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Implementing Universal Design Instruction in Doctor of Nursing Practice Education

Anderson, Kelley M. PhD, RN, FNP, CHFN-K; Davis, Diane MSN, RN, PMHCNS-BC; McLaughlin, Maureen Kirkpatrick PhD, RN-BC, NEA-BC

doi: 10.1097/NNE.0000000000000642
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Background Faculty in Doctor of Nursing Practice (DNP) programs identify challenges of increased enrollment and variances in previous student educational preparation and professional experiences that require innovative approaches to curriculum transformation.

Purpose This article informs nurse educators about the vibrant and inclusive approach of universal design for instruction (UDI), a framework to conceptualize and implement learning strategies in the DNP curriculum.

Approach UDI is guided by 9 instructional principles that anticipate diverse learners and is intentionally inclusive of multiple ways of learning. Principles of UDI were synergized into several DNP didactic courses and the scholarly project process.

Conclusion Integration of UDI into the DNP curriculum included precourse assessments, multiple modalities of content delivery, options to present acquired knowledge, and supporting the adult learner through the iterative work of the scholarly project.

Author Affiliations: Associate Professor (Dr Anderson), Instructor (Dr Davis), and Assistant Professor (Adjunct) (Dr McLaughlin), Georgetown University, School of Nursing & Health Studies; and Nurse Practitioner (Dr Anderson), Division of Cardiology, MedStar, Georgetown University Hospital, Washington, DC.

The authors declare no conflicts of interest.

Correspondence: Dr Anderson, Georgetown University, School of Nursing & Health Studies, 3700 Reservoir Rd, St Mary's Hall, Room 247, Washington, DC 20057 (kma25@georgetown.edu).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.nurseeducatoronline.com).

Accepted for publication: November 15, 2018

Published ahead of print: December 20, 2018

Online date: December 27, 2018

There are currently 303 doctor of nursing practice (DNP) programs in all 50 states, including the District of Columbia, and 124 new DNP programs are in the planning stages.1 In 2015, there was an increase of 3294 students enrolled in DNP programs, expanding the total DNP student enrollment from 21 995 to 25 289.1 The American Association of Colleges of Nursing's report from the Task Force on Implementation of the DNP highlights the development of new, innovative teaching strategies as an important faculty development area to ensure quality outcomes for this growing cadre of students.2 In addition, DNP students enter doctoral programs with diverse backgrounds, durations of time from previous educational experiences, and varied involvement in scholarly work; thus, innovative perspectives of educational practices are essential to promote their scholarly development. Students have varied learning processes, requiring faculty to evaluate their own capabilities to meet students' learning needs.3 Recognizing these student differences prompted our faculty teaching in the DNP program to reframe the delivery of several DNP core courses and the DNP scholarly project process by implementing universal design (UD) strategies. Universal design is not well represented in the nursing education literature; therefore, our purpose is to inform nurse educators about UD for instruction as a framework to conceptualize and implement learning strategies in the DNP curriculum.

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UD for Learning

Universal design originated in the field of architecture to design products and environments that are the most accessible for all ages and abilities.4 Universal design for learning (UDL) emerged through an understanding that many learners, not just those with disabilities, could benefit from curriculum designed for a wide range of learners.5 Universal design for learning is a concept that recognizes individual variability as the norm, not the exception, and proposes 3 guidelines for differentiating curriculum for learning: (1) affective—providing multiple means of engagement for a purposeful, motivated learner; 2) recognition—providing multiple means of representation, for a resourceful, knowledgeable learner; and (3) strategic—providing multiple means of action and expression for a goal-directed learner.6 Universal design for learning is a process of intentional and systematic curriculum design to address the natural individual differences that occur in any group of learners.6 Supplemental Digital Content, http://links.lww.com/NE/A585, Table 1, details the UDL guidelines.

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UD for Instruction

As colleges and universities in the US have enrolled more diverse students, UD for Instruction (UDI) has emerged as a model for teaching on the postsecondary level that is intentionally inclusive of a wide range of learners, including those with disabilities.7 The UDI framework is appropriate for designing all aspects of the learning environment to address diversity of learning characteristics, minimizing the need for adjustments for individual students with special needs.8 Using the original UD concepts and guiding principles for undergraduate education, Scott et al9 developed 9 Principles of Universal Design for Instruction. Supplemental Digital Content, http://links.lww.com/NE/A586, Table 2, describes the 9 principles with examples for instruction based on each principle.

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Literature Review

UDL and UDI in Postsecondary Education

Black et al10 used the principles of UDL/UDI as a framework for a qualitative study of 15 university students, with and without disabilities, to identify strategies conducive to their learning and determine how these strategies aligned with UDL/UDI. The study explored the students' perceptions and preferences related to their learning. Students with disabilities, despite receiving accommodations, reported barriers to their learning sometimes because of accommodations that were too narrow or inflexible. Both groups of students (with and without disabilities) indicated a variety of learning preferences and rated strategies incorporating UDL/UDI principles as useful for their learning.10 The UDL/UDI components were inclusive, reaching a broad range of learners through multiple means of representation and material flexibility to maximize student access. Overall, these authors concluded that students with or without disabilities learned best with a combination of learning opportunities.10

Dean et al11 examined implementation of UDL principles in 2 large business classes with a total of 1285 participants. Four instructional tools, including PowerPoint, lecture notes, clickers, and MindTap, were evaluated for impact on perceived learning, actual learning, and learner satisfaction. MindTap is a digital learning platform with organizational and study tools including several features such as practice quizzes, activity lists, and flashcards. Most participants (N = 928) completed the survey, with items evaluating the students' use of the online instructional tools.11 In general, students perceived that the instructional tools were highly effective and preferred the instructor-generated content of PowerPoints and lecture notes more than the third-party–created materials. Students perceived that the clickers were more effective in helping them learn than MindTap, although the objective measures indicated that MindTap had a stronger impact on actual learning.11 Interestingly, women used the various instructional tools more frequently than men.

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UD in Nursing Education

The concepts of UD are presented infrequently in the nursing education literature, particularly in regards to nursing doctoral education. Heelan et al12 conducted a positive inquiry of 25 faculty in the health field, including nursing, medicine, and physiotherapy, to evaluate the application of UDL for the clinical learning environment. There was an emphasis on an inclusive ethos to design learning while considering the requirements, motivations, and experiences of all learners by recognizing the uniqueness of individuals and promoting choice.12 The Principles of UDI from Scott et al9 provided the framework, and each of the 9 principles was evaluated for the potential application to the clinical environment.

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Application to Doctoral Nursing Education

Our DNP program is in a private university located in the mid-Atlantic region with an average class size of 12 students. The DNP program is a part-time course of study, composed of 7 semesters (38 credit hours) for nurses with extensive clinical experience who hold a master's degree in an advanced nursing specialty area. Primary components of the program are coursework, clinical practice, and the completion of a scholarly project. We currently incorporate UDI into 3 doctoral hybrid courses: Translational Research, Communication and Collaboration in Healthcare Systems, and Organizational Theory and Behavior.

Keeping nurse learners interested and engaged in DNP programs may be challenging if faculty are unaware of the learner's knowledge base, their preferred method of learning, and targeted skills that students may need in the program such as scholarly writing and presenting. Therefore, it is essential that faculty assess new cohorts' learning preferences, learners' baseline knowledge, and skills for a DNP course before the beginning of a semester.13 This precourse self-assessment allows faculty to identify individual and group learning needs based on the course objectives, so that time and attention are dedicated to the appropriate objectives using applicable UDI strategies.

Assessing learner baseline knowledge and needs before the beginning of a course can be conducted using various methods. In the Translational Research course, the objectives were reformatted and changed to declarative statements, which were placed into a table for learners to do a self-assessment of those statements using a Likert scale ranging from 1 (strong disagreement) to 4 (strong agreement). For example, one of the objectives in this course is for the learner to “formulate a compelling clinical question using the PICOT framework.” The faculty modified this objective into the declarative statement: “I can formulate a compelling clinical question using the PICOT format” (Supplemental Digital Content, http://links.lww.com/NE/A587, Table 3). Faculty sent an e-mail to each learner explaining the purpose and intention of the assessment and invited each learner to voluntarily complete the self-assessment. This exercise provided an opportunity for learners to reflect on the course content and their knowledge base, returning meaningful data to faculty to guide emphasis and priorities of the course content. During the first class, faculty reviewed the returned aggregate data with learners to verify and validate which objectives would receive the most consideration in the teaching and to inquire about learning preferences.

For the Communication and Collaboration in Healthcare Systems precourse assessment, 2 different approaches were used with 2 different cohorts. For the first cohort, the faculty sent an e-mail to DNP students before the start of the course with 5 questions to obtain student input: (1) Is there anything specific you would like addressed related to communication and collaboration in this course? (2) Any special learning strategies [you prefer] for the synchronous sessions? (3) For the asynchronous sessions? and (4) for the executive sessions? (5) Any expectations about this course you'd like to share?

For the second cohort, the following year, the faculty used an objective approach for the precourse assessment using 2 tables with Likert scales. The first table was composed of the course objectives modified into statements for which the DNP student assessed their level of agreement, with each statement using a Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). The second table was composed of multiple instruction strategies whereby learners were asked to rate their level of preference for each strategy using a Likert scale, where 1 = least preferred, 2 = sometimes preferred, and 3 = most preferred. The course schedule was developed with assignments that offered learners choices to engage with the course content. For example, for the topic of Collaborative Leaders, learners could select whether to read the assigned article “Are you a collaborative leader?” or watch and listen to the assigned video Are You a Collaborative Leader? or use both formats.14,15 Interestingly, when learners in this course were provided a choice of how to complete a graded assignment to demonstrate their mastery of content, 73% chose a creative format (video, podcast, etc) versus writing a paper and verbalized their satisfaction in the opportunity to have options.

Recent advances in technological modalities facilitate exploration and allow students to construct knowledge in a meaningful way through exposure to a variety of learning materials. Using diverse content and resources allows faculty to create a learning environment to inspire and encourage students to seek additional learning that encompasses multiple formats of instructional content and tools including print, electronic, or audio to listen, watch, read, view, and study.11 Aligning with UDI Principle 1, equitable use, and principle 2, flexibility in use, DNP faculty who identified the learning needs of their students facilitated successful learning by including options for the learners to select their preferred method to engage with the course material. For example, a learner selects reading a chapter in the textbook, watching a video, or listening to a podcast. Other options for learning include reading case studies, doing a reflective exercise, or watching a webcast. The appeal of using UDI strategies is they can be applied to assignments for synchronous online platforms, in-person executive sessions, and asynchronous classwork, including discussion boards.

Once DNP students have experienced understanding and mastery of a particular concept or content area, they may forgo further exploration. Based on various backgrounds and experiences, some learners may be more knowledgeable about particular content areas and can move on to the next topic more quickly than less experienced learners. Students who find the content challenging, new, or unclear can access an alternative format to improve their understanding and comprehension.

UDI Principle 3, simple and intuitive, is operationalized through the syllabi, course rubrics, and course assignments. The course syllabus provides comprehensive information, including mutual obligations, for learners and faculty. An overall rubric is provided in the syllabus, including required assignments and due dates, a description of the assignment, and the weighted percentage for each assignment as it relates to the total grade. Each assignment also has its own separate rubric with detailed guidelines, instructions, and criteria, including the grade points assigned to each section. Learning is evaluated in multiple forms, including presentations, papers, a web-based blog site for electronic portfolios, and discussion boards. These multiple modalities of exhibiting student knowledge and mastery of concepts provide opportunities for a wide range of expression.

In our Organizational Theory and Behavior course, one of the required textbooks operationalizes UDI Principle 4, perceptible information, by using a multimodal learning system. This system provides learners and faculty continuous accessibility to course materials through a hard copy of the textbook, access to eBook online or offline, and synced to computers, tablets, and mobile devices. Learners select how they want to learn the course material as outlined in the course schedule with options to “read, watch, or listen.” Learners select to either read assigned chapters from the book, watch slide presentations, listen to podcasts, or combine all of these options.

Other UDI principles, such as Principle 5, tolerance for error, are applicable throughout the DNP scholarly project process. Most students have limited experiences in conceptualizing, leading, or executing an independent scholarly project, and this iterative process provides challenges and opportunities for intellectual growth. There are many forms of the DNP project, and it is during the defining and development of the project, with its multiple iterations, that faculty anticipate and accept errors while the DNP learner is often required to rework, rewrite, and refine this scholarly endeavor that spans multiple courses with guidance from faculty and mentors.16

Principles 6 and 7 relate to the physical environment of learning. Principle 6, low physical effort, is enhanced by the learners' use of their personal computers or other technological devices to minimize physical effort. Note taking is minimized with tape recording or recorded synchronous sessions. In addition, our students are encouraged to situate themselves in their most comfortable and learning enhancing position during the didactic session, which has included standing for those with musculoskeletal concerns. Principle 7, size and space for approach and use, is exhibited by the containment of each cohort to a small size of 12 or fewer students; however, this approach could be usable with a larger cohort, especially if there could be partitioning into smaller groups in the classroom or online environments. Circular seating arrangements facilitate discussion, and the classroom is changed to a presentation style for didactic content. In the online environment, real-time video sessions promote equitable participation by all students. Both the online and on-campus executive sessions provide ample size and space for face-to-face interactions.

Principles 8 and 9 emphasize the emotive environment of learning. Principle 8, a community of learners, is facilitated by small cohort sizes, which allow personal communication between and among learners and faculty. DNP learners encourage and motivate each other in and out of formal classes using e-mail listserv, study groups, group chat boxes, synchronous modalities with technology, and the telephone. During the on-campus executive sessions, the faculty and administrative staff build community through informal settings with the sharing of meals, volunteer opportunities, and out-of-the-classroom experiences. Principle 9, instructional climate, is operationalized by faculty providing a warm, welcoming “safe” environment for learners. The syllabus includes information on respect and diversity as well as the academic resource center for those with special learning needs. Faculty also address individual learner expectations at the first class session and role model high expectations by leading the courses in the most current and well-prepared manner. In the spirit of sharing our own growth in teaching to the growth of others to learn to be more effective instructors, we offer the following list of Resources (Supplemental Digital Content, http://links.lww.com/NE/A588, Table 4) to benefit your UDI implementation.17,18

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Discussion

Incorporating UDI in the DNP courses is positive for faculty and learners. Faculty appreciate operationalizing adult learning theory by putting andragogy into action and appreciate evaluating the variety of formats that learners select as their best mechanism to complete their assignments. For example, rather than seeing words written on a paper, faculty hear the passion and enthusiasm in the voice/s of learners who use a podcast or webinar. Learners express feeling valued and respected as active participants in their learning process, stating, “I loved being able to choose how I could do this assignment.” Other students expressed disbelief “Did I hear you right? I really get to choose HOW I do this assignment?” Making their own assignment choices as part of learner-centered teaching provides the “balance of power” in shared decision making between faculty and learner.18 There are multiple benefits to implementing UDI strategies and concepts with little or no consequences, and faculty who perceive exploring and implementing new teaching methods as a low-risk educational activity are more likely to make changes.19 UDI can be applied to all levels of nursing learners, not only DNP learners.

There are potential student challenges, including the adjustment from a prescriptive learning environment, which compels reviewing all materials that are provided and not understanding when competencies or objectives are met. This can lead to a student being overwhelmed with the variety and quantity of content material. Faculty need to clarify and explain this teaching and learning style to ensure the best outcomes. Future studies on UDI are required to explore how instructional and technological tools can be combined with or used concurrently inside and outside the classroom, as well as on the perceptions of faculty and learners who use UDI strategies in nursing education. We propose that faculty who teach in DNP programs, regardless of size, reflect on their current teaching strategies and consider incorporating the principles of UDI.

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References

1. American Association of Colleges of Nursing (AACN). DNP fact sheet. AACN website. Published 2017. Available at https://www.aacnnursing.org/News-Information/Fact-Sheets/DNP-Fact-Sheet. Accessed January 26, 2018.
2. American Association of Colleges of Nursing (AACN). The doctor of nursing practice: current issues and clarifying recommendations. A report from the Task Force on the Implementation of the DNP. Available at http://www.aacnnursing.org/Portals/42/DNP/DNP-Implementation.pdf?ver=2017-08-01-105830-517. Published 2015. Accessed March 6, 2018
3. Levey JA. Measuring nurse educators' willingness to adopt inclusive teaching strategies. Nurs Educ Perspect. 2016;37(4):215–220.
4. Story M, Mueller J, Mace R. The Universal Design File: Designing for People of All Ages and Abilities. Raleigh, North Carolina: NC State University: The Center for Universal Design; 1998: Available at https://files.eric.ed.gov/fulltext/ED460554.pdf. Accessed July 1, 2018
5. Jimenez T, Graf V, Rose E. Gaining access to general education: the promise of universal design for learning. Issues Teacher Educ. 2007;16(2):41–54.
6. The Center for Applied Special Technology (CAST). Universal Design for Learning Guidelines Version 2.0. Wakefield, MA: The Center for Applied Special Technology; 2011.
7. McGuire J. Inclusive college teaching: universal design for instruction and diverse learners. J Accessibility Des All. 2011;1(1):38–54.
8. McGuire J, Scott S, Shaw S. Universal design and its applications in educational environments. Remedial Spec Educ. 2006;27(3):166–175.
9. Scott S, McGuire J, Shaw S. Universal design for instruction: a new paradigm for adult instruction in postsecondary education. Remedial Spec Educ. 2003;24(6):369–379.
10. Black R, Weinberg L, Brodwin M. Universal design for learning and instruction: perspectives of students with disabilities in higher education. Exceptionality Education International. 2015;25(2):1–16.
11. Dean T, Lee-Post A, Hapke H. Universal design for learning in teaching a large lecture class. J Market Educ. 2017;39(1):5–16.
12. Heelan A, Halligan P, Quirke M. Universal design for learning and its application to clinical placements in health science courses. J Postsecond Educ Disabil. 2015;28(4):469–479.
13. Gonzales LK, Glaser D, Howland L, et al. Assessing learning styles of graduate entry nursing students as a classroom research activity: a quantitative research study. Nurse Educ Today. 2017;48:55–61.
14. Ibarra H, Hansen M. Are You a Collaborative Leader? HBRs 10 Must Reads on Collaboration. Boston, MA: Harvard Business Review Press; 2013.
15. Harvard Business Review. Are you a collaborative leader? 2011; Video file. Available at https://hbr.org/2011/06/are-you-a-collaborative-leader.html. Accessed April 10, 2016.
16. Moran K, Burson R, Conrad D. The Doctor of Nursing Practice Scholarly Project. A Framework for Success. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2017.
17. Kenny N, Berenson C, Chick N, Johnson C, Keegan D, Read E, Reid L. A developmental framework for teaching expertise in postsecondary education. Poster presented at the International Society for the Scholarship of Teaching and Learning Conference; October 2017; Calgary, Alberta, Canada.
19. Flaherty C. Professors can learn to be more effective instructors. Inside Higher Ed. 2016; Available at https://www.insidehighered.com/news/2016/02/10/new-study-suggests-faculty-development-has-demonstrable-impact-student-learning. Accessed January 28, 2018
Keywords:

diverse learners; DNP curriculum; Doctor of Nursing Practice program; nursing students; universal design

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