Examining Competencies in Nursing
Susan Sportsman, PhD, RN, ANEF, FAAN Managing Director Collaborative Momentum Consulting
What makes a competent nurse? Over the last fifty years, as nursing developed as a profession, leaders in education and practice have worked diligently to articulate standards of practice. The intention is to provide clarity to the public and other healthcare providers regarding the roles and responsibilities of professional nurses. These standards have consistently incorporated the Nursing Process and care for patients with acute and chronic disease processes. However, from a practical perspective, when a nurse’s competence was judged, their ability to safely perform psychomotor skills influenced the perception of their competence. Because the behaviors required for psychomotor intervention could be readily observed, employers and the public used proficiency in this area as a marker of a competent nurse. Can the RN start and maintain an intravenous infusion? Can the RN insert a foley catheter, without contaminating the sterile field? The emphasis on psychomotor skills often plagued new graduates who might not have had sufficient opportunities to practice certain skills. More experienced nurses also had these challenges if they were called upon to perform a skill that was not commonly required in their particular practice setting. This dilemma often raised questions such as, “If I lack experience in a particular skill, or if I have not performed the skill recently, does this mean that I am not a competent nurse?”
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Movement to Competency- Based Education in Nursing
Competency in psychomotor skills continues to be important in the twenty-first century. However, over time, the roles and responsibilities of the nurse expanded to 1) require integration of principles of science and art into the practice of nursing, 2) application of theories and models to guide the assessment, planning, interventions, and evaluation of a healthcare problem, and 3) the impact of the environment on concepts, traditions, policies, and relationships that are a part of care delivery. As the healthcare environment grew exponentially, nursing stakeholders increasingly expected all students at the time of their graduation to demonstrate the ability not only “to know” but also “to do” based on current knowledge. (AACN, 2021) These expectations led nurse educators and other nurse leaders to move toward the idea of a competency-based approach to nursing education.
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Definitions of Competency Competency is a complex concept, and it is essential to establish clear definitions to help students and nurse educators build and navigate a framework to develop competencies. The table below provides some of those definitions.
Table A: Definition of Terms
CONCEPT
DEFINITION
Competent
Having the necessary ability, knowledge, or skill to do something successfully according to some approved standard.
Competency (ies)
An important skill that is needed to do a job.
As nurse educators consider strategies to ensure graduating students have the necessary knowledge, skills, and attitudes to enter the nursing workforce, the definitions below from Benner’s “From Novice to Expert” model
provide a framework for evaluating competence. Table B: Benner’s Stages of Nursing Competence
STAGE
DEFINITION
Stage I: Novice
A nursing student in the first year of clinical education. § Behavior in the clinical setting is very inflexible, with a very limited ability to predict what might happen in a particular patient situation. Nursing graduates in their first job. § They have had sufficient experience to enable them to recognize recurrent, meaningful components of a situation. They have the knowledge and the know-how, but not enough in-depth experience.
Stage 2: Advanced Beginner
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Table B: Benner’s Stages of Nursing Competence - Continued
STAGE
DEFINITION
Stage 3: Competent
These nurses lack the speed and flexibility of proficient nursing, but they have some mastery and can rely on advance planning and organizational skills. § Competent nurses recognize patterns and nature of clinical situations more quickly and accurately than advanced beginners. Nurses who are capable to see situations as “wholes” rather than parts. § Proficient nurses learn from experience what events typically occur and are able to modify plans in response to different events. Nurses who are able to recognize demands and resources in situations and attain their goals. § These nurses know what needs to be done. § They no longer rely solely on rules to guide their actions under certain situations. § They have an intuitive grasp of the situation based on their deep knowledge and experience. § Focus is on the most relevant problems and not irrelevant ones. § Analytical tools are used only when they have no experience with an event, or when events do not occur as expected.
Stage 4: Proficient
Stage 5: Expert
(Benner, 2000)
Definition of Competency-Based Education 3. Definitions of competence alone are not sufficient for nurse educators to develop strategies to teach and evaluate students using competency-based education principles. Competency-based education has been used in a variety of educational programs for the last 40 years. The Education Commission of the States defines this type of education as a strategy that combines an intentional and transparent approach to curricular design with an academic model in which the time it takes to demonstrate competencies varies and the expectations about learning are held constant. Students acquire and demonstrate their knowledge and skills by engaging in learning exercises, activities and experiences that align with clearly defined programmatic outcomes. Students receive proactive guidance and support from instructors and earn credentials by demonstrating mastery through multiple forms of assessment, often at a personalized pace. (https://www.ecs.org/wp-content/uploads/CBE-Toolkit-2017.pdf). Similarly, different groups, including the U.S. Department of Education, define competency-based education as education “that organizes academic content according to competencies—what a student knows and can do—rather than following a more traditional scheme, such as by course.” (AACN, 2023)
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The Essentials: The Core Competencies for Professional Nursing Education 4. The American Association of Colleges of Nursing (AACN) describes competency-based education more broadly than the definitions above. The AACN defines competency-based education as “ a system of instruction, assessment, feedback, self-reflection, and academic reporting that is based on students demonstrating that they have learned the knowledge, attitudes, motivations, self-perceptions, and skills expected of them as they progress through their education.” This broader definition does not require students to move through the content based solely on their ability to demonstrate specific competences. Instead, the assessment of competence may be integrated into specific courses. (AACN, 2021) In addition, Giddens, et al. (2023) set forth four statements which provide a description of a competency, as follows: A Competency: § Provides a set of expectations which, when taken collectively, demonstrate what learners can do with what they know. § Represents clear expectations made explicit to learners, teachers, employers, and the public. § Is visibly demonstrated and assessed over time in different contexts and settings. § Crosses all areas of professional nursing practice. In 2021, in response to the need to prepare nursing students at the BSN level, including RN to BSN students, and various Advanced Practice roles, the AACN developed The Essentials: Core Competencies for Professional Nursing Education. The Essentials serve as a developmental framework as students move through increasing education and experience. The Domains 1. Knowledge for Nursing Practice 2. Person-Centered Care 3. Population Health 4. Scholarship for Nursing Discipline 5. Quality and Safety 6. Interprofessional Partnerships 7. Systems-Based Practice 8. Informatics and Healthcare Technologies 9. Professionalism 10. Personal, Professional, and Leadership Development The ten domains above represent the unique essence of professional nursing practice, including the diversity of practice that may be required in multiple settings available to nurses. Competencies categorized in each domain are designed to be applicable across the lifespan and with diverse patient populations in four spheres of care: § Disease Prevention/Promotion of Health and Well-being § Chronic Disease Care
§ Regenerative or Restorative Care § Hospice/Palliative/Supportive Care
Each domain outlines several competencies appropriate for both entry-level Professional Nursing Practice (BSN, RN-to-BSN) and Advanced-Level Nursing Education. Each of the competencies also lists sub-concepts that further delineate the actions required in each competency. (AACN, 2021) Eight concepts, important in all nursing practice, are integrated in all of the domains. These concepts are:
§ Clinical Judgment § Communication § Compassionate Care § Diversity, Equity, and Inclusion
§ Ethics § Evidence-Based Practice § Health Policy § Social Determinates of Health
(AACN, 2021)
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Impact of Competency-Based Education for Current Nursing Educators 5. The AACN recognizes that transitioning to a competency-based approach, regardless of whether programs integrate this approach into a course-based framework or allow students to progress through the curriculum as they develop specific competencies, may require up to three years to fully implement. Certainly, BSN, RN-to-BSN, and Advanced Practice Nurse programs planning for CCNE accreditation will want to begin the process of integrating competence into their curriculum and evaluation process. Given the emphasis on documentation of competence in all health care professionals, other nursing programs may also want to consider ways to identify necessary competencies. The use of active teaching-learning strategies for these competencies and measures to evaluate student performance over time in a variety of clinical contexts is also important for all nursing curricula. Consider the following as possible strategies to move toward developing a competency-based framework for your nursing program. Step 1: Faculty as a whole: Explore the principles of competency-based education, using resources recommended below and discuss ways in which this approach would be helpful to students in the nursing program. Step 2: Faculty as a whole or Faculty Committee: Compare current Program Goals/Student Learning Outcomes (SLOs) to the AACN Essentials (domains, competencies, and sub-competencies). Integrate competencies (or sub- competencies) into these goals/outcomes as appropriate. Identify the competencies which the group believes are essential for an advanced beginner. Be sure that the competencies clearly articulate the behaviors students should demonstrate. Each program goal/SLO should reflect at least one of the domains and related competencies. Step 3: Course Faculty: Review course objectives to ensure that they are consistent with Program Goals/SLOs. Revise course objectives, as necessary. Tagging each objective with the number of the relevant program goals/SLOs is helpful to document the integration of core competencies throughout the curriculum (https://www.aacnnursing. org/essentials/database ). Step 4: Course Faculty: Plan active learning strategies throughout class and clinical experiences where students can develop skills in identified competencies. The AACN Interactive Teaching Resource Database may be helpful here. ( https://www.aacnnursing.org/essentials/database ) Step 5: Course Faculty: Construct evaluation methods for each competency to effectively capture the level of competency of each student. Step 6: Course Faculty: Map the Program Goals/ SLOs, course objectives, teaching learning activities, and evaluation strategies, using the AACN Essentials Curriculum Mapping Tools ( https://www.aacnnursing.org/essentials/tool-kit/ curriculum-mapping-tools). Step 7: Course Faculty/Evaluation Committee: Continue to evaluate effectiveness of the competency-based curriculum in terms of student performance during the program and after graduation. Step 8: Faculty as a whole: Engage with current and new practice partners to strategize, plan, and implement the new Essentials. (https://www.aacnnursing.org/Portals/0/PDFs/Essentials/Roadmap-to-New-Essentials.pdf )
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The AACN has provided a number of resources to help nursing faculty as they move through this development process. The chart below outlines relevant resources.
COMPETENCY-BASED EDUCATION RESOURCES
AACN Resources § AACN (2021) Understanding the Re-Envisioned Essentials: A RoadMap for the Transformation of Nursing Education. (https://www.aacnnursing.org/Portals/0/PDFs/Essentials/Roadmap-to-New-Essentials.pdf) § What is Competency-Based Education? (https://www.aacnnursing.org/essentials/tool-kit/competency- based-education) § Essentials Resources: (https://www.aacnnursing.org/essentials) § Teaching Resource Tool (Interactive): (https://www.aacnnursing.org/essentials/database) § Domains & Concepts: (https://www.aacnnursing.org/essentials/tool-kit/domains-concepts) § Curriculum Mapping Tools: (https://www.aacnnursing.org/essentials/tool-kit/curriculum-mapping-tools) § Frequently Asked Questions: (https://www.aacnnursing.org/essentials/tool-kit/faqs) § Video Gallery: (https://www.aacnnursing.org/essentials/tool-kit/gallery-of-leadership) § Webinars: (https://www.aacnnursing.org/essentials/webinars-programs) Journal Articles § Giddens, J., Douglas, J., Conroy, S. (2022) The Revised AACN Essentials: Implications for Nursing. Journal of Nursing Regulations. 12(4) 16-22. January. https://www.sciencedirect.com/science/article/abs/pii/ S2155825622000096 § Lewis, L., Rebeschi, L., Hunt, E. (2022) Nursing Education Practice Update 2022: Competency-Based Education in Nursing. Sage Open Nursing, 2022. November. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9685206/
The process of developing a competency-based curriculum is not a simple task. This endeavor requires understanding the principles of the competency approach. However, students who graduate from such programs may find themselves better prepared for the practice arena at the time of their graduation.
About the author Susan Sportsman, PhD, RN, ANEF, FAAN , is a nationally recognized speaker and consultant with over 10 years of consulting experience, providing program development and other consultation services to nursing and health professions programs throughout the United States and Canada. Previously, she served as Dean of the College of Health Sciences and Human Services at Midwestern State University in Wichita Falls, Texas.
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References The Essentials: Core Competencies for Professional Nursing Education, a publication owned by the American Association of Colleges of Nursing. A full copy of The Essentials and the terms and conditions for downloading can be found at https://www.aacnnursing.org/Essentials/Download-Order. American Association of Colleges of Nursing, (2023) The Essentials: Core Competencies for Professional Nursing Education Frequently Asked Questions. Updated, November 2023. Accessed 2024. Benner, P. (2000) From Novice to Expert . Prentice Hall: Health. Giddens, J., Stanley, J., Corbridge, S. (2023) The 2021 AACN Essentials. Presentation to the National Advisory Council on Nurse Education and Practice. February 3rd. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/community-based-linkages/meetings/aacn-cbe-es - sentials-staley-corbridge-winn-nacnep-020323.pdf . Accessed 2023 Strategy Labs: State Policy to Increase Higher Education. (2023) Understanding Competence Based Education Tool Kit. StrategyLab.LuminaFoun - dation.org. Education Commission of the States https://www.ecs.org/wp-content/uploads/CBE-Toolkit-2017.pdf . Accessed 2023. © F.A. Davis
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