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Measuring the 6 Nursing Core Competencies

April 23rd, 2023
April 23rd, 2023

Competency and competency measurement are now essential elements of the nursing profession. They establish the framework for professional expectations and work to define professional development and learning plans that will help assimilate new nurses into practice and experienced nurses into new specialties. The American Nurses Association (ANA) defines competency as an expected level of performance that integrates knowledge, skills, abilities, and judgements.

Nurse competency is a broad topic and includes more than just the expected clinical skills. It encompasses:

  • Patient Care
  • Medical/clinical knowledge
  • Practice-based learning and improvement
  • Interpersonal and communication skills
  • Professionalism
  • System-based practice

Defining competency has been an evolving process and so has the means by which it is measured.

Measuring Competency

Just as the list and scope of competencies has evolved since their introduction, the optimal means of educating and measuring around competency has also evolved.

While the Accreditation Council for Graduate Medical Education (ACGME) model was designed primarily with physicians in mind, it is easily adaptable to continuing education for nurses. Competency-based education is characterized by the following characteristics:

  • Inclusion of individualized learning tailored to the unique needs of the learner is a key component. Education is customized to the nurse’s educational background and level of practice and further defined by the nurse’s role and work setting.
  • Feedback to the learner is an essential component.
  • The primary emphasis is on outcomes—defined levels of proficiency—rather than program admissions or selection criteria. An integrated model that includes practice and education will have a positive impact on patient safety and outcomes.
  • A systematic approach is required to establish and manage milestones and measure outcomes. Both practice settings and nursing education should support individuals as they move through the system.
  • Training is modular and specific to each competency.
  • Both the learner and the learning program have accountability for success.

QSEN Competencies for Nursing

Quality and Safety Education for Nurses (QSEN) competencies are fundamental to preparing nurses to deliver safe and effective care. These competencies encompass six core areas that aim to improve the quality of care and ensure patient safety within healthcare systems:

 

  1. Patient-Centered Care: Nurses must recognize the patient as the source of control and full partner in their care. This involves understanding the patient’s preferences, values, and needs to ensure that patients receive care that respects and responds to their individual circumstances.
  2. Teamwork and Collaboration: Effective interprofessional collaboration is essential for improving patient outcomes. Nurses should communicate and collaborate with healthcare team members, fostering a culture of respect and shared decision-making. Evidence-Based Practice (EBP):
  3. Nurses should integrate the best current evidence with clinical expertise and patient/family preferences to guide decision-making. This involves staying current with research and applying the findings in practice.
  4. Quality Improvement: Nurses are tasked with understanding and applying quality improvement processes to improve patient care. This includes identifying areas for improvement and using data to drive changes that enhance safety and quality.
  5. Safety: This competency emphasizes the minimization of risk factors that could harm patients and providers. Nurses must be proactive in recognizing hazards and implementing safer processes to ensure a secure environment for patient care.
  6. Informatics: Competency in informatics involves using technology to communicate, manage knowledge, mitigate error, and support decision-making. Nurses should be adept at utilizing electronic health records and other digital tools to improve care delivery.

Integrating these QSEN competencies into nursing education and practice helps produce nurses who are equipped to navigate the complexities of modern healthcare and promote a culture of safety and quality improvement.


Building Competence with Technology and Intentional Practice

Beginning in 2013, ACGME has required assessments based on key milestones within each of the core competencies as a key component of the ACGME NEXT Accreditation System. They have defined milestones within each competency along an educational continuum. The milestones serve as a framework for learners and educators to define the observable behaviors that represent development. Success is evaluated through an evaluation of knowledge, attitudes and behaviors as well as observable skills.

Developing nurses that can provide safe, skilled, and competent care is the goal of virtually every nursing program. The path to competency has been a bit more difficult to identify. ACGME’s Milestone program provides an excellent framework, but how do educators ensure competency—particularly in regards to clinical skills? More and more the answer can be found in the world of simulation and artificial intelligence (AI). Repetitive practice and immediate feedback provided either by instructors or the simulation equipment itself can help build confidence as well as competence.

The efficacy of this kind of training is no longer in question. There is ample evidence that simulation is effective in teaching and in improving and retaining clinical skills. This type of intentional practice helps students apply interventions in a consistent way while simultaneously allowing them to practice and maintain specific skills.

Lastly, competency measurement should address:

 

  • Knowledge – the cognitive aspects of competency; demonstration of a grasp of nursing roles and responsibilities
  • Ability – the application of knowledge to specific skills
  • Skills – includes psychomotor skills related to specific activities as well as those skills related to communication
  • Judgement – includes critical thinking and reasoning related to ethical, legal and regulatory issues

Our blog series about measuring nursing competencies was developed to bring attention to all the attributes that contribute to truly competent nursing. In addition to this post, others will address:

 

  • Patient Care
  • Systems-based practice
  • Medical clinical knowledge
  • Practice-based learning and improvement
  • Professionalism
  • Interpersonal Communication

Ensure Competency of Nursing Staff at Every Level

In today’s value-based healthcare environment, it is more important than ever to be able to eliminate guesswork and develop a standard level of competency across the entire organization. Utilizing proven data to identify development needs is not just a nice-to-have. It’s a must-have. Learn more about HealthStream solutions for nurse competency management.

According to Sigma, formerly known as Sigma Theta Tau International Honor Society of Nursing, "More than ever, nurses are present in every healthcare setting and possess a unique role in formulating policy. The Institute of Medicine's 2010 report, The Future of Nursing: Leading Change, Advancing Health, recognized the importance of involving nurses in healthcare policy creation and called for nurses to take leadership in improving the quality of healthcare." Being actively involved in policy formulation is something that most leading nursing organizations advocate. Sigma also provides the examples of how "the American Association of Colleges of Nursing emphasizes the role of nursing in policy and identifies, in its "Essentials" documents, the expected policy involvement that should be addressed in educational programs at the baccalaureate, master's, and doctoral levels of professional nursing, including advanced practice. The National League for Nursing and the American Nurses Association also expect nurses to address policy as part of their professional role."

Nurses Need to Be More Involved in Creating Health Policy

Given that there are more nurses than any other profession in healthcare, it is only natural that nurses should play a larger role in creating healthcare policy. An article in International Nursing Review outlines key organizations worldwide advocating for "how can nurses influence policy" through leadership, advocacy, and policymaking initiatives. Additionally, the article emphasizes the need for nurses to receive more training related to leadership roles that affect health policy. There needs to be a concerted effort to cultivate a cadre of health policy nurses, empowering all nurses to understand "how can nurses influence policy" effectively. The authors insist that nurses globally need to take their rightful place at decision-making tables, engaged in policy, health reform, and advocacy. Nurse leaders must provide access to comprehensive policy training programs, ranging from undergraduate education to specialized graduate programs focused on various aspects of policy, alongside continued educational opportunities.

Impediments to Nurses' Inclusion in the Policy-Making Process

Relative to other healthcare professions, nurses currently are far less involved in creating policy. The International Nursing Review article identifies a lack of support, resources, and time for nurses to engage in policy processes within their workplaces. There are often bureaucratic barriers that prevent nurses, particularly government employees, from voicing their policy concerns openly. Furthermore, many nurses lack the confidence, skills, and understanding necessary for effective participation in policymaking. Enhancing policy creation in nurse leadership education is essential. In promoting "examples of nurses in policy making," having more nurses engaged in health policy research can nurture skills necessary for developing and implementing new healthcare policies. Through policy research, nurses can acquire skills to be accepted, respected, and better informed, thus ensuring their recognition as health professionals equipped with policy and advocacy skills. Additionally, as nursing informatics continues to grow as a specialty, data-oriented skills may also drive more effective policy development.

How Do Nurses Influence Health Policy?

That being said, nurses nevertheless play an important role in health policy change. According to minoritynurse.com, here are examples of nursing led policy change efforts at multiple levels, from national healthcare policy down to local institutions:

National Health Policy – Larger countrywide nursing organizations like "the American Academy of Nurse Practitioners (AANP) and the American Nurses Association (ANA) lobby extensively for policy change and advocacy for all nurses at the national level." Also, "Nurses can help create legislation that affects both national and state-level laws regarding nursing practice, patient safety, and access to health care. Nurses are also able to review proposed health care legislation to help determine changes that promote best practices."

State Health Policy – An important recent example of policy at the state level involves "guidelines regarding telehealth practices [that] were implemented to help maintain access to health care during COVID-19. This required rapid action by policy-makers—including nurses. As officers in state nursing organizations, nurse practitioners can directly influence policies that relate to both scope of practice and education standards."

Local Health Policy – On the local level, nurses "have a unique advantage in recommending guidelines for community-wide, school, and even environmental health issues. Nurse practitioners can also be involved in advisory boards for city and county planning regarding water conservation, hazardous waste disposal, and ongoing public safety concerns."

Facility and Organizational Policy – It is very common for nurses to be involved with policy creation in the facilities where they work, where they "can influence facility policies such as patient care standards, the use of electronic medical records, and guidelines regarding specific populations."

Helping Healthcare Organizations Develop New Nurse Leaders

The need for providers to develop new leaders is what inspired HealthStream to develop the Rising Nurse Leader Pathway, focused on every part of the effort to Identify and develop nurse leaders to address future leadership needs.

Many health care organizations struggle to maintain a consistent approach to leadership competency assessment and skill development that results in preparing the existing workforce for leadership. The Rising Nurse Leader Pathway begins with an assessment of a target population of nurses, their strengths and gaps are identified, followed by a recommended learning path. From there, organizations can pull from the library of nurse leadership development facilitator guides, to offer ongoing learning to further skills and confidence in their future leaders.

Identify your leadership participants using HealthStream's Rising Leader Assessment and data visualization tools:

  • Includes a library of 6 customizable nurse leadership development facilitator guides
  • Reduce costs associated with nurse turnover and selection and training of replacements
  • Next-generation data visualization tools including a 9-box planner and recommended courses
  • Designed for the full continuum of care, including acute care, post-acute care, physician offices, and pharmacies

What Are CoPs?

The CMS Conditions of Participation (CoPs) are essential qualifications developed by the Centers for Medicare & Medicaid Services that healthcare organizations must meet to begin and continue participating in federally funded healthcare programs, including Medicare, Medicaid, and CHIPS. These Medicare Conditions of Participation establish key health and safety guidelines designed to protect beneficiaries by enhancing quality and enforcing patient rights. All healthcare organizations participating in federally funded programs are subject to these Conditions of Participation.

Prior to 1986, the focus of the CMS Conditions of Participation was primarily on structure rather than process measures. This included aspects such as staffing qualifications and the implementation of written policies and procedures. Specific standards dictated the organisational structures required, often mandating the regular review and analysis of clinical work at medical staff meetings, with evidence necessary for surveyors to demonstrate compliance with these Conditions of Participation.

In 1986, significant changes were made to the Medicare Conditions of Participation as part of the Reagan Era's push for deregulation. These revisions eliminated many prescriptive requirements, including those related to credentials and committees, and replaced them with more general performance outcomes to boost administrative flexibility. Significant emphasis was also shifted towards measures like infection control, surgical, and anesthesia services. Furthermore, quality assurance practices were separated, drawing more attention to how healthcare organizations could better adhere to the Conditions of Participation.

Why CoPs Were Established

The primary aim of the CMS Conditions of Participation was to align state licensure requirements with minimal health and safety standards across healthcare organizations nationwide. It became apparent that voluntary accreditation programs, such as those offered by the Joint Commission on Accreditation of Hospitals, were not sufficiently covering hospitals, particularly in rural areas. Even with Medicare's objective to enhance healthcare access, it was recognized that compliance with existing accreditation programs would not guarantee that all hospitals met the necessary health and safety conditions. Therefore, the establishment of Medicare included explicit requirements concerning the maintenance of clinical records and medical staff bylaws, among others—a commitment to ensuring compliance with the Conditions of Participation.

Why CoPs Compliance Is Important

Compliance with the CMS Conditions of Participation is crucial for healthcare providers, as failure to meet these Medicare Conditions of Participation can result in severe consequences. If healthcare organizations do not comply with the Conditions of Participation, they may face various sanctions, including the enforcement of a corrective action plan, monetary penalties, and increased reporting demands. Although exclusion from federal healthcare programs is rare, it may occur if a provider fails to achieve substantial compliance during the corrective period.

References

Lauer, K., Ohta, J., and Hargreaves, A., “Violations of Payment/Participation Conditions as Predicates for False Claims,” Health Law Litigation, Spring/Summer 2011, Vol. 9 No. 2, Retrieved at https://www.lw.com/thoughtLeadership/violations-of-payment-participation-conditions-as-predicates-for-false-claims

McGeary, M., Medicare Conditions Of Participation And Accreditation For Hospitals in Medicare: A Strategy for Quality Assurance: VOLUME II Sources and Methods; 1990, Retrieved at

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