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Multiple dimensions of flexibility in health sciences professional preparation programs: Challenges for curriculum development and organizational change

Mary Jane Mahony
Colleen Mullavey-O'Byrne
Joy Higgs
Fran Everingham

Faculty of Health Sciences, University of Sydney
Sweeping changes currently taking place both in the higher education sector and in the health care sector have far reaching implications for professional preparation programs in the health sciences professions. Jumping on the 'flexibililty bandwagon' is a widespread response. Flexibility is not, however, well conceptualized for either educational or health care contexts. Consequently, a four dimensional conceptual framework is presented in this paper to assist understanding and then operationalizing flexibility. Implications for curriculum development and organizational change within the complex context of 'flexible learning for a flexible society' are addressed for preparation programs for the health sciences professions. This work is informed by the scoping and consultation phase of an Undergraduate Curriculum Reform Project at the University of Sydney's Faculty of Health Sciences.


The term 'flexibility' is now so widely used in higher education as to mean all things to all people. Its prescribed meaning in common language:

1.Capable of being bent; easily bent
2.Susceptible of modification or adaptation; adaptable
3.Willing or disposed to yield.
- Macquarie Dictionary

facilitates this widespread interpretability. Adaptability appears to be the common element when considering current use of the term in the discourses of educational policy and practice. The strength of the ubiquity and variability in its meaning is widespread recognition that flexibility is a key attribute in curriculum planning, implementation, and outcome discussions. Weaknesses, however, include both insufficient agreement about what flexibility comprises, and insufficient consideration of the interacting realities of different flexibility agendas.

The conference theme draws together two uses of flexibility. 'Flexible learning', what ever it may be taken to mean, is a response to the changed societal context, an expectation from and about 'a flexible society' in which both individuals and communities are more capable and adaptable in an era of rapid change.

We aim in this paper both to contribute to scholarly debate about the concept of flexibility as it is used in education and to highlight implications for curriculum development and organizational change when flexibility becomes a central curriculum concept. Although this paper is presented in that context, many of the contextual issues, the emergent dimensions and the implications for curriculum and organizational change are applicable in any professional preparation situation in higher education. We start with a brief reference to our local Undergraduate Reform Agenda, then continue with a broader discussion of the current context of health sciences professional education. We then set out four broad dimensions of flexibility which have emerged for us. Finally, we discuss the challenges which they present for curriculum development and organizational change.

Current challenges in health sciences professional education

Our consideration of the concept of flexibility and its implications is driven by the changing context of health sciences professional education. The Australian situation will be the primary point of reference in this paper; the issues discussed, however, can easily be extended to most other OECD countries. Our contribution arises from analysis of the situation on behalf of the Faculty of Health Sciences of the University of Sydney (formerly the Cumberland College of Health Sciences). The Faculty is recognized as having taken a significant leadership role in the foundation of undergraduate health science education programs in the allied health sciences in New South Wales. While the Faculty's wide range of undergraduate programs[1] continues to be highly regarded, the environment is now complex and competitive. This has far reaching implications for preparation programs for the health sciences professions. We set out the major challenges in this section.

The higher education context according to the Australian government. The Australian Department of Education, Training and Youth Affairs (DETYA) Higher Education Report for the 2000-2002 Triennium (Kemp, 1999) identified these key changes in the operating environment of higher education institutions:

Also listed (ibid, p.3) were the following developments in federal government policies affecting higher education, including: Increasing demands for quality and accountability in curricula. Both government and the community at large expect that teaching and learning throughout undergraduate programs will be of a high quality supported by institutional accountability systems (Australia. Higher Education Council, 1992; Jevons & Northcott, 1994; Billing, 1998; Cram, 2000).

Recognition that health professional environments are multi-professional and multi-disciplinary. The benefits of closer collaboration between the health professions (as perceived by students, governments, the community, the health sector and educators) include enhanced understanding of people's problems and their possible solutions and increased respect and trust for other professionals, their disciplinary perspectives and collegiality. This can lead to effective collaborative work on common health agendas.

We have chosen to use multi-professional and multi-disciplinary as separate but interrelated concepts. Together they encompass the whole health care community wherein some Faculty members have a primary orientation to the health professions (e.g. physiotherapy, occupational therapy) and other Faculty members to specific academic discipline areas supporting them (e.g. psychology, sociology, biomedical sciences). Health sciences educators are challenged to develop and implement multi-professional, multi-disciplinary curricula, to evaluate them rigorously and to communicate the results (Graham & Wealthall, 1999). Unfortunately, multi-professional, multi-disciplinary collaboration is not always easy to achieve in practice.

The cultural diversity of the Australian population. In December 1999, the Commonwealth Government released 'A New Agenda for Multicultural Australia' (Department of Immigration and Multicultural Affairs, 1999). The agenda presents principles which embrace values and practices that are relevant to health care, the education of health professionals, and the need to ensure that graduates have had the opportunity to develop skills associated with cultural competence.

Rapidly increasing use of information and communication technologies (ICT). There is a burgeoning use of information technology in clinical medical care, primary health care and public health and as a means of establishing and maintaining links between sectors, and recording and analyzing data. An example is a view, currently held by some, of hospitals as IT 'hubs'. Rapid ICT increase in health care demands and enables systemic integration of ICT in health professional preparation programs to ensure coherence between university experiences and professional requirements.

Market competitiveness. Most program areas in health science professional preparation now operate in a competitive marketplace-like environment. Any decision to implement curriculum change needs to accommodate a value-adding component which is easily made visible to potential students and their prospective employers.

Student realities regarding employment and other responsibilities. Finally, the realities of many student lives must be acknowledged. Students in professional preparation programs now have working lives as well as student lives. For example, a Faculty of Health Sciences research group has reported that over 50% of first year undergraduates are employed at least part-time and some of them full time, and that this phenomenon is well established (Lee, Jolly, Gelonesi, & Kench, 2000;B.Gelonesi personal communication February 2000). While the impact of employment and other commitments have long been acknowledged in programs targeted towards mature age students (e.g. postgraduate programs, programs offered by distance education), acknowledgement of this factor is relatively new in undergraduate, on-campus programs in Australia.

Four dimensions of flexibility

'Flexible learning' is one aspect of a more fundamental concept, 'flexibility'. Within that part of society which is higher education, 'flexible learning' is informed from several directions. These include a more mature understanding of the nature and variation of learning, the multiple demands on students' (and staff members') lives, changing views of knowledge (including its construction and communication), and response to the demand for workplace preparation). Neither the concept of 'flexible learning' nor the larger concept, 'flexibility' (which also contains 'flexible delivery') have stabilized yet. Flexibility can be applied conceptually to every aspect of education. Our consideration of contextual issues as set out above together with the outcomes of twelve months exploratory and preparatory work through our Faculty's Undergraduate Reform Agenda has led us to draw out four broad dimensions of flexibility for health professional preparation programs (Figure 1) into an overall flexibility approach.

Four dimensions of flexibility

  1. Flexible teaching/learning environments
  2. Multi-dimensional social environments
  3. Systemic dependence on information and communications technologies (ICT)
  4. Living in ever changing workplaces

Figure 1: Four dimensions of flexibility

1 Flexible teaching/learning environments

At our University flexible learning has been conceptualized within this dimension of flexibility as an approach to education which offers the student choice in what to learn, how it is learned and assessed, and when and where learning happens. To increase flexibility in its programs, the University would increase students' choice in one or more of these aspects: Each of these approaches to flexibility offers a wide range of implementation strategies (Laurillard & Margetson, 1997). Most will involve re-thinking at a whole curriculum level for effective, efficient and curriculum appropriate outcomes. Some, but not all, will involve the use of information and communications technology.

Flexibility in learning pathways. Inherent in this approach is a move beyond cohort-based, fixed sequence progression in a particular course or unit. Strategies will range from more opportunity for students to choose from alternative or optional possibilities, on to working with students in negotiating an agreed individually appropriate pathway.

Flexibility in goals and assessment. This is an area of potential debate with regard to health sciences professional entry education programs which are often heavily bounded by the accreditation requirements and expectations of professional bodies. Clear statements of graduate outcomes and an approach which explicitly expects constructive alignment[2] among key priority goals (e.g. Faculty and professions' objectives, workplace expectations) provide a platform on which a variety of approaches can be taken to achieve the agreed outcomes.

Flexibility in delivery, participation and styles of learning. One common characteristic of flexible learning is an increased expectation of students to be both independent and interdependent learners with all the implications this has for understanding and developing self-motivated, self-directed, self-managed and self-confident learners. The application of adult learning principles and independent learning strategies are often considered a solution to the problem of shrinking resources. If introduced simply as a cost-cutting measure, however, strategies to develop and support the independent learner may not be fully conceptualized and integrated into professional education (Taylor, 1997). Developing students as independent and interdependent learners needs to be explicitly addressed through a planned approach integrated throughout curricula to achieve the twin benefits of achieving desired graduate attributes and using limited resources more efficiently.

2 Systemic dependence on ICT

The use of information and communication technology is sometimes equated with flexible learning. We have already indicated why we believe flexibility must be much more broadly conceptualized. Here, however, we wish to re-emphasize the ever widening and deepening dependence of educators and curricula on information and communication technology. Using ICT to support the educational process is only part of the picture, though a significant part. ICT use (including appropriate selection of a particular technology for a specific situation) has also become a generic learning goal. Thus every student (and every university staff member) needs not only to develop a range of expertise in the use of information and communication technologies, but a deep understanding of the properties of particular ICT tools and how they can be used to best advantage.

ICT is increasingly and unavoidably influential in higher education (Katz, 1999). Its potential as a means of supporting teaching and learning (in any time and place) is immense, its ability to make widely visible the image, intentions and efforts of a university, a course and even an individual teacher is powerful, and its influence on the expectations of the younger proportion of the student population is rising.

The most common reasons reported for using technology in education are to improve access to education and training, to improve the quality of learning, to reduce the costs of education and to improve the cost-effectiveness of education (Bates, 1997). There is a wide range of technologies available to be used appropriately. The World Wide Web is linking them all both conceptually and practically, and has thus placed networked multimedia approaches in prominence (e.g. Khan, 1997). The use of systems which support one technological approach may need to be substantially redesigned to support another (Bates, 1995). The final outcome must be that both students and staff use information and communication technologies comfortably and creatively as well as effectively and efficiently

3 Multi-dimensional social environments

An additional, and perhaps more crucial, dimension of flexibility for both students and staff is the ability to learn and work effectively in multi-disciplinary, multi-professional and multi-cultural environments. This requires flexibility in terms of cognitive approaches, cultural interactions and interpersonal communication. A WHO (World Health Organisation, 1988) commissioned Study Group advised that:
if health care is to be effective [health care professionals] must be able to work together in groups, to adapt to a common time-scale, and to recognize the unique role and potential contribution of each member of the team. Training in their own profession not only does not adequately prepare the members of the different health care professions to apply their different disciplines and competencies; it needs to be supplemented with multi-professional training so that the different professions become aware of their different ways of thinking and acting and gain experience of co-ordinated team-work, in which each has an essential role to play. It should also enable them to devise ways of preventing or solving the conflicts that can arise in the course of teamwork. (p.15)
This study group identified the advantages of multi-professional education as set out in Figure 2.

Multi-professional education. . .

  1. develops the ability of students to share knowledge and skills collaboratively and thereby provide individuals and the community with health care more efficiently.

  2. enables students to become competent in the teamwork needed for the solution of priority health problems. It helps to develop mutual respect and understanding between health team members. It helps different categories of health worker assess one another's strengths, limitations and work patterns, and the different ways in which they can contribute to the solution of individual and community health problems.

  3. helps to 'decompartmentalize' curricula and to prevent the development of a corporate mentality, which is a factor in resistance to interprofessional collaboration.

  4. permits the integration of new skills and areas of knowledge that have a role to play in health care, e.g. health economics, sociology, communications science, information sciences, education etc.

  5. helps teachers, learners and service staff of different disciplines to communicate more easily among themselves.

  6. generates, establishes and promotes new roles, competencies, responsibilities and areas of interest: especially when introduced early it extends the range of careers for students to choose from or in which to advance.

  7. promotes multi-professional research, often in new or previously neglected areas, to ensure that all the pertinent aspects of a problem are considered.

  8. requires and promotes interdepartmental and interdisciplinary understanding and cooperation within institutions responsible for training and research.

  9. permits collective consideration of the allocation, utilization and assessment of educational and service resources according to ascertained needs.

  10. helps to ensure consistency and avoid contradiction or conflict in curriculum design.

Figure 2: Advantages of multi-professional education (World Health Organisation, 1988, pp. 16-17)

A crucial point is made in the same discussion: not only should students experience this environment but they must be encouraged to accept and adopt the values that underlie teamwork in health care. 'Hence they should have an opportunity to take part in joint analysis of the structure and functions of the health system. They should also be encouraged to explore the process of professional socialization which they are undergoing and how they are developing a particular set of values and selective ways of interpreting their observations...' (p. 16). These views reinforce the need to create a learning environment for preparing health professionals in which staff are seen as models of appropriate practice and in which student have the opportunity to practice the skills and build their experience of multi-professional, multi-disciplihnary and multicultural teamwork.

4 Living in an ever-changing workplace

The aim of today's health sciences professional preparation programs must be to develop graduates whose professional identity and capabilities are congruent with expected professional competencies and adaptability to complex workplace change. The growing role of information and communications technologies and the multi-dimensional social environments mentioned above are but part of this picture. In addition to the more traditional roles associated with a career as a health professional, opportunities for health science graduates have expanded to include, for example, health related positions in corporate organizations, the area of workers' compensation and health related workplace training and policy development. The expanded career opportunities that have evolved for health professionals also carry with them additional demands in terms of workplace knowledge and skills. These include management skills, skills for functioning effectively in the changing work environments, and teamwork skills for working in partnerships on health related issues in and across workplace contexts with diverse groups. Health care policy changes also continue to have a direct impact on the context in which health care services are provided, the modes of delivery and service delivery systems including evidence-based practice, practice guidelines, professional competencies, a focus on prevention and education, and the expectation of partnerships, linking and sharing.

Impact of the four dimensions of flexibility on learning

These four dimensions of flexibility impact on a professional preparation learning environment which is itself complex. Such programs are particular concerned with both the student context and the professional context. Figure 3 illustrates how these interrelate to impact on learning.

Figure 3

Figure 3: Impact of the four dimensions of flexibility

Implications for curriculum development

Flexibility as presented in the four broad dimensions above must be embedded throughout the curriculum in a systematic, coherent and sustainable manner. Development of generic attributes and attention to flexibility must be clearly linked to profession-specific learning (Figure 4) with the overall picture varying among courses leading to different profession-specific outcomes. This is not the easiest model to implement. In universities, academic content and delivery approaches are often set in a very broad curriculum framework with implementation left entirely to those managing individual units of study or small streams of specialization.

Figure 4

Figure 4: Tripartite Curriculum Development Model

This has implications for overall curriculum planning and management and a franework for action is needed. Eraut, Goad et al (Eraut, Goad, & Smith, 1975 quoted by Everingham & Feletti, 1999) state that a curriculum must be considered as 'the broad pattern or framework within which decisions for curriculum elements are made'. Everingham and Feletti (1999)describe elements which must be considered when managing any curriculum:

These elements interrelate in a complex web which can provide a framework for curriculum action within a specified course structure. This framework can also be used at a larger scale, that of overlapping or inter-related course curricula now required for at least part of any undergraduate health professional preparation curriculum due to decreasing resources and increasing expectations of the multi-professional, multi-disciplinary, multi-cultural health care environment. Developing a framework which supports the management of curriculum coherence, effective and efficient use of resources is thus essential.

It is necessary to facilitate transformative change through curriculum design and implementation (as well as through organizational change as indicated below). Flexibility in teaching and learning may require serious reconceptualisation of time and place, of the locus of control in teaching and learning, and how content and process are interwoven to achieve the three curriculum outcomes indicated in Figure 4. Implications for organizational and professional change Although some may prefer it, the challenges presented in the sections above can no longer be met by each professional preparation program on its own. Consequently, major challenges are faced by university faculties charged with health sciences professional preparation. Related challenges are faced by the professions and employers with whom they are interlinked. We highlight three here:


Preparing students to enter a health sciences profession, or any other profession, has always been a demanding and specialist role for higher education. Flexibility has been conceptualised here in four dimensions to address those demands and set out a framework for curriculum and organisational change. The issues raised here for health professional preparation programs cannot be avoided and must be addressed systematically by higher education. We expect to report further in the future on how one case example at least, the Faculty of Health Sciences at the University of Sydney, achieves the curriculum and organizational change needed to achieve flexible learning for a flexible society.


This work was associated with the Undergraduate Curriculum Reform Project carried out on behalf of the Faculty of Health Sciences, University of Sydney. It draws in particular on an internal discussion paper The Ways Forward: Paper 1 Undergraduate Reform - The Overview by M.J. Mahony, C. Mullavey-O'Byrne, J. Higgs and F. Everingham, part of a Faculty of Health Sciences series of papers on Undergraduate Curricula for Professional Entry of Health Sciences Professionals. The Executive Summary of that paper is available at


Australia. Higher Education Council. (1992). The Quality of Higher Education: Discussion papers. Canberra: Australian Government Publishing Service.

Bates, A. W. (1995). Technology, Open Learning and Distance Education. NY: Routledge.

Bates, A. W. (1997). The impact of technological change on open and distance learning. Distance Education, 18(1), 93-109.

Billing, D. (1998). Quality management and organisational structure in higher education. Journal of Higher Education Policy and Management, 20(2), 139-159.

Cram, L. (2000). Shaping Undergraduate Courses. Internal discussion paper. University of Sydney.

Department of Immigration and Multicultural Affairs. (1999). A New Agenda for Multicultural Australia. Canberra.

Eraut, M., Goad, L., & Smith, G. (1975). Analysis of Curriculum Materials. Brighton, UK: University of Sussex.

Everingham, F. & Feletti, G. (1999). Curriculum management in a changing world: The new imperative. In J. Higgs & H. Edwards (Eds), Educating Beginning Practitioners: Challenges for health professional education (pp. 79-87). Oxford: Butterworth-Heinemann.

Graham, J., & Wealthall, S. (1999). Interdisciplinary education for the health professions: taking the risk for community gain. Focus on Health Professional Education, 1(1), 49-69.

Jevons, F. R. & Northcott, P. (1994). Costs and Quality in Resource-based Learning On- and Off-campus. Canberra: Australian Government Publishing Service.

Katz, R. N. and Associates (Ed). (1999). Dancing with the Devil: Information technology and the new competition in higher education. San Francisco: Jossey-Bass.

Kemp, D. A. (1999). Higher education: Report for the 2000 to 2002 triennium. Department of Education, Training and Youth Affairs, Commonwealth of Australia, Canberra.

Khan, B. H. (Ed) (1997). Web-Based Instruction. Englewood Cliffs, NJ: Educational Technology Publications.

Laurillard, D., & Margetson, D. (1997). Introducing a Flexible Learning Methodology: Discussion paper (Occasional Papers Publications No.7). Brisbane: Griffith University.

Lee, G., Jolly, N., Gelonesi, B., & Kench, P. (2000). First Year Experience in the Faculty of Health Sciences: Report of the 1997 survey (Internal paper ). Lidcombe, NSW: Faculty of Health Sciences, The University of Sydney.

Taylor, I. (1997). Developing Learning in Professional Education: Partnerships for practice. Buckingham, UK: Society for Research into Higher Education & Open University Press.

University of Sydney (1999). Academic Board Statement on Flexible, Student-centred Learning in the University of Sydney.

World Health Organisation (1988). Learning Together to Work Together for Health (Technical Report Series 769). Geneva: World Health Organisation.


  1. Bachelor of Applied Sciences (in the areas of Exercise and Sport Science, Health Information Management, Leisure and Health; Bachelor of Health Science (in the areas of Aboriginal Health and Community Development, Hearing and Speech, Rehabilitation Counselling), Bachelor of Behavioural Health Science and Diploma of Health Science (in the area of Aboriginal Health and Community Development). The Faculty also offers a number of courses in Singapore in association with the Singapore Institute of Management, and at its Sydney campus which are tailored conversion to degree courses for Singaporean health science qualifications.

  2. 'Constructive alignment' (Biggs, 1996) is more often used within a curriculum to ensure that objectives, teaching/learning activities and assessment are aligned to achieved an agreed outcome. The concept is extendable to the alignment of specific curricula with the larger goals of Faculty, University and the professions.
Contact details: Dr Mary Jane Mahony, Faculty of Health Sciences, University of Sydney
Phone +61 2 9351 9754 Fax +61 2 9351 9649 Email

Please cite as: Mahony, M. J., Mullavey-O'Byrne, C., Higgs, J. and Everingham, F. (2001). Multiple dimensions of flexibility in health sciences professional preparation programs: Challenges for curriculum development and organizational change. In L. Richardson and J. Lidstone (Eds), Flexible Learning for a Flexible Society, 460-469. Proceedings of ASET-HERDSA 2000 Conference, Toowoomba, Qld, 2-5 July 2000. ASET and HERDSA.

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