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Original Research

Creating an Evidence-Based Progression for Clinical Advancement Programs

Burke, Kathleen G., PhD, RN, CENP, FAAN; Johnson, Tonya, DNP, RN, CCRN-K, NEA-BC; Sites, Christine, MSN, RN; Barnsteiner, Jane, PhD, RN, FAAN

AJN The American Journal of Nursing: May 2017 - Volume 117 - Issue 5 - p 22–35
doi: 10.1097/01.NAJ.0000516248.15946.76
Feature Articles

Background: The Institute of Medicine (IOM) and the Quality and Safety Education for Nurses (QSEN) project have identified six nursing competencies and supported their integration into undergraduate and graduate nursing curricula nationwide. But integration of those competencies into clinical practice has been limited, and evidence for the progression of competency proficiency within clinical advancement programs is scant. Using an evidence-based approach and building on the competencies identified by the IOM and QSEN, a team of experts at an academic health system developed eight competency domains and 186 related knowledge, skills, and attitudes (KSAs) for professional nursing practice.

Purpose: The aim of our study was to validate the eight identified competencies and 186 related KSAs and determine their developmental progression within a clinical advancement program.

Methods: Using the Delphi technique, nursing leadership validated the newly identified competency domains and KSAs as essential to practice. Clinical experts from 13 Magnet-designated hospitals with clinical advancement programs then participated in Delphi rounds aimed at reaching consensus on the developmental progression of the 186 KSAs through four levels of clinical advancement.

Results: Two Delphi rounds resulted in consensus by the expert participants. All eight competency domains were determined to be essential at all four levels of clinical practice. At the novice level of practice, the experts identified a greater number of KSAs in the domains of safety and patient- and family-centered care. At more advanced practice levels, the experts identified a greater number of KSAs in the domains of professionalism, teamwork, technology and informatics, and continuous quality improvement.

Conclusion: Incorporating the eight competency domains and the 186 KSAs into a framework for clinical advancement programs will likely result in more clearly defined role expectations; enhance accountability; and elevate and promote nursing practice, thereby improving clinical outcomes and quality of care. With their emphasis on quality and safety, the eight competency domains also offer a framework for enhancing position descriptions, performance evaluations, clinical recognition, initial and ongoing competency assessment programs, and orientation and residency programs.

In this study, the authors developed eight nursing competency domains and 186 related knowledge, skills, and attitudes for professional nursing practice, then sought to validate them and to determine their developmental progression within a clinical advancement program.

Kathleen G. Burke is corporate director of nursing professional development and innovation at the University of Pennsylvania Health System (UPHS), assistant dean of clinical nurse learning and innovation at the University of Pennsylvania School of Nursing, and senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia. Tonya Johnson is associate chief nursing officer at Southcoast Health System, New Bedford, MA; at the time of this study, she was nursing clinical director at the UPHS's Pennsylvania Hospital. Christine Sites is a nursing professional development specialist at the UPHS. Jane Barnsteiner is a professor emerita of pediatric nursing at the University of Pennsylvania School of Nursing, Philadelphia, and editor of translational research and quality improvement at AJN. Contact author: Kathleen G. Burke, The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

Health care continues to change at a pace unimaginable even a few decades ago. In recent years, the Institute of Medicine (IOM) and various professional organizations have addressed the need for health care providers and systems to evolve in order to meet the increasingly complex needs of patients, families, and populations.1-6 Yet, although some improvements have been made, preventable adverse events remain a serious problem, causing or contributing to an estimated 440,000 deaths per year in this country.7

In 2003 the IOM published two important reports. The first, Keeping Patients Safe: Transforming the Work Environment of Nurses, identified the critical role of nurses in providing safe patient care and outlined the systems and structures that were needed to ensure such care.6 The second, Health Professions Education: A Bridge to Quality, focused on the role of education, stating that “[a]ll health professionals should be educated to deliver patient-centered care as members of an interprofessional team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”8 In that second report, the IOM identified five core competencies: evidence-based practice, informatics, patient-centered care, quality improvement, and teamwork and collaboration. In response to these reports, with funding from the Robert Wood Johnson Foundation, the Quality and Safety Education for Nurses (QSEN) project was developed to identify additional nursing competencies—quality improvement was separated into two competencies, quality improvement and safety—and to integrate these competencies into nursing education.9, 10 The QSEN project also proposed targets for the knowledge, skills, and attitudes (KSAs) that nurses would need for each competency.

Although the QSEN competencies have been adopted in undergraduate and graduate curricula at schools of nursing nationwide,11 their integration into practice settings remains limited.12, 13 Recognizing the importance of such integration in today's complex health care environment, Lyle-Edrosolo and Waxman have described the need for alignment of the QSEN competencies with both the Joint Commission accreditation standards and the American Nurses Credentialing Center Magnet model competencies, which are used by hospitals in identifying and supporting their practice standards and care quality.14

Nursing clinical advancement programs support clinical practice, enhance professional development, recognize clinical expertise, and increase nurse satisfaction and retention; they constitute a hallmark of a professional nursing practice environment.15 Such programs are typically based on Benner's theoretical novice-to-expert framework.16, 17 They offer nurses a pathway for career advancement without leaving clinical practice by defining stages of competency that reflect the changing practice needs of nurses as they move along a developmental continuum. Mastery of skills at each level is determined by both educational preparation and experience.18 Research has demonstrated that higher levels of nurses’ education and experience are positively correlated with both the quality of patient care provided and the resulting clinical outcomes.19, 20 This suggests that progressive mastery of nursing practice competencies is vital to meeting the complex care needs of patients and families.

As contemporary clinical practice evolves to meet increasingly complex health care needs, so must clinical advancement programs.21 Yet there has been limited research validating the competencies and defined proficiencies required at each stage in a clinical advancement program. In our study, a team of experts at an academic health system used the consensus process to arrive at eight competency domains and 186 related KSAs critical to professional nursing practice. We then sought to validate the results using Delphi methodology and to determine their developmental progression within a clinical advancement program.

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In 2013, the frontline staff and nursing leadership at a multiorganization academic health system recognized the need to revise its four-level clinical advancement program in order to better identify behaviors that reward clinical expertise and enhance patient outcomes. The chief nursing officer council, comprising the chief nursing officers from each of the system entities and select other nursing leaders, appointed a committee to update and revise the program, its nursing competencies, and the related KSAs. The committee was composed of nurses representing all of the nursing roles within the system, including the corporate director of professional development and innovation (one of us, KGB), professional development specialists (including CS), clinical nursing directors (including TJ), nurse managers, clinical advancement committee chairs, shared governance chairs, clinical nurse educators, and clinical nurses. Consultation was obtained from a faculty representative of the affiliated School of Nursing undergraduate nursing program and a faculty expert in the QSEN initiative (JB). The group met over an 18-month period from June 2013 through December 2014 to identify the competency domains that would form the foundation for the updated clinical advancement program, as well as the KSAs needed.

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Literature review. The first step was to conduct a literature review. Several databases, including Academic Search Complete (EBSCO), CINAHL, the Cochrane Database of Systematic Reviews, Google Scholar, the Joanna Briggs Institute Evidence-Based Practice Database, MEDLINE, Ovid, ProQuest Health and Medical Complete, ProQuest Nursing and Allied Health Source, Web of Science Core Collection Science Citation Index Expanded, and Thoreau (Walden University), were searched to identify relevant literature published in English between 1993 and 2015. Search terms included clinical advancement, clinical ladder, competency, domains of nursing practice, healthcare competency, novice to expert, nursing, and practice. After eliminating duplicates and unrelated articles, we used 55 peer-reviewed articles, landmark reports, and white papers to identify competency domains and related KSAs.

Foundational to this work were the six competencies identified in the IOM Health Professions Education: A Bridge to Quality report8 and the QSEN project.9, 10 The literature review further yielded professionalism and leadership as essential competencies to contemporary nursing practice.2, 22-26

Table 1

Table 1

Identification by consensus. Based on the literature review, the committee identified eight competency domains, with related KSAs, as essential to contemporary nursing practice: continuous quality improvement, evidence-based practice and research, leadership, patient- and family-centered care, professionalism, safety, teamwork, and technology and informatics. See Table 1 for a list of these domains and their definitions. The eight competency domains and the related KSAs were then disseminated for feedback from the health system's shared governance councils, clinical advancement committees, nursing leadership, and competency domain content experts. The selected content experts were recognized authorities on the subject matter (the domain of safety was reviewed by a patient safety clinical nurse specialist, for example). Once consensus on all the competency domains and KSAs was reached, the results were presented to and endorsed by the chief nursing officer council and the nursing shared government councils throughout the health system.

The committee then sought to validate the 186 KSAs along a four-level clinical advancement program using a Delphi technique.

Delphi study. The purpose of the Delphi study was to reach consensus on the essential KSAs and assign each to the appropriate level of the four-level clinical advancement program. The Delphi method is a structured process that uses a series of questionnaires or “rounds” to gather information; rounds are continued until group consensus is reached.27 We used SurveyMonkey software to disseminate each round. The technique involves presenting a questionnaire to a panel of informed experts in a specific field in order to seek their opinion or judgment. The recommended process includes maintaining anonymity among the panel members in order to help control for bias in their responses, and offering controlled feedback. We used a modified Delphi technique in this study, inviting the panel members to respond to information that was initially provided, rather than to open-ended questions.28 Although opinion varies among researchers on what constitutes the point of consensus when using a Delphi technique, consensus is generally defined as at least a 51% agreement among respondents on an expert panel.29 We used this definition. The study protocol was approved as exempt from full board review by the University of Pennsylvania's institutional review board.

Magnet hospital program directors were contacted and asked to identify an expert in their organization to whom the survey should be sent. Experts invited to participate were from acute care health care organizations that met all of the following criteria: the facility held Magnet designation, offered a nursing professional clinical advancement program, and either was a member of the University HealthSystem Consortium (now known as Vizient) or was recognized as a top hospital by U.S. News and World Report in its 2014–15 honor roll. Twenty organizations met these criteria; the organization conducting the Delphi study also met all of the set criteria. Potential study participants were invited to participate via e-mail and were given information on anonymity, risks, and benefits. A link to the SurveyMonkey questionnaire was embedded in the body of the e-mail. The survey link remained active for three weeks during each Delphi round. Consent was obtained through agreement to participate in the study.

Participants were asked to respond to three questions, as follows:

  1. At what level (CN I–IV) is a particular KSA of a competency domain essential to professional practice?
  2. Are any of the KSAs not essential?
  3. Would you add any additional KSAs to any of the competencies?

Clinical nurse (CN) practice levels were defined as follows: CN I, a new-to-practice RN with less than two years of experience; CN II, an RN with at least two years of experience whose area of impact lies primarily within a single clinical unit; CN III, an RN with more than three years of experience whose area of impact lies within a unit, department, or service line, or a combination thereof; CN IV, an RN with more than four years of experience whose area of impact is realized throughout the health care organization and beyond.

Responses were collected in aggregate. Consensus was reached when a majority of respondents (51% or more) selected the same clinical level for a KSA. KSAs meeting consensus were then eliminated from the second Delphi round. KSAs not meeting consensus were moved to the second round. The panel experts responded to the same three questions in the second round for the remaining KSAs. Consensus was reached on all KSAs after two rounds, and a third round was not needed.

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Table 2

Table 2

Twenty clinical experts representing the 20 organizations that met the study criteria were contacted; of these, 13 (65%) agreed to participate. Eleven participants provided demographic information (see Table 2). Sample respondents included Magnet program directors, directors of professional development, and nurses responsible for a clinical advancement program. Thirteen experts responded to round one and 10 responded to both rounds. After round one, agreement was reached for 60% of the KSA assignments along the four-level clinical advancement program. After round two, agreement was reached for 90% of the KSA assignments. For the remaining 10%, the experts were evenly divided about assignment to one of two bordering clinical levels. Using their professional judgment, the QSEN consultant and the research team made the final determination in assigning each of the remaining 18 KSAs.

Table 3

Table 3

The experts’ survey responses indicated that the competencies and the KSAs were essential to and complete for all four levels of clinical practice. The experts did not recommend adding, modifying, or deleting any of the competency domains or KSAs. For the final assignment of the KSAs under the eight competency domains at the four levels of practice, see Table 3.

Table 4

Table 4

The highest number of KSAs were assigned to the domains of professionalism (31 or 16.7% of the total KSAs) and patient- and family-centered care (31 or 16.7% of the total). The domain of safety was assigned 26 KSAs or 14% of the total. The domains of leadership and teamwork were each assigned 22 KSAs or 11.8% of the total. The domain of technology and informatics was assigned 21 KSAs or 11.3% of the total; that of continuous quality improvement, 18 KSAs or 9.7% of the total; and that of evidence-based practice and research, 15 KSAs or 8.1% of the total. See Table 4 for the number of KSAs assigned to each competency domain.

In terms of practice levels, 84 (45.2%) of the KSAs were designated CN I, 47 (25.3%) were CN II, 46 (24.7%) were CN III, and nine (4.8%) were CN IV. At the CN I level, the competency domains with the highest percentage of KSAs were patient- and family-centered care (20 KSAs or 23.8%), safety (17 KSAs or 20.2%), and professionalism (16 KSAs or 19%). At the CN II level, the domain with the highest percentage of KSAs was technology and informatics (10 KSAs or 21.3%). At the CN III level, the domains with the highest percentage of KSAs were professionalism and leadership (eight KSAs or 17.4% each). And at the CN IV level, the domains with the highest percentage of KSAs were continuous quality improvement and evidence-based practice and research (four KSAs or 44.4% each).

It's important to note that, although the number of KSAs decreases as one advances along the continuum—from 84 at CN I to nine at CN IV—one cannot reach the next level without first mastering the KSAs at the previous levels. Thus, a nurse at the CN IV level must have demonstrated mastery of the 84 CN I–level KSAs, the 47 CN II–level KSAs, and the 46 CN III–level KSAs, as well as the nine KSAs required at the CN IV level.

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Data analysis revealed several notable themes. First, the Delphi study results provided clear support for the application of the eight competency domains and the 186 KSAs in defining practice expectations in a competency-based, four-level clinical advancement program. These domains and accompanying KSAs reflect the wide variety of competencies that frontline nurses need when caring for patients and families in today's complex health care environment. The results also reinforce the importance of including the KSAs as essential content in prelicensure programs, as the majority were identified as necessary for new nurses.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

The identification of specific quality- and safety-related competencies reflects the strong link between nursing practice competencies and patient outcomes. For example, in the domain of continuous quality improvement, frontline nurses participating in quality improvement initiatives may directly influence and help to reduce hospital-acquired infection rates, fall rates, and other nursing-sensitive quality indicators. And as Dolansky and Moore have noted, effective improvements in the quality and safety of care must involve applying nursing competencies not only to individuals but also to systems,30 and this is supported by the experts’ assignments of KSAs across four practice levels. For examples of the application of KSAs in the safety and continuous quality improvement domains over the four levels, see Figures 1 and 2, respectively.

Second, the panel experts identified the need for proficiency—in a large number of KSAs in all eight competency domains—at earlier levels of practice. A total of 70.4% (131) of the 186 KSAs were deemed essential at the CN I and CN II levels (84 KSAs at CN I and 47 KSAs at CN II). The fact that so many competencies were identified as required early in a clinical nurse's career has important implications for health care and academic settings as they strive to address the preparation-to-practice gap.31 The incorporation of the competency domains and KSAs into prelicensure and residency program curricula, orientation programs, and preceptor programs will better prepare new nurses to deliver higher quality and safer care, improve patient outcomes, and decrease errors. It may also help to reduce nurses’ stress and increase job retention.

Third, the largest number of KSAs were assigned to the competency domains of professionalism (31 or 16.7%), patient- and family-centered care (31 or 16.7%), and safety (26 or 14%). This underscores the essential role that nurses have, as practicing professionals, in engaging patients and families in the plan of care and in ensuring patient safety.

Practice implications. Clearly, the eight competency domains and 186 KSAs offer a useful overall framework for clinical advancement programs. They also provide an evidence-based foundation for how expectations about nursing practice can promote a culture of high-quality care and safety. For example, in our multiorganization health system, nurse recruiters are beginning to use the eight domains in structuring their behavioral interview questions in order to help identify nurses with competency in the necessary KSAs. The competency domains can further provide a framework for position descriptions and performance appraisals. Our organization is using the study findings to develop new clinical nurse position descriptions and a performance appraisal tool. A system-wide learning needs assessment, aimed at identifying nurses’ learning needs in each competency domain, was completed for all nurses, since many were educated before this content was taught in prelicensure programs. The eight domains can also provide a structure for initial and ongoing competency assessment programs, and can be used in designating KSAs for nurse residency, orientation, and preceptor programs.

Limitations. The competency domains were validated with a convenience sample of nurse experts from similar organizations, rather than with practicing nurses at different levels from various types of organizations. We specifically chose experts in clinical advancement and professional development programs in like organizations because they have similar practice environments. Since practice is constantly evolving, additional competencies may be needed; the current list may not be exhaustive. Further research is also needed to examine the relationships between nursing competencies and ongoing competency and performance evaluations of practicing clinical nurses, as well as patient outcomes.

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This study identified 186 KSAs required at each developmental stage in a clinical advancement program for RNs, incorporating eight quality- and safety-related competencies that are vital to meeting patient and family needs in today's complex health care environment. The findings may be used to inform position descriptions, hiring interview questions, performance appraisals, learning needs assessments, residency programs, orientation programs, ongoing competency assessment programs, and preceptor programs. As such, they can help promote a culture of high-quality care and safety.

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