Improve Patient Safety by Defining and Refining Nurse Competencies
Carole Elledge, DNP, RN, AOCN®, clinical program specialist at Methodist Hospital in San Antonio, TX, described the concept of nursing competencies with a kitchen metaphor: “It’s kind of like baking a cake. If you’re going to bake a cake, you need all the ingredients.” For nurses, she said, the ingredients of competency include not only hands-on clinical skills, but also an ability to see past the disease, compassion, critical thinking, self-motivation, patience and insight, leadership, a team approach, and more. “There’s much more to competency than just skills.”
During a session at the 42nd Annual Congress in Denver, CO, Elledge and Catherine Handy, PhD, RN, AOCN®, oncology clinical nurse specialist at New York University (NYU) Perlmutter Cancer Center, defined competency, praised and challenged the checklist approach to competency, and offered strategies to improve the ways the nursing industry assesses competency.
The speakers used ONS definitions to distinguish between competence—the potential ability or capability to function in a given situation—and competency—the individual’s actual performance in a situation. Nursing competencies are unique to each institution, they said, but they all have a common goal: patient safety.
Elledge described how nurses are oriented and competencies are measured in her own institution, as well challenges such as maintaining competency, nurse attrition, cost, shorter orientation periods, a shift of patient care from the inpatient to ambulatory setting, e-learning, shortened work weeks, and a lack of a “gold standard” for evaluating competency.
“Competency is developmental. It doesn’t just happen overnight,” she said. “And a lot of it can’t be taught in classes. It requires time and a culture of competency.”
Although skills checklists may be a part of the competency assessment process, Elledge said assessment should not be limited to a checklist. Other strategies include self‐assessment, discussion and reflection groups, peer reviews, testing, gaming, case studies, presentations, role play, return demonstration, quality-improvement monitors, and observation.
She encouraged nurses to consider flipping the competency model upside down, assessing developmental needs first, then developing the curriculum. All key stakeholders should consider what is new, what is changing, what is high risk, and what is problematic before establishing competencies and assessment. “Create a culture of accountability—we all own it,” she said.
Handy reviewed how her institution evaluates and rewards levels of competency. NYU designed a clinical ladder program based on Benner’s Model from novice to expert. The ladder:
- Defines levels of professional nursing practice and provides opportunities for development and advancement
- Goes from nursing student, to nurse resident, to senior staff nurse, to nurse clinician, to senior nurse clinician
- Provides a system for incentives, recognition, and compensation to encourage achievement to higher levels of practice
- Provides a framework for evaluation.
ONS offers guidelines regarding competencies (https://www.ons.org/sites/default/files/Oncology%20Nurse%20Generalist%20Competencies%202016.pdf) of the oncology nurse generalist who have one to two years of experience, and Handy reviewed the comprehensive process that the society and nurse experts used to create them.
The competencies have two levels (competent and proficient) and five domains:
- Teamwork: Participates in the coordination of care for people with cancer based on evidence‐based practice
- Professional development: Advocates for the delivery of high‐quality, patient-centered cancer care
- Clinical care: Implements symptom management and monitoring parameters based on selected therapy
- Financial: Demonstrates fiscal awareness and responsibility in oncology nursing practice
- Quality: Identifies and uses organizational experts to support multidimensional quality components, including patient safety, performance improvement, accreditation, and infection prevention
The competencies are versatile and can be used across service lines and levels of clinical proficiency, Handy said. And although some of the details can be assessed with checklists, others require a broader, deeper approach.
“I’m guilty of checklists,” Handy said. “Skills checklists are never leaving my side. But I want someone to not only check things off, but explain why they’re doing it.”