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

Leveraging the Tipping-point

The crisis in initial competency of NGRNs must not become a portent of patient safety challenges and NGRN success. In a day when we can transplant a face, a heart, or a uterus, we can certainly design and create processes and grow cultures where patients come first and safety always is a living breathing testament to our great profession's commitment to patients and nurses alike. Whether one's primary role is in academe or practice, five critical sub-narratives demand our reflection and re-evaluation. These sub-narratives include an acceptance of the chasm between academe and practice and the resultant challenge deemed inherent and inevitable in transition-to-practice (TTP); accountability for success and what NGRN residency-readiness requires; speed of learning, education transformation, and moving innovations to scale; the impact of digital disruption, and finally, the divide and inequality in education.

In this, the International Year of the Nurse and Midwife (WHO, 2020), the challenges before us are vast and complex. However, we argue that these challenges are ours to embrace. This is our moment, our time! As nurse leaders, we have the power to either build excitement and anticipation about change, about ongoing and much-needed education transformation, or potentially contribute to stress, anxiety, and even disengagement. We need only look to the past ten months to marvel and celebrate the victories, the quick pivots in unchartered territory. Most academic programs moved from in-person to virtual learning, from in-person clinical to virtual simulations mapped to the curricula within just a few days! Technology was readily incorporated and enhanced remote student classroom experiences introduced as the new normal in instructional design. Agility by fire, and yet we prevailed!

Despite each of these successes, the COVID-19 pandemic added to the chasm in NGRN preparedness. While no one can predict the longitudinal consequences of the pandemic with certainty, there is no question that healthcare and education responded in a profound and remarkably swift way. The demonstration of agility in a time of crisis dissolves long-held assumptions about how much time progress takes (Berwick, 2020), particularly in higher education. The success of an agile and thoughtful response in a time of crisis, albeit not perfect, brings honor to us all and hope for the future.

Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap. Nursing education reform is indebted to the iconic work of Dr. Patricia Benner, whose contributions from the Carnegie Foundation Preparation for the Professions research fueled the celerity of education reform (Benner, Sutphen, Leonard, & Day, 2010). In the past few years, we have seen increasing attention addressing the development of critical thinking, clinical judgment, and clinical reasoning in our pre-licensure nursing students. Significant trends in higher education that foster higher-order thinking include moving from structured, cohort-based education to a personalized, individualized, adaptive learning approach, such as smart book technology and virtual on-screen simulation like NovEx, that adapts information to the learner's progression (Santos, 2013; Hooper-Kyriakidis, Ahrens, & Benner, 2017; Benner, 2020).

Another major trend gaining traction is the severing of time, measured in credit hours, from learning and competency. In a traditional academic environment, programs of study are delineated by credit hours that equate to time spent either in class or online. The credit hour, initially conceived a century ago by the Carnegie Foundation to describe educators eligible for pensions, grew into an easily understood and adopted method to track academic progression, financial aid, and faculty workload. However, no evidence exists that the credit hour and time spent in class or online equates with learning (Laitinen, 2012; Kirst & Stevens, 2015; Robinson, 2018). The 2015 Carnegie Foundation report on the 'Carnegie Unit,' concluded that although flawed, the credit hour remains a necessary model. Laitinen (2012) urged that the credit hour is negatively impacting our nation's workforce and that, as the cost of education soars, federal policy needs to shift from paying for and valuing time to paying for and valuing learning.

Competency-based education (CBE) is gaining momentum buoyed by the 2013 Department of Education Experimental Sites program success, which allowed select institutions to grant credit through competency-based assessments (Cunningham, Key & Capron, 2016; Silva, White & Thomas, 2015). Although CBE and direct assessment are in the earliest phase of development, the transition from time-based to competency-based assessment is a movement whose time has come (Johnson, 2017; Josiah Macy Jr. Foundation, 2017; Robinson, 2018). To date, the United States Department of Education has granted approval for almost 200 universities to offer some form of CBE, and the Higher Learning Commission has embraced CBE as the future of academic preparation (Nodine, 2016; Silva et al. 2015).

The magnitude and significance of Benner's (2010) call for radical transformation and her innovative work to elucidate the current science of teaching and learning has been compared to Abraham Flexner's report (1910) on medical edition. Benner's findings spurred leaders from national nursing organizations to examine the current state of academia and initiate much needed change efforts. The National League for Nursing's (NLN) strategic educational resources, the National Council of State Boards of Nursing's (NCSBN) work to design a psychometrically sound and legally defensible Next Generation NCLEX (Dickinson, Haerling & Lasater, 2019) to assess higher-order thinking better and thus, preparedness for practice of new graduates, and more recently, the American Association of Colleges of Nursing's (AACN) call for reformation of nursing education are substantial attempts to mitigate the NGRN competency gap.

Competency-based education is gaining momentum…

The AACN Vision for Academic Nursing (2019) white paper addresses fundamental academic failings. It proposes an action plan to meet the needs of a dynamic, global society and a diverse patient population (AACN, 2019). The report identifies several trends and changes that inform nursing education. These include a changing higher education climate; competency-based education; learners who hail from diverse backgrounds and generations; advances in neuroscience that have resulted in the development and adoption of innovative educational technologies; a rapidly evolving healthcare system with a shifting workforce; an aging faculty; and the ongoing evolution of regulatory bodies (AACN, 2019). The overarching goals described in the AACN vision statement align with the changing healthcare landscape and accountability for residency-ready graduates. Strengthening academic-practice partnerships, accelerating diversity and inclusion through holistic admission policies, improved faculty development through a greater understanding of the neuroscience of learning, efficient use of resources, and competency-based education and assessment are central to these recommendations.

While the recommendations are intended to be realized as a compendium, it will take time to fully engage the academic community in these initiatives. Innovative thinking and approaches to preparing the nursing workforce of tomorrow are critical if nursing education is to meet the public demands for graduates to be able to know and do the work of nursing (AACN, 2020). The Essentials: Core Competencies for Professional Nursing Education, the framework proposed to supersede the current BSN, MSN, and DNP Essentials documents, is informed by the lived experiences of nursing practice where there is a fusion of knowledge and action (AACN, 2020).

The foundational elements of the new recommendations are built upon nursing as a discipline, the underpinning of a liberal arts education, and competency-based education principles. While considering the vital preparation for a residency-ready graduate, additional elements have shaped the proposed essentials document. These include diversity equity and inclusion, spheres of care, academic partnerships, systems-based practice, technology and informatics, consumerism, and career-long learning (AACN, 2020). The goal is to prepare a generalist who can practice in any setting through mastery of competencies. Scaffolding and measuring these competencies will require nurse educators to foster higher-order thinking. Common competencies for NGRNs will demonstrate the effectiveness of educational programs and assure the public of a graduate's capability.

Advances in teaching-learning technologies and strategies, shifting learning styles of students, and the push for outcome-based education all point to the necessity of competency-based education (AACN, 2020). Public demand for accountability in the health professions is propelling the shift toward CBE (Englander et al., 2013). Nevertheless, there exists no common taxonomy for domains of competence for health professions. Methods to best measure competency in nursing education need further exploration and a design that will challenge students and prepare them for practice. Rigorous quantitative and qualitative research must be conducted to determine the reliability and validity of CBE (Gravina, 2017).

Bridging the gap between CBE, practice, and implementation of knowledge, skills, and attitudes, has been explored by implementing Entrustable Professional Acts (EPAs) in medical education (Wagner, Dolansky, & Englander, 2018. Entrustable Professional Acts are units of professional practice, defined as tasks or responsibilities, to be entrusted to the unsupervised execution by a trainee once they have attained a specific competence. They are not an alternative for competencies but a way to translate competencies into clinical practice (Cate, 2016). Similar to the revised Healthcare Quality Competency Framework that guides academic institutions to reduce variability in quality competencies and supports workforce readiness and effectiveness in healthcare quality (NAHQ, 2020), sequencing domains of competence of increasing difficulty, risk, or sophistication can serve as a practical approach to integrate competencies in nursing.

Competency-based education will require novel approaches to enhance nursing education using technology. Integrating technology into nursing curricula improves efficiency and enhances student experiences, accomplished primarily through active learning and interactive learning designs (Luo &Yang, 2018). The development of augmented, mixed, and virtual reality simulation offers an opportunity for focused application-based learning (Fertleman et al., 2017). Foronda and colleagues (2017) argued that using these realities may influence the length of the learning curve, reduce practice time, and enhance learning outcomes (Foronda et al., 2017). Augmented or mixed reality tools such as Microsoft HoloLens®, and virtual simulations such as vSims® created through a partnership with Laerdal®, Wolters Kluwer Health®, and the NLN have already been integrated into nursing programs to augment existing teaching-learning practices.

AI is being used to create virtual patients (VP) scenarios that improve interactions with patients, the interprofessional team, and nursing colleagues. These scenarios enhance self-efficacy and confidence in effective communication skills. Academe must support the technological and digital transformation to foster student success, improve the TTP outcomes, and provide foundational and advanced faculty development that fosters the adoption of a new educational paradigm.

Finally, the requirement to strengthen interprofessional educational opportunities intensifies the prerequisite of a common language for outcomes for each discipline. The Joint Commission (2017) has cited communication failures among interdisciplinary team members as the most common root cause of sentinel events and pronounces the inability to communicate and work effectively in teams as a significant threat to patient safety. Foundational competencies commonly understood by all professionals will support appropriate role expectations and predictable outcomes and, arguably, improved teamwork and collaboration.