The gap between a new registered nurse graduate’s education for practice and the actual practice requirements of new registered nurses has long been an accepted fact in nursing. This gap reflects the dissonance between the knowledge and skills nursing students learn and use safely under supervision in the academic setting and those needed to function safely and independently in the practice setting. Benner’s (1984) theory of skill acquisition has been embraced by nursing and is often used as a framework for explaining this gap. Benner defined five levels of skill acquisition and development: novice, advanced beginner, competent, proficient, and expert. New graduate nurses are most often categorized as advanced beginners or ones who are able to “demonstrate marginally acceptable performance, ones who have coped with enough real situations to note . . . the recurring meaningful situational components . . . or aspects of the situations” (Benner, p. 22). A competent nurse “develops when the nurse begins to see his or her actions in terms of long-range goals or plans of which he or she is consciously aware. The plan dictates which attributes and aspects of the current and contemplated future situation are to be considered most important and those which can be ignored” (Benner, p. 26).
Although often claiming that new graduates are not prepared for practice, employers have typically not had evidence-based performance outcome measures that could provide the basis of targeted change or interventions within the academic setting. Faculty were not clear about the lack of preparation or the nature of the deficiencies in their graduates. Faculty questions included: (1) Are the deficiencies seen in some or all of the graduates of a specific school? (2) What specific strengths and weaknesses were found in a cohort of new graduates by school, by year, or by semester? and (3) How were deficiencies defined by individuals claiming that the graduates are not prepared?
A barrier to change within the academic settings of this study was their having only vague notions of the magnitude of the issues underlying dissatisfaction with new graduates who had scored well as students and passed the National Council Licensure Examination (NCLEX).
Health care institutions have developed an array of interventions to transition new graduates from advanced beginner to competent level with the assumption that competency also includes performing the necessary nursing functions safely and independently. Some of these interventions include nurse internships and externships, nurse residencies, lengthy orientation programs, and assignment of nursing mentors. The costs of such interventions are high (e.g., a single internship experience lasting several months is estimated to cost between $45,000 and $75,000).
Competency development and validation are professional concerns for both new graduate nurses and licensed practicing nurses. The Texas Nurses Association Nursing Education Redesign Task Force (2005) called for regional interdisciplinary simulation centers of excellence that provide ongoing competency assessment for health professionals including basic and fundamental nursing provider skills.
This article describes the development of an intervention from the academic side to improve the competency of nursing students before graduation to better prepare them for service settings. The intervention is noteworthy because it was developed collaboratively between academia and practice.
North Texas Consortium of Schools of Nursing
In 2003, the deans and directors of several schools of nursing in North Texas and several hospital nurse executives began meeting to discuss mutual areas of concern (e.g., standard orientation of students to area hospitals and criminal background checks and drug screenings required for students prior to hospital clinical experiences). These biannual meetings became more frequent and employers’ concerns about the readiness of graduates to enter the work force were discussed.
Many of the nurse executives indicated that new graduates had difficulty “critically thinking on their feet” or managing patient situations, especially those requiring quick, accurate decisions and actions. Many needed a lengthy orientation period with supervision to assure patient safety. The academic educators were perplexed by the claims of limited critical thinking in new graduates. Most, if not all, academic nursing programs use standardized testing throughout to ensure students’ knowledge and skills in identifying, prioritizing, intervening, and evaluating patient situations, with measures of critical thinking embedded in the testing processes. Many schools set a required score on the standardized tests to graduate. Generally, tests given at the end of the program also predict whether a student will pass the NCLEX, another measure of critical thinking.
With this dissonance among the group regarding new graduates’ critical-thinking skills in clinical situations, further exploration of the concept of critical thinking ensued. Tanner’s (2005) definitions and distinctions between critical thinking and clinical thinking were adopted by the group. Tanner defined critical thinking as “the demonstration of the capability to analyze assumptions, challenge the status quo, recognize limitations in health care, and take action to improve it” (p. 48). Further, Tanner differentiated critical thinking and clinical thinking by stating, “clinical thinking involves skills that may be unrelated to critical thinking . . . skills of clinical judgment and decision making, and they require solid theoretical knowledge and the ability to notice clinical signs, interpret observations, respond appropriately, and reflect on actions taken” (p. 48). By group consensus, the term clinical thinking was adopted and defined as a nurse’s skills and performance in differentiating and identifying patient problems, intervening appropriately and in a timely manner, and communicating needed information to the physician and other providers in a timely, accurate, and appropriate manner.
Competent, Competence, and Competency
Although Benner’s work served as a starting point for discussion regarding competence and measurement of competence, many questions remained. What are the differences between competent, competence, and competency? How does a student’s clinical confidence relate to his or her clinical competence? What level of competence should be expected of a new nurse graduate? Can education increase students’ level of competence prior to graduation so less time is needed by employers to increase new graduates’ competence? What can academia and practice do together to close the education to practice gap, thus increasing new graduates’ competence in caring for patients safely with quality nursing care?
When considering definitions, the North Texas Consortium initially used Jeska’s (1998) differentiation of competent, competence, and competency as reflected in common usage and general understandings of the concepts (Sidebar). Additionally, the consortium considered the Board of Nurse Examiners for the State of Texas and Texas Board of Vocational Nurse Examiners (2002) definition of competency. The Board of Nurse Examiners for the State of Texas and Texas Board of Vocational Nurse Examiners defined competency as the “effective demonstration by the time of graduation of the knowledge, judgment, skills, and professional values derived from nursing and general education content” (p. iii).
The literature is in agreement that to ensure students attain competence, faculty need consistency in three areas: (1) a description of the competence, (2) a standard by which students may be judged as competent, and (3) a means of measuring the competence. The Board of Nurse Examiners for the State of Texas and Texas Board of Vocational Nurse Examiners (2002) competencies are focused on three categories: (1) provider of care, (2) coordinator of care, and (3) member of the profession. The Board of Nurse Examiners for the State of Texas and Texas Board of Vocational Nurse Examiners competencies related to knowledge, clinical behaviors, and judgments address standards of performance in broad statements such as, “Implement a plan of care to assist client to meet physiological needs, including circulation, nutrition, oxygenation, activity, elimination, comfort, pain management, rest and sleep” (p. 14). The Board of Nurse Examiners for the State of Texas and Texas Board of Vocational Nurse Examiners does address specific therapeutic interventions or skills that students need to possess in each of the specific areas. Means of assessment of each competency were not addressed by the Board of Nurse Examiners for the State of Texas and Texas Board of Vocational Nurse Examiners. The methodologies used to assess student learning and the achievement of these broad areas of competency in Texas vary according to faculty members’ preferences and decisions, students’ strengths and weaknesses, and program resources.
Differentiation of Competent, Competence, and Competency
Competent: An adjective used to describe an individual who has met all identified role-related competencies.
Competence: The achievement and integration of many competencies into practice; the overall ability to perform.
Competency: A broad statement describing an aspect of practice that must be developed and demonstrated.
Note. Data from Jeska (1998).
The Performance-Based Development System
Three of the largest health systems in North Texas, consisting of 32 hospitals, use the performance-based development system developed by del Bueno (2005) in 1985 to evaluate new graduates’ competency. The system has been used extensively during the past 20 years and has established validity and reliability. The performance-based development system is a measurement tool using strategies such as scenarios, tests, and simulations to determine nurse competency. A nurse executive from the Health Corporation of America (HCA) was invited to attend a consortium meeting because HCA hospitals in the Dallas/Fort Worth Metroplex had begun using the performance-based development system to evaluate new graduates and had data to share with the schools about their graduates’ performance. They were collecting data by school on the demonstrated competency of all new graduates by semester. The HCA nurse executive continued to be actively involved at all of the meetings, and the HCA provided meeting space and other resources.
During the time period the consortium was meeting, the Texas Nurses Association established a competency task force to determine competency measurement in licensed registered nurses. Because the consortium and Texas Nurses Association groups had similar goals with application to two different populations, the co-chairs of two Texas Nurses Association task forces (competency and education) were invited to join the group in January 2004. As a result of linking the Texas Nurses Association to the consortium, Texas Health Resources became involved, having one of its nurse leaders as part of the group and providing meeting space and other resources.
The data presented by the HCA nurse executive highlighted the overall differences among new graduates by school related to their passing the performance-based development system on their first attempt. With valid and reliable data now available, the representatives of the schools of nursing had two major questions: (1) why did some schools’ graduates perform better than others and (2) what did the schools need to do to ensure that at least 70% of the new graduates could pass this entry to practice clinical evaluation on the first try? The HCA representative shared new graduates’ strengths and weaknesses identified by the performance-based development system (Table 1; Scott, 2005).
Table 1: Strengths and Weaknesses of the New Registered Nurses Identified by the Performance-Based Development System
Additionally, between January and December 2004, 263 inexperienced nurses were assessed by the performance-based development system in HCA hospitals, resulting in an acceptable score of 25% against the national benchmark acceptable score of 30%. After additional supervised clinical experience with a clinical coach, 148 inexperienced nurses were reassessed and had an acceptable score of 78% against the national benchmark acceptable score of 80% (Scott, 2005). These compelling data propelled the consortium to examine underlying reasons for the testing differences in the new graduates.
With the paradox of documented evidence of critical thinking of the graduate nurses on standardized examinations before graduation and pass rates on the NCLEX after graduation and low pass rates using the performance-based development system, the consortium began to explore the teaching–learning strategies used in the nursing programs and expectations for development of clinical thinking and clinical competence of students.
It was discovered that the additional supervised clinical experience that was provided between initial performance-based development system testing and performance-based development system retesting had some unique qualities. The hospital educators employed innovative learning strategies to promote clinical thinking, particularly the use of clinical coaches. No lecture methodology, a traditional way of teaching in schools of nursing, was used. It was also noted that nursing students are rarely, if ever, required to make clinical judgments related to real patient conditions requiring urgent and emergent decisions to prevent irreversible physiological damage. The question was posed, if they did not have this experience in school, when and where would they get it? They would eventually be faced with their first potentially life-threatening crisis situation in the real clinical setting with little or no preparation and would be expected, as licensed registered nurses, to be able to intervene. Would they be in situations that resulted in their actions being labeled “failure to rescue” (Clarke & Aiken, 2003)?
The next step was determining which crisis situations would be the focus of the consortium’s content. On the basis of a review of the literature and risk management data from the hospital systems, the top 10 high-risk, high-volume medical and surgical patient diagnostic groups were selected (Table 2; Tong & Henry, 2005).
Table 2: Top 10 High-Risk, High-Volume Patient Conditions
After the clinical conditions were established, a three-pronged foundation existed on which to proceed: (1) the evidence-based literature, (2) data from the performance-based development system, and (3) a growing commitment to do something positive to impact change to prepare new graduates for entry into practice in new ways. On this foundation, the short-term goal of the consortium was built: to provide nursing faculty and hospital educators with new and innovative learning strategies to increase clinical thinking and competency in prelicensure and licensed nurses. In addition, the consortium’s interim goal was identified: to provide all Texas schools of nursing with the learning modules for use in nursing curricula. The long-term goal was to increase the baseline level of competence of new registered nurse graduates related to high-risk, high-volume patient situations they are likely to encounter in practice. Ways to evaluate the impact of the learning modules on the competency of new graduates are being planned.
Several strategies emerged to meet the short-term goal. First, a summer institute on innovative learning strategies, “Enhancing Students’ Transition to Clinical Practice,” was held. Second, a plan for development of the 10 learning modules on selected high-risk, high-volume patient conditions commonly found in hospitals began. Third, a continuing dialogue with other groups in Texas pursuing measurement of competence in nurses was established.
Summer Institute: “Enhancing Students’ Transition to Clinical Practice”
The consortium planned a 2-day summer institute for faculty of the partner schools of nursing and the participating hospitals. In addition to the financial contributions by each of the schools of nursing, HCA and Texas Health Resources provided funding to support the program. Admission was free, but the numbers were limited.
The purpose of the 2-day program was to update educators in both academia and health care settings about strategies to enhance the entry-level competencies and transition into clinical practice of new graduates. The program included a full day on competency development, presented by Dr. Dorothy del Bueno, and another day highlighting several strategies to promote active learning, including simulations in aviation and nursing, preceptor–student clinical teams in clinical nursing courses, clinical coaching with nurses, and the transition experience of the new graduate nurse. The program was rated as highly successful by the 170 nurse educators and clinicians who attended.
Development of High-Risk, High-Volume Teaching–Learning Modules
Maintaining the momentum of the summer institute, at its completion, each of the schools of nursing in the consortium made a commitment to develop a learning module based on one of the top 10 high-risk, high-volume categories. Each of the categories would focus on development of competence in new graduates using non-traditional, innovative teaching–learning methodologies. The guidelines for module development are presented in Table 3.
Table 3: Top 10 High-Risk, High-Volume Module Development Guidelines
The North Texas Consortium of Schools of Nursing became a member of the Texas Nursing Competency Consortium, formed in 2006. With the support of a National Science Foundation grant, the Texas Tech University Health Sciences Center convened a statewide competency conference in February 2006. The purpose of the conference was to discuss the current state efforts in the area of competency development and direction setting for the state. Dialogue and development of competency instruments continue. Refinement of the terms competent and competency has been of particular help: “A competent nurse is able to independently and reliably integrate knowledge (evidence), interpersonal and technical skills, to provide safe, effective and ethical care in role and context specific situations. Competency is the role and context specific aspects of nursing care that result in competent practice” (Ironside, 2006, p. 1).
To date, the cost of this endeavor in terms of faculty time, school resources, and HCA and Texas Health Resources support has been estimated to be more than $70,000. In the current systems, the cost of providing additional resources to assist new graduates to practice safely is estimated to be between $45,000 and $75,000 per nurse. Partnerships between schools of nursing and practice systems could produce competent, safe graduates who would need fewer hospital system resources focused on the development of their competencies.
Since the beginning of this collaborative effort, there was a plan to widely disseminate the modules to at least the 84 schools of nursing in Texas. Each module has been pilot tested by at least two schools and reviewed for reliability and validity by an expert panel of nurse educators. The Texas Nurses Association has agreed to provide Internet access to the modules through its website ( www.texasnurses.org).
The next step is to determine a standard format to evaluate the usefulness and effectiveness of the modules following integration of one or more of the modules into curricula. The goal is to include the evaluation tools with the modules when they are disseminated.
The Texas Nurses Association has offered to make the modules available online. The thought of the group was to put all or as many as possible of the 10 modules online so they have the best access and use in academic and health care settings. However, because each school has copyright of its module, it has the option to publish the module independently rather than provide it online.
This consortium’s commitment to quality education and safe patient care has been the binding force resulting in an exciting project with everyone working together as a cohesive team. The work in developing the modules reflects the excellence of the faculty and their health care partners as leaders in education and patient care. This project highlights the importance of consortia to achieve mutual goals. Through the consortium project, the health care and education organizations simultaneously benefited by providing better knowledge and skills for new and practicing nurses. Giving nurses the right tools reduces their frustrations when new to practice and directly improves the care they deliver.
- Benner, P1984. From novice to expert: Promoting excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
- Board of Nurse Examiners for the State of Texas and Texas Board of Vocational Nurse Examiners. 2002. Differentiated entry level competencies of graduates of Texas nursing programs. Austin, TX: Author.
- Clarke, S & Aiken, L2003. Failure to rescue: Needless deaths are prime examples of the need for more nurses at the bedside. American Journal of Nursing, 1031, 42–47.
- del Bueno, DJ2005. A crisis in critical thinking. Nursing Education Perspectives, 265, 278–282.
- Ironside, P2006, February21–22. Invitational working conference on the science of competency, forum summary. Presented at the Alliance for Innovation in Nursing Education Consensus Building Forum. , Texas Tech University and the National Science Foundation. , Lubbock, TX. .
- Jeska, S1998. Competence assessment models and methods. In Kelly-Thomas, K (Ed.), Clinical and nursing staff development: Current competence, future focus2nd ed., pp. 121–143). Hagerstown, MD: Lippincott, Williams & Wilkins.
- Scott, T2005, January28. PBDS testing in North Texas. Paper presented at the meeting of the North Texas Consortium of Schools of Nursing. , Texas Health Resources, Health Corporation of America DFW, and Texas Nurses Association, Arlington, TX.
- Tanner, C2005. What have we learned about critical thinking?Journal of Nursing Education, 442, 46–48.
- Texas Nurses Association Nursing Education Redesign Task Force. 2005. The need for innovation in nursing education in Texas. Austin, TX: Texas Nurses Association.
- Tong, V & Henry, D2005. Performance-based development system for nursing students (syllabus selection). Journal of Nursing Education, 442, 95–96.
Strengths and Weaknesses of the New Registered Nurses Identified by the Performance-Based Development System
|Usually identifies a problem
||Fails to give relevant nursing actions relating to specific disease states
|Demonstrates good interpersonal skills
|Consistently reassures patients and families
|Recognizes pain and seeks order
||Gives incomplete or irrelevant information to physician
|Offers nonanalgesic alternatives
||Difficulty giving rationale for nursing actions
|Listens to instructions carefully
||Does not know laboratory values
Top 10 High-Risk, High-Volume Patient Conditions
|Acute myocardial infarction
|Congestive heart failure
|Cerebral vascular accident
|Deep vein thrombosis
|Postoperative care (pain management)
|Altered level of consciousness (e.g., head injury)
|Pneumonia or severe respiratory distress
|Psychosis or dementia
Top 10 High-Risk, High-Volume Module Development Guidelines
To increase the baseline level of competence of new registered nurse graduates related to high-risk, high-volume patient situations they are likely to encounter in practice
Produce a faculty workbook composed of the 10 modules to be available to the 84 schools of nursing in Texas
|Operating team guidelines
Each team will develop a teaching or learning module focused on development of competencies by nursing students in one of the 0 identified high-risk, high-volume patient situations
Each team will include educators from academia and practice
|Template for each module
Identify universal competencies a student or entry-level registered nurse should demonstrate in the selected high-risk, high-volume situation
Develop no more than 5 to 10 competencies
Focus on generic competencies that apply across settings and life span
Make each competency statement clear, observable, and measurable
Base competencies on evidence-based literature and include references
Identify critical behaviors the student or entry-level registered nurse would be expected to demonstrate
Identify behavior(s) that must be done to validate or clarify the competency
Identify essential elements required to provide safe, quality care
Emphasize the integration of:
Identify assessment or evaluation strategies related to each of the competencies and critical behaviors
Include any forms or tools used for assessment or evaluation
Provide a completed sample of a student assessment or evaluation
Provide answers to any tests or sample answers to questions
Develop two or more of the following strategies to help guide students through the learning process:
Simulation without a variety of task trainers
Case study approach using students, actors, and multimedia
Simulation scenarios using Sim Man (Laerdal Medical Corp., Wappingers Falls, NY)/METI (Medical Education Technologies, Inc., Sarasota, F L) manikins with debriefing guidelines
Learning techniques, games, or case studies, coaching, and computer-based case studies
Preceptoring strategies and guidelines
Other creative strategies
Propose evaluation strategies that evaluate the efficacy and efficiency of the module in use (Did it work? How well?)
Include reference list and handouts to be used by faculty
Include multimedia teaching tools (e.g., DVDs and videotapes)