Get It Wright with Competency Testing

June 8th, 2011


By , BSN, RN

Every year, hospitals require competency testing of their entire nursing staff. Many staff members believe this is done for the sake of outside regulatory agencies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Occupational Safety and Health Administration (OSHA) and other state and federal agencies. As competency time rolls around each year, it often seems like just another chore for the educators and staff, and frustration is often high.

Giving the best possible care to patients and other clients, being thought well of in the community, and assuring that healthcare providers are at the top of their game should be every hospital's goal. JCAHO does require all health care facilities to meet certain standards and that staffs meet specific nursing requirements, but the Joint Commission allows facilities to develop their own competencies based around these standards and the hospitals' own policies. This annual event doesn't have to be painful.

Traditionally, the competencies to be completed are determined by hospital leaders, managers and educators. A set of core competencies ( for instance, the steps for verifying blood for transfusion) are determined, and nurses are expected to complete them, most often by review modules then take an online test on the module specifics or through checklists of skills observed by educators. Nurses are told when to do them, how to do them, and given a set time in which to do them. There are only those  few methods of verification, and they generally do not require any critical thinking skills. They are simply assignments to be complete and they merely meet the mandates for competencies set by management and outside organizations.

If the old or traditional ways of approaching annual competencies is a source of frustration for everyone involved, maybe it's time to consider something new. Donna Wright, MS, RN has developed a model for competency assessment, and it is catching on in hospitals across the country.

What’s at the core?

In Wright's model, core competencies are translated into unit-specific skills. On the patient care floors, nurses are expected to show proficiency in IV insertion and hand-off communication, for example. In the operating room, nurses demonstrate positioning, sterile gloving and the proper set-up of the electric cautery. This is known as a process-focused approach.

Wright maintains that the challenge is to create a competency assessment process that is meaningful and provides nursing staff with the tools to deliver safe and effective patient care. Her model is outcome-focused and accountability-based in its approach."What we have created in the past was static," Wright said. "It was a lot of activity with no purpose behind it."

"Being competent is all about changing and evolving, about accountability," Wright said. "More and more we are judged on outcomes. We are seeing our health care system moving to ACOs (accountable care organizations). Healthcare providers and institutions will only be paid for outcomes, not days in the hospital or tests run, just outcomes. For nursing managers and educators that means, 'I need you (the nurse) to have outcomes that look like this, this and this.' The old way of here's how it's done, just do it no longer applies."

Wright's model started to take hold over 20 years ago when she was a nurse educator herself. "I was frustrated, teaching the same stuff all the time to people who were frustrated with the same things." In her book, The Ultimate Guide to Competency Assessment in Health Care, Wright declares that in order to create such a process six essential elements must be incorporated:

  • Competencies that matter
  • Appropriate verification methods for each competency
  • Clarification of accountability (manager, educator and employee)
  • Employee-centered verification process
  • Appropriately identified competency issues
  • Promptly and effectively addressed competency deficits and employee issues

To address the first principle of the model, ask the staff what they need to know or what they need to improve. Ask the unit leaders what competencies they think are important. Take the results, combine them with suggestions from the educators and nurse managers, and find topics, everything from process or policy changes to equipment expertise that matter to the nurses being tested.

Elements of Wright's model are being used in nursing worldwide. In a survey of nurses in Taiwan, nurses' self-assessment of patient care skills contributed to a sense of satisfaction of their own nursing competencies. How nurses viewed their own skills and where they needed improvement were thought to serve as a guide to amend academic nursing courses and on-the-job training.

Wright's second principle consists of "appropriate competency verification method selection." To accomplish this, staff educators are challenged to develop teaching elements, whether didactic, demonstrations or interactive modules and stations configured to meet the specific competencies needing to be addressed.

It is a time for creativity, stepping out of the box or comfort zone of competencies past. Combining competencies in new or different ways cannot only address skill needs but promote teamwork and communication as well as critical thinking on the part of the participants. This format also accommodates the variety of learning styles often found amongst adult learners.

The third principle, "meaningful competency assessment" consists of clarification of the accountability of all the players involved. This means that nurse managers, educators and employees need to have a clear understanding of their responsibility in the competency process. Everybody has a defined role, must attend and take part as prescribed — and if not, there will be consequences. Simply put, show up for competency training or it will affect the bottom line in evaluations and pay rates.

Once the topics for the competencies have been decided and formats devised, a schedule must be put into action. In another break from tradition, Wright's fourth principle, "utilizing an employee-centered verification process," means giving some input back to the nursing staff. Let the nurses choose from a selection of verification models.

This principle allows staff members to choose from a variety of different modalities for competency completion. Participants have more autonomy over their preferred learning style and become increasingly more engaged learners.

Principles five and six require more work for the educators and leaders. Identifying what is a competency problem and what is not and following up on deficits and problems once they are identified is part of the moving forward process. For example, if everything is in place to assess competency, but there is no follow through with problematic employees, eventually an environment is created that sends the message, "don't bother to comply; they never do anything about if you don't." This attitude will quickly spread, and any gains made by enlisting the involvement of the employees will be lost.

Nursing leadership must create an environment for success. Wright's Competency Assessment Model says leaders create a culture of success with a dual focus: one piece is focused on the organizational mission, and the other should be focused on supporting positive employee behavior. Nursing management and healthcare institutions nationwide seem to be looking for that success. When speaking with Wright recently, she was in the Boston airport, and didn't "have exact numbers for hospitals moving to this approach." But "the books are widely available," she pointed out, "and I speak to groups all over the country. What I can tell you is I am definitely traveling more."

Competencies are not stagnant. Therefore, the format and content for assessment should also be continuously changing and evolving. There is always room for improvement and change: educators and managers don't have to be the only people leading competency assessment. Engaging staff champions and departmental content experts to assist their fellow nurses makes the best use of your most experienced staff and also fosters the development of nurse leaders and perhaps future educators.

Competency assessment does not have to be painful, either. Its very nature can shape the environment in which it is used to be functional or dysfunctional. Wright says, "If your competency assessment process is inefficient, and therefore perceived as an ineffective, redundant waste of time, it will serve to create a more dysfunctional environment. If competency assessment is meaningful, it will be perceived as a tool that helps ensure efficient, effective care, and will make the environment in which it exists more functional."

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