., 2016). Education institutions are

expected to lead transformation, but without the necessary capacity and resources (Chisholm and

Leyendecker, 2008) the consequence is often a return to the old curricula. Ineffective
 ACCEPTED MANUSCRIPT
2

implementation of CBCs has been attributed to lack of understanding of CBC on the part of the

educators (Komba and Mwandanji, 2015). According to Medina (2017), the old curriculum was

time based and group learning with emphasis on knowledge with all students expected to move

together through structured content at the same time. The focus was on what and how learners

PT
are taught, and less or not they can use what they learn in problem solving, performance

RI
procedures, effective communication, and good decision making in clinical practice (Gruppen et

al., 2012).

SC
Background

U
Literature review
AN
Nurse educators believe that CBC is impracticable and continue to deliver content-laden

curriculum which fail to develop higher order thinking skills in students (Ndawo, 2015). CBC
M

offers ways to improve college affordability and accurate measures for student learning
D

(Mendenhall, 2012). According to Yap et al. (2016), transition to the new teaching approach has
TE

been slow because educators find it risky and they lack confidence, having themselves been

taught in the old way. Nurse academics have little or no experience of working with a
EP

competency-based curriculum, and many are not prepared for their teaching roles (Chapman et

al., 2013). Shen (2012) reports that many principals or program leaders lack expertise and
C

confidence in regard to curriculum and instruction. Further complications arise in the context
AC

where pre-service nursing and midwifery education institutions have moved from the service

sector to colleges and university campuses, with newly evolving roles that are becoming

increasingly complex (Billings and Halstead, 2009).

 ACCEPTED MANUSCRIPT
3

In a study by Wyngaarden et al. (2008), some nurse educators indicated that the reason why they

were only moderately competent in CBC implementation was because they had not been trained

for it. Ross (2012) found that although most faculty members were positive about CBC, half of

them said that the CBC consisted of theoretical exercises imposed by a higher authority.

PT
Context

RI
In Rwanda, similarly to other developing countries, the introduction of CBCs in 2007 in

SC
undergraduate nursing and midwifery education was associated with a move to post-secondary

education. In the same context, at secondary school level, Nsengimana et al. (2014) found that

U
the implemented CBCs differed relatively little from the traditional curriculum due to lack of
AN
understanding of the CBC concept on the part of the educators. Although at tertiary level this

phenomenon remains poorly researched, it was found in one study that medical students seemed
M

confused because little time was allocated to classroom activities (Gahutu, 2010). To close the
D

gap, this article explores the understanding of CBC by staff in pre-service nursing and midwifery

education at school level.

TE

Methodology
EP

The methodological paradigm used in this study was symbolic interactionism. The meaning of an

event emerges through both verbal and nonverbal behavior by which the interaction becomes the
C

focus of investigation to discover the true meaning (Gillis and Jackson, 2002). The study
AC

follows a grounded theory approach developed by Corbin and Straus (2008, 1990).

Participants
 ACCEPTED MANUSCRIPT
4

Faculty members who were full-time and having or more 3years experiences were invited to

participate. The participants were 17 staff members, made up of 4 administrators and leaders, 7

participants occupying both academic management and teaching positions, and 6 educators.

PT
Data collection strategies

Ethical clearance was obtained from the University ethical committee and research clearance was

RI
given by the Ministry of Education. Permission was obtained prior to data collection by the

SC
School of Nursing and Midwifery and by two coordinators of campuses where this study took

place. Data was collected by individual in-depth interviews for staff until the saturation was

U
reached. Data collection took six months, from July 2015 to February, 2016.
AN
Data analysis
M

NVivo 10 was used to transcribe and analyze qualitative data. Constant comparison analysis and

“let data talk itself” approaches were use in the analysis process. Open coding, axial coding and
D

selective coding were used in this study to generate a useful middle-range theory conceptualizing
TE

CBC in pre-service nursing education.

Findings
EP

Four categories emerged from the data in the way the CBC was conceptualized as: (a)
C

transformative, (b) a tool in primary health care philosophy, (c) technology, and (d) a modular
AC

system.

1. Competency-based curriculum as transformative

The CBC was conceptualized as an educational approach that transforms the students into

competent graduates who are able to deal with a dynamic working environment. This is made
 ACCEPTED MANUSCRIPT
5

possible through four properties: (a) relevance of curriculum, (b) collateral learning, (c) deep

learning, and (d) mastery learning.

Relevance

PT
In the study data, two dimensions emerged under the category of relevance: (a) competencies

expected in graduates’ employability and (b) authentic health problems.

RI
Employability is enhanced in the development of curricula by first describing the graduates who

SC
are needed in the labor market. Expected competencies allow them to competently perform a

clinical role, a leadership role and a management role. Employability empowers the graduates to

U
perform tasks competently and independently in an accountable and ethical manner. A CBC
AN
considers the needs of the employer and of the client that must be satisfied. The following

participant comments relate to these points:

M

A nurse/midwife is … autonomous and accountable in performing clinical role:

D

health promotion, preventive care, curative and palliative care; managerial

TE

and leadership role including human resources and equipment [P02].

Those competencies … were ethics and professional code of conduct,….

EP

leadership and management skills [P12].

C

… they could have competencies in nursing ethic … in whatever they do. They
AC

will also be able … to analyse the situation they meet, able to apply

management and leadership skills because at the completion of their studies

they will be the ones who will lead some unities and sub-unities within the

hospital, health centers …[P04].

 ACCEPTED MANUSCRIPT
6

The study data indicated that the CBC relies on the use of authentic health problems. The

curriculum is thus dynamic in nature, through regular updating to accommodate new challenges

or problems that arise within a society. The students are socialized to critically analyze existing

problems and find alternative solutions. These aspects were noted in the following participant

PT
comments:

RI
Competency-based curriculum helps to produce graduates who are able to

deal with health problems and come up with solutions of real health problem

SC
by using critical thinking and problem solving skills [P01].

U
In first competency-based curriculum, there was a gap in some areas such as
AN
palliative care, geriatic nursing. They are becoming relevant in Rwandan

context today. Non communicable and chronic diseases such as cancers,

M

diabetes, high blood pressure, and diabetes are increasing. You see, people
D

living with HIV, under anti-retroviral treatments are living for long, it is no

longer a killing disease, but a chronic disease [P02].

TE

In the study data it emerged that the CBC was conceptualized as collateral learning that
EP

accommodates the needs of adult students. The CBC empowers the students with general

transferable skills that are useful in the individual and professional life of the graduate. The
C

students are socialized to work as a team, to become independent, critical thinkers, to embrace
AC

lifelong learning, and to be accountable in the learning process. These objectives are achieved

through active participation of the students and through building upon their related previous

experiences. These points are reflected in the following participant comments:

 ACCEPTED MANUSCRIPT
7

Competency-based curriculum is a way of engaging the students in learning by

facilitating … them so that they become responsible for their own learning

[P08].

PT
Competency-based curriculum encourages slow learners to consult fast

learners for more understanding of the module. Also it considers the students

RI
like adult learners who are able to teach themselves [P13].

SC
The students are at the centre of learning … our students are mature and have

experiences. Therefore, they have right to show their input [P02].

U
…. The students used to discuss in group for better understanding. Both
AN
teachers and students search and share the information at the end [P05].
M

Competency-based curriculum is a teaching and learning process based on

sharing ideas between students and teacher in both classroom and clinical
D

settings. The students find the opportunities to update themselves … and

TE

continue that culture even after graduation in their working places [P05].

It emerged that the CBC promotes deep learning in students. Through active participation in
EP

learning, facilitation and opportunities to direct themselves, the students permanently retain what
C

they have learned and are able to apply it in practice. These points are reflected in the following
AC

participant comments:

Competency-based curriculum is a teaching method based on sharing ideas

between students themselves and facilitators…. By sharing information they

end up having the deep understanding of what is learned and retaining what is

learned forever [P06].

 ACCEPTED MANUSCRIPT
8

Students have the opportunities to read more for deeper understanding.

Through active participation of students in teaching and learning process they

retain what it is learned forever [P09].

PT
The students have the opportunities to read more…. If they get difficulties, the

come to the lecturer [facilitator] for more explanations [P01].

RI
It emerged that the CBC requires the students to master learning outcomes for progression

SC
within the program. Objective assessment could be used to make sure that the students achieve

expected competencies, reinforced at each subsequent level of study until they become fully

U
competent in field of nursing and midwifery. The CBC is not time-based, because students differ
AN
from one another and mastery depends on how fast or slow the student is in learning process.

Competency-based curriculum refers to mastery learning by the students of a

M

particular course, so that they will be able to put what they learn into practice.
D

The mastery of what is learned is before they go for clinical practice where
TE

they perform different tasks in different clinical settings [P03].

A student may master what they are expected to learn in different period of
EP

time because we have slow learners and fast learners. Furthermore, the

students build upon compentences learned in previous level [P02].

C
AC

2. Competency-based curriculum as a tool in primary health care philosophy

In the study data it emerged that the CBC extends learning in a community setting which

reinforces the philosophy of primary health care. The emphasis for students is on activities of

health promotion and prevention of diseases, especially in rural areas. This differs from the old
 ACCEPTED MANUSCRIPT
9

curricula in which the focus was on hospital education. These points are reflected in the

following participant comments:

We specified where students will do their clinical learning that include

PT
community, health center, district hospital and referral hospital. We are

training nurses and midwives who can help the client, family, the community as

RI
the whole not only individually [P12].

SC
The curriculum is focusing on health promotion and prevention of diseases ….

Before nursing students were spending their clinical practice only in the

U
hospitals. Changes had been done because now they are going in homes where
AN
people live to teach them and carrying out activities of health promotion and

diseases’ prevention [P13].

M

3. Competency-based curriculum as technological approach to education

D

It emerged from the study data that the CBC was conceptualized as an education approach that
TE

exploits the use of technology (a) to enhance resources for appropriate learning, and (b) to widen

access to tertiary education.

EP

It emerged that both students and facilitators find more resources through use of electronic

devices to locate updated electronic material in addition to what is obtained in printed material in
C

library. These points are reflected in the following participant comments:

AC

… our country is developing in Information Communication Technology use

which is emphasis by competency-based curriculum. Both students and teacher

are expected to use it [P06].

 ACCEPTED MANUSCRIPT
10

Competency-based curriculum … provides the students the opportunities of

developing other life skills such as search of information from library [printed

materials] and internet [electronic materials] [P05].

PT
It emerged from the study data that the CBC increases access to learning for nurses who need to

upgrade their qualification without having to leave their jobs. What makes this possible is the

RI
CBC emphasis on self-directed learning through interaction on the Moodle platform for 60% of

the time and face-to-face contact for just 40% of the time over the whole period of learning. This

SC
point is noted in the following participant comments:

U
The nursing students of e-learning program are those who are already working
AN
as enrolled nurses in different clinical settings…. Those students are coming

and study two weeks and they spent two weeks in their working place to enrich
M

their experiences. When it comes to clinical practice, these students spend

D

almost a half of period comparing to their colleagues who are from secondary

schools [P13].
TE

With this competency-based curriculum, 40% is dedicated to face to face hours

EP

while 60% is for self-directed learning to students. If a semester has 600 hours,

240 hours are for face to face while 360 hours are for self-directed learning.
C

The students should work hard because most of time they have to teach
AC

themselves [P08].

4. Competency-based curriculum as modular system

The study data indicated that the CBC was conceptualized as a modular system with two

attributes: (a) a building block of modules, and (b) decentralization.

 ACCEPTED MANUSCRIPT
11

The CBC is a program made up of interrelated modules. At each level, there are defined modules

that a student must complete to be allowed to progress to the next level. Some of modules serve

as pre-requisite for others to formulate a coherent program rather than fragmented content. These

points are noted in the following participant comments:

PT
Competency-based curriculum is the system that consists of putting related

RI
courses together so that it helps the students to achieve expected learning

outcomes of a particular module [P06].

SC
Competency-based curriculum is a modular system that helps the student to

U
integrate what is taught. This helps the student to understand relationship of
AN
unities in one module…[P12].

The CBC was also conceptualized as decentralized approach. Decentralization is accomplished

M

through the independence given to educators in coordinating and facilitating a module and to a
D

school in reviewing and updating of the curriculum by its members and their collaborators. as
TE

noted in the following participant comments:

We are committed to provide quality of education in our school and everybody

EP

is involved to achieve the goal. Everyone give him/herself an objective and

indicate which strategies to be used in order to achieve objectives [P02].

C
AC

I am a team leader of behavior sciences. I teach one unit [P03].

In our campus, we have a committee that reviews that curriculum. … an

example, a new curriculum that was developed, we sat down, developed an

evaluation tool of clinical practice to use at each level, one, two and three

[P02].
 ACCEPTED MANUSCRIPT
12

Discussion

The Competency-based curriculum was conceptualized as a transformative educational

approach. In this regard, subcategories which emerged were (a) relevance, (b) collateral learning,

(c) deep learning, and (d) mastery learning.

PT
The CBC is relevant in that it indicates expected competences in graduates on completion of the

RI
program of study. This increases graduates’ potential employability because competences are

clear and available to the employers. With the CBC, pre-licensure nurses or midwives are

SC
empowered to competently carry out a range of functions in various clinical, leadership and

U
management, teaching, and research roles. Having this capacity, they are able to cope with a
AN
dynamic working environment and there is no need for employer to spend money training these

graduates on entry to the job, as noted by Mtshali (2005). Barnett (2009) points out that the kind
M

of changes needed in graduates should be determined prior to the knowledge encounter.

D

The CBC is a tool that empowers health profession graduates to deal with authentic health

problems in a particular context which constitutes the content. A curriculum is a dynamic

TE

process reflecting changing realities of health professionals in an ever-changing complex and

EP

multicultural context (Fullerton et al., 2013). The World Health Organisation (2007) notes that

nursing and midwifery curricula could be related to national health priorities, community needs,
C

present and emerging roles of practitioners, professional and legal requirements. Relevance is
AC

enhanced through collaboration between education and health sectors to prepare graduates for

the realities of health care delivery (WHO, 2010).

The CBC promotes collateral learning. Collateral learning takes place when students build their

scientific knowledge in relation to interference and interaction with their indigenous concepts

(Essays, 2015). As indicated in Tanner and Tanner (1995), Dewey argues that the most important
 ACCEPTED MANUSCRIPT
13

attitude that can be acquired through collateral learning is desire to go on learning and if the

curriculum fails to accomplish this, it fails to realise its most important meaning and mission.

According to Christie et al. (2015), every student has a particular view of the world, that may or

may not be well articulated, based on a set of assumptions from life experiences, education, and

PT
culture. Because individuals have difficultly changing their worldviews, which are unconscious

RI
frame of references constructed in their minds, there is need of a powerful human catalyst that

shakes it and leads the person into a dilemma that can trigger changes in attitudes, beliefs and

SC
values (Christie et al., 2015). When a disorienting dilemma is encountered, where choices are

difficult to make, these can, if effectively reflected on, be harnessed as opportunities of

U
transformative learning (Holmes et al. (2015). According to Hytten (2000), building upon on
AN
Dewey’s view, the students' experiences need to be connected to a curriculum that allows them

to develop understanding of learning material and to develop habits and dispositions towards
M

future learning. If the students are given motivation, they are able to change their assumptions
D

and become lifelong learners who act in a rapidly changing world through critical and analytical
TE

reflection and are able to transfer knowledge to a new and unexpected situation. If they decide

that some assumptions are invalid, they have the possibilities to change their beliefs and
EP

behaviors (Christie et al., 2015). Thus, collateral learning should not be regarded as something

outside the curriculum but as integral to the planned and guided learning experiences that
C

comprise the curriculum.

AC

Dewey insists that the more time should be spent on helping the students to become interested,

confident, and engaged in their own learning (Hytten, 2000). Students’ experiences are thereby

given new meaning through a simple transformation of belief or opinion, or through a radical

transformation of total perspective (Foote, 2015). Thus, learning is about how students view,
 ACCEPTED MANUSCRIPT
14

interrelate, value and anticipate experience using a dynamic process in which meaning

perspectives are challenged, destabilized and transformed into new meaning (Hodge, 2011).

Consequently, a new curriculum enacts best professional behaviors, innovates when appropriate,

and confidence (Holmes et al., 2015).

PT
In relation to transformation the CBC promotes deep learning in students. Deep learning occurs

RI
when new information is linked with old information (Tao et al., 2015) in a process of

meaningful learning. In this learning the learners to develop high-order thinking skills through

SC
interactive pedagogical strategies and effective use of technology and its devices (Ndawo, 2015).

U
Facilitators must pay attention to factors that might hinder meaningful learning, which, according
AN
Postareff et al. (2015), include too little time or effort invested by students in studying their

courses, lack of interest in course content and negative attitudes toward a course. In this respect
M

the CBC will potentially increase motivation to learn since the principal content is authentic

situations that the students encounter in their daily activities.

D

Further relating to transformation, the CBC was conceptualized as promoting mastery learning.
TE

Students are expected to have mastered learning outcomes of different modules in a given period
EP

at a particular level in order to be allowed to move to the next level module of semester. These

learning outcomes are established as modules which incorporate the outcomes to be achieved,
C

the content to be seen, the teaching methodologies to be used by a facilitator and the types of
AC

assessments to be used. Rather than re-mastering the content, students need to grow and apply

what is learned in their individual and professional lives. As outlined by Bloom (1968), mastery

learning theory involves the curriculum being structured in small sequential learning steps;

students are able to master what is learned when the school provides sufficient learning time and

appropriate instruction types. Further, this curriculum relies on specific measurable outcomes
 ACCEPTED MANUSCRIPT
15

with objective assessment involving transparent and achievable objectives to be met by the

students (Ebert and Fox, 2014). Skills and self-knowledge could be demonstrated by the student

rather than for the activity itself (Walker, 2014).

PT
Transformative learning theory as developed by Mezirow (1991) suggests that change in an

adult’s perspective at a particular point in life and in the world can be seen as a form of learning.

RI
The goal is to empower graduates with skills that will be adaptable to diverse and ever-changing

health care systems (Ebert and Fox, 2014). To achieve this, transformative learning extends

SC
from fact memorization to searching, analyzing and synthesis of information for decision making

U
(Frenk et al., 2010). AN
Competency-based curriculum is as a tool for primary health care

The study data indicated that the CBC was conceptualised as tool that prepares graduates for
M

primary health care by (a) focusing on health promotion and prevention of diseases, and (b)
D

extending learning in the community.

TE

The CBC emphasizes primary health care strategy by focusing on health promotion and

prevention of diseases according to national health priorities (Ministry of Health, 2005, Ministry
EP

of Health, 2014) rather than on curative aspects. The World Health Organisation (2010) stresses

that education of nurses and midwives should focus not only on quantity but also on quality:
C

justifying the need of the CBC, putting emphasis on primary health care strategy and
AC

encouraging the closer collaboration between education and health systems (Botma, 2014, Frenk

et al., 2010).

Further, with the CBC, learning is no longer hospital-based but rather community-oriented,

whereby the students do their clinical practice in communities with a focus on rural areas and
 ACCEPTED MANUSCRIPT
16

having nursing and midwifery education at decentralised levels. These strategies have triple

advantages in that the students benefit from learning while they serve the community and

graduates are socialized to serve rural communities at early stage of their preparation. These

findings are in line with those by Ndateba et al. (2015), confirming that community-based

PT
learning experiences promote a primary health care philosophy and that underprivileged

RI
community settings constitute a rich learning environment with the focus on prevention of illness

and social problems, health promotion and promotion of self-reliance and self-determination

SC
among community members. In return, this contributes to overall public health and could reduce

poverty among the population.

U
AN
Competency-based curriculum as a technological approach to education

From the study data, it emerged (a) that technology is mainly used in learning process and (b)
M

that it increases access for nurses to tertiary education.

D

To train graduates who are critical thinkers, extensive use is made of technology in the learning

process. With the CBC, the students are given the opportunity to become independent
TE

practitioners by locating information from different resources, analyzing it and coming up with
EP

alternative solutions making their choice of the best options to deal with a particular health

problem. This requires the students to consider their own reasoning and decisions in their
C

professional activities. On this point Holmes et al. (2015) state that we teach the student both to
AC

follow protocols and procedures and to have the creativity and conviction of professional

independence to abandon the protocols when appropriate. Through this process, the students are

motivated by role models, who might be staff or colleagues, in a conducive environment that

involves the groups of learners working together to solve a problem or complete a task (Tao et

al., 2015). This is also emphasised by Tanner and Tanner (1995), who argue that extra-class
 ACCEPTED MANUSCRIPT
17

activities given to students, including the use of library in reading, browsing, and working on

their project assignment, contribute to meaningful learning. Medina (2017) postulates that

programs are more online since the focus is on achieving expected competencies.

PT
It emerged from the data that the CBC enables fuller exploitation of technology. Nurses are able

to access tertiary education that allows them to increase their capacity in their workplace without

RI
necessary leaving their job. This is also noted by McKenzie and Murray (2010), who argue that

technology enhances learning opportunities for qualified nurses with geographical location no

SC
longer a barrier and that students’ control over online interactions makes them more fully

U
engaged than in face-to-face teaching. It was found that educators and students are motivated by
AN
e-learning since it is student-centered and constitutes a blended learning method (Harerimana et

al., 2016). Student-centered, innovative teaching methodologies help the students in return to
M

employ a client-centered approach in line with the prioritised agenda of the health sector

(Ministry of Health, 2014).

D

4. Competency-based curriculum as modular system

TE

It emerged from this study that CBC was conceptualised as a modular system in which there are
EP

two subcategories: (a) modular building blocks, and (b) decentralisation.

The CBC is a coherent education program made up of modular building blocks linked by a
C

logical flow. Learning outcomes are defined for each module and level and for the program as a
AC

whole. Walker (2014) notes that the modular system necessitates continuous negotiation of

curricular coherence. The program of study is sequential when lower-order skills generate and

lead to more complex high-order skills, and is cumulative when what is learned in the lower

level leads to and is added to by knowledge in succeeding levels (Ornstein et al., 2014). Walker
 ACCEPTED MANUSCRIPT
18

(2014) mentions that repetition alone does not signify development and that learning therefore

requires structure, shape, continuity and coherence to enhance intellectual connections.

Each learning task should be a topic that is independent and large enough to form a separable

PT
whole (Benjamin, 1976). Subjects taught according to a strict hierarchical sequence might not be

appropriate under certain circumstances (Benjamin, 1976). Thus, learning tasks should be

RI
grouped according to the logic of the relationship among them, with possibility of different

options (Neuman, 1981). Further, complex hierarchical skills each require mastery before the

SC
next skill is introduced (Neuman, 1981).

U
From the study data it emerged that the modular system relies on decentralization.
AN
Decentralization is accomplished through the independence given to educators in coordinating

and facilitating a module and to a school in reviewing and updating of the curriculum by its
M

members and their collaborators. Students and educators both have a voice in the process.
D

Various authors support this view: According to Benjamin (1976), quality education cannot be

achieved if the school is governed by a bureaucratic system. A decentralized curriculum will be

TE

more appropriate to the students’ local needs and will ensure better ownership by educators
EP

(McKimm, 2003).

Modularization gives students opportunity to make their own choices as consumers of their
C

education through their acquisition of credits that have an exchange value within a university
AC

(Barnett and Coate, 2005). Modules thus become commodities between which the student-

consumers make rational choices. This is also emphasised by UNESCO (2016), according to

which the curriculum system constitutes a documentary asset that in the broader context shows

how learning needs contribute to the attainment of wider goals of competencies and personal

development. To make sure that the program is accurate and up to date, the school could
 ACCEPTED MANUSCRIPT
19

establish a curriculum committee which regularly updates or accommodates changes when

needed. The CBC differs from the traditional content-based curriculum that was centralized at

national level with possibility of renewal after 3 to 5 years.

PT
Conclusion

A CBC is an appropriate educational approach that empowers the graduates with expected

RI
competences for the 21st century. CBCs are transformative in the way that they transform

students into graduates who critically analyse information for appropriate decisions and are able

SC
to bring about changes in workplace. What makes this possible is the relevance which the

U
curriculum derives from its stipulation of expected competencies in graduates which are clear to
AN
the employers, its use of authentic health problem as content, and its promotion of collateral and

deep learning by giving students enough time to direct themselves and learn from each other.
M

Also highlighted in this account of the CBC is its promotion of the philosophy of primary health

care to achieve health for all through a focus on health promotional activities, prevention of
D

diseases and extending learning within the community. In the use it makes of technology the
TE

CBC raises the level of critical thinking and enables access to tertiary education by nurses

without them having to leave their jobs. The CBC is conceptualized as a modular system
EP

comprising modular building blocks with logical flow and decentralization that allows educators’
C

and students’ voices to be heard.

AC
 ACCEPTED MANUSCRIPT
20

REFERENCES

Barnett, R.,2009. Knowing and becoming in the higher education curriculum. Studies in Higher
Education; 34: 429-440.
Barnett, R. and Coate, K. 2005 Engaging the curriculum in higher education, Glasgow Open

PT
university press.
Benjamin, S. B.,1976. Human characteristics and school learning.

RI
Billings, D. M. and Halstead, J. A. 2009 Teaching in nursing: A guide for faculty, United States
of America, Saunders.

SC
Botma, Y.,2014. Implications of accreditation criteria when transforming a traditional nursing
curriculum to a competency-based curriculum. International Journal of Africa Nursing
Sciences; 1: 23-28.

U
Chapman, H., Lewis, P., Osborne, Y. and Gray, G.,2013. An action research approach for the
AN
professional development of Vietnamese nurse educators. Nurse Education Today; 33:
129-132.
M

Chisholm, L. and Leyendecker, R.,2008. Curriculum Reform in Post-1990s Sub-Saharan Africa.

International Journal of Educational Development; 28: 195-205.
Christie, M., Carey, M., Robertson, A. and Grainger, P.,2015. Putting Transformative Learning
D

Theory into Practice. Australian Journal of Adult Learning; 55: 9-30.

TE

Corbin, J. and Strauss, A. 2008 Basics of qualitative research: techniques and procedures for
developing grounded theory, Los Angeles, london, New delhi, and Singapole, Sage.
EP

Ebert, T. J. and Fox, C. A.,2014. Competency-based education in anesthesiology: history and

challenges. Anesthesiology; 120: 24-31.
Essays, U. 2015. Cultural border crossing and collateral learning education essay [Online].
C

Available: https://www.ukessays.com/essays/education/cultural-border-crossing-and-
AC

collateral-learning-education-essay.php [Accessed 6 October 2016].

Foote, L. S.,2015. Transformational Learning: Reflections of an Adult Learning Story. Adult
Learning; 26: 84-86.
Frenk, J., Chen, L., Bhutta, Z. A., et al.,2010. Health professionals for a new century:
transforming education to strengthen health systems in an interdependent world. Lancet;
376: 1923-1958.
 ACCEPTED MANUSCRIPT
21

Fullerton, J. T., Thompson, J. B. and Johnson, P.,2013. Competency-based education: the

essential basis of pre-service education for the professional midwifery workforce.
Midwifery; 29: 1129-1136.
Gahutu, J. B.,2010. Physiology teaching and learning experience in a new modular curriculum at
the National University of Rwanda. Advances in Physiology Education; 34: 11-14.

PT
Gillis, A. and Jackson, W. 2002 Research for nurses: Methods and interpretation, United Satate
of America, F. A. Davis Company.

RI
Gruppen, L. D., Mangrulkar, R. S. and Kolars, J. C.,2012. The promise of competency-based
education in the health professions for improving global health. Human Resources for

SC
Health; 10: 43-49.
Harerimana, A., Mtshali, N. G., Hewing, H., et al.,2016. E-Learning in Nursing Education in

U
Rwanda: Benefits and Challenges. An Exploration of Participants’ Perceptives. IOSR
Journal of Nursing and Health Science; 5: 64-92.
AN
Hodge, S. s. h. d. e. a.,2011. Learning to manage: Transformative outcomes of competency-
based training. Australian Journal of Adult Learning; 51: 498-517.
M

Holmes, C. L., Harris, I. B., Schwartz, A. J. and Regehr, G.,2015. Harnessing the Hidden
Curriculum: A Four-Step Approach to Developing and Reinforcing Reflective
D

Competencies in Medical Clinical Clerkship. Advances in Health Sciences Education; 20:

1355-1370.
TE

Hytten, K.,2000. Essy review: The resurgence of Dewey: are his educational ideas still relevant?
Journal of curriculum studeies; 32: 453-466.
EP

Komba, S. C. and Mwandanji, M.,2015. Reflections on the Implementation of Competence

Based Curriculum in Tanzanian Secondary Schools. Journal of Education and Learning;
C

4: 73-80.
McKenzie, K. and Murray, A.,2010. E-learning benefits nurse education and helps shape
AC

students' professional identity. Nursing Times; 106: 17-19.

McKimm, J.,2003. Curriculum design and development. From: www. faculty. londondeanery.
ac. uk/…/ Curriculum_ de looks to be incomplete.
Medina, M. S.,2017. Does competency-based education have a role in academic pharmacy in the
United States? Pharmacy; 5.
 ACCEPTED MANUSCRIPT
22

Mendenhall, R. 2012. What Is Competency-Based Education? Available from:

http://www.huffingtonpost.com/dr-robert-mendenhall/competency-based-learning-
_b_1855374.html [Accessed 8 April 2017.
Mezirow, J. 1991 Transformative Dimensions of Adult Learning, San Francisco, Jossey-Bass.
Ministry of Health 2005. Health sector policy: Government of Rwanda. Kigali-Rwanda.

PT
Ministry of Health 2014. National human resource for health policy. Kigali.
Mtshali, N. G. 2005 Developing an outcome-based curriculum. Curriculum development in

RI
nursing: process and innovation In: UYS, L. R. & GWELE, N. S. (eds.). London and
New York: Routledge; 171-192.

SC
Muraraneza, C., Mtshali, N. G. and Mukamana, D.,2016. Issues and challenges of curriculum
reform to competency based curricula in Africa: a metasynthesis Nursing and Health

U
Sciences; xxx: xxx.
Ndateba, I., Mtshali, F. and Mthembu, S. Z.,2015. Promotion of a primary healthcare philosophy
AN
in a community-based nursing education programme from the students' perspective.
African Journal of Health Professions Education; 7: 190-193.
M

Ndawo, M. G.,2015. Challenges experienced by nurse educators on the delivery of content laden
curriculum at a nursing college in Gauteng. Journal of Nursing Education and Practice;
D

5: 103.
Neuman, S. B. 1981. Skills Management Systems: A Direct Descendant of the Mastery Learning
TE

Theory?
Nsengimana, T., Ozawa, H. and Chikamori, K.,2014. The Implementation of the New Lower
EP

Secondary Science Curriculum in Three Schools in Rwanda. African Journal of Research

in Mathematics, Science and Technology Education; 18: 75-86.
C

Ornstein, A. C., Levine, D. U., Gutek, G. and Vocke, D. E. 2014 Foundations of Education,
United States of America, Cengage Learning.
AC

Postareff, L., Parpala, A. and Lindblom-Ylänne, S.,2015. Factors Contributing to Changes in a

Deep Approach to Learning in Different Learning Environments. Learning Environments
Research; 18: 315-333.
Shen, J. (ed.) 2012. Tools for improving principal work, United State of America: Peter Lang
Publishing.
 ACCEPTED MANUSCRIPT
23

Strauss, A. and Corbin, J. 1990 Basic qualitative research: Grounded theory procedures and
techniques, United States of America, Sage.
Tanner, D. and Tanner, L. 1995 Curriculum Development: Theory into Practice, New York,
Prentice-Hall.
Tao, Y., Li, L., Xu, Q. and Jiang, A.,2015. Development of a nursing education program for

PT
improving Chinese undergraduates' self-directed learning: A mixed-method study. Nurse
Education Today; 35: 1119-1124.

RI
UNESCO. 2016. Different meaning of curriculum. [Online]. Available:
http://www.unesco.org/new/en/education/themes/strengthening-education-

SC
systems/quality-framework/technical-notes/different-meaning-of-curriculum/ [Accessed
17 April 2016.

U
Walker, L. 2014 The new high education systems, modularity and student capability. Developing
student capability through modular course In: JENKINS, A. & WALKER, L. (eds.).
AN
London: Routledge;
World Health Organisation 2007. Guidelines for evaluating basic nursing and midwifery
M

education and training programs in african region. Geneva.

World Health Organisation 2010. WHO consultation on the transformative scale-up of medical,
D

nursing and midwifery education: Second technical reference group meeting: nursing and
midwifery education experts. Geneva: Patten application.
TE

Wyngaarden, A. V., Meyer, S. M. and Van-Verden, C. E. 2008. Teaching strategies for theory
content in outcome and problem based nursing educational programs. University of
EP

Pretoria.
Yap, W.-L., Neo, M. and Neo, T.-K.,2016. Transforming From Conventional Teaching
C

Environment to Learner-Centred Teaching Environment With the use of Interactive

Multimedia Module in Tertiary Education. Proceedings of the International Conference
AC

on e-Learning: 147-156.