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Leading the Way

Assessing nurses’ competency to achieve highly reliable care

As tenured nurses leave the workplace, healthcare organizations are striving to provide additional development and support for the less-experienced new hires who replace them. Assessing their clinical competency and addressing identified gaps without increasing onboarding and orientation costs poses a significant challenge. Ensuring new nurses are adequately prepared to perform their jobs requires assessment of their clinical competency to identify gaps that must be addressed before they take on independent responsibility for patient-care assignments.

Competency assessment is a complex activity with potentially serious implications—not just for the organization but also for the individual being assessed. Thirteen years ago, CHRISTUS Health (based in Irving, Texas) adopted a standardized, reliable process to assess newly hired licensed nurses—the Performance- Based Development System (PBDS). Funded by an internal innovation grant, the process was piloted in a six-hospital region, with results so dramatic that the strategy was quickly adopted throughout the organization.

Stimulus and response

PBDS assessments are multifaceted, with components that focus on such interpersonal skills as conflict management, teamwork, communication, and clinical reasoning. Content and structure of the assessment align with current evidence-based practice. The assessment is structured in terms of stimulus and response.

Stimulus information may be presented to the learner in any format. The applicant watches a series of 3- to 5-minute video scenarios illustrating patient problems commonly encountered in his or her area of practice. Key aspects of each scenario, such as lab or diagnostic data, are called out and displayed on screen.

• Each video scenario is followed by lead-in questions that trigger a response. The response must identify the primary patient problem, describe interventions to address the problem, explain the rationale for each intervention, and indicate which interventions take highest priority. All responses are free text, or unstructured. (See The value of video scenarios.)

Clinical reasoning skills

Clinical reasoning skills are multifaceted and contextdependent. Nurses draw on their own expertise when making clinical decisions in a dynamic environment where they must consider the personal context as well as the patient’s unique healthcare needs and the environment in which the care is being delivered.

During the PBDS process, the applicant’s responses are evaluated by a trained rater according to a standardized qualitative analysis procedure. The rater compares the applicant’s responses to model answers that include degrees of variation correlating with the nurse’s background, experience, and qualifications. The rater shares assessment results, which include an overall performance summary and a developmental action plan, with the applicant’s manager. The applicant receives feedback on the results and participates in developing orientation goals.

Orientation action plans may include tutorials to address the applicant’s identified knowledge gaps, such as failing to identify patient problems accurately or choosing inappropriate interventions. Preceptors with coaching skills are responsible for engaging the applicant in experiential learning and discussion. Later, a focused PBDS reassessment is conducted to validate that the applicant has achieved developmental goals.

Data aggregation and analysis

Aggregation and analysis of assessment data provide valuable organizational insight into applicant characteristics and priorities for clinical development. The aggregated PBDS data are used for organizational strategic planning; assessment data are used to identify clinical development needs for specific segments of the newhire population. These data are integrated into hiring and turnover analyses to more accurately project specific needs and allocate resources to meet those needs. In addition, nursing schools receive feedback on the assessment results of newly hired nurses who’ve graduated from their programs. This process has led to greater collaboration and development of joint initiatives to ensure new nurse graduates are better prepared for their transition to practice.

Benefits of PBDS

Ensuring clinical competency is more essential than ever. The public expects it and healthcare payers demand it. Our organizational data have provided clear evidence of the benefits of maintaining a robust, evidence- based competency assessment process, including more effective onboarding of new hires, elimination of unnecessary orientation activities, better direction and guidance for preceptors, and validation of competency development goals.

Using a standardized, highly structured, evidencebased process to assess and validate clinical competency may consume more resources than a traditional socially focused orientation, but we’ve found it to be much more effective. It clearly identifies individual developmental needs in a way that’s actionable and validates achievement of orientation outcomes through reassessment.

Robbie Bezemek is the director of clinical education at CHRISTUS Health in Irving, Texas.

Selected references

American Association of Colleges of Nursing. Fact sheet: Nursing shortage. Last updated April 24, 2014.

Benner P, Tanner C, Chesla C. From beginner to expert: gaining a differentiated clinical world in critical care nursing. ANS Adv Nurs Sci. 1992;14:13-28.

Buerhaus PI, Auerbach DI, Staiger DO. The recent surge in nurse employment: causes and implications. Health Aff (Millwood). Jul-Aug 2009;28(4):w657-68.

Schuwirth LW, Verheggen MM, van der Vleuten CP, Boshuizen HP, Dinant GJ. Do short cases elicit different thinking processes than factual knowledge questions do? Med Educ. 2001;35(4):348-56.

Van der Vleuten, CPM, Norman GR, Schuwirth, LWT. Assessing clinical reasoning. In: Higgs J, Jones MA, Loftus S, Christensen N, eds. Clinical Reasoning in the Health Professions. 3rd ed. San Francisco: Elsevier; 2008: 413-21.

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