Competent performance by health care professionals is expected throughout society. However, defining what it is and teaching students how to perform competently faces many challenges. This article provides a brief overview of the contemporary focus on competency assessment in nursing education. The redesigned nursing curriculum at the University of Colorado is presented as an exemplar of a practice-oriented model that requires competent performance among students. Methods for implementing a competency-based curriculum and lessons learned during the process are discussed.
Key Words: Nursing competencies, Competency assessment, nursing education, student assessment
Background
Increased accountability has become a common theme in contemporary society. In the public marketplace, the theme of "let the buyer beware" has been replaced with the philosophy of "excellence is defined by the customer." This perspective has general application across all types of industries. When the "public good" relates to education or health care, standards of acceptable performance are clearly defined by regulatory and professional bodies and society holds practitioners fully accountable when performance is unacceptable or questionable. Whether the focus is on public officials, health care professionals, or educators, the expectation is that standards of acceptable performance will be adhered to and the public trust will be safeguarded. Operationally defining acceptable, competent performance is one of the most challenging and essential components in this accountability paradigm.
Those in nursing education face many challenges. Students approach the learning institution with the assumption that they will be taught the requisite knowledge and skills to become competent nurses. Employers of nursing graduates assume that the nursing degree and the state licensure certify competent performance. Many definitional and methodological issues evolve from these assumptions. The social mandate for accountability, however, does not tolerate ambiguous assumptions or debate. While the assessment of competent practice in the service sector has received considerable attention the past 25 years, the implementation of competency assessment models in nursing education has moved at a much slower pace.
Purpose
The purpose of this paper is to examine selected assessment methods designed to accurately document competence within the context of escalating and changing needs in education and practice. The University of Colorado School of Nursing (CU-SON) is currently in the process of implementing a competency-based, outcomes-focused curriculum in its four nursing education programs: baccalaureate (BS), master's (MS), nursing doctorate (ND), and doctor of philosophy (PhD) programs. The Colorado experience described in this article serves as an exemplar for rationale, methods, and process used to develop and implement a practice-oriented model to promote competence among students and practitioners. The methods used in this comprehensive transition provide examples that can be adapted by others in education and practice settings.
Focus On Competencies in Education and Practice
Multiple requirements for competent nursing practice in the health care system have been established by national associations and agencies. These include the American Nurses Association, the American Association of Critical Care Nurses' Standards for Nursing Care of the Critically Ill and their Education Standards for Critical Care Nursing (Alspach, 1992). The Joint Commission for Accreditation of health care Organizations requires that clinical competence be assessed for all nursing staff and holds institutional leaders accountable for ensuring that competency of all staff is assessed, maintained, demonstrated, and continually improved (JCAHO, 1999).
The legal and financial implications of employee performance and safe practice in a rapidly changing practice environment make continuing professional competence a major concern for all providers and health care organizations. Stressing the importance of assessing what employees can do, not what they know, del Bueno describes the commonly known gap between excellent test takers who have difficulty performing a procedure or recognizing warning signs in a patient experiencing difficulty. The use of criterion-based performance measures determines practice competencies in employees as well as identifies where need exists to correct skill or knowledge deficiencies (del Bueno, Weeks, & Brown-Stewart, 1987).
Competency assessment is always outcome oriented; the goal is to evaluate performance for the effective application of knowledge and skill in the practice setting. Competency assessment techniques address psychomotor, cognitive, and affective domains. Competencies can be generic to clinical practice in any setting, specific to a clinical specialty, basic or advanced (Benner, 1982; Gurvis & Grey, 1995).
Competency-based education has been found to be equally effective in both didactic and self-learning approaches (Lenburg, 1990; Schlomer, Anderson, & Shaw, 1997). Alspach (1984) presents hallmarks of competency-based education that make them applicable both in practice and in educational settings. These include competencies based on validation of what performance by competent practitioners actually comprises. In addition, competency assessment is based on criterion-referenced evaluation methods where the learner's performance is evaluated against a set of criteria provided to the learner so that both the learner and the assessor are clear on what performance is required. Finally, competency-based education is learner-centered in that outcomes are specified and describe what the learner must do to demonstrate competency.
Masson & Fain (1997) discuss the value of a competency-based system in cross-training, which is commonly used in today's cost-containment environment. They illustrate the effectiveness of a comprehensive system of competency validation for long-term staff, orientees, and nursing students.
Del Bueno reports it took approximately eight months of clinical experience before new BSN graduates felt confident and competent in their clinical judgments. Given the array of individual differences in nursing performance, she recommends that employers and educators assess competencies before assigning nurses to practice settings or advancing them in educational programs (del Bueno, 1990).
| While examples of competency-based assessment are more prevalent in the nursing practice literature, limited examples can be found in the nursing education literature as well.
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The CU-SON Example: The Driving Forces for Curriculum Redesign
Over the past two years, the University of Colorado School of Nursing (CU-SON) has undergone a number of major changes. Some of these changes were driven by dynamics in the educational marketplace and some were the result of major organizational changes underway within the School. The CU-SON celebrated its centennial in 1997-98. This celebration resulted in retrospection about the major contributions the School has made to nursing practice and education as well as stimulated discussion around how the School would chart its future course. As the birthplace of the nurse practitioner movement in the 1960s and the caring science of Watson in the 1970s, the School has made major national and international contributions to both practice and education. In addition, the School has long been a pioneer in distance education, providing educational opportunities to Colorado residents in rural areas of the state for approximately 25 years. Initially, faculty and programs were sent to remote areas of the state. As technology advanced, interactive video was used to provide educational opportunities. The School began to use web-based technologies around 1995 as that technology became available. During the Centennial review of past accomplishments, however, it became apparent that these traditions of excellence and pioneering endeavors at CU-SON were not sufficient to deal with the changes needed now to face the uncertain and challenging future.
In 1997, the University of Colorado School of Nursing held a series of focus groups with various stakeholders in response to expressions of increased dissatisfaction around a number of issues. These stakeholders included employers of CU-SON graduates, alumni, and students currently enrolled in one of the various education programs. Employers thought that graduates often were lacking in competencies in many areas needed for practice in the contemporary clinical environment, such as critical thinking, problem solving, communication and effective assertiveness. They also cited deficiencies in computer-related skills required to use the clinical information systems found in the clinical setting. In addition, they stated that graduates often were deficient in working with data and evaluating cost-effective alternatives required for practice in the evidence-based clinical world. Employers face increasing difficulties in helping the graduates make the transition from student to clinician. From the graduates' perspective, they felt unprepared for entry-level competencies needed to practice in the diverse settings they moved into following graduation. Students, as stakeholders, also felt that many aspects of the educational programs were not learner-centered.
Curriculum Redesign
In response to the focus group findings, the faculty decided that fundamental change in the curriculum was needed. They developed a set of guiding principles to provide direction for curriculum redesign which are presented in Table 1. To meet the needs of stakeholders, it was essential that graduates have the expected competencies to move into the practice world, regardless of setting. To meet the demands of the competitive marketplace, accessible programs with an "anytime, anywhere" capability were viewed as the ideal. The goal of modular, flexible learning opportunities was viewed as essential for increased efficiency and effectiveness; students would only take those modules needed to meet program requirements and not repeat content after competencies were demonstrated. Use of available and evolving technologies and virtual learning resources was considered essential to enhance both learning and delivery of courses. And finally, the faculty affirmed that the core values that had become a standard of excellence of the CU-SON were foundational in the redesign process.
| Table 1. Guiding Principles for Curriculum Redesign. |
| The redesigned curriculum at the University of Colorado School of Nursing will be:
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The faculty selected the Competency Outcomes and Performance Assessment (COPA) Model, designed by Dr. Carrie Lenburg, as the most effective framework for addressing both the competency-based focus as well as the educational methodologies essential for undertaking the curriculum redesign. Dr. Lenburg was retained as a long-term consultant for ongoing guidance in this extensive redesign and implementation effort. Her COPA Model provides a framework for the concepts and methods essential to competency assessment. Eight core practice competencies in the COPA Model are: assessment and intervention, communication, critical thinking, teaching, human caring relationships, management, leadership, and knowledge integration. The COPA Model is applicable for documenting either initial or continuing competence and can be applied to a diverse array of practice environments (Lenburg, 1979; Lenburg & Mitchell, 1991).
The curriculum redesign has resulted in a unique approach to nursing education at the undergraduate and graduate levels. One conceptual framework and curriculum has been implemented in all degree programs: baccalaureate, master's, nursing doctorate, and the doctor of philosophy. Ten specific competency-based outcomes, listed in Table 2, have been identified for the curriculum. These competency-based outcomes focus on education and social change abilities, including: competent effective reflective practice; generation of nursing knowledge, and leadership and social change for improved health for individuals, communities, populations, and global environments. This single set of outcomes applies to all four degree programs; each outcome, however, is operationalized specifically to fit the expectations for graduates from each particular program.
| Table 2. Competency-based Curriculum Outcomes for all Educational Programs
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By the completion of the nursing program, students will be able to incorporate competencies, knowledge, and values for direct and indirect provider roles to:
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Research competencies in each program provide an example of how leveling is implemented. The basic nursing research course is taken in the first or junior year of the upper division baccalaureate program. In the basic course students develop beginning competencies in understanding and evaluating research findings that have implications for their practice. These competencies are refined in their second year. At the MS level, students develop competencies in evaluating the strength of research evidence to make informed decisions in practice and synthesizing pertinent research literature into practice guidelines and protocols. At the Ph.D. level, students develop competencies in designing and conducting research studies that will contribute to the development and dissemination of knowledge to guide clinical practice.
The curricular framework incorporates evidence-based, theory-guided critical thinking and core practice competencies that focus on: respect for diversity and culture; relationship-centered caring; and social justice and responsibility. The curricular framework is based on the foundation of reflective nursing practice and concentrates on four practice/inquiry foci: the human experience of health-illness-healing; the human/technology interface; environmental context of health and health care; and quality and cost-effective outcomes. These foci reflect scholarship programs of the faculty and are included in all nursing programs.
Implementation of Competency Assessment in the Curriculum
Since 1998, faculty have been actively and continuously engaged in the process of redesigning the entire curriculum in all four programs to implement the competency-based outcome focused curriculum. Each course is reviewed for conversion to the competency-based model. In some cases an entirely new course is developed rather than conversion of an existing one. The familiar traditional behavioral objectives are replaced with "outcome competencies" in each course and module. Learners are oriented at the beginning of the course to the specific outcome competencies and requirements they are expected to acquire, and how they will be evaluated.
Two Assessment Methods
Two methods are used to assess competence in learners. Competency Performance Assessments (CPAs) are used to assess all class assignments that have consequences for the course grade, such as papers, projects, participation and presentations. Competency Performance Examinations (CPEs) are used in clinical situations to evaluate clinical outcomes. Both CPAs and CPEs are comprised of critical elements that collectively define competence for particular skills or abilities. Critical elements are single, discrete, observable behaviors that are mandatory for the specific competencies being evaluated. They specify exactly what is required for acceptable performance in clinical and non-clinical courses; the course grade is based on this pre-determined foundation.
Faculty, who are clinical experts, work in collaboration with colleagues in practice settings to specify the critical elements for CPEs and CPAs. Approximately 30 % of the faculty are active practitioners who participate in the School's faculty practice plan and teach in one or more of the educational programs. These faculty provided essential input in defining the competencies essential for practice in different settings. In addition, designated "clinical scholars" from clinical agencies affiliated with CU-SON became active participants in the process of defining outcome competencies for all students. All faculty participated in these curriculum redesign to address how these competencies might be learned and assessed.
| Learners in each course are oriented to the specific competency outcomes ...
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The advanced health assessment course required in the MS and ND programs provides an example of what the faculty wanted to accomplish in the redesigned curriculum, given the guiding principles described above. The graduate level course consists of a series of modules, each one credit, which are available to students in both the MS & ND programs. The modules cover core assessment concepts, and one or more of the following specialty areas: adult, geriatric, women's, children's, newborn, and prenatal assessment. Students complete only those modules necessary for their specialty option requirements. Entry level competencies have been set for each module. Any student who has completed the content of a required module at another point in their education, or has had extensive clinical practice in that area, or has completed a continuing education program on that content may demonstrate their competency by completing the designated clinical performance examination (CPE). If successful, that student has met the competency requirements for that module and may progress on to a subsequent requirement. Students who are deficient in basic health assessment knowledge and techniques are urged to complete an intensive basic assessment module and demonstrate competency before beginning the advanced modules. This enhances their ultimate success, confidence and competence.
Students taking Advanced Health Assessment complete the didactic portions of the various modules in a web-based format. They also have the opportunity to attend lab sessions where they can demonstrate assessment techniques, ask questions of supervising lab faculty, practice particular techniques and demonstrate their proficiency with faculty direction. At various points, testing situations are required and students are presented with a focused clinical scenario and evaluated using the designated CPE and related critical elements. Results of the completed CPEs are part of the official course records, just as any other test result or grade. Specific evaluation comments, therefore, must be written to withstand legal scrutiny. The faculty established the policy that a failed CPE may be repeated only once. Students cannot advance into a subsequent assessment module until they have demonstrated proficiency for prerequisite competencies necessary for entry into that module.
Although still in the early implementation phase, this competency-based approach has worked well to date. All enrolled graduate students in both the ND and MS programs are required to complete the modules appropriate to their specialization. In addition, nurses who are seeking prescriptive authority from the State of Colorado Board of Nursing enroll in the appropriate modules if they are deficient in the advanced assessment requirements. This can be done on a continuing education basis or as an enrolled post-MS certificate student. Some health care agencies are considering contracting for various modules for their staff as a means to acquire required competencies for incorporation into practice in the agency. Regardless of the purpose for taking the modules, learners are required to pass the designated CPEs and/or CPAs.
Lessons Learned
| The experience with the competency-based curriculum at CU-SON over the past 15-18 months has been very positive, although not without numerous challenges.
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The curriculum committee has provided oversight through review of every course in all programs, whether on campus or web-based. This has been an ongoing process as courses are revised and new courses designed. Each course is reviewed from the competency-based perspective, including review of competency outcomes, interactive learning strategies, and the CPEs and CPAs proposed for that course. In addition, each course is reviewed for its relationship to the overall mission, philosophy, conceptual framework, and program outcomes for the unified curriculum. This process promotes internal consistency essential to the overall success of the school and its graduates.
The syllabus for every course uses a template that includes a standard set of definitions, explanations, and other information related to competency-based approaches and methods. This insures that students are continuously reminded of the performance expectations required for the course within the context of contemporary practice.
The redesign also has required the development of a new evaluation plan for the curriculum. This includes new evaluation instruments to measure achievement of competency-based outcomes, effectiveness of learning strategies and assessment methods, and the satisfaction of students, graduates, faculty and employers. These evaluation methods and ongoing focus groups held with students and faculty provide the foundation for continuous quality improvement; they help faculty determine which components are working effectively and which need improvement. Both process and outcome data have provided important insights as additional courses are designed and implemented.
The competency-based approach to nursing education has been endorsed by our stakeholder groups, particularly our colleagues in the clinical agencies. This model is very familiar to them and one that they believe has demonstrated validity and reliability. Overall, implementation of the competency-based COPA Model at CU-SON is an evolving success story. It has provided an exciting and educationally sound pathway as the school begins its second century of educational programs for local and distant learners and the consumers they serve.
Summary
The experience in converting to a competency-based curriculum has been both successful and challenging. Faculty and student experiences to date have been positive. The redesigned curriculum is viewed as responsive to the competency-oriented environment and employers believe the transition of graduates into practice settings will be more effective, efficient, and successful. This competency-based approach to education can serve as a model which offers a wide variety of applications to education and service environments.
Authors
Richard Redman, PhD, RN
E-mail: richard.redman@UCHSC.edu
Richard Redman, PhD, RN, is associate dean for academic affairs and professor at the University of Colorado Health Sciences Center, School of Nursing, Denver, Colorado. He has served on the faculty at the University of Michigan, State University of New York at Buffalo, and University of Iowa. His research area addresses the evaluation of clinical outcomes with a particular focus on patient expectations and satisfaction with care.
Carrie B. Lenburg, EdD, RN, FAAN
E-mail: clenburg@naxs.net
Carrie B. Lenburg, EdD, RN, FAAN, Loewenberg Chair of Excellence in the School of Nursing, University of Memphis from 1997-1999, worked with the nursing faculty to convert the BSN program to the competency outcomes and performance assessment model and methods. She also is engaged similarly with the nursing faculty of the University of Colorado Health Science Center to integrate the model to its range of four degree programs (BSN, MSN, ND, and PhD), and into all UC-SON Internet courses. She also is ongoing consultant to the newly developing BSN program at King College (Bristol TN), implementing the COPA Model from the outset.
Patricia Hinton Walker PhD, RN, FAAN
Patricia Hinton Walker, PhD, FAAN, is dean and professor at the University of Colorado Health Sciences Center, School of Nursing, Denver, Colorado. Previously, she served as the Kate Hanna Harvey Visiting Professor in Community Health at the Frances Payne Bolten School of Nursing at Case Western Reserve University, and was associate dean at both Emory University and the University of Rochester. Dr. Walker's research interests include cost and quality outcomes of care, interdisciplinary practice and advanced practice nursing, and development of practice-based care.
Article published September 30, 1999
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