Crisis in Competency: A Defining Moment in Nursing Education

Joan M. Kavanagh, PhD, MSN, RN, NEA-BC, FAAN; Patricia A. Sharpnack, DNP, RN, CNE, NEA-BC, ANEF, FAAN


Online J Issues Nurs. 2021;26(1) 

In This Article

Declining Initial Competency of New Registered Nurses

Jim Collins (2001), famed author of Good to Great, cautions that if success is ones' goal, one must first ask, what are the brutal facts - not what are our opinions, but what are the facts? If we do not confront the facts, they will surely rise-up and confront us. While we continue to appreciate the many in-roads and tangible signs of excellence in the evolution of teaching and learning, from flipped classrooms to simulation and standardized patients; from monologue to dialogue and Socratic method; to makerspaces and virtual learning, there remains substantive work yet to be considered (Forneris, 2020).

As educators, we must address the brutal facts of failing to prepare graduates as residency-ready and confront the issue that the academic, or preparation-to-practice gap, is increasing despite current efforts. While we continue to explore and research how best to prepare nurses for practice, Ironside (2008) conceded long ago that practice is evolving faster than education can respond. Our current educational model, developed in the 19th century, is obsolete (Gidley, 2016). Gidley (2016) argued that we are unable to solve tomorrow's problems with yesterday's thinking.

We suggest that tomorrow's problems are already here. Transforming nursing education to meet the technologically savvy, digital native students of today requires embracing the capacity of technology to transform education (Clark, Glazer, Edwards, & Pryse, 2017). We must shift to a post-formal pedagogy to prepare students for the higher-order thinking and knowledge work required for today's clinical practice (Forneris & Fey, 2018).

New data suggest that we are continuing to lose ground in the preparedness of New Graduate Registered Nurses (NGRNs) at a time when it is needed most. Initial competency of NGRNs is declining at an alarming rate, slightly exacerbated by the impact of the COVID-19 pandemic as many traditional in-person clinical and classroom experiences have been adapted or abbreviated. In her seminal work, del Bueno (2005) shared aggregate national data on initial NGRN competency for all hospitals utilizing Performance Based Development System (PBDS), an assessment del Bueno designed to identify growth opportunities in critical thinking and provide insight into the thought processes of the NGRN. Del Bueno (2005) reported that 35% of NGRNs assessed as safe or in the acceptable range. Kavanagh and Szweda (2017) documented a decline in initial competency with assessments of more than 5,000 NGRNs from 2011–2015, from more than 140 nursing programs in 21 states, with 23% scoring in the acceptable range for a novice new nurse. Current aggregate assessment data utilizing the same PBDS assessment collected between 2016–2020 on more than 5000 NGRNs indicate that 14% of them demonstrated entry-level competencies or readiness for residency, and 2020 YTD graduate data (n=1222) from 200 unique schools of nursing display an even more disturbing decline, with only 9% of NGRNs in the acceptable competency range for a novice nurse.

A decade of PBDS assessments representing more than 10,000 NGRNs reveals an alarming year-over-year decline in initial competency. PBDS assessments are administered post-hire but prior to orientation to ensure that results are indicative of the time before patient care initiation and that orientation and residency are not cofounding variables in the assessment results. Although the assessment is only one data point, it captures a snapshot of NGRN initial competency after graduation and, in most instances, post successful completion of the NCLEX.

The PBDS assessment is a valid and reliable tool (del Bueno, 2001). The tool has not changed over time, other than updating clinical scenarios to reflect modern equipment and technology. The subjects in data collection from 2016–2020 included 60% holding a BSN; 35% an ADN; 1% a diploma; and 1% were MSN graduates. Consistent with earlier findings from del Bueno (2005) and Kavanagh and Szweda (2017), there was no difference in assessment ratings regardless of the type of nursing program. Site-specific aggregated PBDS assessment data is depicted in the Table. Aggregate data (2016–2020) indicated 14% of NGRNs assessing in the acceptable range; 29% failing to recognize urgency or a change in a patient's status; and 57% demonstrated opportunities for growth in the management of patient problems, including selecting the proper nursing interventions, communication of relevant data to the Licensed Independent Professional (LIP) and rationale for nursing actions.

The 2020 aggregate PBDS data includes an n of 1222, with less than 10% assessing in the acceptable range. When further subdivided to isolate the April/May 2020 graduates who experienced the impact of limited clinical experiences (sample size of 626), 7% assessed in the acceptable range for a novice nurse and 40% assessed in the lowest domain, failing to recognize urgency or a change in a patient's condition. In sum, evidence supports a continued decline in the competency of HGRNs.