Multiple-choice examinations traditionally are used to validate nurse continuing competence and to meet the requirements for specialty certification. However, many other methods and frameworks are used for assessing competence and continued competence. Portfolios, simulations, skills checklists, and peer, patient, and self-evaluations have been used by many academic and health care systems to validate skills, knowledge, and abilities (Vandewater, 2004).
Although no single method can fully document a person’s knowledge or skills, the increased interest in portfolios (Billings & Kowalski, 2005; Cangelosi, 2008; Scholes et al., 2004; Williams & Jordan, 2007) as an alternative to traditional summative testing is increasing. This article describes the role of portfolios in documenting competence and continued competence, and cites a specific example of how one specialty nursing certification organization has used this method for recertification or reactivation of a lapsed credential.
Portfolios are considered by some to be a “portable mechanism for evaluating competencies that may otherwise be difficult to assess, such as practice-based improvements, use of scientific evidence in practice, professional behavior and creative endeavors” (Byrne, Delarose, King, Leske, Sapnas, & Schroeter, 2007, pp. 24–25). In its simplest form, a portfolio is a professional scrapbook of one’s accomplishments. The more comprehensive, thoughtful examples include significant qualitative and quantitative evidence to communicate examples of exemplary individual practice, professional endeavors, or even continuing competence in a variety of areas. Professional portfolios demonstrate reflective critical thinking, lived experiences, narratives, and intrapersonal understanding that illustrate competence.
The nursing profession emphasizes lifelong learning, personal reflection, and even more critically, the integration of that learning into the nurse’s continued ability to deliver safe patient care in a rapidly changing environment. Portfolio preparation may help an individual identify unmet personal learning needs and clarify future professional goals. Portfolios provide an in-depth, comprehensive, holistic, and relevant way to assess continuing competence.
A comprehensive process for the creation of a professional portfolio has several important characteristics. A clear purpose is essential. The context for portfolio usage should be determined first. Will the portfolio be used for personal documentation or systematic documentation of lifelong learning goals? Will the portfolio be used to illustrate how accreditation standards were met? After the purpose is determined, the criteria that will be linked to the competency indicators should be described. What outcome will need to be documented to support specific competency standards? The setting for performance also must be articulated. For example, is the purpose to assess competency in clinical, educational, research, or other contextual spheres? The portfolio scoring or validation method then must be determined. The final consideration is to keep the portfolio process simple! Using a simple method for completing and evaluating the portfolio will keep the process manageable and viable.
The portfolio method of assessment relies on the theoretical underpinnings of experiential and reflective learning. Behaviorists may assume that learning is demonstrated by an observed change in behavior. Many scholars, however, currently believe that the core of learning is personal reflection (McMullan, 2003; Rolfe, 2002). Central to the reflective learning process is a specific practice event, experienced uniquely by the individual, from which a number of more abstract generalizations can be derived.
Some experts (Hatton & Smith, 1995; Moon, 2002; Van Manen, 1991) define reflection as a mental action during which the individual distances himself or herself from events to view them more objectively. Reflection is the process of learning from experience that allows individuals to use experiences to determine what they may do differently as a result of that learning.
The strength of the reflective process lies in the individual’s taking responsibility for his or her own learning, which is a basic tenet of adult learning principles (Knowles, 1975). Reflection may raise new questions that will aid in self-assessment and drive future learning and goal planning. The subjectivity of reflection supports introspection and cannot be evaluated using traditional objective standard measures.
Portfolios in Specialty Nursing
Portfolios have been used to showcase abilities in education, architecture, photography, and the arts for many years. They are only now being increasingly investigated by specialty nursing certification organizations as a means of recertification or, in some cases, initial certification. The use of portfolios in nursing and medicine is supported by various experts and organizations (Carraccio & Englander, 2004; Driessen, Van Der Vleuten, Schuwirth, Van Tartwijk, & Vermunt, 2005; Jasper & Fulton, 2005; Joyce, 2005; O’Sullivan, Reckase, McClain, Savidge, & Clardy, 2004).
The American Nurses Credentialing Center (ANCC) is considering using portfolios for recertification of specialty and advanced practice nursing credentials (Smolenski, 2008). In addition, the ANCC offers an electronic professional portfolio management system to aid in maintaining the records and documents necessary for portfolio development (American Nurses Credentialing Center, 2008b). The National Association of Clinical Nurse Specialists is partnering with the ANCC to develop a specialty professional portfolio that will provide the basis for certification of clinical nurse specialists (National Association of Clinical Nurse Specialists, 2007). The Genetic Nursing Credentialing Commission (Genetic Nursing Credentialing Commission, 2007), the Wound Ostomy Continence Nursing Certification Board (Wound Ostomy and Continence Nursing Certification Board, 2006), and the American Association of Diabetes Educators (American Association of Diabetes Educators, 2008) all offer a portfolio process as a way to maintain certification at an advanced practice level. The Competency & Credentialing Institute (CCI) is using portfolios as an optional method of recertifying its Certified Perioperative Registered Nurse (CNOR) credential, and also offers the portfolio as a means of reactivating a lapsed CNOR credential (Competency & Credentialing Institute, 2008). Because many of these portfolio processes are new, the evolution of evaluating competence based on qualitative indicators, such as credibility and dependability, is ongoing (Driessen et al., 2005).
Specialty nursing practice includes multiple professional roles, which frequently evolve differently from generalist roles. For example, leadership, educational, and research roles are often undertaken by nurses with expanded knowledge and experience in a specialty. Using professional portfolios as evidence of the scope and depth of a clinician’s practice is more illustrative of competency in those varied roles. The usual methods of demonstrating professional competence via paper-and-pencil or computerized testing, oral presentations, or performance observations may only provide a picture of competence at a given point in time, based on didactic content recall. Portfolios provide an opportunity to present more competency evaluation points over a longer period, which is foundational to the philosophy of lifelong learning.
Competency & Credentialing Institute: An In-Depth Case Study
Established in 1979, CCI is the leading provider of certification and competency assessment for perioperative nurses (the CNOR credential) and registered nurse first assistants (the CRNFA credential). CCI provides CNOR and CRNFA credentials to more than 30,000 registered nurses, making it one of the world’s largest specialty nursing credentialing bodies.
CCI’s primary credential, the CNOR, is initially awarded to perioperative nurses who meet defined eligibility requirements and who successfully pass a 200-item, multiple-choice examination. The credential is valid for 5 years, and certificants must meet defined recertification requirements at the end of the initial 5-year period. Several recertification methods are available; however, the majority of certificants elect to recertify by the “contact hours” method (i.e., submitting documentation of participation in 125 approved contact hours). More details on certification and recertification requirements and options are available on the CCI website, www.cc-institute.org.
Development of the CCI Competency-Based Portfolio Method for Reactivation and Recertification
In 1996, CCI instituted a portfolio program for reactivation of the CNOR credential. Reactivation is the process of regaining a credential that has lapsed or was not renewed using one of the available recertification methods. In 2006, CCI appointed a research committee and charged it with expanding the original program to include portfolios as an optional recertification method, as well as to strengthen its overall rigor and evidence base. The committee first reviewed the available literature, specifically focusing on existing portfolio programs. The findings supported the concept that portfolios are appropriate for the documentation and communication of continuing competence (Byrne et al., 2007; Endacott et al., 2004; McCready, 2007).
The committee used the CNOR job analysis, which defines and measures content domains and core competencies for perioperative nurses, to develop the first draft of the portfolio. Data from a Perioperative Nurse Competency Continuum Survey, which documented changes in perioperative nursing practice that come with experience, corroborated the job analysis data (Competency & Credentialing Institute, 2006a, 2006b). These perioperative elements were compared and contrasted with the American Nurses Association standards of practice and professional performance (American Nurses Association, 2001) and the ANCC Forces of Magnetism (American Nurses Credentialing Center, 2008a) (Table 1).
Table 1: Comparison of Professional Practice and Performance Principles
An analysis of these initiatives resulted in a list of nine overall domains of perioperative nursing practice, reflecting two major foci: patient care and professional development. The specific domains included:
- Patient assessment and diagnosis.
- Identification of expected outcomes and ability to develop a plan of care.
- Intraoperative activities.
- Discharge planning.
- Cleaning, disinfecting, packaging, and sterilization.
- Emergency situations.
- Management of personnel, services, and materials.
- Professional accountability.
The research committee originally envisioned requesting evidence for each of these nine domains. On further analysis and discussion, however, they determined that many types of evidence (e.g., clinical pathways, narratives, education verification, and peer support letters) transcended individual domains. To avoid redundancy, the committee suggested that an integrated and holistic approach to nursing practice, such as that used on the National Council Licensure Examination-Registered Nurse (NCLEX-RN), would be more appropriate for the portfolio project.
Initial Portfolio Requirements
Based on the findings of its initial investigation, the CCI research committee determined that the following 13 categories of professional activities captured the essence of the nine domains of perioperative nursing practice:
- Care planning.
- Clinical pathways.
- Educational resources.
- Continuing education.
- Standards application.
- Continuous quality improvement.
- Evidence-based practice.
- Risk management.
- Contributions to the institution or professional organizations.
- Educational presentations.
- Professional writing.
- Academic courses taught or completed.
The CCI research committee indicated that, in addition to supplying evidence of participation in professional activities, a portfolio-based competency process should include a reflective component. Therefore, a customized reflection form is required for each activity being submitted. Based on the premise that reflection is a two-stage process, both describing and internalizing the event so that a meaningful learning experience can be translated into competence (Williams, 2003a, 2003b), a clear and thorough explanation of the activity is requested, including the applicant’s role and what was learned. A question on implications for perioperative practice directs the applicant to examine the consequences of the activity from both a personal and a professional viewpoint. This segment of the activity requires applicants to move beyond simply submitting materials to analyzing what that experience meant to them on a personal and a professional level (Williams & Jordan, 2007).
CCI Portfolio Program Pilot
After the initial analysis and development of the elements discussed earlier, the 13 categories were included in a pilot project to evaluate the clarity of directions, verify certificant understanding, and confirm the extent to which portfolio documentation demonstrated continuing competence in perioperative nursing. Twelve nurses, including those who had lapsed certifications and those with current CNOR certification, were asked to self-select 5 professional activities from the 13 categories and submit evidence that demonstrated their competence in those activities. This evidence was corroborated by requesting a reflection of their learning for each of the five selected activities. The pilot project was completed in 8 months and was essential in refining the CCI portfolio.
Portfolio Revisions Based on Pilot
The pilot group indicated that the process was initially perceived as more complex than it actually was. Although the instructions were generally understandable, they were revised to enhance clarity and simplicity. The CCI research committee synthesized the list of professional activities after the pilot project and made some specific changes to the original design. Because it was deemed more inclusive of direct patient care activities, patient-centered care terminology was adapted, rather than the terms “care planning” and “clinical pathways.” The committee decided that continuous quality improvement and evidence-based practice were similar enough to be combined into one activity. The concept of precepting was added to the mentoring activity. In addition, contributions to the institution and professional organizations were divided into two separate activities.
As a result of these changes and other pilot participant feedback, the final program includes a requirement that applicants submit documentation for 4 of the 12 activities (Table 2). Currently, evidence is requested to support the narrative on the reflection form, which is completed for each of the four selected activities. Evidence submitted must be timely (i.e., within the last 5 years) and relevant because the overall purpose of the portfolio is to demonstrate current competence. The final step is to complete a resume and submit all documentation for review.
Table 2: Professional Activities in the Competency & Credentialing Institute Portfolio
Portfolio Evaluation Process
Completed portfolio applications are evaluated independently by two peer evaluators (i.e., CNOR-certified nurses) who use the tool shown in the Sidebar. One evaluator is a CCI staff member, and the other is selected from a pool of external portfolio evaluators. If the two evaluators disagree about whether the application meets the requirements, the opinion of a third evaluator is sought. If an application is not approved, the candidate is sent a letter outlining the necessary steps for successful completion; applicants are given 45 days to correct the application or submit missing information.
Inter-rater reliability is scored on all portfolios to determine the level of agreement between the evaluators and to track trends among activities, reviewers, and components of the reflection form. This information is also valuable in validating the final approval of the portfolio submission.
Implications for Future Process Improvement
The importance of clarity and simplicity continues to be emphasized, and several aspects of the process have been identified for improvement. It is important to use consistent language throughout the instructions and to ensure that all directions are interpreted uniformly by participants. The portfolio application should be as short as possible and should limit the use of jargon or unfamiliar language. Examples are helpful, and CCI suggests making the examples available at another resource site (e.g., the organization’s website) instead of in the portfolio directions. CCI found that including too many examples overwhelmed the users. Some applicants suggested that a communication plan be developed to address common questions. This could be accomplished on the organization’s website or in a frequently asked questions resource document. CCI now asks applicants whose submissions exemplify the intent of an activity for their permission to post their work on the website for others to use as a model.
Some applicants struggle with writing an in-depth or insightful reflection form. Perhaps the preponderance of computerized charting, standardized care plans, and charting by exception has made narrative writing an unpracticed skill. The technical nature of perioperative nursing does not lend itself easily to creative writing. This tendency toward paucity in documenting personal accomplishments is compounded by the natural hesitancy of many people to expound on their own achievements.
A suggestion was made by CCI that portfolio creation become a prospective rather than a retrospective enterprise. Some applicants have observed that they did not retain requested evidence. Often, course materials, committee assignments, and even annual evaluations have been discarded or lost. The decision to recertify or reactivate a credential by this method requires pro-active planning that may not be realized by potential candidates. Therefore, future CCI communication and educational initiatives will include anticipatory planning and retention of records in conjunction with upcoming recertification or reactivation initiatives.
Ongoing training sessions will ensure a simpler and clearer evaluation process and add more specific competency outcomes for each activity. Orientation is vital so that all reviewers use a standardized approach to evaluating portfolios. As the pool of portfolio applicants and reviewers grows, the need for other changes will likely become apparent.
A portfolio for perioperative nurse recertification has been received positively by the nursing credentialing community. This process holds particular attraction for specialties, such as perioperative nursing, with a relatively small membership and a highly focused scope of practice. The portfolio provides a method of validating these personal accomplishments in an interactive, multidimensional format. The continued use of this method of determining competence will help refine the integration of thoughtful self-evaluation and the delivery of safe patient care.
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Comparison of Professional Practice and Performance Principles
|American Nurses Association (ANA) Standards of Practice/Professional Performance
||Certified Perioperative Registered Nurse (CNOR) Core Competencies (Job Analysis)
||Quality of Carea
||Assess Health Status
|Quality of Practice
||Professional Models of Care
||Formulate Nursing Diagnosis
||Nurses as Teachers
||Evaluate Patient Responses to Plan of Care
||Develop Plan of Care
||Participate in Discharge Planning
Coordination of Care
Health Teaching and Health Promotion
Prescriptive Authority and Treatment
||Includes all 14 Magnet Forces
||Implement Plan to:
Prevent Physical Injury
Optimize Physiological Protection
Document Perioperative Activities
Select and Use Methods for Cleaning, Packaging, Sterilizing, and Disinfecting
Organize and Coordinate Team Members, Supplies, Equipment, and Support Services
Communicate Patient Information
||Implement Plan of Care Consistent with Patient Rights and Responsibilities
||Nurses as Teachers
||Implement Plan of Care to Enhance Patient/Family Education
Communicate Patient Information
||Develop Plan of Careb
||Consultation and Resources
|| Communicate Patient Information
||Quality of Organizational Leadership
Chief Nurse Executive Management Style
Image of Nursing
||Evaluate Patient Responses to Plan of Careb
Professional Activities in the Competency & Credentialing Institute Portfolio
||Requires submission of a patient care plan demonstrating the nursing process, or a clinical pathway for a specific patient population or surgical procedure. Applicants should submit a comprehensive plan of care that identifies how assessment data were used to manage care, an individualized nursing diagnosis, and expected outcomes that are age-specific.
||The applicant provides a sample of a patient or staff teaching tool. Several applicants have provided examples of educational information to aid staff in the operation and troubleshooting of equipment.
|Continuing education (minimum of 35 hours required)
||Applicant is asked to reflect on the one session that most affected practice.
||This activity requires integration into practice of either Association of periOperative Registered Nurses (AORN) standards, recommended practice, or guidelines (Association of periOperative Registered Nurses, 2008), or the Perioperative Nursing Data Set (Association of periOperative Registered Nurses, 2007).
|Evidence-based practice/continuous quality improvement Project
||This activity asks for examples of how research or evidence-based practice was used to validate or change practice. One applicant used the process to implement a medication reconciliation program into her hospital.
||The applicant is asked to provide documentation of an unexpected patient outcome. Although patient anonymity and privacy were discussed in a previous section, these issues are reinforced for this activity.
||Activity involves documenting the precepting experience for three staff members or students.
|Contribution to institution
||This has proven to be one of the most popular activities. Applicants discuss leadership contributions to hospital committees.
|Contribution to professional organization
||This is also a very popular activity. Most reflections detail volunteer activities with AORN because there is a strong correlation between being a member of this professional specialty organization and certification.
||Requirements for this activity include at least 3 hours of teaching.
||Two examples of published professional writing are required. Several applicants have submitted work that has been published in the newsletter of either a hospital or a professional organization. One applicant even submitted two books she had written.
|Academic courses completed or taught
||Evidence must include a course (three credits minimum) that has been used for professional degree advancement.