In "Alice's Adventures in Wonderland," Alice happens on the Cheshire Cat. Unsure of what her next steps should be, Alice asks the Cat for directions:
"Would you tell me, please, which way I ought to go from here?"
"That depends a good deal on where you want to get to," said the Cat.
"I don't much care where," said Alice
"Then, it doesn't matter which way you go," said the Cat.
The Cheshire Cat has a good point: If you do not have a clear idea of what you are trying to accomplish or what the end result will be, then one path is really just as good as any other. The same principle applies to a good nurse residency program (NRP)-you have to have a clear idea of what you want to accomplish and what the end results will be. In other words, you have to begin with the end in mind.
The best NRPs start with an inexperienced, but eager and willing, new nurse and end with a competent professional. However, what is a "competent professional?" What is competency? How is it developed? Measured? Evidenced? The truth is that competency means different things to different organizations, but Donna Wright has a meaningful definition: "the knowledge, skills, behaviors, and attitudes needed to carry out a job" (Wright, 2005).
If you are a nursing professional development specialist involved in (or building) an NRP, you will ultimately need to define what exactly a "competent nurse" is and what knowledge, skills, attitudes, and behaviors they need to have. These are tough decisions to make, and making them from the start will help you later on. These decisions will direct you on what to add/leave out of the NRP curriculum, how you will manage the onboarding process for the new nurses, and what you will need to focus on going forward.
Fortunately, NRP leaders do not have to work alone. It is a good idea at this point in the process to involve some key stakeholders who are invested in the success of an NRP. A key reason to involve them in the competency development process is that it allows an NRP leader to design or shape the program to meet the expectations of those who are most invested in it. In the business world, this idea is referred to as "return on expectations" and is slowly replacing the increasingly outdated notion of return on investment for gauging the merits and relative worth of training and development programs across the industry (Kirkpatrick, 2010).
One key stakeholder is the nurse executive (or Chief Nursing Officer) who is probably financing the program and has a long-term, strategic view of what competencies nurses will need to go forward. Another group of stakeholders will be the managers who actually hire new nurses. They are great resources what their nurses need to know today as they practice at the bedside. Involving managers and executives will set it up to succeed with powerful, efficacious, and applicable content.
That being said, chances are that this group of stakeholders might not understand competency and how it is defined, developed, and evaluated nearly as well as the professional development specialist-after all, that is your specialty, not theirs. To assist you in the process, what follows are four different competency frameworks for new graduate nurses. Each has been reported in the literature and is available for review online or in the literature source itself. Each framework is quite distinct and unique, and all have been developed with the acute care environment in mind. So, peruse them, evaluate the strengths and weaknesses of each, and compare and contrast them with the specific needs that your organization has for new graduate competency.
THE QUALITY AND SAFETY EDUCATION FOR NURSES COMPETENCIES
In 2003, the Institute of Medicine released a report entitled "Health Professions Education: A Bridge to Quality." In it, they affirmed that all healthcare providers (not just nurses) in the 21st century would need a core set of competencies to meet the demand for quality and safe health care in the United States. There are six core competencies:
* Patient-centered care
* Teamwork and collaboration
* Evidence-based practice
* Quality improvement
* Safety
* Informatics
The nursing profession took the report a step further and started the Quality and Safety Education for Nurses (QSEN) project. Its goal is to improve nursing education by finding specific nursing competencies, called "KSAs" or knowledge, skills, or attitudes, and promoting their development in nursing students and new graduates. These competencies are so seminal that they often are a foundational competency framework for all of the others and are woven into most NRPs today.
There are dozens of KSAs for each competency, and they are all listed online for you at http://www.qsen.org. Although QSEN is intended to be a resource guide primarily for nursing school curricula, many of the KSAs can be adapted to effectively fit an NRP. Many of them, however, are not completely specific and actionable, whereas others are very appropriate. Whether you utilize QSEN in your NRP or not, you can still familiarize yourself with it, and it is definitely worth your time to look through.
THE COMMISSION ON COLLEGIATE NURSING EDUCATION POSTBACCALAUREATE COMPETENCIES
The American Association of Colleges of Nursing (AACN) develops standards for nursing schools nationwide and publishes them every 4 years or so. They mandate that new nurses must have demonstrable competency in these following areas (AACN, 2008):
* A liberal foundation for generalist nursing practice
* Quality care and patient safety system leadership
* Evidence-based practice
* Information management and technology
* Healthcare policy, finance, and regulatory environment
* Interprofessional communication and collaboration
* Population health
* Professionalism and professional values
Using these standards, the Commission on Collegiate Nursing Education (CCNE) created a competency set for new nurses and rolled it into a set of NRP accreditation criteria. For those of you who are familiar with it, this is the foundational framework for the University Health Consortium/AACN postbaccalaureate NRP, which is the probably the oldest large-scale NRP in America. The competencies for new graduate nurses are centered in three domains: leadership, patient outcomes, and professional role. Each domain has about 30 individual competencies in it, and you can look over the complete list of competencies online at http://www.aacn.nche.edu/ccne-accreditation/resstandards08.pdf.
This collection of competencies is the result of a hard look at what the healthcare industry needs in a new nurse, as seen through the lens of the academic world. This competency set clearly emphasizes the professional role and advances the standards of the AACN. More importantly, they speak to a vision of nursing's role in a reformed healthcare system of the future.
Recently, the CCNE competencies have been scrutinized around the industry for being unaccommodating to organizations that employ a large percentage of nonbaccalaureate nurses educated in associate or diploma programs (which is most of them). The competencies have been increasingly viewed as more idealistic than practical, more "ivory tower" than actionable, and decidedly more future focused than emphasizing what the nation needs today in a nursing workforce. Nevertheless, the CCNE competencies are worthy of consideration by anyone serious about ensuring a robust and cogent NRP.
THE ADVISORY BOARD
In 2007, the Nursing Executive Center (a division of the Advisory Board, a large healthcare consulting firm in Washington, DC) took a close look at the performance gaps in new graduate nurses as they left school and began their careers in nursing. They assembled a cadre of nurse executives and academics to define a universal set of new nurse competencies. Their goal was to develop a competency set that was specific, definable, and actionable, but not so detailed that there would be too many to make workable. The result was the development of 36 competencies in six nursing domains:
* Clinical knowledge
* Technical skills
* Critical thinking
* Communication
* Professionalism
* Management of responsibility
You can purchase the report to get the entire list and the results of their work, but they summarized their research well and published the list of 36 competencies in the literature (Berkow, Virkstis, Stewart, & Conway, 2008).
The laudable elements of this competency set stem from the collaboration involved (both academia and industry), a relevance to current nursing practice, and simplicity-there are only 36 instead of over 100 in other frameworks. They have a good balance of professional and technical competencies and would be an excellent fit for most any NRP today.
PATRICIA BENNER'S COMPETENCIES
The ubiquitous novice-to-expert model by Patricia Benner (1984) has been a foundational framework for nursing professional development since its publication 30 years ago. Most nurses are used to seeing the familiar novice-to-expert framework embedded in nursing evaluations and competency assessment programs. What is much less known, however, is that Benner also identified 30 practice competencies that nurses progress from "novice" to "expert" in over time. These 30 competencies are grouped into seven nursing domains of practice:
* The helping role
* The diagnostic and patient monitoring function
* Administering and monitoring therapeutic interventions and regimens
* Effective management of rapidly changing situations
* The teaching-coaching function
* Monitoring and ensuring quality practice
* Organizational-specific competencies
There is not an easy way to find these 30 nursing competencies online, so to review them, you can purchase a copy of the original book From Novice to Expert: Excellence and Power in Clinical Nursing Practice and look through it. It is easy to find, with large discussions about each using Benner's original research.
Looking over these competencies in any detail will quickly reveal their age to the reader. Some of them are quite outdated now (they are 30 years old after all), and they only allude to some of the biggest issues in health care today (like patient safety and technology). They emphasize the technical practice of nursing and only hint at all the important professional domains that dominate other competency set decisively describes the CCNE set.
On the other hand, this competency set decisively describe the real world of nursing practice, and Benner describes an "in the trenches" competency set like no other. In addition, because she was interested in describing the overall nursing expertise of both new and experienced nurses, this competency set is useful for assessing nurses before, during, and after they complete an NRP. This allows for a longer continuum of development in nurses that follows a consistent set of competencies. They also speak more to the human element of nursing, more than some of the other sets discussed above. They are very operable and definable, and most are still very pertinent to nursing practice today.
As you look over the various competency sets above, maybe one fits your organization perfectly. If so, then use it! Alternately, maybe you found the competencies you need to spread among two or more sets and need to adopt a "pick and choose" strategy to define what a competent new graduate nurse is for your organization. That's fine too. The important thing is for you to examine the work environment in your organization (with stakeholder input) and define how you want an NRP graduate to think, act, and interact with others in their professional practice. As you decide on a set of specific competencies, you will essentially define what the end result of your NRP will be, and that will guide you as you create or modify your NRP to deliver the competencies you have assembled.
So, wave goodbye to the Cheshire Cat, and (as Donna Wright would say) "competently go where no one has gone before."
Until next time...
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