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Critique the following article in a one-page summary, describing its usefulness to curriculum development and evaluation process: Population health is inseparable from care provision. Epidemiological and demographic shifts (towards chronic disease and older societies) require ongoing responses to meet present and future global healthcare needs [1]. Health professionals are already struggling to fulfill their mission of comforting, curing, and caring for people in need [2]. Since 2000, three seminal reports have indicated that worldwide health-professional education must equip clinicians for the changing needs both of patients and of healthcare systems. Core competencies put forward by the World Health Organization (WHO) (2005) for all health professions include patient-centeredness, partnering with patients, providers, and communities, quality improvement, the use of information and communication technology, and a public health perspective of care. Based on demographic and societal developments and population needs, in ‘The Future of Nursing: Leading Change, Advancing Health’, the Institute of Medicine (IOM) recommends that nursing education focus on older people, emphasize collaboration, and adopt a patient- and family-centered perspective. Further, the authors recommend redirecting nurse education towards primary care settings, switching its focus to community care and prevention rather than acute care. The groundbreaking “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world” report suggests that using transformative learning as instructional reform will lead to more equitable, more efficient health systems [3]. In sum, nurses should be educated to deliver patient and family-centered care as members of inter-professional teams embedded in the community, emphasizing evidence-based practice, quality improvement approaches, and full use of information technology [1, 3, 4]. In developed and developing countries alike, a healthcare focus is moving towards people living with non-communicable chronic conditions, e.g., heart disease, diabetes, and dementia, and the need to care effectively for these groups and their families via inter-professional collaboration [1]. Calling for enhanced clinical skills and an expanded scope of practice for all health professionals, these new complexities are reflected in five basic competencies: 1) patient-centered care; 2) partnering; 3) quality improvement; 4) information and communication technology; and 5) a public health perspective. This expansion does not invalidate existing competencies, e.g., evidence-based practice and ethical care; rather, it underscores the need for new ones to complement them. And while they apply to all health professionals, these competencies are particularly crucial for nurses, whose duties span health system levels and settings from remote primary care clinics to urban acute care hospitals [1]. With their advanced clinical skill sets and broad scope of practice, Advanced Practice Nurses (APNs) strengthen healthcare systems by providing expert care, especially to people who are older and/or have chronic diseases [5-7]. The International Council of Nurses defines an Advanced Practice Nurse (APN) as a registered nurse who holds a master’s degree and “has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/ or country in which s/he is credentialed to practice” [8]. APN competencies incorporate direct clinical care (e.g., clinical assessment, clinical interventions, advanced health assessment skills, decision making, diagnostic reasoning skills, case management). They also include expert coaching and guidance (communication, facilitation, reflection and coaching skills), consultation (patient education), research skills (translational research, evaluation of healthcare services), clinical and professional leadership (practice development, planning, implementation and evaluation of programs, change management, quality management), collaboration (intra- and interprofessional), and ethical decision-making skills [9, 10]. To equip nurses for their new responsibilities and ensure a well-educated health workforce, ‘nurse educators need to keep up with a rapidly changing knowledge base and new technologies’; ‘Nursing education, in addition to conveying necessary skill sets, needs to provide students with the ability to mature as professionals and to continue learning throughout their careers’ [2]. Nursing education in Europe in the wake of the Bologna process. With the Bologna Declaration, the European Union’s ministries of education collaborated to develop a comparable, compatible, and coherent system for European higher education [11]. The ultimate goal is a system of academic degrees that are easily recognizable and comparable (i.e., bachelor, master, PhD), promote mobility among students, teachers, and researchers, and ensure high-quality learning and teaching. Key focus areas include lifelong learning, employability, funding, degree structures, and international openness, as well as data collection and quality assurance employing the European Credit Transfer System (ECTS). ECTS credits are numerical values that express student time investment, with one credit mirroring 25-30 h of student work in and outside the classroom. For nursing education, the Bologna Declaration has led to numerous developments to harmonize Europe’s diverse academic structures and regulations. After a transition of several years, professional nursing education is now offered in bachelor’s, master’s, and doctoral programs recognized across the EU [12]. In Switzerland, a non-EU country, the Federal Council ranked implementation of the Bologna reforms as essential to its higher education system. Also within the Bologna process framework, the Swiss University Conference published directives for the coordinated renewal of teaching at Swiss Universities in 2004 [13]. Switzerland was one of the last European countries to adopt academic nursing education into its higher education system [14]. Methods – the work packages Prior to the curriculum revision, we formulated three central aims: 1) to review relevant reports in view of local and international health professional education; 2) to analyze the content of the curriculum’s semester courses via the analytical insights of reports, combined with alum perceptions of professional gaps; and 3) to re-design and/or overhaul the courses as appropriate. The reform process consisted of three interrelated phases-preparation, revision, reform, and legislation- including six thematic work packages (WPs). For the preparation phase, i) relevant reports regarding health professional education were analyzed, followed by ii) a curriculum analysis using insights from publications identifying new content requirements (WP 1). A structured survey helped explore alum experiences and opinions about the program, and highlighted perceived professional gaps (WP 2). The revision phase included the MScN program accreditation process (WP 3) and the reformatting of all courses, as required by the Bologna Declaration, to focus on learning outcomes, i.e., competencies, rather than pure knowledge (WP 4). The reform and legislation phase included studying regulations adapted to fit the University of Basel’s legal requirements (WP 5) and the newly designed MScN curriculum, with its core study program and two study track possibilities, Research or ANP (WP 6). The entire study program reform process was led by a curriculum revision team (CuRT) consisting of INS faculty and administrative support, as well as external consultancy from higher education experts on process reflection and feedback. The CuRT devised the action plan that guided and coordinated the six work packages’ implementation (see Fig. 1). Preparation phase WP 1 – curriculum analysis For the curriculum analysis, the CuRT used a self-developed analysis matrix to systematically review each semester course, paying close attention to the WHO’s five core competencies [1] and Hamric’s APN competencies [9] as evaluation criteria (Table 2). To determine whether individual courses addressed the postulated competencies for each of these criteria, we used a simple rating scale: 0 = not addressed; 1 = partially addressed; 2 = mainly/fully addressed; or not applicable. The CuRT analysed the curriculum and reviewed the courses. By consensus, each of the courses was rated to indicate its fit with the WHO core competencies and APN competencies. Reviewing and analyzing the curriculum’s 25 courses (10 from the BScN transition program and 15 from the MScN study program) resulted in an overview indicating whether applicable WHO core competencies and APN competencies were addressed, partially addressed, or not addressed. Our expert group’s findings suggested that the majority of the courses’ content matched the criteria. First, where applicable, the five WHO core competencies were addressed in all courses at least to some extent (specific competencies were not appropriate in certain research or ANP courses). Second, APN competencies were addressed partially or fully in all courses in all areas of interest. Based on these findings, and considering recent publications on nursing education [3] and future directions of nursing [2, 4], INS faculty discussed priorities for the curriculum revision. Based on the lecturer’s experience in previous years, we also considered integrating collaborative, non-formal evaluations of student outcomes vs. program aims and faculty expectations. More specifically, the faculty reached consensus on courses in need of redesign or new development in view of transformational learning, use of technology, collaborative care, and emerging nursing issues. As this is an extremely context-oriented process, many decisions were made according to the specific healthcare needs of the Swiss population or innovations in the Swiss educational landscape. During the same process, it was also decided further to elaborate on a series of topics for future courses. blended learning methods in selected courses as appropriate and to consider inter-professional education, e.g., including medical students (in collaboration with their departments within the Medical School). All of the above-mentioned topics were then further elaborated and delegated to INS lecturers and CuRT for stepwise development and implementation (see WPs 5 and 6). WP 2 – alum survey In developing the MScN study program and APN roles in Switzerland, it was extremely important to explore our graduates’ perspectives on their professional roles and clinical positions, as well as their experiences with the INS study program and their suggestions and visions regarding future needs. Therefore, in December 2008, all 76 alumni were contacted via e-mail and invited to participate in the first INS alumni survey. The survey was conducted via a self-developed paper-and-pencil questionnaire with standardized response categories to tick and free text comment boxes where appropriate. Its domains included socio-demographic and professional status information, evaluation of the study program, APN role status and future prospects for APN development. Of the 76 alumni (90% female) initially contacted, 51 completed the questionnaire, yielding a response rate of 67%. The mean age of participants was 38 (range: 28- 52) years at the time of graduation. Two-thirds (65%) worked in hospitals, 24% in educational institutions and the remaining 13% in long-term, community or mental health care settings or other positions. All were employed either full- or part-time. Although a clear majority (57%) of respondents worked in APN or similar roles, many expressed regret that their current roles did not allow the application or expansion of clinical competencies, or that they felt insecure taking clinical decisions autonomously. Results confirmed that only a minority of respondents has integrated Hamric’s suggested APN core competencies, especially clinical skills in their field of expertise, in their care practices [9]. Involvement in direct clinical patient care and support of care teams in ethical decision-making and other activities received the highest and lowest values-respectively 24 and 5%. The INS faculty team’s discussion of the survey findings additionally inspired curriculum revision activities, Table 2 WHO core competencies for caring for patients with chronic conditions & APN competencies 1. Patient-centered care -Interviewing and communicating effectively -Assisting changes in health-related behaviors -Supporting self-management -Using a proactive approach 2. Partnering -Partnering with patients -Partnering with other providers -Partnering with communities 3. Quality improvement -Measuring care delivery and outcomes -Learning and adapting to change -Translating evidence into practice 4. Information & communication technology -Designing and using patient registries -Using computer technologies -Communicating with partners 5. Public health perspective -Providing population-based care -Systems thinking -Working across the care continuum -Working in primary health care-led systems Advanced Practice Nurses competencies -Advanced direct clinical care -Expert coaching and guidance -Consultation -Collaboration -Clinical and professional leadership -Ethical decision-making skills -Research skills Schwendimann et al. BMC Medical Education (2019) 19:135 Page 5 of 11 particularly regarding new topics or changes elements of existing courses, e.g., methods and didactics. More specifically, considering the pioneering character of such roles in the Swiss healthcare context, these results highlighted the need for more advanced clinical and scientific training in practice settings, as well as increased support in terms of APN role development. Revision phase WP 3 – accreditation of the master study program After several years of delivering a pioneering MScN study program, the INS faculty arranged an independent review by an official agency. In December 2008, the INS requested national accreditation by the Swiss Agency for Accreditation and Quality Assurance (AAQ) (https:// aaq.ch/). After an initial meeting between representatives of the INS and the agency, the schedule for the accreditation process (a self-evaluation report, an expert onsite visit, and an expert report with recommendations) was discussed and confirmed. Following the agency’s standard procedure, the necessary application documents were drafted and submitted, after which the experts’ 2-day site audit took place in May 2009. The agency forwarded the official report and recommendations to the Swiss University Conference, which granted the revised MScN study program unconditional accreditation for 7 years. As standard accreditation procedure, the expert group also proposed a set of recommendations for strengthening the study program, e.g., “Examine the ways in which greater use could be made of IT in terms of supporting the learning environment, providing some ‘virtual mobility’ (especially for those whose options for ‘physical’ mobility are limited by work, family and other (non-study) commitments.” While these recommendations were not conditions of the accreditation itself, they were congruent with IOM recommendations [4], and thus were integrated into planned didactic changes by promoting blended-learning course formats. Thus, recommendations by AAQ were, first, adopted directly in the new MScN study program (WP 6) and, second, incorporated into the action plan for the current strategic planning phase (2014-2018): course re-design demands critical review of IT and e-learning options at the institutional / educational management system level, as well as at the faculty level, requiring additional preparation for both lecturers and students [3]. WP 4 the learning outcomes initiative Alongside the transformation of traditional (i.e., knowledge-based) descriptions of qualifications and qualification structures into competency-based aims and objectives, the Bologna process stipulates the definition of learning outcomes for all modules and programs (i.e., bachelor, master, PhD) in tertiary institutions [21]. Learning outcomes are used to express which competencies learners will be expected to achieve and how they will be expected to demonstrate that achievement at the end of a learning activity. Although, structurally, the INS’s master study program was implemented according to Bologna from the beginning, at the level of individual semester modules and courses, its instructional mode still followed a traditional teacher-centered methodology. The new learning outcome-oriented perspective’s potential to shift the INS from a teacher-centered to a student-centered approach was well received by both faculty and CuRT. Therefore, via a small teaching-the– teachers (ttt) project group, consisting of three curious, highly motivated and experienced lecturers, CuRT prepared the learning outcomes initiative. Delivered in 2010 and audited collegially by the University of Leuven, Belgium’s curriculum design department, this ttt project laid the groundwork not only for a discussion and subsequent accord on how best to switch to the new model, but also for ongoing contact and mutually beneficial curriculum design consultancy and educational expert exchanges. Reform and legislation phase WP 5 reforming the study regulations The overhaul of the INS MScN study program regulations was an intense process, requiring close collaboration between university administrative experts, faculty, pedagogical authorities and legal experts. From its beginning in 2009, when the INS submitted a formal request to the University’s board of education, a tenacious INS CuRT core group navigated the process through the course of its development, including a host of formal and legal issues, to its official release, in 2013, by the University Council. As early direct results of the curriculum reform, the existing accelerated BScN program regulations were terminated, and the MScN program regulations underwent major revisions. Finally, the University Council’s decision to implement the revised study regulations as of October 2013 allowed the new MScN program’s first student cohort to commence in the 2014 fall semester. WP 6 the new MScN study program The new dual-track MScN program allows students to choose between two tracks: Research, leading to academia or other science-related domains; and ANP, leading to advanced clinical practice. In either case, the study program is composed of a 1-year basic study program of 10 single-semester courses (60 ECTS) and a 2-year core study program with a total of 12 single-semester courses, including electives and 4 special courses for each of the chosen tracks (see Fig. 2). Entry criteria for the MScN study program include either a BSc in Nursing or Midwifery plus two years of professional experience, or a nursing or midwifery diploma from a tertiary-level degree program, a successful matriculation exam (e.g., Matura, Abitur) and two years of full-time experience in a healthcare profession. Course dispensations are possible and vary depending on the candidates’ educational backgrounds. The 2010 IOM recommendations for nursing education [4], Frenk et al. [3], the results of the alumni survey and our MScN curriculum analysis all facilitated major changes to many of our courses. To strengthen research and clinical education, we decided on two actions. First, we would redesign first year courses; and, second, we would create two specializations-‘research’ and ‘APN’-as study options for the post-basic study program (20 KP ECTS each, see the right and left sides of Fig. 2). To enhance research education, we redesigned first-year research courses (i.e., Research I, Introduction to quantitative and qualitative methods, and Research II, Expansion of quantitative and qualitative methods). To broaden the program’s ethical foundation, we added one course in Philosophy of Science. The following secondand third-year courses were newly developed or redesigned: Qualitative research (specific qualitative methods), Advanced Research Methods (comprised of 3 courses: Health economics, Using large routine datasets for health services research, and Intervention development and evaluation). These course revisions necessitated major changes to a mandatory research internship (whereby students join existing research groups and experience ‘research in practice’). To extend clinical education, the following second and third year courses were newly established or redesigned: Clinical Assessment III (individual clinical internships mentored by physicians/ APNs in their field of expertise); and to introduce ANP roles, APN role development: working through the PEPP A (Participatory, Evidence-based, Patient-centered Process for APN role development, implementation and evaluation) framework [22]. To adapt to the latest developments in terms of nursing knowledge, we tailored our educational offerings to fit local conditions and integrate new technology [2, 3]. Therefore, two two pilot courses-eHealth (Advancing the use of information technology Discussion and conclusions From the early days of Switzerland’s first MScN program in 2000 to the enrolment of the first cohort to study under the new curriculum in 2014 in this profoundly altered educational context, the overhaul of this program’s curriculum facilitates our mission to educate and encourage nurses not only to take up leading roles, but “to leverage opportunities to improve frontline care. We develop, promote and lead the implementation of research driven innovations through clinical partnerships, and drive innovation in Advanced Nursing Practice education in the German speaking world’ (https://nursing.unibas.ch/de/ins/leitbild/). The INS’s rigorous approach, with a sharp focus on the Swiss population’s current and future care needs, can serve as a framework for others revising a nursing curriculum at the MScN level. Our method of comparing current curriculum content with WHO core competencies and ANP competencies was generally successful. Regarding overall content, our educational direction was well-corroborated; and from the program’s implementation, the curriculum was well aligned with APN competencies and with most of the WHO’s 5 proposed core healthcare competencies [1]. We realized that technology was well represented in course content, but needed strengthening regarding instructional design. Moreover, supporting Frenk et al. (2010), seminal IOM reports (2011) pointed out the importance of balancing strong clinical and research options for advanced nurses. Reflected in the core findings of our alumni survey, these reports led the way to our twin (‘Research’ and ‘ANP’) specializations. Frenk et al. (2010), for instance, stressed that the target outcome of instructional reforms should be transformative learning based on the development of professional competencies adapted both to fit local contexts and to promote inter-professional learning. Our ANP role development course integrates these elements; it is conceptualized in terms of clinical activity across two semesters, during which the students develop their future ANP roles in their local contexts and in collaboration with stakeholders, e.g., physicians and other professionals. Table 3 Examples of course objectives, learning outcomes and content APN role development (ECTS: 4) General objectives: Following the ‘Participatory, Evidence-based, Patient-centred Process for APN role development, implementation and evaluation’ (PEPPA) framework, based on an unmet healthcare need across the care continuum, students develop a model of care for a specific patient population. In close collaboration with key stakeholders (e.g., other medical professions, patients and families, external support system representatives), they further develop a model of care, meeting the care need and define their new, expanded role within this new model of care. Learning outcomes (selection): On completion of the module students will be able to: a) define a patient population and identify an unmet health care need; b) identify and gain the views/opinion of stakeholders regarding the unmet health care need and a potential ANP role; c) engage stakeholders in the development and implementation of the proposed model of care and ANP role; and d) develop and present an overview of the proposed model of care and ANP role using a logic model Content (selection): Action learning, role development principles, PEPPA framework / toolkit Student evaluation: Each student will work through the PEPPA model steps and hand in a completed needs assessment, stakeholder analysis, logic model and a summary reflection on own experiences with applying the PEPPA framework. Using large routine datasets (LRD) for health services research (ECTS: 3) General objectives: To enhance the in-depth understanding of the planning and implementation of the analysis of large routine data in the context of health services research. Today’s healthcare systems provide a wide range of data sources like large discharge datasets, epidemiological registries or data from the electronic health record, which offer many opportunities for health and nursing research. The course will provide students the basis to plan and conduct LRD analyses in the context of their own area of research. Learning outcomes: On completion of the course, students will a) understand the basic steps in the analytical process of LRD sets; b) develop and assess answerable research questions in the context of LRD; c) evaluate scope and limitations of popular analytical techniques in the context of LRD; d) understand and apply principles of reproducible research and e) plan, conduct and present a contained LRD project Content (selection): The complete process from importing, preparing, analyzing, reporting and presenting the data will be covered; unique design features to be considered in the planning and stages of a study so that specific methods can be employed during the analysis. Student evaluation: Written analysis plan and written report Schwendimann et al. BMC Medical Education (2019) 19:135 Page 8 of 11 Experiences with two student cohorts already indicate that, especially in Switzerland, this course facilitates transition to novel, advanced professional roles (IOM, 2011). Regarding individual courses, the structured curriculum analysis indicated how fully each course addressed the requisite ANP and WHO professional competencies. The interpretation of the results posed various challenges, as from the commencement of the revision process it was never clearly confirmed whether all criteria needed to be applicable to all courses. For example, the “Patient centered care” criterion would not apply to the research module, or to courses on scientific method or statistics but rather to courses of Clinical Assessment or APN role development. Therefore, to overcome these and other concerns regarding the rationale for specific course content adaptations, we addressed the applicability of the core competency criteria pragmatically and focused on specific courses. To provide essential information on which courses required changes regarding the ANP and Research specialization, any concerns were dealt with via discussion and consensus within the CuRT and faculty. A clear definition of the context in which each revision is being made, i.e., regarding specific population needs or the coverage of educational offers by other schools, may enhance the validity of decisions regarding new courses or course redesign. Following decisions on which elements to update or replace, the creative and challenging endeavor of structuring the material was conducted by the CuRT. They worked through each issue by asking basic questions, trying ideas, puzzling, thinking aloud, and often laughing. This team approach to problem solving, which nurtured unconventional thinking and questioning apparently self-evident constructs, often became the initial step for groundbreaking changes and innovative solutions. For example, by asking whether all students actually benefit by doing Clinical Assessment 2, a problem of allocating ECTS credits was resolved by integrating that course into the ANP track; i.e., recognizing that advanced clinical assessment actually has little relevance to students in the Research track, it was allocated to the ANP specialization. After successfully framing the new master’s program, study plans were necessary for students in both tracks. Characterizing learning outcomes as target competencies according to “Bologna” was a vital change; and the precept that curricula need to be competence-driven has remained valid throughout our journey. With the long-range goal of evaluating and ensuring quality care outcomes for the population, the students’ acquisition of advanced competencies via the integration of competency-driven instructional design was at the core of both the IOM recommendations (2011) and Frenk et al. (2010). All INS course leaders and lecturers engaged in drafting, reviewing and finalizing the courses of the MScN curriculum. This level of individual investment promoted identification with the new approach, providing a strong basis for its sustainability. Study regulation reform demanded intense concerted collaboration between the members of a committee including CuRT, representatives of the University’s student administration, the legal department, and the rector’s office. This group met every 1-2 months over a period of 18 months. Along with the rector’s office’s provision of a project plan, including milestones, the University’s contributions of services (e.g., meeting rooms) as well as the sincerity of the collaboration facilitated a lean and unhindered process from start to finish. However, while all participants were eager to contribute and proceed, it was essential to allocate ample time for discussion of meanings or concepts, and to develop a common understanding first of the INS’s fundamental aims, then of the curriculum revision’s ultimate objectives. This semester, 1 year after launching the new curriculum and its regulations, the INS experienced an unexpected surge of students opting for the ANP track. Apparently, while our students clearly appreciate the practical aspects of our BScN program, few understand the excitement, fulfilment and profound value of nursing research. Obviously, we must work harder to expose students to the many rewards of existing nursing research. In the coming years, by integrating promising students into research groups and offering research internships, more will choose the research track. Additionally, inviting students from other disciplines to join our research-track courses will foster robust inter-professional exchange among the participants. Implications and next steps Recommendations from the above-mentioned reports and results of our analyses not only informed our curriculum redesign but were also considered for the institute’s 2014-2018 strategic planning phase. For education, for instance, four major goals and corresponding action points in the domains relevance, quality and innovation, impact, and sustainability were defined

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