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Methods Dr. Scott Tilley is Nursing Director, Texas Christian University, Fort
Worth, Texas.
A review of nursing, medical, public health, and edu-
The author discloses that she has no significant financial interests in
cational literature from the 5 years prior to January 2006 any product or class of products discussed directly or indirectly in this
was conducted. The keyword “competency” was used activity, including research support.
to search publications in English. The search engine CI- Address correspondence to Donna D. Scott Tilley, PhD, RN, Texas
NAHL yielded 187 articles and the search engine Ovid Christian University, TCU Box 298620, Fort Worth, TX 76129.
Sidebar 1 Sidebar 2
Concept Analysis Steps Competency outcomes and
l Select a concept performance assessment: Core
Competencies
l Determine the aims or purposes of the analysis
l Assessment and intervention
l Identify all the uses of the concept that can be discovered
l Communication
l Determine the defining attributes
l Critical thinking
l Identify a model case, borderline case, and contrary case
l Teaching
l Identify antecedents and consequences
l Human caring relationships
l Define empirical referents
l Management
Note. Data from Walker and Avant (2004).
l Leadership
l Knowledge integration skills
graduate level and beyond must be offered with increas- Note. Data from Lenburg (1999b).
ing competency as a goal.
Although education based on competency may be
agreed upon, determining which competencies are most 1990s as professional nursing organizations, consumer
critical, at what level they should be demonstrated, and advocacy groups, and a rapidly changing health care en-
how to teach them remains unclear. Evaluating cogni- vironment led nursing to continue its efforts to create
tive, affective, and psychomotor achievement of skills safe environments for patients. This movement was ac-
and knowledge that increase in complexity throughout celerated by the Pew Health Professions Commission’s
a career is challenging. reports (Pew Health Professions Commission, 1995) and
the Interprofessional Workgroup on Health Professions
Origin of the Concept of Competency Regulation (IWHPR; 1997) continuing competence
Competency is derived from the Middle French and summit in the mid-1990s.
Latin word competens. To be competent is to be proper In 1999, Lenburg (1999b) described the Competency
or rightly pertinent, to have requisite or adequate ability Outcomes and Performance Assessment (COPA) model,
or qualities, to be legally qualified or adequate, or to have which was applied in an academic setting but viewed as
the capacity to function or develop in a particular way equally applicable in the practice setting (Redman, Len-
(Merriam-Webster Online, n.d.). The National Coun- burg, & Hinton Walker, 1999). This model uses four
cil for State Boards of Nursing (NCSBN; 2005) defined guiding questions to create an organizing framework
competency as “the application of knowledge and the to assist in the transition to competency outcomes and
interpersonal, decision-making, and psychomotor skills performance assessment. Eight core competencies were
expected for the practice role, within the context of pub- identified (Sidebar 2). Evaluation is performed at didactic
lic health” (p. 81). McMullan et al. (2003) distinguished and clinical levels to promote accountability in the eight
between competence and competency, stating that com- core areas.
petence is focused on the description of the action or be- Also in 1999, the Accreditation Council for Graduate
havior, while competency is focused on the individual’s Medical Education (n.d.) endorsed general competen-
behavior that underpins the competent performance. cies for residents. This was the first step in the council’s
These terms are frequently used interchangeably. process of incorporating these competencies into its
Beginning in the early 1980s, many boards of nursing requirements. The general competencies identified for
began to explore the issue of competencies for graduating medical residents were patient care, medical knowledge,
nurses in their states. Several states developed essential practice-based learning and improvement, interpersonal
competencies of nursing program graduates. Typically, and communication skills, professionalism, and systems-
these competencies are specified by educational program based practice.
preparation (e.g., diploma, associate degree, and bach- Genomics, once considered a specialty area, is in-
elor’s degree). Most identify the knowledge, judgment, creasingly being recognized as a central science for all
skills, and professional values expected of graduates of health care professionals. With this in mind, a panel of
nursing programs. nurse leaders convened in 2005 to establish competen-
Continued competency became a topic of intense cies required for delivery of genetic and genomic fo-
and frequent discussion among nurses nationally in the cused nursing care. The essential competencies of pro-
fessional responsibilities, professional practice domain, for new graduates, other states have opted to improve
referral activities, and provision of education, care, and the preparation of nurses for entry into practice through
support were identified. Each core competency has spe- other means (New Mexico Consortium for Nursing
cific behaviors by which it can be assessed. The Genom- Workforce Development, 1999; North Carolina Board
ics Consensus Panel recommends strategies to facilitate of Nursing, 2005). The Kentucky Board of Nursing
the development of the competencies to include long- (2006), after examining the congruence between educa-
term planning to incorporate genomic information to tion and practice, proposed the implementation of an in-
improve public health, faculty and practice nurses seek- tegrated practicum to be completed prior to graduation
ing continuing education or academic courses to update and a clinical internship to be completed immediately
their genetic and genomic knowledge, and collaboration following graduation.
with other disciplines (International Society of Nurse Certification by national agencies has historically
Geneticists, 2007). been a voluntary process, yet some states use certifica-
tion as an indicator of entry-level competency. However,
Uses of the Concept of Competency research is lacking to demonstrate that certification ex-
The NCSBN (2005) acknowledged the relevance of aminations are linked to competency or improved pa-
continued competency of nurses at all levels as an im- tient outcomes (Whittaker et al., 2000).
portant issue for all state boards of nursing. To apply the The performance-based development system is a
concept of competency to all practitioners at all levels of competency assessment system that uses video, audio,
practice, the NCSBN definition focused on the practice and written simulations to measure competency for
role within the context of public health. practice (del Bueno, 1990). del Bueno developed this as-
Competency-based education is defined by the Ac- sessment tool to standardize the orientation program for
creditation Council for Graduate Medical Education new hires. The performance-based development system
(n.d.) as an approach to instruction and assessment that measures critical thinking as well as interpersonal and
places primary emphasis on identifying and measuring technical skills in many practice settings.
specific learning outcomes or competencies. This ap- Competency Assessment in Initial Education. A com-
proach to instruction contrasts with more traditional petency-based approach to initial nursing education is
didactic methods of teaching and evaluation. Didactic not the norm for most prelicensure schools of nursing.
course evaluation uses objective testing strategies to de- Watson et al. (2002) noted the absence of a reliable and
termine cognitive achievements, whereas competency- valid method of competency-based training. Many pro-
based education uses demonstration of skills and knowl- grams issue a grade for didactic content mastery and a
edge to evaluate performance potential. pass–fail grade for clinical performance (Fordham, 2005).
Competency Assessment. Currently, in most states, a This practice further distances graduates from an expec-
nurse is determined to be competent when initially li- tation of an assessment of ongoing competence.
censed. Continued competency is assumed thereafter un- Evidence of fitness for practice can be demonstrated
less otherwise demonstrated. The dominant method to through the development of a practice portfolio (Ford-
assess a health care professional’s continued competency ham, 2005; Girot, 2000; McMullan et al., 2003). A port-
is traditional didactic continuing education (e.g., formal folio is a purposeful collection of traditional and nontra-
conferences, lectures, and dissemination of educational ditional work that represents student or nurse learning
materials; IOM, 2003). Little evidence exists that these activities, progress, and achievement over one’s academic
methods have any effect on clinicians’ behavior or pa- career (Scholes et al., 2004).
tients’ or systems’ health outcomes (IOM). State boards The development of a practice portfolio places the
of nursing are considering other ways to determine con- onus for learning and development with the individual.
tinued competency of practicing nurses. Indeed, the use of practice portfolios is based on prin-
Evaluating continued competency is a difficult pro- ciples of adult learning and active learning rather than
cess, primarily because the evaluation standards are not passive learning (McMullan et al., 2003). In addition to
yet clear for nursing. The NCSBN (2005) outlined several promoting active learning and individual accountabil-
options for a basis for evaluation: the current entry-level ity, portfolios are thought to promote development of
National Council Licensure Examination (NCLEX), critical-thinking skills. Although portfolios are widely
generalist core competency at each licensure level, fo- used and accepted by schools of nursing and offer many
cused areas of practice, essential emerging knowledge, or positives, their evaluation continues to be a subjective
some combination of these. process that is not easily amenable to standardization or
Whereas some states have differentiated competencies objective assessment (McMullan et al.). Ensuring equity
and consistency in evaluation is a key concern with the Academy of Nurse Practitioners certification renewal
use of portfolios (Scholes et al., 2004). process requires documentation of clinical practice as
Krenz (2003) suggested using nursing outcomes clas- a nurse practitioner, and continuing education (Yoder-
sification as the foundation for a competency-based un- Wise, 2006). The American Nurses Credentialing Center
dergraduate curriculum. Krenz used discipline-specific accepts practice hours, continuing nursing education,
outcomes in curriculum revision to write competency academic education, presentations, publications, and
statements that reflected what nursing students were to preceptorship for certification renewal (Yoder-Wise).
achieve in care implementation. Analysis of this curricu- Portfolios, widely used to evaluate competence in
lum development determined that it provided clarity and initial education programs, are gaining popularity as a
direction to the curriculum. tool for documenting ongoing competency in practice.
Similar to the COPA model, Reising and Devich (2004) Web-based systems for tracking competencies for pro-
suggested assessing progressively difficult skill sets in suc- fessionals in practice are available and gaining popular-
cessive semesters of a baccalaureate nursing program as a ity. Software for this inexpensive and portable method
way to evaluate competency. Consistent evaluation criteria of maintaining records related to ongoing competency
across all courses should include critical thinking and pri- activities continues to be developed (Hobbs, 2005).
ority setting, health assessment, psychomotor skills, and
communication, including patient teaching and documen- Defining Attributes of Competency
tation. As with other methods of competency assessment, In their review of the literature regarding competency
lack of evaluation consistency was a drawback identified in nursing education, Watson et al. (2002) found that in 22
by students and faculty. Student anxiety, not necessarily a of 61 articles on the topic, authors did not define the term
disadvantage of other methods of assessment, was a sig- competency. The NCSBN (2005) elucidated the reasons
nificant drawback as well (Reising & Devich). why there is no clear solution to evaluating competency.
In addition to competency assessment for students, The reasons for the lack of clarity in defining competency
competency assessment in ongoing and advanced prac- include that competency is multifaceted and difficult to
tice is becoming more common. measure; the volume of nurses in practice makes it diffi-
Competency Assessment in Ongoing Practice. The IOM cult to identify feasible and meaningful, yet cost-effective,
(2003) recommended that all licensed health professionals regulatory approaches; agreement is lacking about who
be required to periodically demonstrate their ability to should be responsible for continued competency; nursing
deliver patient care as defined by the core competencies careers are widely divergent with various levels of practice;
for health professionals. These competencies were to be and there is an inherent evolution of practice from the new,
measured directly through technical competence, patient entry-level graduate to the experienced nurse (Bargagliotti,
assessment, evaluation of patient outcomes, and other Luttrell, & Lenburg, 1999).
evidence-based assessment methods. Further, the IOM The barriers to clarity outlined by the NCSBN are
recommended that certification bodies require certificate compounded by the fact that there are currently two
holders to maintain competence throughout their careers common uses for the concept of competency: maintain-
by periodically demonstrating their ability to deliver care ing ongoing competency in practice and preparing for
reflecting the core competencies. initial licensure (Sidebar 3).
Currently, the most common method of demon-
strating continued competence for licensure renewal is Cases of a competency focus in
continuing education (NCSBN, 2005). Continuing edu- education
cation is required for license renewal by 25 registered A Model Case
nurse boards and 24 licensed vocational nurse boards. A model case provides an example of the concept that
Of these, 12 boards require specific subject matter as a demonstrates all defining attributes of the concept, or a
part of licensure maintenance (NCSBN). Other boards pure exemplar (Walker & Avant, 2004). For an example
require a specific number of continuing education or of a model case, consider the following actual nursing
practice hours. For renewal of an inactive license, many school curriculum.
boards require a refresher course and some require a Alverno College is known for its innovative focus
competency examination (NCSBN). Advanced practice on the learner. This college was among the first to use
nurses may also be required to seek specific content (Yo- a web-based diagnostic digital portfolio to allow nurs-
der-Wise, 2006). ing students to track their learning progress through
Advanced practice nurses have a similar model for their years of study (Alverno College, n.d.). As students
demonstrating ongoing competence. The American receive feedback from faculty, external assessors, and
Alverno College. (n.d.). Alverno’s diagnostic digital profile. Retrieved J., et al. (2003). Portfolios and assessment of competence: A review
January 4, 2008, from www.alverno.edu/academics/ddp.html of the literature. Journal of Advanced Nursing, 41(3), 283-294.
Bargagliotti, T., Luttrell, M., & Lenburg, C. B. (1999). Reducing threats Merriam-Webster Online. (n.d.). Retrieved January 4, 2008, from www.
to the implementation of a competency-based performance assess- m-w.com/dictionary/competent
ment system. Retrieved January 9, 2008, from www.nursingworld. National Council for State Boards of Nursing. (2005). Business book:
org/ojin/topic10/tpc10_5.htm NCSBN 2005 annual meeting. Chicago, IL: Author.
del Bueno, D. J. (1990). Experience, education, and nurses’ ability to New Mexico Consortium for Nursing Workforce Development.
make clinical judgments. Nursing & Health Care, 11(6), 290-294. (1999). Standards for differentiated competencies of the nursing
Fordham, A. J. (2005). Using a competency based approach in nurse workforce at the time of entry/advanced beginner. Albuquerque,
education. Nursing Standard, 19(31), 41-48. NM: Author.
Girot, E. A. (2000). Assessment of graduates and diplomates in practice North Carolina Board of Nursing. (2005). Continuing competence. Ra-
in the UK: Are we measuring the same level of competence? Jour- leigh, NC: Author.
nal of Clinical Nursing, 9(3), 330-336. Pew Health Professions Commission. (1995). Performing health care
Hobbs, D. (2005). Tracking clinical competencies on the web. Radio- workforce regulation: Policy considerations for the 21st century. San
logic Technology, 76(5), 345-349. Francisco: University of California San Francisco Center for the
Institute of Medicine. (2001). Crossing the quality chasm: A new health Health Professions.
system for the 21st century. Washington, DC: Author. Redman, R. W., Lenburg, C. B., & Hinton Walker, P. (1999). Com-
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quality. Washington, DC: Author. tion in nursing education. Retrieved January 4, 2008, from www.
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