Recent national initiatives in tracking patient outcomes clearly reveal the need for significant improvement in patient safety and quality care in the U.S. health care system. Nurses are crucial participants who contribute to emerging local and national quality and safety standards. An important Robert Wood Johnson Foundation initiative, Quality and Safety Education for Nurses (QSEN), was developed in response to several reports by the Institute of Medicine (IOM) that outlined core knowledge is essential across health care professional education (Greiner & Knebel, 2003; IOM, 2000, 2001, 2004). Although many nursing curricula underwent substantive revision in the 1990s based on valuable work in competency-based models, the current call is to critically reassess nursing education models. As nursing programs respond to vital initiatives such as QSEN, nursing faculty will discover important shared values exist between competency-based curricular models and the latest call for stronger foci on safety and quality. Emerging trends in health care emphasize even more clearly the necessity of competence in contributing to strong patient outcomes. Now is the time to design nursing curricula that reflect current shifts in health care practices that contribute to more effective systems that ensure patient safety.
This article describes how one university is using the QSEN competencies to enhance its competency outcome performance assessment (COPA)-based curriculum, thereby updating and strengthening its graduates’ skills in quality improvement and safety. Using the example of one pilot school, this article illustrates how the integration of a competency-based curriculum and the QSEN competencies is a logical process to promote quality education, competent new nurses, and safe quality patient care. When used together, they create a synergistic relationship between essential content and the desired end-result outcomes and verified performance competence.
The interface of a competency-based curricular model with the QSEN recommendations for changes to meet 21st century requirements is the current, unfolding experience for the faculty at the University of Colorado Denver College of Nursing (UCD CON). From 1997 to 1999, the University of Colorado faculty engaged in a multipart process to reassess its curricular model. Key stakeholders including community partners, students, and alumni voiced dissatisfaction related to gaps in nursing students’ competence in skills such as critical thinking, problem solving, and communication skills, and concerns about graduates’ ability to practice in complex care environments. In addition, students voiced their feelings about their lack of confidence related to entry-level competencies required in various clinical settings (Redman, Lenburg, & Walker, 1999). The faculty selected the COPA model, created by Dr. Carrie Lenburg more than 20 years ago, as the educational framework for the curricular redesign. The nursing curriculum has flourished in its orientation around the COPA model. It has not only provided a consistent framework for all levels of curricular development, but has also effectively addressed the concerns of the original stakeholders and students, resulting in stronger clinical competence in the university’s nursing graduates.
The definition of competence is shifting within all heath care professional education models as these professions heed the IOM’s call to develop aptitude in five core areas (Greiner & Knebel, 2003):
- Delivering patient-centered care.
- Working as part of interdisciplinary teams.
- Using evidence to guide care decisions.
- Focusing on quality improvement.
- Using information technology to improve patient safety.
The QSEN framework modified the IOM competencies by making a distinction between quality and safety competencies. As a result, six QSEN competencies were identified, with discrete knowledge, skills, and attitudes (KSAs) for each competency. The QSEN framework provides direction in how to educate nurses with the requisite KSAs to continuously improve the quality and safety of the health care systems in which nurses practice.
In Phase I of the QSEN initiative, an interdisciplinary national panel of experts explicated the KSAs that define each competency and collected data on the presence of these systems-focused concepts in nursing curricula. Survey and focus group data collected in Phase I revealed new graduates felt they had not adequately learned components embedded in the QSEN KSAs, and they doubted faculty competence to teach this content (Smith, Cronenwett, & Sherwood, 2007).
The University of Colorado Denver College of Nursing (UCD CON) participated in Phase II of the QSEN initiative as one of 15 pilot schools. The purpose of Phase II was to invite innovators in nursing education to develop and test pedagogical strategies to address the QSEN competencies. The 15 pilot schools were charged with the undertaking of incorporating the six QSEN competencies into the nursing curriculum in simulation and skills learning laboratories, clinical experiences, and didactic learning settings. Because of the curricular redesign of the late 1990s, an early inquiry of CON’s faulty and clinical partners questioned the compatibility of the COPA model with the QSEN initiative. To adequately analyze this question, the faculty and clinical instructors engaged in a rigorous review of the COPA model in the context of QSEN recommendations.
Overview of the COPA Model
The COPA model is a comprehensive, structured framework of concepts, core competencies, and methods designed to promote competency-focused and practice-focused nursing education. The model is organized by four essential concepts, as supporting pillars that are embedded in four questions that guide decisions and change:
- What are the essential competencies required for practice?
- What are the most effective outcome statements that integrate these competencies?
- What are the most effective interactive learning strategies to promote achievement of the outcomes?
- What are the most effective performance assessment methods to validate competence and achievement of the stated outcomes?
These questions provide a constructive organizing framework for curriculum change and implementation, whether in academic or practice settings. The model is designed to emphasize patient safety by requiring competent, safe practice, verified by performance examinations. The KSAs required are integrated in the outcome statements, the learning experiences, and most emphatically in the performance examinations. These examinations, based on psychometric concepts, provide evidence of ability to implement KSAs in clinical practice. The COPA model also is applicable in practice settings, as described by Boyer (2002, 2008) for a successful new nurse internship program.
In the COPA model, all nursing skills and abilities can be clustered under one or more of eight core practice competency categories: assessment and intervention, communication, critical thinking, human caring relationships, teaching, management, leadership, and knowledge integration skills. Each one is a distinct ability and is emphasized individually during early learning periods but progress in complexity consistent with course content. As in actual practice, several competencies typically are integrated into outcome statements and practice expectations. These core competencies are universal; they are applicable across all theory and clinical courses, environments, levels of performance, and positions, to one extent or another. None can be excluded in nursing practice.
The learner-oriented competency outcome statements express what students will achieve after a designated period of learning, at the program and course levels. Unlike typical program and course objectives, outcomes are not ambiguous statements for learning; they are stated as end-result, practice-relevant abilities that must be achieved. Effective, practice-driven interactive learning strategies implemented by the faculty are concentrated on the achievement of specific competency outcomes. The criterion-referenced performance examinations, as originally described in the seminal book by Lenburg (1979), require students to achieve standards for patient safety and practice by meeting the specified critical elements for all designated skills related to the eight core competencies. These critical elements are the mandatory, discrete actions (principles) that define competence for the level and content of each course. Students know the expectations from the outset and therefore learn and practice accordingly to achieve that standard as required by the examinations. The interaction among the integrated competencies ensures that students validate essential KSAs. Detailed description and illustration of these COPA concepts are described elsewhere (Bargagliotti, Luttrell, & Lenburg, 1999; Boyer, 2002, 2008; Klein, 2006a, 2006b; Lenburg, 1999a, 1999b, 2005, 2008, in press; Lenburg, Klein, Abdur-Rahman, Spencer, & Boyer, 2009; Luttrell, Lenburg, Scherubel, Jacob, & Koch, 1999; Redman, Lenburg, & Walker, 1999).
The COPA philosophy also encourages essential changes in the roles of faculty and students, and the delivery of the curriculum. Faculty are responsible for structuring the outcomes to be achieved, implementing interactive and practice-based methods to effectively help students learn them, and implementing standardized performance examinations in didactic and clinical courses. Students are responsible for achieving the designated competency outcomes and skills as the means to promote patient safety and quality care. The model also provides an effective method to organize and promote quality improvement in teaching, learning, and program evaluation. Moreover, it provides a structure for continuing competency development in the workplace that is more critical than ever to ensure safe patient outcomes.
Using QSEN to Enhance COPA
In exploring an effective integration of the COPA model and QSEN competencies, the strong philosophical and value overlap became clear. The CON faculty noted a similar value base between the eight core practice competencies of COPA and the six overarching competencies of QSEN. The explicit value of ongoing competency in both COPA and QSEN is a critical and timely focus. The current complexities of nursing practice demand, more than ever before, that competency is viewed as ongoing learning and assessment. Rather than a series of discrete demonstrations of skills, today’s practice requires students are educated in models that support continuing competency (Ironside, 2008). Competence cannot be assumed or subjectively evaluated; it must be objectively standardized and validated. The COPA model provides the educational foundation, methods, and processes for such assessment (Lenburg, 1999a, in press; Lenburg et al., in press).
Both COPA and QSEN value an integrative definition of nursing practice that rejects traditional clinical education models in which the focus on proficiency is primarily on technical skills. Integration of nursing care in the multi-faceted context of currently complex, fast-moving nursing practice is an important bedrock value of both models. The QSEN competencies evolved from the ongoing work by the IOM, with patient outcomes considered in the context of health care systems. Nurses have long been a vital part of interprofessional teams, and it is essential that nurses are key participants in developing new clinical education models. Similarly, the use of the COPA model as a comprehensive curricular framework begins with specifying essential competencies required for practice and then developing effective learning and assessment methods to validate competence consistent with course content. With the COPA model, competency outcomes inherently require the acquisition of KSAs for all eight core competencies as integrated in course content and practice; all are essential for comprehensive professional practice in the current health care systems in which nurses practice.
The QSEN and COPA approaches both have a clear emphasis on preparing students to be competent practitioners in contemporary health care settings. Defining competent practice is a dynamic goal, ever shifting as nursing practice responds to emerging needs and emerging evidence. Both approaches depend on collaborative partnerships with clinical agencies to discern core content in defining clinical competence for nurse clinicians. This close connection to nursing practice in QSEN and COPA effectively bridges the age-old theory-practice gap that has burdened nursing education and practice for decades.
Core competencies are defined in both approaches, although differently, using action-oriented terms. The national emphasis on patient safety requires that faculty implement more standardized criterion-referenced measurements, or rubrics, to effectively evaluate learning in clinical education. The COPA outcome competencies are end-result practice abilities that must be achieved by students to validate competence. Each of the six QSEN competencies is divided into corollary KSAs to operationalize these distinct aspects of content competence. The operationalization of definitions of competence into measurable outcomes is vital in developing objective measures of clinical learning. The COPA model as a curricular framework was instrumental in the shift to performance-based definitions for verification of competence. The QSEN initiative’s KSAs offer complementary components to definitions of content competency by including system-focused criteria that are necessary for practice.
Both QSEN and COPA have the capability to level competencies consistent with clinical learning progression. In the COPA model, competencies are integrated in learning and examination periods with the increasing complexity of course content. Typically, two or more competencies are integrated simultaneously into a single complex outcome consistent with actual practice. Thus, the COPA curricular model adjusts systematically to a learner’s developmental progression. The QSEN competencies and the KSAs also are relevant across all levels of a nursing curriculum. Barton, Armstrong, Preheim, Gelmon, and Andrus (in press) recently completed a national Delphi study to determine developmental progression of the QSEN KSAs in prelicensure curricula. The results provide specific direction regarding where KSA elements from each competency are best introduced and where they are best emphasized. As faculty look to integrate the QSEN competencies and KSAs across a curriculum and across teaching settings, results of the Delphi study provide helpful guidance about where to target specific KSAs of each competence. Both QSEN and COPA incorporate the importance of using tools that reflect the increasing complexity in content and processes in clinical education.
In addition, safety is a top priority in both approaches. Lenburg’s work emphasizes the necessity of operational definitions of competence to teach and evaluate students effectively, thereby ensuring safe, competent clinicians. The QSEN initiative includes content and learning opportunities that teach students about human factors and basic safety design principles in health care. Both approaches to clinical education result in a stronger professional formation of nurse clinicians who can practice effectively in the context of interdisciplinary teams, evidence-based health care systems, and quality improvement processes. By implementing learning and psychometric principles, skills such as critical thinking, problem solving, communication, and other core competencies can be operationalized more effectively by integrating both approaches to promote competent care.
Neither QSEN or the COPA model is restricted to one educational setting. Both are maximally used when content and processes are integrated across classroom, simulation and skills learning laboratories, and clinical environments. Teaching in silos is ineffective, especially when gaps exist between the classroom, simulation and skills learning laboratories, and clinical settings. Repeated reinforcement of concepts across learning settings ensures the foundation of a professional identity is rooted in these explicitly recurring competencies. A concept emphasized in both COPA and QSEN is that competence is learned most effectively when it is consistently and progressively integrated across all learning environments.
Synergy of QSEN and COPA
Ultimately, the CON faculty found there is dynamic synergy between the COPA model and the QSEN content competencies. The COPA model enhances the QSEN initiative and vice versa. Each adds value to the other; however, QSEN has a distinct focus on a systems component. The six competencies of QSEN are rooted in the nurse as part of an interdisciplinary team practicing in a complex health care system. In the COPA model, this perspective is implicit and integrated in the eight core practice competencies, consistent with course content and practice expectations. As nursing professional identity becomes more clearly grounded in participating in health care systems, nursing students also will need to have an unequivocal systems focus in their education.
The COPA model offers clear direction for standardized evaluation of competence. The COPA model explicitly emphasizes actual performance examinations focused on the integration of the eight competencies and relevant skills that are embedded in didactic and clinical courses. This requirement enhances students’ motivation to learn and meet the specified standards for safe practice. Achievement of outcomes as verified by performance examinations increases students’ clinical competence and confidence. The QSEN initiative outlines the KSAs for each of its six competencies, and the recent Delphi study by Barton et al. (in press) indicates the KSAs are being leveled in their use in pilot schools, but the metrics of evaluation have not yet been identified or defined. An important goal of QSEN’s emerging Phase III work is assessing achievement of quality and safety competencies in nursing programs. The CON faculty discovered integration of the QSEN KSAs into the competency performance examination process produces a stronger basis for comprehensive assessment of student achievement of practice-based competencies.
Integrating QSEN and COPA Across All Courses
An analysis of COPA competencies and QSEN competencies reveals their strong shared values. All eight COPA core practice competencies and all six of QSEN’s overarching content competencies need to be present in all nursing courses. It would be illogical to pull out COPA’s “human caring and relationship skills” or QSEN’s “patient-centered care” as a discrete nursing course. With close analysis, the synergy of integrating these two value sets into a new framework for nursing education became evident. Table 1 illustrates how each QSEN content category requires all eight COPA core practice competencies to achieve the outcomes embedded in the QSEN competency definition. None of the QSEN competencies can be achieved without integration of all eight COPA core practice competencies. This interrelationship is true for each of the other five QSEN competencies.
Table 1: Integration of COPA Practice Competencies and QSEN Content Competencies for a Synergistic Framework
For example, the QSEN competency of patient-centered care is defined as (Cronenwett et al, 2007):
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values and needs
All eight of the COPA practice competencies are required to achieve this competence. Nursing students must develop assessment skills to implement their part of the partnership. Relevant professional communication skills must be used to have an exchange about a patient’s preferences and needs. Nursing students use critical thinking during these exchanges to determine how best to meet the patient’s needs; human caring and relationship skills are at the foundation of this interpersonal respect. Teaching is implicit in all nursing care, especially as nurses are adjusting a plan of care to include values of mutuality and respect. Management and leadership skills become vital as nurses communicates a patient’s preferences and wishes to the health care team, as the plan of care shifts to acknowledge the patient as full partner. Finally, the implementation of best evidence consistent with the patient’s diagnosis, treatments, preferences, values, and needs requires extensive knowledge integration skills. It would be unwise to omit any of the COPA core practice competencies in teaching any of the KSAs of QSEN’s patient-centered care competence. The same analysis applies to all of the QSEN overarching competencies.
The COPA model and the QSEN initiative clearly are complementary. The integration of a COPA-QSEN framework throughout a curriculum would ensure students learn the KSAs for the essential content and competencies required for beginning practice, with an updated emphasis on an understanding of systems. The CON faculty found the task of revising the competency performance evaluation tool that had been used to measure students’ clinical competence relatively easy to update with QSEN concepts.
Developing a Comprehensive Clinical Evaluation Tool
The CON faculty developed and has been using the COPA Competency Performance Examination (CPE) methods in clinical courses for the past 10 years. When the COPA model and CPE tool were reassessed in the context of becoming one of the QSEN pilot schools, the complementary and shared values of safety, competence, and specific action-oriented definitions became apparent. The intended purpose and language of each have much in common, and in fact when integrated, they added important synergy to the educational process. Table 2 presents one example of how a QSEN competency and skill elements can be integrated into a COPA-based CPE tool related to a medical-surgical nursing II course. Table 2 offers some of the University of Colorado’s work in updating a competency-based evaluation tool with elements of QSEN’s patient-centered care competence. Only one-sixth of a QSEN-COPA evaluation tool is presented in Table 2; this example only offers a potential approach for patient-centered care. The CON faculty have continued to work to incorporate all six QSEN competencies into their CPE evaluation tools for all clinical courses. The original essence of the learner-oriented competency outcome statements was not altered; rather, it was expanded by including the important systems contexts and content competencies developed by QSEN.
Table 2: COPA Competency Performance Examination Revised to Integrate QSEN Competencies
In this approach, the COPA CPE is the bedrock on which objective clinical evaluation of student performance is made. The CPE was designed by the faculty using COPA’s competency outcomes, the eight core practice competencies, and course-related skills and critical elements required for practice (Lenburg, 1999a; Lenburg et al., in press). These components define expected proficiency in clinical practice in clinical courses. As such, CPEs are valuable clinical evaluation tools, used at our university to provide a concrete, objective assessment of actual student clinical competence.
The integration of QSEN and COPA competencies in the CPE initially was challenging; however, the transitional development is well under way throughout the program. The six QSEN competencies are used as overarching competency content areas. Specific outcome statements that incorporate the QSEN KSAs are defined and integrated with COPA’s eight core practice competencies and methods in the CPEs. The CPE was formatted into an easy-to-use recording form for clinical preceptors to use for legal documentation when they conducted midterm and final clinical examinations. The final assessment instruments and process are more valuable because they contain content and competency outcomes, and specific, objective, measurable standards (critical elements) to validate student competence. The integration of the COPA model and the QSEN competencies has resulted in a more synergistic and reliable interaction of course content and practice abilities made evident during the competency assessment of students.
Nursing education is undergoing a revitalization as the mandate for educational models to become more relevant to current practice is more urgent than ever. Due in part to demand from key stakeholders in the community for increased clinical competency as well as the IOM reports, clinical nursing education models have shifted in the past decade to provide increasing specificity in defining and measuring competence in clinical outcomes. This article explores one school and one approach to addressing QSEN competencies in a competency-based curriculum. Other schools are considering similar questions. For example, the Oregon Consortium for Nursing Education (OCNE) is a progressive statewide initiative to develop new nursing clinical education models that effectively address the nursing and nursing faculty shortage, the increased enrollment in nursing programs, the decreased availability of clinical training sites, smaller budgets, and the increased complexity of nursing care in diverse settings. To respond to these competing demands, OCNE’s model is a competency-based curriculum that includes the system-specific competencies identified by IOM as essential for health care professionals (Tanner, Gubrud-Howe, & Shores, 2008). The OCNE’s model exemplifies an effective blend between creating a competency-based curriculum and responding to the important systems elements that are vital to current nursing practice.
The QSEN initiative is now moving into Phase III of its work. The main aims of Phase III are the national dissemination of the QSEN competencies and KSAs to nursing programs, and integration of QSEN competencies and KSAs in textbook content, accreditation and certification standards, licensure examinations, and continued competence requirements ( http://www.qsen.org). Some nursing programs that shifted the curricular framework to COPA concepts, outcomes, and validation methods may raise concerns about the emerging implementation of the QSEN initiative. The relevance of the COPA model and value system is increased in the context of QSEN, in which not only clinical competence is necessary to protect patient safety, but systems competence also is equally vital.
Nursing faculty resist the message that a new nursing curricular model must replace the model that recently was fully instituted. As the CON faculty continues to explore ways to implement the components of QSEN into its prelicensure curriculum, they are relieved to discover the COPA work of the past decade will not be undone or replaced. In fact, QSEN and COPA are complementary and enhance each other; both reinforce the emphasis on competence and patient safety. The COPA model was developed more than two decades ago, and it is a clear testament to its efficacy and effectiveness that its primary focus and concepts are evident in, and readily applicable to, the new QSEN initiative. Developed separately and from different perspectives, they share the same concerns for promoting student competence and continuing competence in nursing practice to safeguard patient safety and enhance quality care. Both approaches are relevant and applicable in diverse nursing education programs and varied care settings. Until now, each model has been perceived as separate but our experience illustrates the complementary synergy obtained from integrating them into a more comprehensive educational framework.
The QSEN initiative provides explication of several essential content competency categories that are interwoven in essentially every course throughout the curriculum. They guide course development and focus student learning toward competent safe nursing care. The COPA model provides the structure for implementing these content competencies into practice-based competency outcomes and standardized performance assessment in both didactic and clinical courses. Integrated into a unified framework, they create a positive synergistic relationship between essential content and the desired end-result outcomes and verified performance competence.
Over time, a new model can evolve that integrates both frameworks into a more synergistic and comprehensive model that is supported by research. The pilot schools in the QSEN project, the schools that incorporate the COPA model, and the agencies that employ the graduates all provide rich resources for ongoing education research. Multiple studies are needed to determine the effectiveness of these and other potential evolving models, all of which now have a greater mandate to advance the competence of clinicians to ensure safe patient outcomes and quality care.
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Integration of COPA Practice Competencies and QSEN Content Competencies for a Synergistic Framework
|COPA Practice Competencies||QSEN Competency Categories|
|Eight Practice Competencies||Patient-Centered Care||Teamwork & Collaboration||Evidence-Based Practice||Quality Improvement||Safety||Informatics|
|Assessment & intervention||✓||✓||✓||✓||✓||✓|
|Human caring relationship||✓||✓||✓||✓||✓||✓|
COPA Competency Performance Examination Revised to Integrate QSEN Competencies
|QSEN Patient-Centered Care Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs|
|Mid Term Evaluation||Final Evaluation|
|Met||Not Met||Met||Not Met||By the end of the clinical experience, the student will be able to meet the following critical elements:|
|Obtain individualized patient data by the following:|
|A. Interview patient to obtain an accurate and relevant history consistent with patient cultural values, preferences, and expressed needs|
|B. Perform a focused physical assessment to determine relevant objective data|
|C. Assess levels of physical and emotional pain and comfort, and patient and family’s expectations for relief|
|D. Analyze other relevant data from tests and other health care providers|
|E. Write a plan of care that integrates data obtained consistent with patient values, needs, and evidence-based practice|
|F. Consult with other relevant health care providers and the patient (designee) to complete a plan of care|
|Provide individualized patient care by the following:|
|A. Inform patient of care process prior to beginning care|
|B. Provide treatments consistent with protocols and care plan, with respect and sensitivity to patient’s preferences (e.g., medications, procedures, treatments)|
|C. Engage patient (designee) as a partner in care, to extent possible|
|D. Teach aspects of care to patient (designee) during care given to promote participation|
|E. Implement measures to relieve pain (as needed) and promote comfort|
|F. Consult with other providers as indicated and required by changes in patient’s condition|
|G. Document care in written and oral form and format, consistent with protocols|
|H. Communicate patient’s preferences, values and needs to other relevant health care providers|
|Evaluate individualized patient care by the following:|
|A. Consult with other relevant health care providers to determine more effective interventions to promote patient’s health and comfort|
|B. Research relevant resources to determine best practices for patient’s current condition and needs|
|C. Modify plan of care to integrate patient’s current condition and needs, recommendations from other providers, and evidence-based practice|
|D. Communicate revised plan of care to other health care providers consistent with oral and written protocols|