The Journal of Continuing Education in Nursing

Leadership and Development 

Reverse Engineering to Ensure Course Competencies Are Linked to Clinical Proficiency

Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN

Abstract

Higher education and continuing education are increasingly focused on clinical proficiency and readiness for practice. This article describes the art and science of setting competencies. It further recommends that field-based competencies, referenced as clinical proficiency, become a strong foundation for developing and distinguishing course and program competencies. In this way, academic and service needs are aligned. [J Contin Educ Nurs. 2019;50(7):297–299.]

Abstract

Higher education and continuing education are increasingly focused on clinical proficiency and readiness for practice. This article describes the art and science of setting competencies. It further recommends that field-based competencies, referenced as clinical proficiency, become a strong foundation for developing and distinguishing course and program competencies. In this way, academic and service needs are aligned. [J Contin Educ Nurs. 2019;50(7):297–299.]

In both higher education and continuing education circles, increased reference is made to competency-based education and learning. This same effort is underway in K-12 education with a focus on ensuring that students are ready for college, a career, and life. As cited by Lopez, Patrick, and Sturgis (2017), competency-based educational structures place a balanced skill emphasis in areas of growth mindset, metacognition, learning how to learn, problem solving, advocacy, collaboration, creativity, and the habits of success as they do on academic content knowledge and skills. In higher and continuing education, these pursuits remain very similar in spoken word but not in practice.

Traditional approaches to education and learning outcomes remain generally oriented to professional tasks, minimum safe practices, and achieving outcomes aligned with an academic paradigm—for instance, authoring a scholarly paper using a prescribed American Psychological Association or other writing style guideline, even though this is not a field-based proficiency often used. In traditional education on content mastery, students remain in a static time-based learning environment, dictated by semesters and structures that keep individual learners together in a group environment until they are released to the next term. Traditional education grading practices encourage rubrics for rating and ranking in the academic milieu, giving a false sense of what might make for success in an actual clinical setting (which I reference as field-based proficiencies). For instance, in the field, the soft skills of fluent communication, the ability to translate complex medical terminology to a level of patient-family comprehension, and the ability to persuade and influence other team members are critical proficiencies, but they may not be measured or even valued in the academic mi-lieu. The question addressed in this article is whether reverse engineering could positively influence the course and program outcomes in any formal learning environment.

The Challenge of Competency-Based Learning

A universal challenge for any educator writing course objectives is to determine the level, nature, depth, and breadth of objectives to state as their aim, even before considering competency-based learning outcomes. It is a growing trend to embed competencies in health care learning and practice settings. But which competencies should be embedded and who sets the standard for these competencies?

Most professional organizations have developed explicit competency statements that can number in the hundreds, another universal challenge for an educator to navigate. In leadership education, one example is the competencies developed by the American Organization for Nursing Leadership (formerly the American Organization of Nurse Executives) (American Organization of Nurse Executives, 2005). Although five domains of competence for nurse executives are noted (communication and relationship building, knowledge of the health care environment, leadership, professionalism, and business skills), each has numerous subdomains, and multitudinous skills under the subdomains. It takes an experienced educator–practitioner to discern among this list. Consider other sources for standards and competency-based expectations such as these: in test blueprints, implicit standards are linked to state board examination preparation; specialty organizations such as the Oncology Nursing Society have published Scope and Standards of Oncology Nursing Practice that address access device standards, documentation standards, chemotherapy administration safety standards, and more; or the American Association for Critical Care Nursing, which has published standards for progressive and critical care nursing practice, standards for a healthy work environment, and advanced practice nursing standards; and the American Nurses Association with its professional standards for a range of nursing specializations and a code of ethics. With just these few examples, one immediately sees the volume of standards and competency statements that are in play, which are nuanced, aimed at different target audiences, and in no unifying format. Adding yet another layer of complexity is to determine the degree to which the standards developed have been vetted against current evidence-based knowledge and the level to which they can be applied in the field beyond the classroom and whether they have the specificity to aid the educator in preparing the learning environment.

Depending on the course and its aims within a curriculum, it is plausible that competencies can be based at the procedural skill level (i.e., to proficiently and safely administer medication in its prescribed route). At a higher level, competency-based learning can be linked to an individual's ability to manage care through critical thinking and critical actions. Drawing on standards of practice, the learner may use procedural skills as part of managing the patient care trajectory of a person with, for instance, congestive heart failure. Shifting focus, other competencies could also come into play at the care management level. They could include clinical procedural skill abilities, psychosocial interactions to alleviate anxiety and fear, disease management abilities tied to teaching and coaching on medication regimens, exercise routines, self-care strategies, and more. Or, yet again, the learning outcome could aim at the health system level, where competencies may include successful communications with the health care team, or the ability to ensure care transitions with handoffs to other clinical agencies postdischarge or to advocate for resources for an uninsured patient who is homeless. On reflection, there are many sources that call for action on what competencies are needed in our discipline, more than can be achieved. It takes a highly seasoned educator with strong practice ties to interpret and select the number, type, and level of competencies to include in an educational offering.

Reverse Engineering as an Alternate Approach to Course or Program Design

Can the conundrum of selecting and discerning course or program competencies be solved by reverse engineering? This approach has merit. The origin of reverse engineering involved analyzing something, determining how it worked, and then making something similar to it. In our case, let us consider the “somethings” as field-based skills and abilities and how they manifest in clinical practice. Course designers usually have field-based skills and abilities as peripheral to course design, rather the priority is aimed at theoretical and academic skill sets to linked to course objectives. In reverse engineering, course designers first ensure that course objectives account for field-based observed needs and then back into theoretical and didactic content to wrap around clinical practice. This practice ensures readiness for practice to enhance theoretical and didactic application. Reverse engineering has the benefit of factoring out obsolescence, thereby ensuring that courses are relevant and timely, can fix flaws, and can be an education tool to enable understanding of current and best practices (Interaction Design Foundation, 2017).

In the following hypothetical scenario, we return to leadership skills and abilities as an example of how to reverse engineer a continuing education course; we note that providing feedback in formal and informal ways is a crucial leadership function. In 1 day of unit-based observation, the professional development educator sees a unit-based leader provide coaching to a new staff member, interacting with an upset patient and family, and having to confront a physician who is insistent that his specialized view of the patient supersedes the other medical and clinical care needs of the patient. Having observed three very different scenarios where communication was critical, the educator provides the learner with feedback that encompasses their adaptive style of communication, varying levels of self-confidence, and persuasive capacity in each situation. Communication concerns in this unit are high volume, high risk, and problem prone, which makes it relevant for competency-based learning.

Using reverse engineering, the educator backs into and verifies where and what standards exist within professional organizations and searches for competency statements and exemplars that align with the lived reality of this unit, a form of gap analysis. Finding several evidence-based sources, an added plus, the educator determines how to best prepare the learning environment with this aim: learners will possess a self-assured style in two scenarios. The first is to give performance feedback to a new graduate. The second is to interact in a crucial conversation with an insistent physician who is not prone to a team orientation or a holistic perspective.

In reverse engineering, these polar scenarios set the stage for didactic and scholarly development. The educator ensures theoretical and practice didactic content covering giving and receiving feedback is used, and that conflict management is incorporated into the course. For readings, an article from Psychology Today is selected, along with a YouTube video on the same subject. The course textbook titled Thanks for the Feedback: The Science and Art of Receiving Feedback Well by Douglas Stone and Sheila Heen (Stone & Heen, 2014) is selected because of its applied nature, a reference that might have otherwise been overlooked had the course developed in the usual manner. Role-playing now becomes a part of the class assignment, using a set of principles as the rubric for evaluating the learner's style and impact, rather than microlevel checklists. The continuing education course has the following course objectives: (a) communicate effectively when providing crucial feedback; (b) examine evidence-based communication strategies to deescalate high-risk incidents; and (c) apply knowledge of human behavior in an organizational setting.

But the course also offers something else. The following are field-based competencies that the learner will show beginning proficiency in achieving, both emanating from and complementary to the course objectives. The learner will be able to (a) prepare a formal written performance evaluation on a new graduate that reflects the RN's achievements and areas for growth and improvement; (b) engage in deescalating a high-stakes clinical event; and (c) prepare an incident report that captures the context and content of the high-stakes clinical event.

Summary

There is no end in sight when it comes to competency-based education. Educators will bear the responsibility of selecting the level, nature, depth, and breadth of competencies to employ in a single class or within a course or program of study. Competency-based learning requires a level of faculty expertise that is substantial. A potential solution to the conundrum is to consider reverse engineering strategies, starting with field-based observations of the skills and abilities needed to align clinical practice with course learning opportunities. This strategy may be a needed bridge to improve and narrow the gap between academic–service partnerships.

References

Authors

Dr. Bleich is Senior Professor and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer, NursDynamics, Ballwin, Missouri.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Michael R. Bleich, PhD, RN, NEA-BC, FNAP, FAAN, Senior Professor and Director, Virginia Commonwealth University School of Nursing, Langston Center for Innovation in Quality and Safety, and President and Chief Executive Officer, NursDynamics, 221 Jasmin Park Court, Ballwin, MO 63021; e-mail: mbleich350@gmail.com.

10.3928/00220124-20190612-03

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