Article

An evaluation of the
baccalaureate-nursing
program within the (MOPH),
Thailand
Kamolrat Saksomboon, Margaret McMillan and Krys Cholowski

This research study was designed to evaluate the baccalaureate-nursing curricula undertaken
in the nursing colleges under the jurisdiction of the Ministry of Public Health (MOPH),
Thailand. A stakeholder approach was used to incorporate mixed methods of data collection
and models of evaluation within the research framework. Both qualitative and quantitative
approaches were used. Newly registered nurses and their colleagues were generally positive
about the course outcomes. However, qualitative data demonstrate a need to focus more on
the development of abilities related to life-long learning and critical thinking. The findings
suggest challenges in achieving program outcomes attributed to the feasibility of
Kamolrat implementation strategies. Concepts in the curriculum plan are not fully translated into
Saksomboon RN,
practice. A number of factors have a major impact on the actual program implementation or
Dip (Nurs),
Chonburi Nursing course organisation and teaching/learning processes. There is evidence of competing or
College, Mahidol conflicting ideologies about nursing practice and education. Findings suggest that the
College, Callaghan,
NSW 2308, Australia preferable educational models for contemporary and future nursing education are process
Margaret McMillan rather than content-based. It is challenging to develop ways of accommodating the more
BA, MCurrSt (Hons),
DipNEd, PhD, desirable professional nursing and educational approaches within the context of Thailand
Currently Dean, and MOPH nursing education policies where resources are limited and the maintenance of
Faculty of Nursing,
The University of
Thai culture is of paramount importance. ª 2002 Elsevier Science Ltd. All rights reserved.
Newcastle, University
Drive, Callaghan,
NSW 2308, Australia.
Tel: +61 2 4921 6005; Introduction successful in meeting health service needs for
Fax: +61 2 4921 6981 nursing personnel.
Krys Cholowski RN, This study focuses on an evaluation of the At the time of the study there were 35
BEdStud, MEdStud, baccalaureate-nursing curricula undertaken nursing colleges located across the country
PhD, in nursing colleges under the jurisdiction
Currently Senior under the authorisation of the MOPH. The
Lecturer and Assistant of the Ministry of Public Health (MOPH), baccalaureate-nursing curriculum, which is the
Dean, Research, Thailand. focus of this study, was first developed in 1977
Faculty of Nursing, The MOPH assumed responsibility for the
The University of and has been used since then with two
Newcastle, University production of nursing personnel for its revisions, the latter moving towards a more
Drive, Callaghan, hospitals and health centres in 1946. At that process orientation to teaching and learning.
NSW 2308, Australia. time, there was a shortage of nurses in
Tel: +61 2 4921 6833;
Thailand as a result of the impact of World War
Fax: +61 2 4921 7069
II. The first MOPH nursing school, which is
Literature review
(Requests for now known as the Boromarajonani College of The MOPH have produced approximately
offprints to KS)
Manuscript accepted: Nursing Bangkok, was established to help fulfil 40–50% of nurses graduating in the country
29 April 2002 the demand for nurses. This strategy was each year since 1987 (Jamjan 1997). All MOPH

0260-6917/02/$ - see front matter ª 2002 Elsevier Science Ltd. All rights reserved Nurse Education Today (2002) 22, 641–647 641
doi:10.1016/S0260-6917(02)00105-3, available online at http://www.idealibrary.com on
Evaluation of the baccalaureate-nursing program
colleges use the same nursing curriculum
provided by the Praboromarajchanok Institute
(PBRI) as a guideline and accommodate the
WHO’s goal of ‘‘Health for all by the Year
2000.’’ In 1979, primary health care was set as a
national strategy to improve the quality of life of
the population (Watanakij & McElmurry 1995).
Dumrongrattana (1994) recommended in her
study of 1090 faculty members from nursing
schools across Thailand that faculty needed to
have a broad knowledge and experience with
the recommended philosophy of
Problem-Based Learning (PBL) along with
positive attitudes and beliefs about its
application to their teaching. She supports
literature, indicating that not all teachers either
in classroom or clinical placements were ready
to accommodate the new principles written
into the curriculum (Crotty 1993; Crotty &
Butterworth 1992; Jones & Brown 1991;
Robinson 1991).
Chuaprapaisilp (1989) argued that clinical
education in Thailand focused on ‘‘doing
rather than learning.’’ She stated that the
clinical learning of student nurses was not
effective because clinical teachers focus too
much on content. Furthermore, students were
left to apply theory into practice by themselves.
Rapid change in society and people’s life
styles have resulted in dramatic alterations in
the nature of health problems, which demand
changes in the scope of health care and practices
in nursing. The development of curricula that
prepare nurses to meet societal needs for health
care and services is of paramount importance in
nursing education. It is recognised that a
curriculum plan is the most important element
influencing graduate characteristics. Several
educators suggest that providing new
graduates that are well prepared for the future
calls for curriculum revolution (Bevis 1989;
Clayton & Murray 1989; Joel 1988).
There has never been any research which
focused on the curriculum of the MOPH in a
large-scale format using both quantitative and
qualitative approaches. Most reported studies
have been conducted in small-scale evaluative
formats within a single college and focused
only on a limited number of program
outcomes. Rarely have qualitative approaches
been used in previous studies. To overcome the
shortcomings of each approach, we combined
642 Nurse Education Today (2002) 22, 641–647
both qualitative and quantitative methods of
data collection and analysis within this study.
A stakeholder approach, involving people
closely associated with or involved in the
program, was used to obtain data from a range
of people involved in nursing education. Many
of these people make decisions which directly
impact on the future development of the
program (Weiss 1986, p. 151).
Research purposes
There were two main research purposes:
• To evaluate the baccalaureate program
of nursing of the MOPH regarding
implementation and outcomes
• To identify the potential impacts of trends in
health care and the scope of nursing practice
on nursing education in the next decade.
These purposes were expanded to form six
sub-elements:
• Consistency between program
implementation and stated objectives
• Extent of match between graduates’
competencies and course objectives
• Trends in population health
• The extent to which current college
programs meet the changing health
service environment
• The appropriateness of the conceptual
framework and philosophy in the
MOPH-nursing curriculum to the health
service needs
• Models of nursing education and practice
suitable for the next decade.
Research methodology
An eclectic research framework used by
McMillan 1987 and including concepts from
Tyler’s Objective, Stufflebeam’s CIPP and
Parlett and Hamilton’s Illuminative Model of
evaluation allowed for a process that explained
the complexities of the real world. The data
collection methods, including closed and
open-ended questionnaires, were used to
survey student nurses’, newly graduated
nurses’, and nurse practitioners’ views on the
implementation and outcomes of the existing
curriculum plan. Closed-ended questionnaires
ª 2002 Elsevier Science Ltd. All rights reserved
 Evaluation of the baccalaureate-nursing program
comprised three identical sets of 24 questions
that were relevant to the statements about
nursing competencies reflected in curriculum
objectives.
A semi-structured interview elicited opinions
from selected student, academic, and clinician
subjects who responded to the questionnaire.
A three-day stakeholder workshop focused on
the potential impact of trends in health care
delivery on the scope of nursing practice
and future developments in nursing
education.
Data analysis and results
Descriptive and inferential statistics with factor
analysis was used to limit the number of scales.
Content analysis was applied to all qualitative
data from open-ended questions, interviews,
and the workshop activities.
Having performed factor analysis, three
distinctly derived factors incorporated all items
of nursing competencies.
Factor 1 consisted of 11 items related largely
to nursing practice and a small portion of
communication, decision, and problem
solving skills. Most items in this factor related
to practical skills, hence, the name Nursing
Skill scale. An alpha coefficient of .88 was
found, indicating a high level of internal
consistency.
Factor 2 composed of seven items related to
management, creativity and enthusiasm,
research, professional development, and
practice. This factor was labelled the
Professional Practice scale. An alpha coefficient
of .83 was found, confirming a high level of
internal consistency.
Factor 3 composed of five items related to
professional values, human rights,
professional etiquette, and collaboration. It
was identified as the Ethics scale. An alpha
coefficient of .76 was also considered
confirming a high level of internal consistency.
Similar patterns emerged from qualitative
data, open-ended questions, interviews, and
workshop activities, yielding five themes. The
two additional themes were named Course
Organisation and Processes and Curriculum
Context. The main results of the research
project are presented as follows:
ª 2002 Elsevier Science Ltd. All rights reserved
Program implementation
Descriptive statistics of the three factors
illustrated high mean scores on perceptions
from both junior and senior students regarding
the curriculum implementation. In most
instances, means from the 5 point Likert scale
were higher than 3.50, except those instances of
the Professional Practice scale. On closer
inspection it is evident that there were relative
differences among the means within the three
scales: The Ethics are higher than those of
Nursing Skills and Professional Practice,
respectively.
In relation to Nursing Skills, high scores on
perceptions of both junior and senior students
indicate that students in both years from all
chosen colleges had positive views on the way
they were prepared for competencies.
Students’ perceptions of the preparation for
Professional Practice were less positive than
those of Nursing Skills and Ethics. This finding
suggests that the preparation for abilities
related to management, supervision, self-
directed learning, and research was less
satisfactory. The data from interviews
elaborated on this view.
Students’ perceptions of preparation for the
Ethics component were highly positive. The
information from interviews also supported
these findings. Both students and instructors
expressed views that students were encouraged
to develop positive professional values and to
be aware of patients’ rights and dignity.
In the open-ended questions, a large
number of both junior and senior students
from all three colleges perceived that they
have been well prepared in terms of
knowledge and nursing competencies,
including abilities in decision making,
managing, and problem solving. However,
some students stated that they had not been
provided with adequate time for theoretical
preparation and self-directed learning. The
development of abilities in the conduct and
utilisation of research, teaching and
supervising subordinates, critical thinking, and
life-long learning were also perceived as
needing more attention in learning materials.
Some instructors expressed views that
students were well prepared to achieve what
was stated in the curriculum whereas others
Nurse Education Today (2002) 22, 641–647 643
Evaluation of the baccalaureate-nursing program
expressed different views. However, the area
for which they all thought students were well
prepared was the Ethics component.
Open-ended question responses showed that
most students had positive perceptions of
clinical placement preparation and skills
development. However, the development of
practical skills was seen as inadequate. A need
for improvement in the organisation and
management of quality clinical education
experiences was deemed appropriate.
Extracurricular activities were seen by
students who live on the college sites as helpful
for practising social interaction skills.
However, some factors beyond the college
control impacted on the development of
interaction skills. These were instructors’
teaching styles, the clinical placement
atmosphere, and registered nurses’ manners.
Curriculum outcomes
Quantitative data using a 5 point Likert Scale for
responses were examined for determination of
the extent to which course outcomes match
expectations. Descriptive statistics of the three
major elements of factor analysis show positive
perceptions from both new graduates and
experienced nurses on new graduates’
competencies relevant to the domains of
Nursing Skills and Ethics, with most means over
3.50. The scores on Ethics in particular were very
high, with means ranging from 3.87 to 4.15 for
new graduates and 3.70 to 3.95 for experienced
nurses. The Professional Practice component
was scored lowest, with means of 3.08–3.44 for
new graduates and 3.23–3.50 for experienced
nurses. The patterns of the findings about
curriculum outcomes assessing new graduates’
competencies were consistent with those of
senior students’ perceptions of the curriculum
implementation.
Qualitative analysis of data from open-ended
questions and interviews indicated more
diversity in graduates’ perceptions of their
competencies. Some noted that they had been
well prepared in all components. Others
indicated that they lacked knowledge, practical
skills, and self-confidence. They experienced
difficulties in relation to decision making,
problem solving, management, and working
collaboratively with others.
644 Nurse Education Today (2002) 22, 641–647
Experienced nurses in response to
open-ended questions and interviews confirm
ambivalence in views on new graduates’
competence. Some had positive views about
graduates’ enthusiasm, their sense of
responsibility, demonstration of appropriate
manners, and their interaction skills whereas
the others noted some difficulties in working as
registered nurses. These included aspects of
decision making, problem solving, managing,
and supervising. They stated that graduates
lack practical skills, knowledge, and abilities in
applying theory into practice. Some aspects of
the ethical component such as responsibility,
altruism, patient rights, and professionalism
were raised as problematic. Abilities related to
research utilisation and conduct were also
problematic domains in the eyes of both
graduates and experienced nurses.
Current and future curriculum
developments
The analysis of the data provided in response
to the workshop activities reveals that there
were aspects of the context that one should
highlight when developing a nursing
curriculum. Issues related to nursing practice
and education and included a need to focus on
a community-based approach in health care
delivery systems because of the changes in the
population’s health problems.
The current MOPH curriculum plan was
generally perceived by the workshop
participants to have the potential to be
responsive to the changes in society. However,
lack of resources, including learning materials
and personnel, were reported as barriers to
implementation of the program as it is
envisioned.
Workshop participants saw that the
philosophy and objectives stated in the program
were comprehensive and cover all professional
competencies. The program was perceived as
appropriate for the next decade, but the
conceptual framework needed to be clearly
articulated in the curriculum. This is, however,
a major force on the extent of success on all
aspects of program implementation.
Nevertheless, the outcomes of the program
were believed by the workshop participants
to partly meet the objectives, for example, in
ª 2002 Elsevier Science Ltd. All rights reserved
 Evaluation of the baccalaureate-nursing program
respect to the abilities of critical thinking,
decision making, leadership, collaborative
work, and self-directed learning. Some
influential factors impacted on implementation
in a negative way and limited the extent to
which these objectives were met. These factors
were identified as budget constraints, cultural
limitations, the traditional educational system,
a conservative college climate, inadequacy in
numbers of instructors, lack of readiness of
learners, inappropriate teaching and learning
methods, bureaucratic organisational
structures, and poorly prepared clinical
placements. These findings were consistent
with those from the surveys.
The models of nursing education which
emerged from the workshop activities were
derived from the concepts identified in the
program philosophy. The basic elements of the
models are humans (students, teachers,
patients, and nurses), contexts, care, and
teaching and learning methods that focus on
problem solving and self-directed learning.
Again, the use of models demonstrates the
potential clearly to articulate a conceptual
framework to guide implementation processes.
General discussion
Study findings suggest that the majority of
junior and senior student nurses perceived
that they were being prepared to acquire the
abilities stated in the objectives of the program.
Therefore, it is apparent that the curriculum is
implemented predominantly as planned.
Newly registered and experienced nurses were
generally positive about the course outcomes.
However, there were notable issues raised
about nursing education undertaken through
the MOPH. It is evident that some issues were
paramount in the minds of respondents and
were seen as a hindrance to achievement of the
objectives of the program. Similar trends were
evident in the range of respondents from a
range of institutions. There was also equally
strongly weighted evidence of opposite views
on the same issues. The polarised views on
particular issues reflect ‘‘competing ideologies’’
and impact on the extent to which course
objectives can be achieved. The following
discussion centres on the noticeable divergent
views on issues emerging from the findings.
ª 2002 Elsevier Science Ltd. All rights reserved
One of the more striking issues to emerge
from the data related to opposing views on
professional status, the things that are peculiar to
carrying out interventions or forming
relationships in nursing activities in a manner
that has professional overtones versus a
perception of poor status of nursing in society.
Even though the population at large thinks that
nurses are ‘‘good’’ in a general sense, nurses’
experiences are influenced by their poor social,
economic, and political status within society.
It would seem that whilst nurses in Thailand
and elsewhere are seen as essential to the
achievement of health outcomes, they are not
well rewarded or acknowledged for the
contribution they make in society.
There was a clear expression of views across
student groups and colleges that the
MOPH-nursing program was intense in
demands on students but they only gained a
general overview of things and sometimes
learned in a superficial way.
There were extreme views expressed on the
use of the process-based approach in the context of
content-based implementation strategies.
Students were meant to take responsibility for
their own learning, but they were being asked to
accommodate an overwhelming amount of
content that was provided to them within the
classroom. This reflects a polarisation in
expression of ideologies. As Casey (1996, p. 117)
indicates ‘‘it is unrealistic to expect nursing
graduates to go from passivity to critical activity
merely by virtue of entering the practice arena.’’
Barriers to active learning centre on the
faculty members and their skill levels in, and
commitment to, interpreting the curriculum
philosophy. Teachers lacked skills in facilitating
students’ self-direction and critical learning.
Some were worried that self-directed learning
alone cannot adequately provide the essential
knowledge needed. Therefore, they ended up
trying to provide students with additional
content as much and as often as they could.
The clinical learning experience of nurses is
considered an essential feature in nursing
education and in this study drew an extensive
range of comments. Students complained that
there was a very heavy practice orientation
coming through, but in fact it was noted that
the practice component was actually a poor
learning experience.
Nurse Education Today (2002) 22, 641–647 645
Evaluation of the baccalaureate-nursing program
Students indicated that there were
inadequate numbers of clinical instructors on
the wards. They spent a large amount of time
on clinical placements but did not gain much
experience because without the clinical
educators’ supervision they were allowed to
perform only routine work. Lack of role
modelling of good clinical teaching may be an
explanation for this phenomenon.
Organisational and power structures in the
context in which nursing education takes place
are considered major constraints on the
implementation of the curriculum. The
workshop findings showed that nurse
educators presently implement the new
principles under pressure and within a series
of constraints.
There were extracts or elements of factors
within the findings that are peculiar to the Thai
culture. Whilst nurses are requested to respond
to global trends in education and in meeting
health service needs, they are also expected to
exhibit their traditional Thai manners.
There were conflicts among nurses
themselves about the desirable attributes of
nurses. According to global trends in health
service needs and health care delivery systems,
like nurses from other nationalities, Thai nurses
are required to be more independent,
autonomous, confident, and creative. However,
they are also expected to behave in Thai ways,
which sometimes can contrast with the more
recently recognised desirable attributes in the
nursing literature. For example, the
respondents in the study expressed concern that
the system of seniority where younger people
show respect to older people by not engaging in
confrontation impedes Thai nurses from being
independent, active, and creative. This finding
supports the study of Chuaprapaisilp (1989)
which showed that some Thai behaviours such
asnon-confrontation seemed to inhibit student
nurses from being critical and effective in
clinical conferences.
There is a very clear expression of students’
views about rules and people feeling bound by
rules. The curriculum philosophy demands that
they be much less rule bound and more
self-regulatory professionals. A large number of
student nurses in this study complained that the
rules and atmosphere of the colleges hindered
them from being active and independent. A
646 Nurse Education Today (2002) 22, 641–647
strict environment made them become inert and
wanting to do only things that they have to do.
Relationships between students and teachers
were also noted as important factors that
encourage or obstruct the development of self
confidence or autonomy. It was reported that
sound relationships based on a contract and
focused on a learning partnership could
enhance students’ capacities to be more active
in learning and therefore enable them to be
active professionals.
There were comments from study
respondents on issues related to the more
traditional foci in the curriculum and the
requirement to do interesting extracurricular
activities. Whilst the traditional curriculum
might have been tightly managed like the Tyler
model advocated, there is evidence to show that
the curriculum needs a more student-centred
learning orientation. The extra-curricula
activity that is adding value to all of the existing
additional elements, however, may impact on
the time available for core learning because of
the time it takes to undertake these activities if
they are not integrated as outcomes within the
core structures.
Nursing service: bureaucratic versus
professional orientation
There were issues about the development of
nurse-centred behaviours which detracted
from the recognition of a need to develop
patient-centred behaviours. There is a
contemporary view that the scope of nursing
practice and nurses’ roles and functions should
be determined by clients’ needs and the context
of practice. However, sometimes nurses
perform tasks according to the ward schedule
or routine. Therefore, they may not produce a
meaningful outcome for patients. More
research into the links between nursing
intervention and patient outcomes is needed.
Health care delivery approach: institutional-
based versus community-based orientation
There is a controversy evident in the data over
the choice between a curative focus including
institutional-based curriculum activities, as
opposed to implementation of strategies for
community-based care. There appears to be a
ª 2002 Elsevier Science Ltd. All rights reserved
 Evaluation of the baccalaureate-nursing program
discrepancy between health care policy, which
is moving toward primary health care, and
actual practice, which still focuses on the
provision of individualised care.
Evidence-based approach: research
orientation versus non-research milieu
This study highlights the need for a greater
research orientation in nursing practice and
education. This acknowledges a need to be
focused on practices that are really meaningful
to clients in the contemporary context of
practice and for nurses to be able to provide
evidence of sound practices as opposed to a
very limited focus on remote skill
development. The use of actual research or
developing the potential to do research
associated with practice is the first step in
addressing this concern.
It is interesting that research has been
accepted by those developing philosophies as
the key element to improve nursing service
and education but research-oriented activity
does not currently have a role in actual
practice. Lacey (1994) argues that a low
research base and inadequate research
utilisation can impede nurses from increasing
the level of credible professional status.
Therefore, there is a need to focus more on
research-based education and practice to
improve knowledge, development, quality of
care, and professional status.
Conclusions and
recommendations
Recommendations were proposed for
consideration as strategies to minimise the
obstacles in achieving program outcomes and
to produce graduates who are able to provide
contemporary and safe nursing care for the
diverse range of customers in varied contexts
of practice.
Whilst the MOPH Curriculum is being
implemented predominately in the manner
envisioned by the curriculum developers, this
study demonstrates the existence of
‘‘competing ideologies’’ which are recognised
but need to be dealt with if a closer alignment
between the needs of the clientele of Thai
health services and nursing interventions is to
ª 2002 Elsevier Science Ltd. All rights reserved
be achieved. The challenge of nurse
educators is to develop curricula which in
turn develop nurses with the range of
abilities appropriate to contemporary health
service needs.
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