Sportsman, Susan PhD, RN, ANEF; Poster, Elizabeth PhD, RN, FAAN; Curl, Eileen Deges PhD, RN, CNE; Waller, Paul PhD, RN; Hooper, Janice PhD, RN
Patient safety, a national concern, is inextricably linked to the competence of all health professionals. As a result, ensuring the competence of new graduates is a mandate for nursing education and practice. The complexity of healthcare delivery and limitations faced by both education and practice present many challenges in preparing prelicensure graduates to meet multiple stakeholder expectations. One of the challenges for education is to ensure that specific “essential” patient care competencies are demonstrated by students before graduation. In addition, practice settings are challenged to provide adequate space for important clinical experiences and other learning resources. These challenges are magnified because of the lack of clarity regarding the essential knowledge, clinical judgments, and behaviors necessary for nursing practice in the first 6 months after graduation. The challenges are illustrated by the differences of opinion expressed by nurses in education and practice regarding essential competencies for entry into practice.
Over a 17-year period, the Texas Board of Nursing (BON) published 3 versions of a document articulating competencies, including knowledge, clinical judgments, and behaviors, expected of prelicensure nursing graduates in the state. This article describes the results of strategies taken to integrate the recommendations of practicing nurses into the recent revision of this document.1
In the beginning, nursing students are novices who require context-free rules to guide their nursing actions.2 With experience, nurses are able to demonstrate marginally acceptable performances because they have coped with enough real situations to note recurring meaningful situational components.2 Nurses become competent, according to Benner,2 when they have been on the job in the same or similar situation for 2 to 3 years. Assuming they continue to practice in a particular context, nurses may become proficient and, finally, an expert. Ten years of required engagement has been suggested as necessary to attain high-level expert performance.3 If nurses change work environments, they may return to a previous level of competence, although probably never to a novice position.2
Benner’s2 conceptual framework suggests that new graduates of prelicensure programs will not achieve competence at the time of graduation. This finding was corroborated in an evaluation of new bachelor of science in nursing (BSN) graduate performance that found that upon graduation, new prelicensure graduates demonstrated characteristics of novices and/or advanced beginners at the time of their first employment.4 Assuming that this finding is consistent across nursing programs, the question then becomes “What should the expectations of new prelicensure nursing graduates be in specific practice situations?
Most of the literature regarding the competence of prelicensure graduates only reflects practice in acute care. Even in this setting, differences of opinions among educators, students, and nurses in practice regarding the expectations of new graduates at initial licensure are frequent. In 2005, del Bueno5 reported that only 35% of new graduates assessed through the Problem Based Development System (PBDS) could meet job expectations related to interpersonal, technical, and critical-thinking skills at the time of their initial employment. Burns and Poster6 found that when new graduates in the Dallas-Fort Worth, Texas, area were evaluated via the PBDS during their first job, new graduates had low PBDS scores, despite success on standardized examinations before graduation and the NCLEX-RN afterward. The Nursing Executive Center evaluated the views of 57,000 nurse leaders (nursing directors, clinical nurse specialists, educators, charge nurses, and nurses with >2 years of experience). Only 25% of the respondents were fully satisfied with new graduate performance at the time of initial hire.7
Lack of confidence in the competence of new graduates seems to be shared by the new graduates themselves. Candela and Bowles8 surveyed 352 nurses in Nevada who had graduated from a prelicensure program within the last 5 years. Although these respondents were satisfied with their competence in technical skills, they felt a lack of confidence in pharmacology, management, leadership, organizational skills, and the use of electronic medical records. The majority felt that their education better prepared them to take the NCLEX-RN than for actual practice and that they did not have enough clinical hours in their nursing programs to feel fully competent.8 This need by new graduates for more clinical experience was reiterated in the National Council of State Boards of Nursing (NCSBN) postentry competence study.9 This study highlighted the notion that the new graduate’s definition of competence changed during the first 5 years of practice. Initially, juggling complex patients and assignments efficiently was “the sum total of competency.”9(p7) Later, being able to judge what should be done quickly and what warranted additional time or consultation became more important.9
Differentiation of Competence at Entry Into Practice According to Level of Nursing
Not only is there little agreement regarding the level of competence expected of graduates of prelicensure nursing programs, but also, the lack of consensus is even greater when competence associated with different levels of nursing education is considered. The NCSBN postentry competency study suggests that BSN graduates were more likely to focus on psychosocial complexity and therapeutic use of self to know patients and families. They were also more likely to be engaged in self-examination and insight than other levels of nurses. Nurses with an associate degree in nursing (ADNs) working on their BSN degree showed more insight and commitment than did those who were not enrolled in further education. There were exceptions to these generalizations, and education did not specifically predict behaviors.10
The scope of practice between a registered nurse and a licensed vocational/practical nurse (LVN/LPN) is defined in broad strokes in most state nursing practice acts; however, differentiation between the ADN or diploma graduate and the BSN graduate is generally not addressed. Practice acts are typically silent on the impact of experience on the competence of the nurse. In an effort to bring clarity to the expectations for new graduates, a task force representing various nursing educational groups under the auspices of the Texas BON developed a framework, the “Essential Competencies of Texas Graduates of Educational Programs in Nursing,” in 1993.11 The framework identified core competencies of new graduates from the 3 types of prelicensure programs in Texas: LPN, ADN/diploma, and BSN. These competences were revised in 2002 to reflect changes in professional practice. This revision, “Differentiated Entry Levels for Competencies” (DELCs), was used by educators in various ways, including revising course objectives and outcome statements for educational programs.12
In 1993 and again in 2002, nurse administrators from the state’s practice sector were included in work groups that developed or revised the essential competencies. In addition, selected nurse administrators of healthcare organizations in Texas had the opportunity to comment on each draft. However, after both revisions, there was not widespread awareness of the competencies among nurse leaders working with students or new graduates in clinical settings. Only a small segment of nurses in practice in Texas were familiar with the competencies or realized that they described expectations for new prelicensure graduates. Recognizing this limitation, BON staff and work group made a concerted effort to include nurses in practice, particularly administrators, into the dialogue regarding the 2011 revision.
Revision of Competencies
The most recent work group authorized by the BON to revise the competence framework included educators and practicing nurses who were selected by various professional organizations in the state (Table 1). The work group was charged with the task of revising the DELCs to reflect changing nursing practice. Over a 2-year period, the work group, guided by the BON staff, developed the “Differentiated Essential Competencies of Graduates of Texas Nursing Programs” (DECs). The roles of the nurse were expanded to include 4 role categories: member of the profession, provider of patient-centered care, patient safety advocate, and member of the healthcare team. The original 14 competencies, which were categorized by role, were expanded to 25. Related knowledge and clinical judgments and behaviors to reflect the evolving role of the nurse were included in each category.13
The 2008-2010 work group was concerned that even with input from several nurses representing practice in the first 2 editions, there was still limited awareness of the usefulness of the competencies as a framework for shared expectations between those in academia and those in practice. The work group used 2 specific strategies to integrate input from practice into the DECs. These included an evaluation survey sent to agencies that serve as practice sites for nursing programs throughout Texas and focus groups across the state by the BON staff and work group members.
Before a review of the competencies by the BON, the director of nursing sent a letter by e-mail to 959 contacts that nursing programs had identified in their annual report as providing clinical experience for students. In at least 60 cases, e-mails were sent to several individuals within a single organization. Most commonly, 2 or 3 contacts were from a single organization; however, in larger healthcare systems, there were as many as 9 contacts. The e-mail introduced the purpose of the DECs, as well as the framework used to identify competencies, and asked the recipients to use an online survey site to evaluate the DECs. A copy of the DEC draft document, including the 25 essential competencies and related knowledge, clinical judgments, and behaviors, was attached to the e-mail as a point of reference. The online survey asked respondents to rate the descriptions of each of the competencies according to a 5-point scale, as follows:
* The competencies clearly define the educational preparation of each level of nursing education.
* The competencies help differentiate between the scope of practice of the prelicensure graduate for each level of nursing education (LVN/LPN, ADN/diploma, or BSN).
Respondents were asked to select 1 or more ways in which the competencies would be useful in their particular organization, including (a) job descriptions, (b) planning orientation, (c) developing in-service programs, (d) making assignments to new graduates, (e) validating expectations for different levels of practice, (f) developing steps for employees to move from LPN to ADN to BSN, (g) planning internships, and (h) assessing staff competencies. They were also asked to identify the major role categories (member of the profession, provider of patient-centered care, patient safety, and member of the healthcare team) that they believed would be useful to their institution. The respondents were given slightly more than 2 weeks to complete the survey. Because the healthcare organizations were the point of contact for the BON and individual responses could not be traced through the online survey site, complete anonymity of respondents were assured.
The response rate for the survey was 16% (n = 155). When rating the statement that “Competencies clearly defined the education of each level of nursing education,” a large majority (92.3%, n = 143) of the respondents either agreed or strongly agreed. Similarly, 89.1% (n = 138) of the respondents either agreed or strongly agreed with the statement “Competencies help differentiate among the scope of practice of entry-into-practice nurses in each level of nursing education.” The data were analyzed using percentages; no inferential statistics were used. Table 2 defines the respondent’s specific rating of each statement.
Most of the respondents indicated that the categories “provider of patient-centered care” (74.3%, n = 115) and “member of the healthcare team” (63.8%, n = 99) identified competencies that were most useful in their organizations. Less than half of the respondents indicated that competencies within the “member of the profession” (42.1%, n = 65) and “patient safety advocate” (48%, n = 74) were useful in the organization.
Respondents had the opportunity to include individual comments on the survey. Of the 155 respondents, 35 (22%) included at least 1 comment, including some of those below:
An excellent tool that can be used to differentiate various levels of nursing which I believe is extremely important in an industry that is rapidly changing.
The competencies were not well defined, indicating that “usefulness is difficult to determine since the actual behaviors were not well-explicated in measurable terms.”
Some of the competencies were not applicable to our setting.
The competencies would limit the nurses’ practice, particularly the ADN/diploma graduate.
I hope this does not mean that restrictions will be placed on how a nurse should be assigned in a hospital.
Some of the comments compared the BSN new graduate unfavorably to the ADN or diploma graduate, noting that BSN graduates are more focused on “theory” and less interested in caring for patients. One of those who addressed concerns regarding the need for differentiation stated, “If all nurses graduate and take the same NCLEX-RN exam and pursue the same licensure, differentiated practice models are irrelevant for entry level nurses in acute care, as they all work under the same job description.” Another stated, “My experience is there is little differentiation in practice initially. Once the core competency is mastered, there is a difference in potential competence.” One comment suggested that there should be further differentiation at the master’s level.
To fully integrate practice views into the revision of the competency framework, BON staff and selected work group members held 6 focus group meetings across the state. The groups were hosted by healthcare associations in Dallas-Fort Worth and Houston, a long-term care association, and hospital systems in Austin and the Rio Grande Valley. Nurse leaders in these areas were invited to attend.
Each focus group lasted approximately 1.5 hours. The BON staff presented an overview of the DECs, followed by group discussion. Consistent with the quantitative results of the survey, participants generally spoke favorably about the DECs. There were minor editorial suggestions, many helping to clarify the specific intent of the DECs. Nurse educators in prelicensure programs and educators working in orientation or in-service programs in practice were particularly supportive. Educators in practice settings emphasized that the DECs would be helpful in their career ladder structures. Consistent with the qualitative results of the evaluation survey, nurses involved primarily in direct patient care had some initial hesitancy about the validity of the DECs. However, discussion during the focus groups seems to dissipate participants’ concerns.
Most of the nurses in the practice environment responded positively to the revised DECs. Less than 8% (n = 12) of the survey respondents disagreed or were uncertain regarding whether the framework clearly defined the competencies expected at the time of graduation. A slightly higher percentage, although still a small minority (11%, n = 17), felt that the competencies did not effectively differentiate among the levels of nursing practicing in Texas.
The authors hypothesized 2 potential factors that may have influenced those who had negative perceptions of the DECs. First, clearly defining specific knowledge, clinical judgments, and behaviors applicable in all clinical settings was a challenge because the more explicit the description, the more extensive the length of the document. The work group struggled with this dichotomy, ultimately agreeing that the usefulness of the document was related to its brevity.
Second, the issue of differences in competencies of new graduates of ADN or diploma and BSN programs, given that all new graduates take the same licensing examination, causes some consternation in both education and practice at all levels. As noted in The Future of Nursing: Leading Change, Advancing Health,13 the educational qualifications required for entry into the nursing professional have been widely debated for more than 40 years. The impact of nurses’ educational level in patient outcomes remains controversial in professional literature; this national debate over the relative impact of the ADN-, diploma-, and BSN-prepared graduates upon patient outcomes was reflected in the comments regarding the DECs.
Despite the continued discussion about differentiation, it was encouraging to note that the large majority of the practice respondents viewed the competencies to be clear, accurate, and representative of the differentiation among the graduates of the 3 types of prelicensure programs in the state. The usefulness of the DECs was confirmed by more than half of the respondents who indicated specific ways in which the competencies could be used. Whether the competencies are actually integrated into job descriptions, orientation, and/or competency validation for new graduates in the practice arena will be important to determine after the DECs have been in place for a year or more.
Not surprisingly, given the emphasis on patient care, less than half of the respondents saw the category “member of the profession” as useful to the organization. Interestingly, almost half of the respondents did not identify the categories of patient safety advocate as useful in their organization. This category was added to the most recent revision of the competencies, based on the national emphasis on patient safety. However, because patient safety is a major component of patient care, the fact that almost half of the respondents did not find competencies related to patient safety as useful should be explored in more depth. Perhaps, expectations of these competencies are pervasive across levels of nursing practice without strict differentiation and were not seen as important in a document that explicated differences in competencies based on educational background. However, these competencies do support the mission of the BON to protect public safety and must be validated further.
Efforts to articulate knowledge, clinical judgments, and behaviors with an increasing degree of specificity should continue both in acute care settings and in other environments. As opportunities for new graduates expand in non–acute care environments, identification and application of competencies specific for each practice site will be important. Evaluation of the outcomes of the integration of DECs into job descriptions, orientation materials, competency validation, and career ladder documentation in practice sites will also provide important information for nurse educators and administrators. Feedback to nursing programs will assist faculty to make curriculum revisions that are most relevant in response to changes in healthcare practice expectations.
© 2012 Lippincott Williams & Wilkins, Inc.