Perspective Chapter: Clinical Competency Framework – Standardized Nurse Competence Development

Abstract

A regional nurse leadership group established the Clinical Competency Framework with representation from academic, regulation, and practice-based settings. The framework provides structures, tools and workplace systems that address the full continuum of care. It is the only competency framework that: 1) integrates evidence-based preceptor support systems, 2) standardizes competency and coaching tools, 3) addresses all levels of nurse hires with a universal set of competencies, and 4) offers shared ownership for program dissemination. The Framework supports clinical preceptors, orientees, students, and transition into new specialties. It addresses issues of competency validation for nurses in multiple settings and the same templates/guidelines are used for settings across the continuum of care. The competency-based orientation is achieved through a preceptorship model, emphasizing the need for preceptor development. Allied healthcare partners have adapted the tools for their use and the model is shared via a membership venue that invites educators to ‘share and share back.’

1. Introduction

The Clinical Competency Framework (CCF) was established by a state-wide nurse leadership group with members from academia, regulation and practice-based roles and settings. The project sought to bridge the transition to practice gap experienced by new graduate nurses. Currently, the model provides supporting structures, tools, and workplace support systems for a transition framework that addresses the full continuum of care within a single competency framework [1]. The CCF is the only competency framework that a) integrates evidence-based preceptor development/support systems, b) standardizes competency and clinical coaching tools, c) addresses all levels of nurse hires with a universal set of competency expectations, and d) offers a shared ownership model for program dissemination.

The framework delivers a competency-based orientation process supported by clinical preceptors. Fundamental model concepts include evidence-based practice, sampling, accountability, high-end apprenticeships, coaching plans, concept-based development, reflective learning, and patient-centric practice [2, 3, 4, 5, 6]. The concepts within the model are constantly evolving, but users must comprehend the role of each framework element before recommendations for change are reliable.

Conducting research validity and reliability analysis is not a sufficient measure to validate a competency-based orientation tool that must adapt to diverse care settings and evolving healthcare practice [7]. The core measure of a successful tool is whether the collected data reveals an accurate portrayal of the ability of the employee to provide safe, effective care; based on agency protocol. Another important measure is whether the regulatory surveyors accept the contents and process as addressing their core requirements [8]. These measures of reliability are met by the CCF as adapted and used in multiple settings – both urban and rural, from trauma center to critical access hospital, and across the continuum of care.

The initial literature search led to the realization that foundational orientation tools focused on tasks, procedures, and equipment; but overlooked the role of critical thinking, reasoning, clinical analysis, and nursing judgement within professional practice. When this competency requirement gap is combined with the need for preceptor development systems, the team recognized that three subsets of response were required. First, our orientation, internship, and competency tools need to detail what critical thinking and clinical judgement looks like within our care settings. Secondly, essential instruction must occur to establish critical thinking (CT) development within the preceptor’s role and responsibilities. And thirdly, the competency or transition tools must state specific strategies for developing reasoning skills in the newly hired nurse. These framework components were addressed along with updates in the identified roles of the preceptor to increase focus on the roles of protection and evaluation.

2. Benefits and measures

Patient care outcomes are significantly impacted by new graduate preparation for practice. Del Bueno [9] reported in 2005 that new graduate nurses met entry level expectations only 35% of the time. A follow-up study conducted 10 years later, revealed a drop to 28% meeting expectations [10]. This presents a serious concern with the ever- increasing complexity of healthcare environments and interventions. One component of the problem is development of clinical judgement and the importance of teaching nurses how to think like a nurse [11].

Multiple research and quality improvement projects have applied the CCF tools and processes. The Nebraska Center for Nursing project [12] included specific data collection regarding cost of orientation. CCF resources were used to modify how preceptors are taught and utilized in both urban and rural settings across Nebraska. Managers reported significant reduction in estimated orientation costs between the control and treatment periods. Baseline orientation costs were reported at $7,028 per new graduate, with reduction to $4,961 with CCF implementation. Outcomes also revealed a reduction in incidence of errors or near misses. The study concluded that new nursing graduates were more satisfied, better prepared, and had fewer errors.

Robbins [13] reported that nurse employment turn-over rate decreased from 33.6% (prior to program) to 16.5% in the year following completion of the program, a 50% decrease (p < 0.1). He averaged the cost of $85,000/nurse oriented to the Burn ICU specialty, thus retention results in significant cost savings. Data analysis validated both efficacy and improved staff satisfaction resulting from model use. The success within the Burn Unit was demonstrated as replicable in other specialties and further work within the military medical system ensued [14]. Currently the CCF tools and process are being adapted for both military nurse competency and combat casualty care development.

Multiple studies, performance and quality improvement projects have utilized CCF components. Program outcomes show a reduction in incidence of patient errors/near misses, lowered orientation costs, and improvements on factors of satisfaction, retention, and positive workplace culture [12, 14, 15].

3. Program overview

The CCF is a ‘best practice’ clinical transition program that has been in place for over two decades and has seen annual growth, expansion, evaluation, and advancement. The preceptor supported design provides experience and deliberate practice to support learning and successful transition into clinical practice. The experiential learning within the CCF occurs synergistically with individual studies, staff development courses, clinical conferences, and one-on-one support and instruction from a preceptor. The program advances clinical practice skills needed to deliver safe, comprehensive care in existing and emerging organized health care systems. Collaborative resource development, ongoing research, and evidence-based preceptor support systems are featured within the framework. The model is suitable for new hire orientation, transition of new graduates (or new to specialty), nurse residency programs, and/or competency validation for contractors or travelers.

The CCF is built upon prominent nursing theories which include, Benner’s novice to expert model, her more recent call for three high-end apprenticeships, and the Competency Outcomes Performance Assessment (COPA) model [16, 17]. Core concepts related to teaching and learning, emotional intelligence, team process, systems thinking, transition shock, reflective learning, professional accountability, and sampling theory are incorporated within the framework. The COPA model works synergistically with Quality and Safety Education for Nurses (QSEN) [17, 18] as displayed within the competency tools and process. While addressing the same core performance focus of QSEN knowledge, skills, and attitudes, the CCF shifts the goals to target the manner in which nurses provide clinical care. Specific skills identified within the competency tools emphasize nursing clinical practice, clinical reasoning, and professional judgement. CCF performance criteria reflect the need to view the patient in a holistic manner and consider the possibility of differential diagnoses or related issues. The nurse development targets a concept-based approach to learning and to competence development.

Reflective learning theory integrates with competency validation work to ensure current practice capability while developing reasoning and judgment skills. Both reflective and experiential learning strategies are employed within clinical coaching plans that guide the preceptor in their crucial role [19, 20, 21]. The preceptor fosters reflection within the clinical learning environment, provides deliberate practice to enhance both skill development and professional practice confidence, and documents achievement of specific competency requirements [21].

4. Core concepts integrated within the CCF

The Competence Outcomes Performance Assessment (COPA) model sets format and content considerations for competency tools within the CCF [16]. Lenburg identified eight essential competencies of: assessment and intervention, communication, critical thinking, teaching, human caring relationships, management, leadership, and knowledge integration. All the specific skills. actions, and judgement that nurses engage can be listed under one of these categories. This model initiated a complete re-thinking of new hire orientation tools [22]. Previously, most agencies used diverse sets of checklists detailing the tasks and procedures pertaining to the nurse’s role. The COPA model caused a shift in thinking to quantify and prioritize aspects of critical thinking and knowledge integration; while focusing energy and evaluation on aspects of leadership and management within our direct care roles. With Dr. Lenburg’s help, the competency criteria address high-level performance expectations within clear, concrete, and concise statements. Performance criteria address the top levels of Bloom’s pyramid of action verbs [19, 23], rather than the bottom.

The Clinical Transition Framework uses COPA because it is a model that also fits for the full interdisciplinary team. The universal competencies for nurses are easily adaptable for Rehabilitation, Respiratory, and other direct care personnel [24]. The COPA model establishes the performance outcomes focus of the assessment process. It targets critical thinking and clinical judgement, as crucial aspects of professional practice and goes a step further in its focus on action statements that reveal actions, reflection, reasoning, and clinical judgement. Core strengths of the COPA model include the focus on practice-based outcomes that are integral to actual practice.

The CCF uses the COPA model in both universal and unit specific CBO tools. The Universal Competency tool is outlined by the eight core competencies and offers aspects of practice that are engaged in all clinical care settings [24]. The Unit-Specific tools build upon the foundation presented within the Universal tool and present performance goal statements in the manner in which we provide care, or within goals related to specific aspects of patient presentation and clinical practice. Integration of the COPA model ensures that the Competency Based Orientation tools extend beyond the commonly seen lists of tasks, procedures, equipment, and documentation issues. Dr Lenburg provided guidance in how to write specific statements to achieve clear, concise, and concrete criteria that are observed within clinical practice. The resulting documents provide a systematic standardized approach to competency development and validation.

Professional accountability is a core function that requires commitment from every licensed care provider [5, 6, 25]. Inclusion of the accountability statement within the orientation form defines what accountability looks like in this setting and provides a specific testimony from the orientee. Each universal and unit specific tool concludes orientation with a ‘summary statement’ within the signature page for completion of the onboarding program. This summary statement is introduced by the preceptor at the start of the preceptor/preceptee relationship. The statement starts the new hire with specific directions related to their professional practice expectations. It then becomes part of the signed form attesting to clinical competence validation for the individual [22, 26].

Summary statement signature attests to individual accountability for:

• recognizing the limits of their capability or knowledge base

• seeking assistance to meet professional performance criteria

• using learning modules to meet individual knowledge base needs

• accepting personal obligation to maintain practice capability, knowledge base, and patient safety

The orientee accepts responsibility for their practice by signing the accountability statement on completion of orientation. The signature indicates personal responsibility for their actions and inaction, as well as their knowledge base. As a professional care provider, each licensed nurse is responsible and accountable for both their practice and the ongoing capability development. Our profession requires continuous professional development to ensure that we maintain capability and can provide competent patient care. Without ongoing development, the practice of any nurse is outdated within months of completing their coursework and orientation.

Ensuring nursing and patient centric goal statements is essential to professional practice. When questioned about “How do we know what they know?” leadership response has often entailed building systems that attempt to address every detail of practice. This response leaves us bogged down in the minutiae of nursing, instead of focusing on professionalism. Orientation and competency tools often present extensive lists of the tasks and procedures that are completed, but these lists do not describe professional nursing practice. What makes nursing care unique and valuable is the clinical reasoning and nursing judgement skills integrated with delivery of tasks, procedures, assessment, and care. The nursing unique parts of our practice apply clinical reasoning and judgement skills within care delivery. Individual tasks are inherent to achieving goals that are patient focused and nursing centric. The ‘medical model’ of knowledge and skills development approaches learning and competency from a system perspective – as in body systems, or a set of tasks and procedures that are components of care. Many of us continue to follow the patterns with in the medical model due to our prior experience with learning and competency systems. But our prior experience was often not based in evidence or theory, which calls for re- evaluation of those aspects within further development.

Documentation is easier when we use statements that are shaped by the manner in which patients present. The preceptor can sign off on observations of care within a specific patient assignment instead of searching for scattered elements of care in extensive lists of tasks and procedures.

The nurse and patient centric model of developing competencies portray the relationship between tasks, procedures, equipment, tools, assessments, and nursing judgement. Assessment skills are empty and incomplete if a conclusion is not determined and then acted on. The judgement call comes before implementing the plan and is a fundamental responsibility of the clinical nurse.

Competency and coaching goal statements should target aspects of nursing care, while keeping the patient at the center of that care. When goal statements present in the manner in which we provide patient care, they follow the pattern of patient assignments and nursing practice. This presentation makes the preceptor’s competency verification and documentation requirements easier, as the aspects of care that are performed are directly linked with the goal statement which was the center of the performance development and/or validation.

Wording does make a difference in how we interpret our role. The shift to a nursing focus is represented in the competency statements listed below in Table 1.

Medical model		Nurse and patient centric
1. Assists the ED physician in the minor procedure room	vs.	2. Ensures patient well-being with minor procedures with/without sedation
3. Determines hemodynamic effects of cardiac dysfunction	vs.	4. Manages care of the patient presenting with ‘complaints of chest pain’

Table 1.

Nursing focused competencies vs. those based on the medical model [20].

In the first statement, the work of the nurse targets the physician and patient care is a by- product. In reality, our work is patient centric and engages nursing unique aspects of practice, thus the second statement better identifies the role and function of nursing. The third competency reveals the traditional, medical view of targeting the heart instead of considering and treating the patient as a whole. The nursing and patient centric statement reflects the manner in which patients present. This presentation guides our practice to start with the presenting problem, and then continue care in a manner that considers differential diagnoses as well as any urgent interventions.

Sampling theory serves a crucial goal of the model – to ensure a process that remains as clear, concrete, and concise as possible. With this goal in mind, competency validation engages sampling theory to reduce the volume of practice observations [2, 27, 28].

Addressing every possible procedure, task, and care issue is not possible in the medical field as our practice changes weekly with advances in medical technology and health management. With that in mind, sampling methodology provides the most effective approach in selecting the required elements for orientation and competence validation data. Sampling also reduces the workload of the educator, preceptor, and manager.

The concept of sampling allows a selection of specific performance elements to be validated within orientation, and that overall competence can be extrapolated based on this sample. Sampling concepts are used consistently in research, pharmaceutical studies, testing for knowledge base, the assessment that NCLEX uses for licensing, and Joint Commission surveys.

The directions for the form and process need to detail how sampling is applied within the program. Form directions should remain with the documentation files to answer any questions posed by reviewers or surveyors. Having the directions remain with the form is also helpful to the preceptor/orientee team as they complete the tools and revisit the scoring key for accuracy.

Sample selection is impacted by the capabilities that the learner brings to the clinical setting. The performance criteria that are validated can remain the same, even when the patient assignment is modified to the user’s capability. For example: the preceptor will want to see a significant amount of clinical practice by a new graduate before signing them off, whereas they might be able to validate performance for a traveler within a single assignment. In the CCF the required elements are highlighted in bold print and the form directions indicate the minimum requirements for completion of competency validation within a competency-based orientation.

It is important that we identify both the initial and ongoing performance expectations for the new hire. By communicating this within orientation, each individual can establish an ongoing performance improvement plan that evolves beyond the basic expectations and carries them into proficient/expert practice. Without this presented on initial orientation, the question remains as to when and how this information is communicated to the new hire. With ongoing expectations identified within orientation documents, everyone is aware of practice expectations at the start of employment. Both high-level, complex performance criteria and the scoring key elements of proficient and expert are used to indicate further advancement of clinical practice. Preceptors and educators involved in learner development support concepts of continuous development within role modeling and discussions of professional goals. Yet the orientation process and preceptor roles remain the same for each direct care provider.

Determining competency validation requirements entails identifying the high risk, high frequency aspects of nursing care that occur on your unit, in your agency. In the process of selecting elements to be included in the sample, the experienced nurse educators and managers consider what clinical care and level of practice is a reasonable expectation for new graduate achievement within an orientation period. The selected sample is then evaluated with consideration of whether it is feasible to achieve within a few days of patient assignments for the traveling nurse. Within the CCF process we have identified these elements in bold script with the directions stating specifically that the bolded items indicate the selected sample for orientation competency validation.

Deliberate practice can bridge the gap between didactic knowledge and clinical application in those engaged with their first nursing position or a new specialty practice. Instead of challenging the orientee with a new and more complex assignment each day, concepts of deliberate practice encourage repeating a same or similar assignment for enough times for the learner to develop dexterity and some level of automaticity in care delivery. Preceptors allow deliberate practice by the newly hired nurse, which results in growth of confidence along with clinical competence [21, 29, 30, 31]. This practice establishes a foundation of clinical capability that supports new challenges within later assignments.

There are four core tenets within Deliberate Practice:

1. motivation to attend to task and exert effort,

2. tasks that are outside of a learner’s comfort zone,

3. opportunity for immediate feedback, and

4. repeated performance.

Deliberate Practice (DP) allows integration of thinking and skills in a controlled environment, through repeated opportunities to practice skill performance [21]. The repeated practice provides an opportunity to develop automaticity and dexterity with manual skills. With the technical skills becoming habitual, the care provider gains time for thinking through the process to determine its impact and the data that is forthcoming from ongoing assessment and clinical reasoning.

Integrating three high-end apprenticeships – The CCF responds to the ‘call for radical transformation in Educating Nurses’ as proposed by Benner et al. [3]. Based on her research, Benner calls for three high end apprenticeships as part of the education and development of nurses.

The apprenticeships include stages of:

1. Developing the nursing education, science, and specialty knowledge required as a foundation for safe practice

2. Engaging in deliberate clinical practice to enhance skilled know-how, dexterity, and reflective learning

3. Professional Formation – An apprenticeship in ethical affect, demeanor, and professional formation as a healthcare professional.

These apprenticeships are deliberately integrated within the CCF with coaching plans which provide specific, standardized knowledge content and guidance for the preceptor/new hire team.

Professional Formation is the third essential apprenticeship identified by Benner [3]. Competency within professional practice is an elusive concept that is based in attributes required to act effectively in a healthcare setting. True clinical competency is much more than skills proficiency and requires blended aspects of reasoning, judgement, and decision-making [2, 21].

Reflective and concept-based learning strategies – True clinical competency is much more than skills proficiency and requires blended aspects of reasoning, judgement, and decision-making [21, 29, 32]. Within the CCF, specific strategies target development of clinical reasoning and nursing judgment. The original CCF coaching plans addressed reflective learning strategies with specific questions related to success, challenges and alternative responses to issues that occurred during the week. Weekly conference time is factored into the preceptor’s role and responsibilities in pursuit of fostering critical thinking development in the new hire. Reflective questions within the coaching plans start the conversation and assist preceptors in accomplishing this role component. Teaching about how to support reflection learning and clinical reasoning strategies are part of core instructional needs of preceptors.

Concept based learning is engaged within the CCF model of development. It is a concept-based process which views each patient holistically, from a nursing perspective. The forms, format and preceptor development promote replacing traditional ‘systems-based’ instruction with concept-based learning. This approach engages reflective learning in that the preceptor is encouraged to query “what is the same, what is different” to highlight how aspects of care are related within different diagnosis or issues. Concept-based learning in academia utilizes authentic learning opportunities that mirror actual practice. It also shifts from a focus on task to emphasizing reasoning skills and this shift requires specific instruction and guidance for preceptors. The preceptor needs to target an organizing principle, or a classification of information, and emphasize how aspects of nursing care are related. Preceptors learn new ways to present concepts and exemplars that require problem-solving, and learners strive to understand how to connect facts and concepts within actual patient care for in-depth understanding. The process encourages nurses to use effective thinking skills, promoting safety and quality of care for their patients.

KISS principle represents the phrase, Keep It Short & Simple! With adherence to this principle, educators strive to eliminate extraneous verbiage and multi-faceted scoring keys as they develop tools and process for transition into clinical practice. Within the CCF tools and model, we strive to simplify – to make the form and process as easy to use as possible. The tools within the framework focus on clear, concrete, and concise statements and work expectations. The scoring key identifies observed performance or explanations and targets only the aspects pertinent to the clinical preceptor’s role and responsibilities. For example, the preceptor should not be expected to document attendance in general orientation, computer training or other elements that are tracked elsewhere. If they are not part of the preceptor’s role to deliver, it should not be an element on their documentation tools.

The KISS principle is a key concept applied to preceptor expectations. Traditionally, agencies and schools of nursing have engaged preceptors for work with students and new hires without planning for the additional time required for effective teaching, deliberate practice by the learner, and the time needed for performance validation. VNIP chooses to look at all expectations for the clinical preceptor and evaluate whether the work and timing is feasible for clinical application. With that in mind, courses, tests, education classes, and simulation do not appear on the preceptor’s documentation tool, as participation in those events is managed and documented elsewhere. The CCF limits tool contents to aspects of learning or validation that are clearly under the preceptor’s jurisdiction. The scoring key is structured in the simplest manner possible with reminders inserted wherever suitable. Time for teaching is factored within policy statements and considered as an essential aspect of developing assignments. Formative evaluation of the program is constantly considering whether the KISS principle is being met to the greatest extent possible. As new tools or concepts are added or evaluated, a key question is its fit with the KISS principle.

Standardized knowledge is outlined within the coaching plans. These tools identify the knowledge that is inherent to practice in a specialty setting or is needed to achieve a specific clinical care goal. Within the coaching plan, this knowledge is identified and linked with the specific performance goal and may be indicated by titles of policy statements, standards of practice, clinical practice guidelines, specialty practice texts, and/or and specific learning modules. With expert published resources available from specialty practice organizations, the educator and preceptor can simply refer to the text, rather than creating, listing, and updating individual resource materials.

Administrative workload reduction within a planned assignment is essential for protecting the role and efficacy of preceptors. As tools and process are established, those developing documentation forms and model requirements must consider who will be responsible for completion of the model or tools. Line by line analysis of orientation tools must include identifying the number of times a preceptor, educator or manager must sign off on elements of competent practice, and how easy it is to find the correct line for documentation. One major health system was able to reduce the required lines for signing with date and preceptor name/initials from 682 to 124 [33]. This workload issue must be considered when planning the assignment of those responsible for guiding the new hire, student, or new graduate nurse.

Administrative workload is a crucial consideration when writing guidelines or policy documents regarding the competency validation process. Asking the clinical care provider to precept, is asking them to complete another task within their workday. Those additional tasks need to be planned into the assignment – with consideration of how the provider will find time to ensure that the task is completed in a safe, effective, and efficient manner.

Program success measures are crucial concepts within the model. A comprehensive competency program provides documentation of performance-based, evidence to validate that requirements were met and/or gaps in capability identified. Performance issues may indicate a need for further development or termination.

A successful competency framework clinical competency framework tracks and documents:

1. Achievement of clearly defined performance expectations, or

2. Early identification of when the new hire is a ‘wrong fit’ for the unit or role

3. Early identification of when new hire is a potential threat to safe, effective care

All participants must keep these aspects in mind as new staff members are developed. If we are unable to identify early when there is a ‘wrong fit’ for the novice, the individual’s self-esteem and potential are reduced due to inability to meet competency requirements. With early identification of barriers, a remediation plan can be developed, whether it provides additional learning/practice support or recommends a move to a different practice area.

Identifying a potential threat to safe care is core to protecting our patients from potential harm. Making this determination early decreases the potential for a clinical error or harm to the patient. Educators and preceptors must consider these measures of success as they guide the new nurse to a specialty area or aspect of practice where they may flourish. The competency program should be structured to assist educators, managers, and preceptors in identifying those who may succeed, while guiding those that are not doing well to a more suitable practice setting.

Documentation identified as the learner’s responsibility. Some preceptors have reported leaving gaps in competency documentation due to the demands and complexity of their dual roles as care provider and preceptor. The complications of the added role can be eased by establishing appropriate expectations. The learner is in orientation for the sake of learning and/or competency validation. They are being paid to complete orientation process and documentation, thus need to take responsibility for both clinical performance and documentation follow-through.

The orientee or student can review the documents and identify which elements might be ‘signed off’ each day or week. Making this request of the preceptor can assist in completing documentation, while leaving the decision of sufficient evidence to the preceptor. The process may also foster specific discussions about performance accomplishments and needs. To achieve these results, learners must be guided and directed to routinely review and request documentation of the day’s accomplishments. This shift in responsibility requires that both preceptors and new hires are instructed and guided in the process change.

Rapid cycle quality improvement process is utilized to ensure that the tools, teaching, and framework are effective [27, 28]. Within this approach to evaluation, changes in content and format occur in an ongoing manner of prompt response to concerns, issues, and environmental influences. The tools and model remain evidence based, as the changes and adaptations are based on the current evolving evidence within clinical practice.

To establish a sampling strategy for Rapid Cycle Quality Improvement, Etchells & Woodcock recommend two useful guiding principles for sampling. “1. obtain just enough data to guide next steps 2. make full use of local subject matter expertise in selecting the most appropriate samples” [34, p. 63].

The rapid cycle quality improvement process reflects the execution of plan-do-study-act cycles as detailed by Taylor et al. [30]. “The PDSA cycle presents a pragmatic scientific method for testing changes in complex systems. The four stages mirror the scientific experimental method of formulating a hypothesis, collecting data to test this hypothesis, analyzing, and interpreting the results and making inferences to iterate the hypothesis. The pragmatic principles of PDSA cycles promote the use of a small-scale, iterative approach to test interventions, as this enables rapid assessment and provides flexibility to adapt the change according to feedback to ensure fit-for-purpose solutions are developed. Starting with small-scale tests provides users with freedom to act and learn; minimizing risk to patients, the organization and resources required and providing the opportunity to build evidence for change and engage stakeholders as confidence in the intervention increases” [30, p. 29].

Within the CCF, the local subject matter experts are the clinical care providers within each unit or specialty. The framework collects data in an ongoing manner to evolve the model for optimal engagement of both new and experienced staff members. These experts provide the necessary data to ensure that changes in the delivery model produce safe and effective care that adheres to protocols as established by the agency and specialty practice organizations.

Identifying core elements of nursing practice must be a first priority. A crucial goal of the CCF is to establish evidence that the individual is competent to engage in independent nursing practice. With the assistance of competency assessment tools, evidence collection within orientation or transition programs seeks to determine if the new hire consistently engages four elements of professional practice.

The program is successful and effective if it ensures that the new hire can meet four practice elements:

1. Provide safe and effective care as per protocol

2. Adapt plan of care to patient’s changing needs & priorities

3. Identify the limits of capability

4. Seek assistance appropriately

Consider your current program tools, documentation, and reflective learning strategies to support nurse development. Are the tools complete and are they completed fully/correctly by the preceptors? Do they support the development of preceptors as clinical educators? Are preceptors able to engage strategies that foster critical thinking, reasoning skills, and clinical judgement? If those aspects of practice are important in our clinical settings, the agency needs to invest in instruction, resources, tools, and preceptor support systems to ensure that they are communicated, tracked, and developed.

Core questions for nurse leadership include: “Which clinical performance elements portray nursing practice in your agency and how are the elements prioritized within the orientation and/or competency validation system?” The answer to these questions establishes our focus for nurse performance development and competency data collection.

When line by line content itemization was completed on previously used orientation and competency validation tools, the practice elements identified within a specific “Agency” tool produced the chart displayed in Figure 1.

Figure 1.

Percentage of “Agency” RN orientation/competency items addressing elements of nursing practice as listed in the documentation tool.

The same itemization of content for the CCF Universal Competency tool reveals a different picture of nursing practice. Within this chart, CCF Universal the practice elements were re-sorted in order of percentages, Figure 2 shows how the tool prioritizes elements of nurse practice. Within the Universal tool, a single performance criteria statement may pertain to multiple elements as listed. In this case, wording makes a significant difference in what is communicated about our practice.

Figure 2.

Percentage of CCF Universal RN orientation/competency items that addressed identified practice elements as listed in the documentation tool.

From the practice elements listed in, which ‘non-task elements’ should be included within your orientation and/or competency validation tool? And what percentage of practice should they represent?

5. Tools and templates for competency development and validation

The CCF uses a Universal Competency Tool to track performance expectations that are engaged in all settings. The performance criteria listed herein address universal aspects of professional practice as outlined by the essential elements within the COPA model. With these common aspects of clinical practice outlined herein, the unit specific tools may focus on aspects that are unique to specialty practice settings.

Competency tools include both 1) Universal and 2) unit specific performance expectations. These are valid and reliable tools for competency verification that identify specific, measurable performance-based criteria for assessment. Competency criteria include aspects of caring, leadership, management, teaching, safety, accountability, knowledge integration, critical thinking, reasoning, and clinical judgment capability.

The framework of the COPA model essential practice competencies provides the categories within the Universal competency form. Performance criteria address elements of nurse practice that are used in all healthcare settings, rather than breaking down to specialty- specific content. Unit specific tools outline clinical performance in practice-based statements that reveal the manner in which care is provided or a practice component that is unique to the specialty.

Within this division of skills sets, the common criteria lay the foundation for performance and the unit specific address the specialty-unique knowledge and skills. The initial completion of the universal tool is the basis for cross training that focuses on elements within specialty practice.

Both universal and unit-specific CBOs are used for competency development and validation. The Universal CBO tool is outlined with the COPA model core elements of practice. Under each of the eight categories, specific sub-skills and tasks are detailed. Specific documentation directions guide the preceptor in validating a sample of skills that give evidence of overall capability and clinical competence.

Important features of the universal CBO tool include that it:

• Addresses skills and practice that nurses apply in all settings, all specialties

• Specifies practice categories of: Communication, Leadership, Management, Critical Thinking, Teaching, Human relationships/ethics, and Knowledge integration to be combined within completion of Assessment and Interventions as essential nursing practice components

• Provides detailed performance criteria and sub-skills that give evidence of the above list of essential elements of practice

• Communicates that these elements are threaded through all that we do as professional care providers

• Identifies the required sample of skills that must be validated

• Introduces a specific description of accountability expectations

Unit specific competencies address nursing care as applied for specialty practice settings. Herein you will find the elements of patient care and nursing practice that are unique to the setting, rather than universal in all settings. By separating the Universal and unit specific tools, care providers do not need to repeat universal competency validation when they change specialties. Instead, they can immediately focus on what is unique to the new practice setting. Unit specific competencies can be presented as a set of complete coaching plans, or may be condensed to offer only the performance criteria statements.

Form directions and scoring key apply documentation at the Advanced Beginner or Capable level (see Table 2.) as evidence that the individual not only meets the specific performance criteria that is being signed off, but also identifies the limits of their capability and seeks assistance appropriately (see definition of 2 Capable). That assistance is detailed further within the accountability or summary statement at the end of the competency assessment tool.

CCF competency tool scoring key	Novice to expert
1. Identified limitation – requires direct guidance & support, little or no experience with skill	Novice = Inflexible, rule-based. Little or no background understanding of why and how to apply or adapt the ‘rules’
2. Capable – familiar with skill/equipment, but may need assistance, seeks support when unfamiliar with process/skill	Advanced beginner = starting to use and make sense of situational elements & depend on the context. Temporal focus is immediate & present
3. Performs independently – knowledgeable to perform tasks safely as a result of training & experience	Competent = Increased efficiency; planning is still conscious, abstract, analytic, and deliberate.
4. Proficient – extensive experience in this area/skill, able to teach and mentor others	Proficient = situations are perceived as a whole rather than as unconnected aspects
5. Expert – all of the above; fluid performance; ensures evidence-based practice for clients and agency	Expert = Understanding of task, as well as the decision of what to do next, performance is intuitive and fluid

Table 2.

Scoring key matched with Benner’s Novice to Expert definitions [28].

While the tools and process make use of Benner’s model for skills acquisition, the scoring key uses different titles from those used by Benner and Dreyfus for the first three levels [35, p. 19]. The terms selected for the scoring key deliberately focus on performance enhancement instead of words indicating failure, or not able to achieve.

In clinical practice, it may take 2–3 years for a new graduate to achieve the competent level as defined by Dreyfus [19] and Benner [35]. Yet the new nurse is a safe and effective practitioner prior to this level of experience, so long as he/she recognizes the limits of their own capability and seeks assistance appropriately. These aspects of practice are inherent to the explanation of the codes in Table 2.

The description of the numerical code of 2 is: “Capable – familiar with skill/equipment, but may need assistance, seeks support when unfamiliar with process/skill”. Your policy statement and/or the directions for the form reinforce this statement as the ‘passing’ requirements to complete basic orientation. “A score of 2 = capable, matches with the Advanced Beginner level within Benner’s model for development of clinical skills. The achievement of this level of practice is linked with the accountability statement that is included in the sign-off process for completing orientation.

The response outlined in the CCF targets the scoring key and accountability. With a score of 2 being addressed within initial competency validation, the preceptor is validating that the orientee consistently recognizes when they are unfamiliar with an aspect of care and that they seek appropriate assistance, resources, or guidance.

With the use of Benner’s model and this scoring key, a crucial need to teach preceptors about the Novice to Expert continuum was experienced. Additional supporting documents may be indicated to help clinical staff understand the concepts and what they are looking for within competence validation.

At the beginning of each Competency Assessment Tool there are specific directions on how to complete the tool, where to document, and what the observer’s initials/date indicate within the tool. It is intended that the directions remain with the tool, ensuring readily available clarification when a surveyor or reviewer asks questions specific to an individual’s orientation and/or competency evidence.

Self assessment of capability - At the start of orientation, the new hire will use the scoring key to self-assess their capability and skills. Self -assessment is not a valid or acceptable method of competency validation. Instead, this information is used to build an individualized learning plan for each new hire, with a focus on validation of core competencies in a timely manner. The directions also provide an ongoing reminder of how to document within the form and what is communicated within specific locations on the form.

Clinical coaching plans are a single page tool that provides an outline of specific expectations, resources, achievements, reflections, and what practice (competence validation) gaps remain. When documentation is kept current and complete, the tools function as a safety guide and ensure continuous development for the learner. These individualized teaching plans are developed to support clinical and experiential learning with preceptor supervision. Each plan addresses a specific goal as listed for the specialty practice or developmental process. The coaching plan is a single page tool that adds details about both learning activities and measurable performance outcomes. The tools include a nurse-focused, patient centered goal statement, standardized knowledge required to meet the goal, performance criteria that show achieving the goal outcome, and a specific reflective learning activity. These tools assist the preceptor and new hire by providing an outline of learning resources and clinical expectations, along with preceptor ‘hand-off’ communications. The tools move us towards viewing both patient care and the learning process in a holistic, evaluative manner. That evaluation continues to improve care quality and professionalism through rapid cycle quality improvement.

While providing a learning/teaching guide, coaching plans ensure a venue for documentation of the learner’s progress, needs, and achievements. Coaching plans are a single page tool that provides an outline of specific expectations, resources, achievements, reflections, and what practice (competence validation) gaps remain. When documentation is kept current and complete, the tools function as a safety guide and ensure continuous development for the learner.

The coaching plans are concrete, concise, and current tools that support both experiential learning and performance validation. CCF resources include more than 200 individual coaching plans to support development of work organization skills and clinical expertise in multiple specialties from across the continuum of care. The plans are written and used to support development of the nurse new to an aspect of healthcare. Preceptors and educators determine which plans best serve the new nurse’s learning needs, and then customize the plan to match the individual.

Coaching plans follow principles of teaching/learning while they foster progression of the novice through competency/orientation requirements. Coaching plans outline the core knowledge related to the goal statement and guide reflective learning strategies for fostering critical thinking development.

These standardized plans serve multiple functions. When used effectively, they can:

• Outline the standardized knowledge required for a specific aspect of patient care

• Establish clearly defined expectations in measurable, observable performance terms

• Track completion of critical elements of performance – with opportunity for positive feedback as the learner progresses through, and completes each tool

• Document progression – and lack thereof – to clarify and ease the process of difficult communications pertaining to performance issues

• Offer specific questions for fostering critical thinking development

• Direct discussion and reflective learning

• Ensure accurate, complete, and concise ‘hand-off communications’ from one preceptor to the next (or from preceptor to manager or educator).

• Be adapted for use as an action plan or performance improvement tool by adding a time frame requirement for meeting specific goals

• Provide effective, legal documentation of both the learning process and competency validation within the domain of a specialty practice

CCF coaching plans and competency tools address acute, long term, clinic, and home care settings. Currently validated tools include target groups of RNs and LPNs, with some tools for respiratory therapy, rehabilitation professionals, medical assistants, and nurse aides. Others may be developed in collaboration with content experts

Hand-off communications are a core function of the plans. The tools ensure communication of progress, challenges, and achievements from one preceptor to another. Without this vital ‘hand-off’ communication, progress of the learner may be hampered by each preceptor taking the learner, student, or orientee back to prior steps or expectations.

Orientees can maintain their documentation tools within a folder that is present in the clinical setting or compiled within an electronic data management system. Having this information available in the practice area ensures that changes in preceptor, educator, or manager include a fluid transition of clinical learning. The tools track evidence of capability that supports patient care and task assignments that build progressively more complex, while recognizing the foundational skills and evidence already accomplished. The assignments consider appropriateness based on prior experience and demonstrated capability. The documented observations also determine whether supervision of clinical performance is appropriate and required, or not.

6. Integrated preceptor development and support

A unique feature of the CCF is integration of preceptor development and support as a crucial component of the competency program. Agencies have often implemented nurse residencies or new orientation programs without quantifying the challenges placed upon the shoulders of preceptors. Through 20 years of work with preceptors, students, and newly hired nurses, the CCF team learned that preceptors require basic development related to: Communication, Competency Assessment, Critical Thinking skills, Delegation/Liability, Interpersonal Issues, Roles/Responsibilities, Teaching/learning styles, Novice to Expert Continuum, Challenging Experiences, and Documentation. This content is taught using multiple media to ensure addressing all learning styles and time constraints. Preceptor texts and workbooks have been developed for collaborative learning experiences. The full allied healthcare team has benefited from the instruction and courses have included participants from across the continuum of care.

For success of the overall program, preceptors require specialized education related to their roles as preceptors along with focused instruction that addresses the unique challenges presented by the CCF. Defining clinical competence for preceptors is core to the issue, as preceptors are called upon to create meta-cognitive knowledge through reflective practice and reflective learning [26, 29, 30].

Specific planning for critical thinking development is engaged. Critical thinking and reasoning lead to clinical judgement and decisions regarding optimal nursing care. To develop this judgement in others, a preceptor must engage core competencies in: higher-order thinking; conducting assessment in a reliable, valid manner; effective communication; and supporting learners in evidence- based practice. Preceptors are the essential partners who facilitate the development of practical skills, communication, professional socialization, documentation, prioritization, and planning of daily activities. They fill a crucial role in bridging the nurse education theory-practice gap when they have preparation and supporting structures for their specialized role.

Preceptor roles and responsibilities have been defined and researched for the CCF model with emphasis on roles of Protector, Educator, Competency Validator, and Facilitator. The CCF engages preceptors with specific instruction related to roles and the skills required to fulfill the roles. Preceptors must also strive to foster development of clinical judgement in the new nurse – whether a new graduate or an experienced nurse transitioning into a new workplace.

There are many elements within each role component and all must be integrated effectively to support both students and new hires. When the Educator role is engaged by the preceptor, one of the most important aspects is that of fostering critical thinking development and reflective practice. Development of the nurse’s skills and capability in reasoning leads to improved Clinical Judgment skills [21].

Preceptors engage specific strategies for fostering reflective learning and development of clinical judgment [19, 29]. Critical thinking provides the foundation for clinical reasoning, which leads to decision-making – or the application of Clinical Judgment to the patient’s unique issues and needs. The preceptor uses weekly meetings, case scenarios, documentation tools, discussion, and/or problem solving to foster critical thinking development. Discussion, dialogue, constructive feedback, and reflections contribute to the “thought development’ of the novice nurse.

7. Membership venue

Clinical Alliance (Alliance) membership with annual renewal requirements created a venue to share, sustain, grow, improve, and disseminate the model. Alliance members gain proprietary rights to all CCF resources and contribute to ongoing development of best practices in clinical competency and preceptor development. The Alliance provides an innovative means for sharing proprietary rights for the competency framework components, tools, instruction, and resources. The shared templates and model are systematic, standardized, evidence-based and readily available in commonly used formats. The practice-based concepts and tools provide a foundation for competency validation in more than 700 healthcare agencies across the nation. Starting in 2000, the CCF innovation developed from a local initiative, to statewide implementation, to national influence, and now global linkages; creating a solid foundation upon which others build. The membership venue is managed by Nurses International, a non-profit organization that is creating affordable, technologically savvy nursing curriculum for developing countries, thus empowering nurses to change their world [36].

8. Conclusion

The CCF engages core theories and concepts to establish a comprehensive, evidence-based approach for supporting students, new graduates, and experienced nurses as they undergo transitions within healthcare. The engages universal and unit specific competency tools to detail the clinical performance requirements. Sampling theory is engaged to gather evidence of capability.

The American Nurse Association believes that competence is situational, dynamic, and is both an outcome and an ongoing process [4]. The situation, setting and challenges determine what competencies are necessary. With a focus on the dynamic, situational nature of competence; the CCF tools, documentation, and model focus on care of the patient instead of targeting equipment, skills, and completion of procedures. The performance criteria within the CCF specifically outline the way in which professional practice incorporates clinical reasoning, judgment, and decision-making within serious situations [17, 33]. In clinical practice, skills and tasks are incorporated as part of the larger picture identifying the multiple attributes leading to effective action. Transitional evaluation is not complete until an accountability statement summarizes the professional responsibilities and ongoing learning needs of each care provider.

Preceptor education and support is a crucial element of the successful transition system [37]. Preceptors apply concepts pertaining to communication skills, giving feedback, conflict management, teamwork, competency validation, sampling theory, accountability, novice to expert, and fostering critical thinking development. Use of coaching plans in the clinical setting is a new and unique challenge for preceptors which has proven a positive experience with projects implemented to date [2].

Unique aspects within the framework include: an emphasis on fostering critical thinking development; integrating professional accountability; role development related to gathering evidence of competence; and both introduction to, and practice with, the CCF unique tools. A comprehensive competency development framework also requires supporting the structures such as policies, standards of practice, survey or evaluation tools, and rapid cycle quality improvement process.

The CCF supports safe transition within healthcare roles, experiential learning, and competence validation in the clinical setting. This type of competency-directed framework requires specific protections to ensure safe, effective patient care and a supportive learning environment. Preceptors protect both patients and learners, while collecting evidence related to clinical competence. CCF resources include curriculum outlines for preparing preceptors, policy templates, and evaluative survey tools; as well as competency tools and clinical teaching plans used to support learners within the practice setting.

A membership venue is used to share the resources, model, templates, and instructional tools. This approach ensures sustainability of the work, continues the evidence-based development, and allows nurse educators to start their work from established templates, instead of ‘re-inventing the wheel’ of orientation and competency model development.