Competency Assessment: Methods for

Development and Implementation in

Nursing Education

Richard W. Redman, PhD, RN

Carrie B. Lenburg, EdD, RN, FAAN
Patricia Hinton Walker, PhD, FAAN

Abstract

Competent performance by health care professionals is expected throughout society.

However, defining what it is and teaching students how to perform competently faces
many challenges. This article provides a brief overview of the contemporary focus on
competency assessment in nursing education. The redesigned nursing curriculum at the
University of Colorado is presented as an exemplar of a practice-oriented model that
requires competent performance among students. Methods for implementing a
competency-based curriculum and lessons learned during the process are discussed.

Citation: Redman, R.W., Lenburg, C.B., Hinton Walker, P. (Sept. 30, 1999):
"Competency Assessment: Methods for Development and Implementation in Nursing
Education." Online Journal of Issues in Nursing. Vol 4, No 2, Manuscript 3. Available
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/T
ableofContents/Volume41999/No2Sep1999/InitialandContinuingCompetenceinEducation
andPracticeCompetencyAssessmentMethodsforDeve.aspx

Key words: Nursing competencies, Competency assessment, nursing education, student

assessment

Background

Increased accountability has become a common theme in contemporary society. In the

public marketplace, the theme of "let the buyer beware" has been replaced with the
philosophy of "excellence is defined by the customer." This perspective has general
application across all types of industries. When the "public good" relates to education or
health care, standards of acceptable performance are clearly defined by regulatory and
professional bodies and society holds practitioners fully accountable when performance is
unacceptable or questionable. Whether the focus is on public officials, health care
professionals, or educators, the expectation is that standards of acceptable performance
will be adhered to and the public trust will be safeguarded. Operationally defining
acceptable, competent performance is one of the most challenging and essential
components in this accountability paradigm.
Those in nursing education face many challenges. Students approach the learning
institution with the assumption that they will be taught the requisite knowledge and skills
to become competent nurses. Employers of nursing graduates assume that the nursing
degree and the state licensure certify competent performance. Many definitional and
methodological issues evolve from these assumptions. The social mandate for
accountability, however, does not tolerate ambiguous assumptions or debate. While the
assessment of competent practice in the service sector has received considerable attention
the past 25 years, the implementation of competency assessment models in nursing
education has moved at a much slower pace.

Purpose

The purpose of this paper is to examine selected assessment methods designed to

accurately document competence within the context of escalating and changing needs in
education and practice. The University of Colorado School of Nursing (CU-SON) is
currently in the process of implementing a competency-based, outcomes-focused
curriculum in its four nursing education programs: baccalaureate (BS), master’s (MS),
nursing doctorate (ND), and doctor of philosophy (PhD) programs. The Colorado
experience described in this article serves as an exemplar for rationale, methods, and
process used to develop and implement a practice-oriented model to promote competence
among students and practitioners. The methods used in this comprehensive transition
provide examples that can be adapted by others in education and practice settings.

Focus On Competencies in Education and Practice

Multiple requirements for competent nursing practice in the health care system have been
established by national associations and agencies. These include the American Nurses
Association, the American Association of Critical Care Nurses’ Standards for Nursing
Care of the Critically Ill and their Education Standards for Critical Care Nursing
(Alspach, 1992). The Joint Commission for Accreditation of health care Organizations
requires that clinical competence be assessed for all nursing staff and holds institutional
leaders accountable for ensuring that competency of all staff is assessed, maintained,
demonstrated, and continually improved (JCAHO, 1999).

The legal and financial implications of employee performance and safe practice in a
rapidly changing practice environment make continuing professional competence a major
concern for all providers and health care organizations. Stressing the importance of
assessing what employees can do, not what they know, del Bueno describes the
commonly known gap between excellent test takers who have difficulty performing a
procedure or recognizing warning signs in a patient experiencing difficulty. The use of
criterion-based performance measures determines practice competencies in employees as
well as identifies where need exists to correct skill or knowledge deficiencies (del Bueno,
Weeks, & Brown-Stewart, 1987).

Competency assessment is always outcome oriented; the goal is to evaluate performance

for the effective application of knowledge and skill in the practice setting. Competency
 assessment techniques address psychomotor, cognitive, and affective domains.
Competencies can be generic to clinical practice in any setting, specific to a clinical
specialty, basic or advanced (Benner, 1982; Gurvis & Grey, 1995).

Competency-based education has been found to be equally effective in both didactic and
self-learning approaches (Lenburg, 1990; Schlomer, Anderson, & Shaw, 1997). Alspach
(1984) presents hallmarks of competency-based education that make them applicable
both in practice and in educational settings. These include competencies based on
validation of what performance by competent practitioners actually comprises. In
addition, competency assessment is based on criterion-referenced evaluation methods
where the learner’s performance is evaluated against a set of criteria provided to the
learner so that both the learner and the assessor are clear on what performance is
required. Finally, competency-based education is learner-centered in that outcomes are
specified and describe what the learner must do to demonstrate competency.

Masson & Fain (1997) discuss the value of a competency-based system in cross-training,
which is commonly used in today’s cost-containment environment. They illustrate the
effectiveness of a comprehensive system of competency validation for long-term staff,
orientees, and nursing students.

Del Bueno reports it took approximately eight months of clinical experience before new
BSN graduates felt confident and competent in their clinical judgments. Given the array
of individual differences in nursing performance, she recommends that employers and
educators assess competencies before assigning nurses to practice settings or advancing
them in educational programs (del Bueno, 1990).

While examples of While examples of competency-based assessment are more

competency-based assessment prevalent in the nursing practice literature, limited examples
are more prevalent in the can be found in the nursing education literature as well.
nursing practice literature, Lenburg has provided major contributions in the use of
limited examples can be found competency-based assessment as an essential component of
in the nursing education nursing education (Lenburg, 1991). Her Competency
literature as well. Outcomes and Performance Assessment (COPA) Model
provides a framework for assessing the full range of core
competencies essential for nursing practice. These include psychometrically sound
techniques for assessment across psychomotor, cognitive, and affective domains in all
specialty content areas of nursing education (Lenburg, 1979; Lenburg & Mitchell, 1991).
Luttrell and colleagues (1999) successfully employed the COPA model to develop a
competency-based undergraduate nursing curriculum and used a variety of competency
performance examinations and assessments to measure student performance and
achievement.

The CU-SON Example: The Driving Forces for Curriculum Redesign

Over the past two years, the University of Colorado School of Nursing (CU-SON) has
undergone a number of major changes. Some of these changes were driven by dynamics
in the educational marketplace and some were the result of major organizational changes
underway within the School. The CU-SON celebrated its centennial in 1997-98. This
celebration resulted in retrospection about the major contributions the School has made to
nursing practice and education as well as stimulated discussion around how the School
would chart its future course. As the birthplace of the nurse practitioner movement in the
1960s and the caring science of Watson in the 1970s, the School has made major national
and international contributions to both practice and education. In addition, the School has
long been a pioneer in distance education, providing educational opportunities to
Colorado residents in rural areas of the state for approximately 25 years. Initially, faculty
and programs were sent to remote areas of the state. As technology advanced, interactive
video was used to provide educational opportunities. The School began to use web-based
technologies around 1995 as that technology became available. During the Centennial
review of past accomplishments, however, it became apparent that these traditions of
excellence and pioneering endeavors at CU-SON were not sufficient to deal with the
changes needed now to face the uncertain and challenging future.

In 1997, the University of Colorado School of Nursing held a series of focus groups with
various stakeholders in response to expressions of increased dissatisfaction around a
number of issues. These stakeholders included employers of CU-SON graduates, alumni,
and students currently enrolled in one of the various education programs. Employers
thought that graduates often were lacking in competencies in many areas needed for
practice in the contemporary clinical environment, such as critical thinking, problem
solving, communication and effective assertiveness. They also cited deficiencies in
computer-related skills required to use the clinical information systems found in the
clinical setting. In addition, they stated that graduates often were deficient in working
with data and evaluating cost-effective alternatives required for practice in the evidence-
based clinical world. Employers face increasing difficulties in helping the graduates make
the transition from student to clinician. From the graduates’ perspective, they felt
unprepared for entry-level competencies needed to practice in the diverse settings they
moved into following graduation. Students, as stakeholders, also felt that many aspects of
the educational programs were not learner-centered.

Curriculum Redesign

In response to the focus group findings, the faculty decided that fundamental change in
the curriculum was needed. They developed a set of guiding principles to provide
direction for curriculum redesign which are presented in Table 1. To meet the needs of
stakeholders, it was essential that graduates have the expected competencies to move into
the practice world, regardless of setting. To meet the demands of the competitive
marketplace, accessible programs with an "anytime, anywhere" capability were viewed as
the ideal. The goal of modular, flexible learning opportunities was viewed as essential for
increased efficiency and effectiveness; students would only take those modules needed to
meet program requirements and not repeat content after competencies were
demonstrated. Use of available and evolving technologies and virtual learning resources
was considered essential to enhance both learning and delivery of courses. And finally,
the faculty affirmed that the core values that had become a standard of excellence of the
CU-SON were foundational in the redesign process.

Table 1. Guiding Principles for Curriculum Redesign.

The redesigned curriculum at the University of Colorado School of Nursing will be:

• Competency-based and outcome focused.

• Accessible by all who seek either a degree program or life-long opportunities.
• As seamless as possible between and within programs.
• "Real world" in focus with emphasis on evidence-based nursing practice.
• Modular and flexible.
• Learner-centered and user friendly.
• Cutting edge in its use of technology and virtual learning resources.

• Built on the School of Nursing core values of relationship-centered caring, reflective practice,
culturally competent nursing practice, and a commitment to social justice and responsibility.

The faculty selected the Competency Outcomes and Performance Assessment (COPA)
Model, designed by Dr. Carrie Lenburg, as the most effective framework for addressing
both the competency-based focus as well as the educational methodologies essential for
undertaking the curriculum redesign. Dr. Lenburg was retained as a long-term consultant
for ongoing guidance in this extensive redesign and implementation effort. Her COPA
Model provides a framework for the concepts and methods essential to competency
assessment. Eight core practice competencies in the COPA Model are: assessment and
intervention, communication, critical thinking, teaching, human caring relationships,
management, leadership, and knowledge integration. The COPA Model is applicable for
documenting either initial or continuing competence and can be applied to a diverse array
of practice environments (Lenburg, 1979; Lenburg & Mitchell, 1991).

The curriculum redesign has resulted in a unique approach to nursing education at the
undergraduate and graduate levels. One conceptual framework and curriculum has been
implemented in all degree programs: baccalaureate, master’s, nursing doctorate, and the
doctor of philosophy. Ten specific competency-based outcomes, listed in Table 2, have
been identified for the curriculum. These competency-based outcomes focus on education
and social change abilities, including: competent effective reflective practice; generation
of nursing knowledge, and leadership and social change for improved health for
individuals, communities, populations, and global environments. This single set of
outcomes applies to all four degree programs; each outcome, however, is operationalized
specifically to fit the expectations for graduates from each particular program.

Table 2. Competency-based Curriculum Outcomes for all Educational Programs

By the completion of the nursing program, students will be able to incorporate
competencies, knowledge, and values for direct and indirect provider roles to:
 1. Implement caring and competent nursing practice with individuals, families, and
communities based on understanding the human experiences of health, illness and
healing.
2. Integrate the ethical use of technology and information systems to augment the
human capacity for health, facilitate decision-making, support collaboration, and
foster communication.
3. Promote health of local to global communities through promoting safe
environments and safe and effective health care addressing the interaction among
individuals, communities and their environmental contexts.
4. Manage care to achieve quality, cost effective and ethical outcomes in the delivery
of health care for individuals, families and populations.
5. Engage in leadership to promote social justice related to access, quality and socio-
cultural acceptability of health care through relationship-centered caring,
advocacy, and empowerment.
6. Negotiate and adapt the delivery and management of health care and health care
systems for diverse populations and environments.
7. Practice relationship-centered caring through self-awareness, by developing and
maintaining respectful relationships, communicating effectively, and integrating
the influence of the human experience of health/illness/healing.
8. Practice nursing reflectively, guided by theory, based on best evidence, and
integrating creative and critical thinking.
9. Participate in generating and testing knowledge regarding nursing, health care, and
reflective caring practice.

10. Actively engage in self-directed learning to maintain state of the art nursing
practice and to facilitate the education of future practitioners, paraprofessionals,
and healthy communities.

Research competencies in each program provide an example of how leveling is

implemented. The basic nursing research course is taken in the first or junior year of the
upper division baccalaureate program. In the basic course students develop beginning
competencies in understanding and evaluating research findings that have implications
for their practice. These competencies are refined in their second year. At the MS level,
students develop competencies in evaluating the strength of research evidence to make
informed decisions in practice and synthesizing pertinent research literature into practice
guidelines and protocols. At the Ph.D. level, students develop competencies in designing
and conducting research studies that will contribute to the development and
dissemination of knowledge to guide clinical practice.

The curricular framework incorporates evidence-based, theory-guided critical thinking

and core practice competencies that focus on: respect for diversity and culture;
relationship-centered caring; and social justice and responsibility. The curricular
framework is based on the foundation of reflective nursing practice and concentrates on
four practice/inquiry foci: the human experience of health-illness-healing; the
 human/technology interface; environmental context of health and health care; and quality
and cost-effective outcomes. These foci reflect scholarship programs of the faculty and
are included in all nursing programs.

Implementation of Competency Assessment in the Curriculum

Since 1998, faculty have been actively and continuously engaged in the process of
redesigning the entire curriculum in all four programs to implement the competency-
based outcome focused curriculum. Each course is reviewed for conversion to the
competency-based model. In some cases an entirely new course is developed rather than
conversion of an existing one. The familiar traditional behavioral objectives are replaced
with "outcome competencies" in each course and module. Learners are oriented at the
beginning of the course to the specific outcome competencies and requirements they are
expected to acquire, and how they will be evaluated.

Two Assessment Methods

Two methods are used to assess competence in learners. Competency Performance

Assessments (CPAs) are used to assess all class assignments that have consequences for
the course grade, such as papers, projects, participation and presentations. Competency
Performance Examinations (CPEs) are used in clinical situations to evaluate clinical
outcomes. Both CPAs and CPEs are comprised of critical elements that collectively
define competence for particular skills or abilities. Critical elements are single, discrete,
observable behaviors that are mandatory for the specific competencies being evaluated.
They specify exactly what is required for acceptable performance in clinical and non-
clinical courses; the course grade is based on this pre-determined foundation.

Faculty, who are clinical experts, work in collaboration with colleagues in practice
settings to specify the critical elements for CPEs and CPAs. Approximately 30 % of the
faculty are active practitioners who participate in the School’s faculty practice plan and
teach in one or more of the educational programs. These faculty provided essential input
in defining the competencies essential for practice in different settings. In addition,
designated "clinical scholars" from clinical agencies affiliated with CU-SON became
active participants in the process of defining outcome competencies for all students. All
faculty participated in these curriculum redesign to address how these competencies
might be learned and assessed.

Learners in each course are Critical elements are created within the context of accepted
oriented to the specific standards of practice, evidence-based research literature, and
competency outcomes ... course objectives. Specific CPEs are then constructed using
these critical elements as essential items for defining and
measuring competent performance in the learner for designated modules or courses.
Learners in each course are oriented to the specific competency outcomes and all related
critical elements that establish the mandatory level of performance for that course. In
testing situations, students are presented with one or more focused clinical cases — actual
or simulated — and examined in terms of their ability to demonstrate the required critical
elements for competent practice to meet the specific needs of that clinical situation.

The advanced health assessment course required in the MS and ND programs provides an
example of what the faculty wanted to accomplish in the redesigned curriculum, given
the guiding principles described above. The graduate level course consists of a series of
modules, each one credit, which are available to students in both the MS & ND programs.
The modules cover core assessment concepts, and one or more of the following specialty
areas: adult, geriatric, women’s, children’s, newborn, and prenatal assessment. Students
complete only those modules necessary for their specialty option requirements. Entry
level competencies have been set for each module. Any student who has completed the
content of a required module at another point in their education, or has had extensive
clinical practice in that area, or has completed a continuing education program on that
content may demonstrate their competency by completing the designated clinical
performance examination (CPE). If successful, that student has met the competency
requirements for that module and may progress on to a subsequent requirement. Students
who are deficient in basic health assessment knowledge and techniques are urged to
complete an intensive basic assessment module and demonstrate competency before
beginning the advanced modules. This enhances their ultimate success, confidence and
competence.

Students taking Advanced Health Assessment complete the didactic portions of the
various modules in a web-based format. They also have the opportunity to attend lab
sessions where they can demonstrate assessment techniques, ask questions of supervising
lab faculty, practice particular techniques and demonstrate their proficiency with faculty
direction. At various points, testing situations are required and students are presented
with a focused clinical scenario and evaluated using the designated CPE and related
critical elements. Results of the completed CPEs are part of the official course records,
just as any other test result or grade. Specific evaluation comments, therefore, must be
written to withstand legal scrutiny. The faculty established the policy that a failed CPE
may be repeated only once. Students cannot advance into a subsequent assessment
module until they have demonstrated proficiency for prerequisite competencies necessary
for entry into that module.

Although still in the early implementation phase, this competency-based approach has
worked well to date. All enrolled graduate students in both the ND and MS programs are
required to complete the modules appropriate to their specialization. In addition, nurses
who are seeking prescriptive authority from the State of Colorado Board of Nursing
enroll in the appropriate modules if they are deficient in the advanced assessment
requirements. This can be done on a continuing education basis or as an enrolled post-MS
certificate student. Some health care agencies are considering contracting for various
modules for their staff as a means to acquire required competencies for incorporation into
practice in the agency. Regardless of the purpose for taking the modules, learners are
required to pass the designated CPEs and/or CPAs.

Lessons Learned
The experience with the The experience with the competency-based curriculum at
competency-based curriculum CU-SON over the past 15-18 months has been very positive,
at CU-SON over the past 15- although not without numerous challenges. Considerable
18 months has been very faculty development in the methods of competency outcomes
positive, although not without and performance assessment has been ongoing and will
numerous challenges. continue for the next one to two years. From the outset,
faculty need a comprehensive orientation to the multiple and
interrelated components of the COPA Model; they also need ongoing reinforcement and
encouragement, and the time to learn and implement new methods.

The curriculum committee has provided oversight through review of every course in all
programs, whether on campus or web-based. This has been an ongoing process as courses
are revised and new courses designed. Each course is reviewed from the competency-
based perspective, including review of competency outcomes, interactive learning
strategies, and the CPEs and CPAs proposed for that course. In addition, each course is
reviewed for its relationship to the overall mission, philosophy, conceptual framework,
and program outcomes for the unified curriculum. This process promotes internal
consistency essential to the overall success of the school and its graduates.

The syllabus for every course uses a template that includes a standard set of definitions,
explanations, and other information related to competency-based approaches and
methods. This insures that students are continuously reminded of the performance
expectations required for the course within the context of contemporary practice.

The redesign also has required the development of a new evaluation plan for the
curriculum. This includes new evaluation instruments to measure achievement of
competency-based outcomes, effectiveness of learning strategies and assessment
methods, and the satisfaction of students, graduates, faculty and employers. These
evaluation methods and ongoing focus groups held with students and faculty provide the
foundation for continuous quality improvement; they help faculty determine which
components are working effectively and which need improvement. Both process and
outcome data have provided important insights as additional courses are designed and
implemented.

The competency-based approach to nursing education has been endorsed by our

stakeholder groups, particularly our colleagues in the clinical agencies. This model is
very familiar to them and one that they believe has demonstrated validity and reliability.
Overall, implementation of the competency-based COPA Model at CU-SON is an
evolving success story. It has provided an exciting and educationally sound pathway as
the school begins its second century of educational programs for local and distant
learners and the consumers they serve.

Summary

The experience in converting to a competency-based curriculum has been both successful

and challenging. Faculty and student experiences to date have been positive. The
redesigned curriculum is viewed as responsive to the competency-oriented environment
and employers believe the transition of graduates into practice settings will be more
effective, efficient, and successful. This competency-based approach to education can
serve as a model which offers a wide variety of applications to education and service
environments.

http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/T
ableofContents/Volume41999/No2Sep1999/InitialandContinuingCompetenceinEducation
andPracticeCompetencyAssessmentMethodsforDeve.aspx