Globally, health care is experiencing issues in work force shortages and skill gaps and is retooling health work force education and professional development to address these problems. As the nature of work and work force development in health care shifts to address these issues, building capacity to engage a work force pipeline competition for talent grows. Thus, traditional methods of education and professional development are being challenged (World Economic Forum, 2018). Leaders at all levels within health care organizations (HCOs) have an obligation to prioritize and ensure that nurses and other members of the health care work force have the tools and resources to provide competent and high-quality care. This requires providing facilitators of learning the ability to learn, to be innovative and creative, and to engage in using models of education and learning that are realistic in meeting identified learner outcomes and competencies. It also requires that competency assessment be directly tied to identified outcomes that are appropriate for the identified underlying educational needs. This mind shift provides HCOs with the opportunity to turn the work force into a learning organization, not just a service organization, to achieve their strategic goals. Professional development is not limited to clinical practice and should be supported in all aspects of health care, from leadership to academia.
Defining Competency-Based Education and Competency Assessment
The literature describes several taxonomies for competency, including taxonomies that reflect both performance and education. Often competency and competency-based education (CBE) are approached without having a true understanding of what competency means. The American Nurses Association (ANA, 2015, p. 86) defines competency as “an expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgement, based on established scientific knowledge and expectations for nursing practice.” The American Nurses Credentialing Center Accreditation (ANCC, 2019, p. 10) in Nursing Continuing Professional Development (NCPD) program defines competence as “the potential ability to function in a given situation.”
Competency in academia is further defined as “the ability to apply knowledge, skills and/or abilities including intellectual behaviors that are required to meet performance metrics and outcomes” (Bushway, Dodge, & Long, 2018, p. 1). Specifically, the Competency Based Education Network (CBEN, 2015) within their definition focuses on that the time it takes for a learner to master a competency is variable, but that the learning expectations, outcomes, and criteria for successful mastery completion remain constant. Further, within the CBEN (2015) definition, competency is determined through multiple forms of assessments that address mastery of the identified knowledge, skills, and abilities. It is important to note that competencies can be individualized or personalized not only to a learner but also to a group or team of learners.
Backwards Planning in Competency-Based Education and the Relationship to Professional Development
An outcome is defined as “something that follows as a result or consequence” (“Outcome,” 2009). The ANCC (2019, p. 4) defines outcome measures as “a specific and quantifiable variable by which attainment of objectives may be judged.” Both Miller's model of clinical competence and Moore's seven levels of continuing medical education outcomes are examples of models that are used to evaluate health care provider performance (Miller, 1990; Moore, Green, & Gallis, 2009). In both models, a backwards planning approach to designing educational experiences is encouraged to facilitate the application of learning in its appropriate context—knowledge, skill, and/or practice (competence). This is especially important in health care, where health care providers, such as nurses, need to apply learning within a rapidly changing context (Daugherty, 2006). Specifically, the Miller and Moore models are used in the backwards planning of continuing professional development. CBE also includes the identification of the “end in mind” or desired state versus current state. In continuing professional development, this strategic approach is often referred to as a professional practice gap. The professional practice gap is the difference between the current state of “what is” and the desirable or achievable state “what should be.”
Competency Assessment in Competency-Based Education—A Nontraditional Approach
One notable difference in CBE backwards planning from professional development is the deviation from the traditional approach in that the learning assessments are created prior to the content design (Bushway et al., 2018, p. 36). Typically, the assessment or evaluative component in traditional activity design is either generated in concert with content development or after content is developed. Often in professional development, how to evaluate or assess the outcomes or competence of the learner is challenging due to no defined relationship between the content and the competency assessment methods. Further, it is not unusual for competencies to be broadly chosen without clear rationales or affirmative direction for achievement. This often results in competency checklists being checked off rather than incorporating assessment methods that identify that knowledge and skill is articulated and/or applied to practice. Therefore, competencies must be thoughtfully identified and based on professional practice gaps, including where the underlying needs for the learner exist—knowledge, skill, and/or practice. By designing the competency assessments or evaluations prior to the content design—the interventions or activities—one can ensure that the educational experience is aligned to the identified learning outcomes and competencies. Thus, the educational experience will be evaluated or assessed based on what the learner or learners should know, do, or show as a result of participating. Competency assessment can also be evaluated through proxy measures, such as evidence of impact to practice, patients, and/or system outcomes. This shift in how professional development is designed will ensure that content is directly parallel with the identified desired state, outcomes, and competencies.
The Outcome-Based Continuing Education Model© and CBE
In CBE and the Outcome-Based Continuing Education Model© (OB-CE), assessing competence and achieving learner outcomes is the focus and time is the variable. In traditional continued professional development (CPD), the credit hour, or contact hour system, is where “seat-time,” or time spent in the educational experience, is the focus rather than the assessment of outcomes and/or competence. A culture shift is needed with systemic support and acceptance from leaders, academics, facilitators of CPD, and learners in health care that time does not equate to learning. The ANCC OB-CE Model©, where knowledge serves as the foundation for applied learning in an integrated performance framework, aims to achieve this concept.
The ANCC OB-CE Model© does not use a time-based metric but instead requires validation of learner engagement and performance from foundational or basic knowledge to evidence of integration into performance, and impact on practice, patient, and/or system outcomes. The OB-CE Model© also acknowledges that CPD takes place in a learning environment that is impacted by such things as culture, resources, institutional structure, and systems issues. The model also acknowledges that learning is affected by individual/group behaviors, attitudes, values, judgments, and beliefs that can positively or negatively impact the achievement of desired outcomes. CBE promotes a learning environment that is focused on the growth and development of a learner or learners. It requires that learners “not be left on their own” and that learning tools and resources are thoughtfully selected to achieve the identified outcomes (Bushway et al., 2018, p. 36). Both the OB-CE Model© and the CBE framework require that mastery in the domains of knowledge, skill, and/or practice (abilities)—including intellectual or professional behaviors—are achieved. The five levels within the OB-CE Model© begin with articulation of knowledge and skills and progress through application, demonstration, integration, and impact on practice, patient, and/or system outcomes. The five levels are designed to demonstrate evidence of growth and learning achieved in each domain (Figure 1). The concept of growth mindset—moving the learner from one place to another—is a key focus of both CBE and the OB-CE Model©.
American Nurses Credentialing Center Conceptual Model for Outcome-Based Continuing Education Model©. From Awarding Credit for Outcome Based Professional Development: Outcome Based–CE©Model Manual, by American Nurses Credentialing Center, 2019, Silver Spring, MD: Author. Copyright 2019 by American Nurses Credentialing Center. Reprinted with permission.