Recognizing a disconnect between classroom learning and real-world practice, Benner, Sutphen, Leonard, and Day called for a radical transformation in nursing education about a decade ago.1 In their research, they found that nurse educators spent time in the classroom giving lectures, leaving few opportunities for students to apply the skills needed to become effective nurses. Since then, researchers have continued to share evidence of a troublesome academic-to-practice gap with a negative impact on quality and safety in patient care. Graduate nurses who enter the workforce underprepared have been shown to increase the risk of medical errors, worsen patient outcomes, and inflate the cost of healthcare.2 To address this problem, nursing professional organizations are now leading a transformation from traditional, lecture-based teaching to competency-based education.3 This article shares how one university adapted its curriculum and assessment systems to focus on student competency and better prepare nursing students for clinical practice.

Shifting to competency-focused learning

A competency is a complex and interrelated set of knowledge, skills, and abilities that can be flexibly applied to recognize and solve complex problems in real-world situations. In the past, nurses were trained with the assumption that they must have a solid knowledge base about physiology, pathophysiology, health assessment, and similar content that would directly translate to addressing healthcare problems in the clinical setting. This assumption has become problematic for two reasons. First, evidence suggests that rote learning or simple memorization of content covered in a traditional lecture-based curriculum never transferred well to the clinical setting.4 Second, in the information age, there is just too much knowledge to memorize through rote learning. Thus, nurse educators should focus on what students need to know as well as how they think, make decisions, solve problems, and communicate what is required to prepare nurses for 21st-century practice.1

Next-generation NCLEX

The National Council of State Boards of Nursing recently showed that critical thinking, critical decision-making, and problem-solving are interrelated core skills involved in nearly all important nursing tasks.4 The Council is developing a next-generation (NextGen) National Council Licensure Examination (NCLEX) focused on competencies related to clinical decision-making with new types of items. In this new NCLEX, items will include evolving realistic case studies and other complex test items requiring students to engage in decision-making processes like recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes. Although students will need background knowledge, the emphasis of the test will be on applying decision-making competencies. In fact, many items will include in-depth details that would be available to nurses in clinical practice such as drug information. To prepare for this new test, nursing students will need to spend less time learning concepts and memorizing facts, and more time practicing the cognitive skills that underlie the competencies required for effective clinical decision-making.

Transforming curricula in nursing schools

Nursing schools are responding to the shift to competency-based learning required by accreditors, which will soon be reflected in the NextGen NCLEX.3 Schools are in the process of transforming curricula to focus on competency-based outcomes aligned with student-centered active learning strategies that provide opportunities to apply knowledge in authentic contexts.5 This radical transformation in the traditional approach to teaching requires a similar change in the way educators assess, report, and share student learning. Traditional assessments, grades, and transcripts were designed to track a student's progress through a lecture-based curriculum, but don't communicate competency or readiness for practice.

Active learning

Learning competencies require students to engage in deliberate practice through real or realistic experiences that present clinical challenges in context. This type of experiential learning allows students to practice, receive meaningful feedback, and reflect on their learning.5 Repetitive practice of the cognitive skills required for clinical decision-making allows students to have background knowledge and learn how to apply that knowledge in a range of complex contexts.

Traditionally, schools of nursing have had a clear differentiation between didactic instruction focused on teaching basic knowledge and clinical instruction focused on application. Benner, Sutphen, Leonar, and Day found that this differentiation significantly undermined students' ability to learn how to apply knowledge in patient care.1 Now, curricula are being transformed so that all parts of the curriculum focus on active experiential learning.

Take the University of Rochester School of Nursing, for example. In the classroom, our faculty now engage students in active learning through case-based learning in written cases and active scenarios using standardized-patient actors for students to practice assessments and develop plans of care in collaboration with their peers. Faculty members are also expanding the use of simulation, giving students opportunities for realistic practice individually or in small groups. Clinical learning at the University now utilizes clear sets of expectations and evaluation rubrics that illustrate expectations for a student's demonstration of clinical competencies as he or she progresses through the program.

Developing a coherent curriculum

Competency-based learning requires a curriculum that is designed to prepare students to graduate with clear goals, with a course of study that has well-designed steps toward achieving those goals. In addition, the curriculum must be coherently communicated to students so each knows how to achieve benchmarks as he or she progresses. A coherent curriculum requires several components:

* Clear, measurable, and competency-focused program learning outcomes

* Courses mapped and leveled to these outcomes

* Faculty collaboration to ensure step-by-step progression of skills across courses

* Assessments designed to measure student progress toward competencies

* Systems to communicate progress toward achieving program learning outcomes to students, faculty, and student affairs staff

At the University of Rochester School of Nursing, we have recently revised our program learning outcomes and the faculty is developing new courses that build student competency step-by-step. The faculty is also revising major exams and assignments to focus on assessing progress toward competencies. Exams are being developed using test blueprints aligned with leveled program learning outcomes, with items similar to competency-focused items being planned for the NextGen NCLEX. Assignment rubrics are being revised to focus explicitly on competencies with clearly defined levels based on specific curricular milestones.

For the coherence of the curriculum to be clear to students, faculty are developing a comprehensive learner record-a new electronic portfolio (ePortfolio)-enabled by modern assessment management systems. This system will allow faculty to complete curriculum mapping to align program learning outcomes to courses, exams, test items, major assignments, and rubric items. Once this highly granular mapping is in place in the Comprehensive Learner Record (CLR) system, students would be able to track their progress from course to course and assignment to assignment across a curriculum. The CLR will also provide students with ongoing feedback on their progress, enabling opportunities for reflection on areas of strength and weakness, and to plan improvements. Students will also be able to share their CLR in the form of an ePortfolio to show their level of achievement on specific competencies to employers.

Conclusion

Nursing education is in the midst of a radical transformation, shifting away from traditional teaching methods focused on memorized information to education focused on developing the complex competencies required for effective, safe, and high-quality care. This transformation involves emphasizing experiential learning and opportunities to practice complex skills and abilities, further enhanced by frequent feedback and reflection. Finally, effective competency-based learning will require new assessment systems that permit students and faculty to track progress toward competency-focused learning outcomes. This transformation in teaching, learning, and assessment will help close the academic-to-practice gap and empower novice nurses to provide high-quality, effective, and safe patient care as they enter the workforce.

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