Demonstration of competency for nurses is increasingly emphasized in the culture of safety environment (Ironside, 2008). Assessing nurse competencies has been difficult due to the varied definitions of competencies (Levine & Johnson, 2014), differing competency assessment methodologies (O'Hearne Rebholz, 2006), and the challenge to assess nursing competencies within a health care system (Rusche, Besuner, Partusch, & Berning, 2001).
A five-hospital health care system identified that inconsistencies in the implementation of competencies assessment existed. Each nursing specialty had varying approaches to validating annual nursing competencies within the health system, with no standard approach for identification, implementation, and evaluation of competencies. In addition, there was a lack of understanding between assessing competency and providing education, and the two were often used interchangeably. The clinical nurse educators (CNEs) were presented with the challenge to standardize and implement competencies for nurses across the health system. The purpose of this article is to describe an evidence-based approach to standardizing and implementing annual nursing competencies in a five-hospital health care system.
Whelan (2006) stated, “The ultimate goal in validating staff competency is to provide safe patient care” (p. 201). The need for nurses to participate in competency assessment has long been reported in the literature, although trends in competency assessment are moving away from a standard checklist completion format into an area where competencies are assessed on multiple factors (Benner, 1982a; LaDuke, 2001; Levine & Johnson, 2014; Whelan, 2006). As Schroeter (2008) noted, “even though this competency-based approach to education has been evident in nursing for the past 30 years, little consensus exists regarding the definition and application of competence in nursing” (p. 1). Multiple authors have noted that competency assessment that includes skills and knowledge only in the form of checklists does not truly assess competency (Maddox, Waller-Wise, & Weed, 2014; Scott Tilley, 2008; Wilkinson, 2013; Wright, 2005).
The terms competence and competency need to be clearly defined, as they are often incorrectly used interchangeably in the nursing literature (Axley, 2008; Case DiLeonardi & Biel, 2012; Ironside, 2008; McMullan et al., 2003; National Council of State Boards of Nursing, 2005; Whelan, 2006; Wilkinson, 2013). The National Council of State Boards of Nursing (2005) defined competency as “the application of knowledge and the interpersonal, decision-making, and psychomotor skills expected for the practice role, within the context of public health, welfare and safety” (p. 1). As defined by The Joint Commission (2008), competency is “a determination of an individual's skills, knowledge and capability to meet defined expectations” (p. GL-4). Rusche et al. (2001) believed that competency is “a process whereby nurses apply their knowledge as they demonstrate the skills and abilities necessary to care for patients” (p. 34), whereas others incorporated the actual work environment into their definitions of competency (Benner, 1982b; del Bueno, 1990; O'Hearne Rebholz, 2006). Wright (2005) defined competency as “the application of knowledge, skills and behaviors that are necessary to meet the requirements of the organization, department, and work setting requirements under the varied circumstances of the real world” (p. 8).
Some of the most well-known competency assessment methods include del Bueno's Performance Based Development System (del Bueno, 2001); the American Association of Critical-Care Nurse's synergy model, which provides a “framework for developing competency in nursing practice” (Collins & Strother, 2008, p. E2); and the competency model developed by Wright (2005). The use of portfolios was also explored (McMullan et al., 2003; Scott Tilly, 2008), as well as the competency outcomes and performance assessment model (Lenburg, Abdur-Rahman, Spencer, Boyer, & Klein (2011). A need exists for multilevel competency assessment, including a core competency for all nurses, as well as unit-specific competencies (Allen et al., 2008; Whelan, 2006).
Other considerations identified in the literature review included the need to incorporate adult learning principles (Wright, 2005), use of clearly written objectives with outcome measures (Chappell & Koithan, 2012), observation of daily work (LaDuke, 2001; Meretoja, Leino-Kilpi, & Kaira, 2004; Wright, 2005), and the concept of competency assessment as a changing and continuing process (Wright, 2005). Consideration must also be given to promote active learning and use of previous knowledge (Arcand & Neumann, 2005; del Bueno, 1978; Kubin & Fogg, 2010; Levine & Johnson, 2014; Whelan, 2006).
Finally, there remains great variability in the use of different tools, how to develop and implement the individual competency programs, and the difficulty in establishing a standardized method to evaluate nurses who work in a variety of health care settings (Allen et al., 2008; Scott Tilley, 2008).
Wright's Model of Competency Assessment
Competency assessment begins with the identification of ongoing competency needs. This is a collaborative process that includes input from staff nurses, managers, educators, and senior leadership. A work sheet for identifying ongoing competencies is used during this process to identify new or changed procedures, policies, equipment, and initiatives; high-risk and time-sensitive aspects of the job; and problematic aspects of the job. For each competency identified, the nurse can select from multiple methods of verification, thus utilizing the principles of adult learning. This provides increased autonomy and places the responsibility of competency completion on the individual nurse. This system of competency assessment can be used to evaluate not only technical skills but also critical thinking and interpersonal skills (Maddox et al., 2014), as well as to accommodate differing levels of nurses on the novice-to-expert continuum. Eleven methods of verification exist—exemplars, case studies, presentations, evidence of daily work, return demonstrations, mock events and surveys, peer reviews, self-assessments, tests and examinations, quality improvement (QI) monitors, and discussion and reflection groups. Competencies are evaluated and feedback is connected to an annual performance review (Wright, 2005). For example, Table 1 demonstrates the competency for care of chest tubes and the methods of verification the nurse may select for verifying this competency.
Example of The Competency Validation Tool for Chest Tubes
The nursing work environment is ever changing, and competencies should be modified annually to reflect such changes. The work sheet for identifying ongoing competencies is crucial to the assessment of competency needs, as the competencies will often not be the same year after year.
Wright's (2005) work sheet for identifying ongoing competencies is prioritized based on the following four categories:
- What is new?
- What is changing?
- What is high risk/time sensitive?
- What is problematic? (pp. 25–26)
A challenge to implement this model into a health care system is the paucity of literature available on the topic of implementation of system-wide competencies. After a careful literature review, Wright's (2005) competency model was chosen by the competency steering committee, composed of CNEs representing each hospital and all clinical specialties across the health system. One advantage to this model is its adaptability to meet the needs of a health system. The model was presented to senior nursing leadership and was accepted as a standard model for implementation. To convey information about the model and its implementation to all nurse managers and CNEs, announcements were made at system-wide meetings. Informing the entire nursing staff system-wide about the changes required multiple methods of communication. A video featuring the chief nursing officer was launched to announce the new competency model. The CNEs also provided system-wide information sessions, which were held at each campus over a 2-month period. A website was created on the nursing intranet for reference and included an introductory video, a recorded information session, frequently asked questions, required documents, and the time frame for completion. The CNEs referenced this website when providing unit-based education. The nursing competency policy and procedure was revised to standardize accountability, time frames, and methodologies for evaluating competency. With the transformational leadership support of the chief nursing officer and director of nursing education, the new competency model was initiated.
The First Year: Core Competencies
Implementation of the new competency model came on the heels of a successful survey by The Joint Commission and allowed time for restructuring the competency program for nursing. The new model was approved midyear; therefore, the competency steering committee was charged with implementing the process within 6 months to meet the requirement of the health system's policy to perform competency assessment annually. Given the time constraints, three core competencies were developed, which were applicable to all nurses within the health system. The three core competencies were communication, patient satisfaction, and patient safety. For example, the communication core competency included the demonstration of safe patient handoff. The method of verification included either completing a bedside hand-off evaluation checklist, writing an exemplar describing a patient safety issue identified during a bedside handoff, or creating a presentation demonstrating an example of an effective handoff. A single form was created for each method of verification for the purposes of standardization and simplicity. An effort was made to decrease the need to recreate the verification forms each year; therefore, forms for the common methods of verification were created (e.g., Presentation Form, Exemplar Form).
Subsequent Years: Specialty-Specific Competencies
During the initial 4-month time frame of the first-year core competencies, additional work preparing for the subsequent year was being completed. The CNEs in each specialty across the system worked together to lead the competency identification process for the following year. The CNEs worked with staff, unit councils, nurse managers, and other unit-specific stakeholders to identify specific competencies, using the work sheet. Because the health system comprises multiple hospitals, some unique units exist that perform specific skills. The competencies chosen had to meet the needs of all specialty units. Therefore, the unique knowledge or skill of staff in those units was not selected. Those topics were to be completed in an education format for a specific unit. Most units selected five to 10 competencies. In addition to the specialty-specific competencies, one core competency must be completed annually by every nurse in the system. The determination of the core competency is a collaborative process between the chief nursing officer, the director of nursing education, and the competency steering committee. Topics identified during brain-storming sessions that do not meet Wright's competency guidelines become specialty education topics for the year. For example, because intra-aortic counterpulsation therapy was not identified as a competency based on the work sheet, education on this topic was implemented over the course of the year for all critical care areas.
Other Specifics for Implementation
The competency year coincides with the fiscal year—beginning July 1st and ending June 30th of the following year (e.g., July 1, 2014 to June 30, 2015). Nurses are required to return their completed competency documentation to their respective CNEs by May 1st for their evaluation of competencies. Written feedback is given to staff using an electronic template that describes their successful completion or need for remediation. The CNE provides feedback to the nurse manager by July 1st so that it can be reflected in annual performance appraisals.
In response to the difficulties in developing methods of verification for the various specialties, the competency steering committee was tasked with reviewing the work of each specialty, offering feedback and giving final approval, with the goal of standardization and consistency throughout each specialty and across the health care system. After competencies are identified and the associated methods of verification and documentation forms are approved, they are uploaded into the nursing intranet, which is considered the most current resource for staff to learn about competency requirements.
Newly hired nurses demonstrate initial competency through an orientation checklist and documentation. They must complete annual competencies starting in the fiscal year following their 90-day probation period. Nurse residents complete competencies beginning in the year after graduation from the residency program.
In reflecting on the journey of implementing a new nursing competency model as a five-hospital health system, lessons were learned. Implementation of the new competency model was initially challenging and time consuming for the CNEs in the conceptualization, development, implementation, and evaluation phases.
The lessons learned include the following:
- Full engagement of Wright's (2005) model by all nursing stakeholders is essential.
- Align the indicators and outcomes with QI data.
- Individualize the needs of the unit.
- Closely align the methods of verification with the measurable competency.
Lesson 1: Full Engagement of Wright's Model by All Nursing Stakeholders Is Essential
The Wright (2005) model functions smoothly in an environment of collaboration with an identified unit-based competency team, including staff, the CNEs, and nurse managers. This paradigm marks a tremendous change from the previous process, as historically the CNEs had been solely responsible for the assessment of competencies. The first 2 years of the competency assessment process revealed that the CNEs are undertaking most of the workload of the competency process, with the exception of identifying competencies. There has been support from the nurse managers but very little involvement from staff. As this model was further embedded into the authors' health care system, the process had to be changed to include increased collaboration with nursing leadership and staff in the identification, implementation, and evaluation of competencies. Knowing that engaging the stakeholders in this new competency model takes time, the CNEs intend to include staff and all levels of nursing leadership through collaboration with unit councils, policy and procedure committees, and the formation of unit-based competency teams.
Lesson 2: Align the Indicators and Outcomes With QI Data
In an outcomes-based work environment, the CNEs struggled with using QI data as a method of verification, which influenced the evaluation of the new model. To create a successful competency process, it is important to incorporate QI activities into the overall process (Wright, 2005). Quality monitors can also be used as methods of verification to measure competency, provided they reflect individual performance (Wright, 2005). The method of verification can have an impact on an organization's QI program, as it encourages employees to become part of the QI process. A lesson learned at the authors' organization was to use QI data to monitor the mastery of skills verified during the competency assessment period. The authors are working to improve this process and are collaborating with stakeholders.
Lesson 3: Individualize the Needs of the Unit
Nursing competencies were originally selected in specialty department groups throughout the health system, not as unit-specific competencies. The specialty units at each hospital identified their unique needs with the involvement of managers, staff, and CNEs. When the individual specialty units across the health system combined to meet as a system-wide specialty, some of the needs of the individual units were not selected to be competencies by the health system. Consequently, some of the identified needs on a per unit basis were eliminated when their needs were discussed within the system specialty group. This served as a dissatisfaction to stakeholders, as some unit-specific problems were not being addressed. As a result, when the competency assessment work sheet is completed and competencies are identified, the topics that are not selected as competencies may be chosen for unit-based education. Moving forward, it has been decided to implement competencies within the respective specialties and to add unit-specific competencies as identified.
Lesson 4: Closely Align the Methods of Verification With the Measurable Competency
During the first 2 years of selecting the appropriate verification methods, the health system erred on the side of using multiple methods of verification, thinking that there should always be several ways to verify a competency. It was found that sometimes the selected methods of verification were not the best methods for determining the objective for the competency. For instance, a written exemplar is not the best method for assessing blood transfusion competency, as the nurse needs to actually demonstrate his or her ability to complete a blood transfusion following the policy. Therefore, the methods selection process has been adjusted to emphasize that the method of verification should match the competency (objective) that is being evaluated.
Evaluation of the Model Implementation
Competencies were successfully standardized and implemented throughout the health care system, leading to increased efficiency and cost effectiveness. Table 2 shows a summary of the changes. Formal evaluation of this initial competency roll-out was not conducted; however, anecdotal feedback from the nurses was mixed. Some nurses believed the new process was not assessing “real competencies,” especially after the first year of selecting core competencies. They did not want to change from the previous hospital-based skills fairs, and some felt overwhelmed by the cultural shift of increased accountability. However, the nurses liked the ability to choose which method of verification they preferred versus the lack of selection of the prior competency model. Another advantage of the new method was the availability of system-wide opportunities; for example, a nurse who chose to participate in a skills fair could attend one at any of the hospital campuses during the variously offered time frames.
Previous Competency Methods Versus Wright's (2005) Competency Model
With the strong support of the health system's nursing leadership and with the CNEs remaining unified as a group, a 99% competency completion rate was achieved. Identifying the initial three competencies and methods of verification as the first phase over a 4-month period provided the nurses and CNEs with an opportunity to learn this new model and set the path for the following year of specialty-specific annual competencies.
As a system-wide Magnet® organization, there is immense pride among the CNEs regarding collaboration and sharing of resources. Specialty-specific nursing competencies are now standardized across every hospital campus, which has decreased education costs and increased CNE efficiency, compared with the previous use of skills checklists. However, despite best efforts to standardize specialty-specific competencies across the health system, variances will occur due to uniquely specialized patient care areas. In addition to improved CNE collaboration and the standardization of competencies, nurses now have greater flexibility to attend a skills fair, discussion group, or mock event at any site across the health system. Most importantly, nurses have increased accountability for their own competencies.
In evaluating the success of implementing the new system-wide competency model, the authors are pleased with the progress; however, taking the road less traveled has its challenges as well. Implementing this model across the multihospital health system was a great undertaking, and because competencies are evaluated annually, more changes are to come to ensure that the nursing staff is competent and safe in the delivery of health care.
- Allen, P., Lauchner, K., Bridges, R.A., Francis-Johnson, P., McBride, S.G. & Olivarez, A. Jr.. (2008). Evaluating continuing competency: A challenge for nursing. The Journal of Continuing Education in Nursing, 39, 81–85. doi:10.3928/00220124-20080201-02 [CrossRef]
- Arcand, L.L. & Neumann, J.A. (2005). Nursing competency across the continuum of care. The Journal of Continuing Education in Nursing, 36, 247–254.
- Axley, L. (2008). Competency: A concept analysis. Nursing Forum, 43, 214–222. doi:10.1111/j.1744-6198.2008.00115.x [CrossRef]
- Benner, P. (1982a). From novice to expert. The American Journal of Nursing, 82, 402–407.
- Benner, P. (1982b). Issues in competency-based testing. Nursing Outlook, 30, 303–309.
- Case Di Leonardi, B. & Biel, M. (2012). Moving forward with a clear definition of continuing competence. The Journal of Continuing Education in Nursing, 43, 346–351. doi:10.3928/00220124-20120116-18 [CrossRef]
- Chappell, K. & Koithan, M. (2012). Developing a skills-based competency course. The Journal of Continuing Education in Nursing, 43, 535–536. doi:10.3928/00220124-20121120-93 [CrossRef]
- Collins, A.S. & Strother, D. (2008). Synergy and competence: Tools of the trade. Journal for Nurses in Staff Development, 24(4), E1–E8. doi:10.1097/01.NND.0000320672.58200.8d [CrossRef]
- del Bueno, D.J. (1978). Competency based education. Nurse Educator, 3, 10–14. doi:10.1097/00006223-197805000-00005 [CrossRef]
- del Bueno, D.J. (1990). Experience, education, and nurses' ability to make clinical judgments. Nursing Health Care, 11, 290–294.
- del Bueno, D.J. (2001). Buyer beware: The cost of competence. Nursing Economic$, 19, 250–257.
- Ironside, P.M. (2008). Safeguarding patients through continuing competency. The Journal of Continuing Education in Nursing, 39, 92–94. doi:10.3928/00220124-20080201-09 [CrossRef]
- The Joint Commission. (2008). 2008 comprehensive accreditation manual for office-based surgery practice. Oakbrook Terrace, IL: Author.
- Kubin, L. & Fogg, N. (2010). Back-to-basics boot camp: An innovative approach to competency assessment. Journal of Pediatric Nursing, 25, 28–32. doi:10.1016/j.pedn.2008.07.004 [CrossRef]
- LaDuke, S.D. (2001). The role of staff development in assuring competence. Journal for Nurses in Staff Development, 17, 221–225. doi:10.1097/00124645-200109000-00001 [CrossRef]
- Lenburg, C.B., Abdur-Rahman, V.Z., Spencer, T.S., Boyer, S.A. & Klein, C.J. (2011). Implementing the COPA model in nursing education and practice settings: Promoting competence, quality care, and patient safety. Nursing Education Perspectives, 32, 290–296. doi:10.5480/1536-5026-32.5.290 [CrossRef]
- Levine, J. & Johnson, J. (2014). An organizational competency validation strategy for registered nurses. Journal for Nurses in Professional Development, 30, 58–65. doi:10.1097/NND.0000000000000041 [CrossRef]
- Maddox, B.L., Waller-Wise, R. & Weed, L.D. (2014). Perinatal nurses' perceptions of competency assessments. The Journal of Continuing Education in Nursing, 45, 453–460. doi:10.3928/00220124-20140925-17 [CrossRef]
- McMullan, M., Endacott, R., Gray, M.A., Jasper, M., Miller, C.M., Scholes, J. & Webb, C. (2003). Portfolios and assessment of competence: A review of the literature. Journal of Advanced Nursing, 41, 283–294. doi:10.1046/j.1365-2648.2003.02528.x [CrossRef]
- Meretoja, R., Leino-Kilpi, H. & Kaira, A.M. (2004). Comparison of nurse competence in different hospital work environments. Journal of Nursing Management, 12, 329–336. doi:10.1111/j.1365-2834.2004.00422.x [CrossRef]
- National Council of State Boards of Nursing. (2005). Meeting the ongoing challenge of continued competence [White paper]. Retrieved from https://www.ncsbn.org/Continued_Comp_Paper_TestingServices.pdf
- O'Hearne Rebholz, M. (2006). A review of methods to assess competency. Journal for Nurses in Staff Development, 22, 241–245. doi:10.1097/00124645-200609000-00007 [CrossRef]
- Rusche, J.D., Besuner, P., Partusch, S.K. & Berning, P.A. (2001). Competency program development across a merged healthcare network. Journal for Nurses in Staff Development, 17, 234–240. doi:10.1097/00124645-200109000-00004 [CrossRef]
- Schroeter, K. (2008). Competence literature review. Retrieved from http://www.cc-institute.org/docs/default-document-library/2011/10/19/competence_lit_review.pdf
- Scott Tilley, D.D. (2008). Competency in nursing: A concept analysis. The Journal of Continuing Education in Nursing, 39, 58–64. doi:10.3928/00220124-20080201-12 [CrossRef]
- Whelan, L. (2006). Competency assessment of nursing staff. Orthopedic Nursing, 25, 198–202. doi:10.1097/00006416-200605000-00008 [CrossRef]
- Wilkinson, C.A. (2013). Competency assessment tools for registered nurses: An integrative review. The Journal of Continuing Education in Nursing, 44, 31–37. doi:10.3928/00220124-20121101-53 [CrossRef]
- Wright, D. (2005). The ultimate guide to competency assessment in health care (3rd ed.). Minneapolis, MN: Creative Health Care Management.
Example of The Competency Validation Tool for Chest Tubes
Method of Verification (Choose One)
Verification Documents (All Forms Are on the Nursing Intranet)
|Sahara™ dry suction chest tube
||Return demonstration: Skills fair (dates/times on the nursing intranet)
||Chest tube skills checklist
|Presentation (topic must be approved by the clinical nurse educator and presented to 15 staff members or to 75% of staff on the units with 20 or fewer staff members)
|Teleflex® online learning, which can be accessed at http://www.teleflex.com/en/usa/ucd/ (provides 2 contact hours)
|Peer review: set up, change, or maintain chest tube
||Chest tube skills checklist
Previous Competency Methods Versus Wright's (2005) Competency Model
Previous Competency Method
Wright's Competency Model
|Unclear definition of competency, including many educational items that were not competencies
||Standard definition of a competency identified
|Competencies often an educational presentation, with no standard way of validating competency
||Outcomes-focused and accountability-based approach where only verification can measure competency
|Competencies evaluated only once per year
||Competencies demonstrated throughout the year in the real work environment
|Staff passive participants in the process
||Staff actively involved in the process
|Varying formats for competency delivery
||Format consistent and standardized across the system
|Varying time frames for annual competency evaluation
||Format and time frames consistent and standardized across the system
|Varying methods of evaluation of competency
||Evaluation consistent and standardized across the system
|Varying methods of competency identification across hospitals, units, and specialties
||Competency selection consistent and standardized across the system, using a standardized work sheet to identify competencies