Practice-Based Competency Outcomes

One trend that has a powerful influence on nursing education and practice at all levels is the emphasis on competency outcomes and criteria that establish realistic expectations for clinical practice (Cronenwett et al, 2007; Lenburg et al, 2009; NCSBN, 2006). The NONPF has developed one set of core competencies for all graduating nurse practitioners (NONPF, 2012) Competency outcomes, with related criteria (critical elements), specify expected results, the destination students need to reach; they are the measurable results of time and effort spent in learning. The ability to implement realistic practice-based abilities competently therefore is the essential outcome; competence is the target, the endpoint to be reached, the purpose of study and education. The related interactive learning strategies are the road map, the means for getting there; the subsequent performance-based assessments confirm that students have arrived at the right place: They are competent for practice (Lenburg et al, 2009). The ability of graduates in practice is the proof (Candela and Bowles, 2008; Pellico, Brewer, and Kovner, 2009).

The outcomes approach requires a mental shift from trying to memorize voluminous readings and class notes (resulting in frustration and the attitude of “just tell me what I need to know”) to actually learning to think like a nurse, to integrate information in problem solving and decision making and providing competent patient care (DiVito-Thomas, 2005). Typical objectives begin with words like describe, discuss, list, or recognize; they are directions for learning, not what nurses do. Outcomes convert the meaning of the content objectives to actions that nurses actually do, such as implement, integrate, plan, or conduct. This change in approach can be confusing at first, but by achieving the end-results/outcomes, students are more prepared to meet the competency expectations of nursing practice with more confidence and success (Glennon, 2006; Klein, 2006). Unprepared new nurses experience stress and frustration in the workplace and require longer orientations and internships to help them gain necessary skills and confidence (Boyer, 2008; Candela and Bowles, 2008).

Accrediting and certifying organizations must mandate demonstrated mastery of skills, managerial competencies, and professional development at all levels (Institute of Medicine [IOM], 2012; NONPF, 2012). Explore the websites in Table 3-2 for the most current information on groups concerned with accreditation, licensure, certification, and practice issues.

Validation of competencies often causes anxiety and stress in some students, faculty, nurses, and others, but they are a major incentive to promote patient safety and effective care (Bargagliotti et al, 1999). Practice competencies to promote patient safety have been studied extensively by nurses and physicians under federal auspices; see the 2000 report on the website: http://bhpr.hrsa.gov/nursing/nacnep/reports/first/2.htm, and click on the link Collaborative Education to Ensure Patient Safety. In response to the Institute of Medicine report (IOM, 2000), Finkelman and Kenner’s (2009) book promotes implementation of the recommendations in nursing education. The Robert Wood Johnson Foundation funded a national initiative, Quality and Safety in Nursing Education (QSEN), to help nursing programs reorganize curricula to focus on patient safety and quality care (Cronenwett et al, 2007). Lenburg’s Competency Outcomes and Performance Assessment (COPA) model has been used since the early 1990s (Lenburg, 1999, 2009; Lenburg et al, 2011). Additionally, as the populous becomes more diverse, the importance of evaluation of cultural competence cannot be overlooked (Waite and Calamaro, 2010). These and other efforts focus on the imperative to improve competency outcomes to promote patient safety.

Performance-Based Learning and Assessment

Trends related to learning and evaluation methods are changing fundamentally, due in part to changing technology and the increased focus on patient safety. The emphasis on competency outcomes and criteria for acceptable practice has prompted leaders in nursing education to promote innovative programs and learning methods (IOM, 2012) as well as more interactivity and engagement interspersed with lectures. Passively listening, reading, and passing written tests does not necessarily promote competence in the core performance skills expected in practice. Increased emphasis on critical thinking and learning to integrate principles is more effective than trying to remember “all the content,” which often leads students to retreat and just want to pass the test. Competency-based learning creates an entirely different atmosphere that is focused on learning concepts and encourages collaboration between teacher and learner to achieve actual practice competencies (Lasater and Nielsen, 2009).

Practice-based competence uses terms like interactive learning, collaborative learning, and competency-based learning. This trend requires changes in the roles of teachers and students. The teacher is less a “lecturer” and more a facilitator and coach, providing direction for learning stated outcomes; the student is more actively accountable and responsible for achieving competence in designated knowledge and practice skills. The question is: What are the most effective ways to learn such actual performance skills as assessment, communication, critical thinking, and patient teaching? Listening to lectures and reading is less effective than active engagement and application in real practice situations. Performance skills are learned more effectively through participation in interactive strategies (Clayton and Dilley, 2009; Lenburg et al, 2009). In this new paradigm, instructors focus on the most essential content; create practice-based case studies and simulations; and set the stage for students to engage in problem solving, critical thinking, and integration of concepts, knowledge, and evidence-based practice (Horan, 2009). They provide feedback and validation that cannot be gained through books or the Internet. Memorization of basic facts is still important, but it is insufficient when nursing practice emphasizes skills, such as assessment, critical thinking, communication, patient teaching, caring, and advocating for patients. The focus on practice competence helps students learn how to access and integrate ever-changing information as required in actual practice, rather than trying to remember “all the content.” Learning to access and use digital resources on mobile devices has been found to be more effective when introduced early into the nursing curriculum and embedded throughout the program (Zurmehly, 2010). Additionally, technology has become integrated into our lives, both personally and professionally, so much that academic environments need to incorporate various technologies into distance education programs in an effort to assist students to become effective health care providers (Jones and Wolf, 2010).

Many nurse leaders cite critical thinking skills and implementation of evidence-based practice as the most fundamental skills for competent practice. Tanner (2000) emphasizes that this is not the nursing process, as some think. del Bueno (2005) writes about the crisis in the lack of critical thinking in nursing practice. New partnerships with agency staff are designed to promote clinical learning and how to think like a nurse (MacIntyre et al, 2009). A recent systematic review of 12 studies on simulation found that six of the studies found gains in critical thinking skills through the use of simulation (Cant and Cooper, 2010). Critical thinking is an essential part of applying evidence-based practice, using research findings to guide actual practice (Ireland, 2008).

A trend in many programs is the development of study tracks or majors in evidence-based practice, such as the one implemented by Arizona State University in 2006 (www.asu.edu/graduate/studies/asucert.html). The Academic Center for Evidence-Based Practice (ACE) at the University of Texas San Antonio, which was developed as a center for excellence (http://www.acestar.uthscsa.edu/), provides up-to-date information about evidence-based practice. Additionally, many other universities have developed evidence-based practice centers. In 1997, the Agency for Healthcare Research and Quality (AHRQ) developed an evidence-based practice center program (http://www.ahrq.gov/clinic/epc/).

Simulation, in various forms, is another major performance-based learning strategy. Mannequins have become more essential and incorporate sophisticated computerization to promote more realistic learning and critical thinking (Bruce et al, 2009; Hawkins et al, 2008; Horan, 2009; Rush et al, 2008; Smith-Stoner, 2009a; Wagner et al, 2009). Another form of simulation is the use of standardized patients and telemedicine technology to achieve outcomes. More recently, faculty are using web-based broadcast of simulations to increase learning (Smith-Stoner, 2009b). Cited within a systematic review (Cant and Cooper, 2010), the Objective Structured Clinical Examinations (OSCEs) are the most valid assessment measurement. These authors assert that more studies are needed that use the OSCE as an evaluation measure. Other interactive learning strategies include portfolio learning (Norris et al, 2012) and peer-to-peer learning (Robinson and Niemer, 2010). Higgins (2006) describes how peer teaching helps students at risk. Skiba (2009) describes and evaluates new learning technology methods in each issue of Nursing Education Perspectives.

Interactive strategies are even more important when the location of clinical learning is considered. More and more diverse settings are used because these are places where nurses’ expertise is needed. In addition to hospitals and extended care facilities, clinical learning often takes place in alternative settings, such as nurse-run clinics in schools, daycare and senior centers, and prisons (Kirkham et al, 2005). Over the past decade, service-learning projects have also helped students learn actual practice skills throughout the community (Bentley and Ellison, 2007; Clayton and Dilley, 2009; Hunt, 2007). Another form is faith-based learning projects with nurses in churches and congregations (Brendtro and Leuning, 2000; Kotecki, 2002). Many interactive clinical-related learning strategies and more traditional clinical assignments increasingly engage practicing nurses as preceptors (Murray, 2007; Wieland et al, 2007).

The change to competency outcomes and practice-based learning requires changes in evaluation methods that focus on valid, actual performance of required competencies in realistic scenarios; paper-and-pencil tests and inconsistent subjective clinical observations by instructors or preceptors are not adequate. Structured, objective validation of competence requires performance examinations that specify the core skills and related critical elements (the application of mandatory principles) that must be met according to established practice standards (Boyer, 2008; Lenburg et al, 2009; Rentschler et al, 2007). In addition to performance of nursing skills, structured portfolios are used to document other competencies (Norris et al, 2012).

Needless to say, this more interactive approach in clinical and classroom courses is difficult for some students and creates issues; faculty and students have to change traditional habits and expectations of each other. Sometimes students think it is easier just to figure out “what the teacher wants” and “study for the test” rather than engage in learning to think and integrate best practices through teacher-assisted interactive exercises. Such exercises, however, help students learn to make effective decisions, and to collaborate in the group process, and manage time and resources. It may cause some anxiety, but performance examinations that require 100% accuracy of the mandatory critical elements (principles) provide more reliable evidence of practice competencies (Boyer, 2008; Lenburg et al, 2009). This kind of competence is what consumers need, employers expect, and practitioners must deliver. The increase in reported medical-related errors vividly emphasizes the need for more effective validation of performance competence in schools and the workplace (Boyer, 2008; IOM, 2000; Finkelman and Kenner, 2009).