Gap analysis: a method to assess core competency development in the curriculum.
Aim. To determine the extent to which safety and quality improvement core competency development occurs in an undergraduate nursing program.
Background. Rapid change and increased complexity of health care environments demands that health care professionals are adequately prepared to provide high quality, safe care.
Method. A gap analysis compared the present state of competency development to a desirable (ideal) state. The core competencies, Nurse of the Future Nursing Core Competencies, reflect the ideal state and represent minimal expectations for entry into practice from pre-licensure programs.
Results. Findings from the gap analysis suggest significant strengths in numerous competency domains, deficiencies in two competency domains, and areas of redundancy in the curriculum.
Conclusion. Gap analysis provides valuable data to direct curriculum revision. Opportunities for competency development were identified, and strategies were created jointly with the practice partner, thereby enhancing relevant knowledge, attitudes, and skills nurses need for clinical practice currently and in the future.
Key Words Core Competencies--Curriculum Evaluation--Competency Development--Undergraduate Nursing Education
IN AN ENVIRONMENT OF RAPIDLY CHANGING TECHNOLOGY, INCREASED PATIENT ACUITY, AND CONTENT SATURATION WITHIN UNDERGRADUATE CURRICULA, SYSTEMATIC APPROACHES ARE NEEDED TO ENSURE THAT NURSING EDUCATION ADEQUATELY PREPARES GRADUATES TO PROVIDE SAFE QUALITY CARE (Tanner, 2007). One educational approach assesses the development of core competencies among nursing students, but what competences are central to nursing, and how do nurse faculty assess if these competencies are adequately addressed in a nursing curriculum? This article reports on the use of gap analysis to identify opportunities for competency development in a basic undergraduate nursing curriculum.
The Massachusetts Department of Higher Education (MDHE) Nurse of the Future Nursing Core Competencies Committee (NOFNFC) identified 11 core competencies essential to nursing in a document titled Creativity and Connections (2007). (The document was updated in 2010, reducing the number of competency domains from 11 to 10.) These core competencies, which provided the basis for the curriculum analysis, were derived from competency documents developed in other states, practice standards, education accreditation standards, national initiatives, and the projected health care needs of the Massachusetts population. They are: patient-centered care, professionalism, leadership, system-based practice, informatics, communication, teamwork and collaboration, safety, quality improvement, evidence-based practice, and nursing knowledge.
The project involved two phases: a) conducting a gap analysis as defined by the NOFNCC initiative, and b) developing a curriculum plan to address the gaps identified. This article reports on the first phase of the project, the gap analysis.
Background and Significance COMPETENCY INITIATIVES In the health care literature, the term competency is often used to describe a level of knowledge or skill attainment. The purpose of identifying fundamental nurse competencies for a beginning practitioner is to allow all participants in nursing education, at both schools and practice sites, to focus on specific behaviors to be attained at each developmental level (Cronenwett et al., 2007). Competency-based education allows educators and clinicians to have a common language, to apply standards to determine levels of proficiency by student and practice level, and to transcend all types of educational programs and practice locations (Lenburg, Klein, Abdur-Rahman, Spencer, & Boyer, 2009). Well-defined competencies are also used in preceptorships and the development of agency orientation programs for new graduates (MDHE, 2007).
Several important publications have influenced the development of core competencies in practice and education. After reporting on concerns about patient safety in 1999, the Institute of Medicine (IOM, 2003) recommended five competencies be achieved in all education programs for health care professionals: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement, and use informatics. Subsequent to publication of the IOM's recommendations, the Robert Wood Johnson Foundation funded a national study to educate nursing students on patient safety and health care quality (Cronenwett et al., 2007). The Quality and Safety Education for Nurses (QSEN) initiative names six core competencies for future nurses, five based on the IOM report (evidence-based practice, informatics, patient-centered care, teamwork and collaboration, quality improvement), and the sixth, safety.
As discussed by Swing (2007), the Accrediting Council for Medical Education (ACME) Outcomes Project began in 1998 and was revised in 2007. The general competencies as program requirements include: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. The Massachusetts Nurse of the Future Nursing Core Competencies Model included professionalism, system-based practice, communication, and discipline-specific knowledge from the ACME project in addition to the previously named competencies, and added the domain leadership.
GAP ANALYSIS Gap analysis refers to the difference between the current state and the ideal or preferred state (Institute for Manufacturing, n.d.). Gap analysis is useful when the desired outcomes or objectives are known. In the Massachusetts model, the desired outcomes were represented by the core competency statements identified by the Nurse of the Future Committee.
Gap analysis shares some features with the processes of needs assessment and curriculum audit. Needs assessment is conducted to evaluate the educational currency of a program (Keating, 2011). Certain desired outcomes may be predetermined. Curriculum audit correlates competencies to courses and learning activities across an entire curriculum (Billings & Halstead, 2009).
Typically, gap analysis involves developing goals and objectives, identifying the competencies and performance level of the present situation, and determining the gaps between "what is" and "what should he." It is an effective method to determine deficiencies in knowledge and practice. The nursing literature provides examples of the use of gap analysis to address a variety of care issues. No studies were found that used the process of gap analysis for curriculum assessment.
Davidson, Boyer, Casey, Matzel, and Walden (2008) used a gap analysis to identify the cultural and religious needs of hospitalized patients. Their findings identified several gaps in the knowledge and practice of caregivers as well as lack of adequate supports, such as prayer books and prayer rugs. Shapiro and Donaldson (2008) employed a gap analysis in the emergency setting to identify the knowledge and skills advanced practice nurses need to implement evidence-based practice.
Ravert and Merrill (2008) reported on the use of gap analysis to determine readiness of a hospital alliance for Magnet recognition. The requirements of Magnet status were used as the ideal state and were systematically compared to the current status in the health care facility. The gaps identified included nursing research, resources, and consultation essential to conducting research. As a result, measures were established to promote the development of a research program and evidence-based practice within the hospitals.
The Gap Analysis Process In the Massachusetts initiative, the publication Creativity and Connections (MDHE, 2007) identifies and defines 11 core competencies. The NOFNCC document also outlined the knowledge, attitudes, and skills (KAS) necessary in each competency domain. Each KAS statement represents a minimal expectation for entry into practice following completion of a pre-licensure nursing education program. Table 1 outlines two core competencies and examples of specific KAS behaviors.
The core competencies and the KAS behaviors needed in each competency domain became the decision tool for the gap analysis. The project team used the NOFNCC core competencies and related KAS statements as the ideal state and then compared them to determine to what extent the competencies were achieved in the baccalaureate nursing program. Since the process had not been applied to curriculum assessment in the past, each step in the process had to be developed as the work proceeded.
THE PROJECT TEAM The team consisted of two faculty, one graduate student, one former graduate student, a retired faculty member, and a hospital-based practice partner experienced with graduates of this nursing program. The project director determined the expertise essential for the project and developed the criteria for joining the team: knowledge of curriculum development in nursing and, for faculty, experience teaching across various levels in the undergraduate program. It was determined that the practice partner must have a strong background in nursing education and familiarity with graduates of the program in order to be responsible for the continued competency development of inexperienced nurse graduates. The practice partner selected, the director of professional development for a large health care system, also consulted with staff development educators on various issues that arose during the gap analysis.
PROCEDURE The team met several times to design the curriculum assessment. Definitions of knowledge, attitudes, and skills were developed to guide the process; these were not included in the original NOFNCC document. Knowledge was defined as facts and ideas relevant to nursing practice; attitudes, as beliefs, feelings, and values to act consistently in professional nursing practice; and skills, as the ability to carry out nursing practice activities. Early in the process the team decided that nursing knowledge was not a core competency, but, rather, a prerequisite for competency development in nursing practice that pervades the entire curriculum.
Next, the team members were assigned specific competencies and asked to identify relevant learning experiences in the curriculum. Each team member conducted a systematic review of each course in the nursing curriculum for the current academic year. The review identified content that was introduced, developed, and reinforced across the curriculum. The course materials examined included syllabi, lecture notes, PowerPoint presentations, handouts, learning assignments, evaluation materials, and any other resources used by students. If materials were missing, the faculty-of-record was asked to provide the materials/resources.
For ease of data collection, analysis, and presentation, the project team used a grid to identify the degree of competency development across all courses. The vertical column outlined the nursing course names and numbers; the horizontal column contained the competency definitions with didactic and clinical objectives. Blank areas within the grid represented lack of information. (See Table 2.)
DETERMINING THE ADEQUACY OF COMPETENCY DEVELOPMENT
The number of meaningful learning opportunities available in the curriculum to develop knowledge, attitudes, and skills for each competency was determined. Then, the number of opportunities to accomplish the selected competency was tabulated across the curriculum.
The team next addressed the question: How many opportunities are needed for students to achieve sufficient learning in each competency domain? To answer this question, the faculty on the team reflected on the number of opportunities to achieve competency in three strong competency domains in the existing undergraduate program: leadership, communication, and teamwork and collaboration. They used the NOFNCC Gap Analysis Tool to group learning opportunities currently available to students. The tool uses a scale of 1 to 4 as follows: 1 represents no opportunities for student learning; 2, a few opportunities (between 1 and 10); 3, several opportunities (between 11 and 29); and 4, many opportunities (more than 30).
The rating scale was then used to compare the number of opportunities that should be available (the ideal state) for students to achieve the KAS in each domain with the actual number of learning opportunities currently in the undergraduate curriculum. The practice partner and his colleagues independently identified the number of opportunities for student learning in each competency domain using the same rating scale.
When all ratings were complete, faculty ratings were compared to the ratings by practice partner colleagues. This step led to discussions regarding the ideal number of opportunities needed to achieve each competency. For example, leadership was rated 3 (several opportunities) across the current state, program desired state, and the practice partner assessment. Thus, no gap was noted between the desired state and the current state or between the practice partner's rating and that of the nursing program.
In contrast, quality improvement was rated in the 1 to 2 range for current state (indicating few opportunities for competency development); 2 to 3 for the faculty desired state; and 3 to 4 for the practice partner desired state. Thus, there was a gap of +1 between the current state and the desired state, and a gap of +2 between the practice partner rating and the faculty rating. (A gap indicates a deficiency state. Hence, gaps are expressed in positive numbers. The larger the positive number, the larger the gap; the smaller the number, the smaller the gap.) The findings indicated a need to increase opportunities to learn about quality improvement across the curriculum.
Results The gap analysis identified existing strengths of the curriculum and areas needing curriculum development. The major findings were: a) there were inadequate opportunities to develop attitudes in all core competency domains, and b) competencies associated with safety and quality improvement were undeveloped in all KAS categories. Strengths of the curriculum were noted as follows: a) six of the 11 core competency domains were clearly delineated in undergraduate program outcomes (leadership, professionalism, communication, teamwork and collaboration, evidence-based practice, and nursing knowledge); and b) three core competencies (safety, quality improvement, and system-based practice) were imbedded in other program outcomes. Two competencies (patient-centered care and informatics) were not apparent in the program analysis.
When examining the KAS statements, the curriculum was deficient in all outcomes related to attitudes, possibly demonstrating the faculty's reluctance to identify outcomes that are not easily measured. In addition, the analysis showed that while there were adequate learning opportunities in the areas of leadership, teamwork and collaboration, communication, and professionalism, some learning domains were not fully developed. For example, communication-related competencies appeared across all levels of the curriculum, but the skill, "contributes to resolution of conflict and disagreement," and the associate skill, "initiates actions to resolve conflict," were not apparent. These skills need to be strengthened in the curriculum and included in orientation programs for recent graduates of the program.
The project team anticipated the gap analysis would demonstrate significant deficiencies in a few core competency domains such as safety and quality improvement. Content and practice in the area of safety could not be easily identified in the curricular materials, but, on closer analysis, the team realized that it is imbedded in many other areas. Quality improvement-related learning activities were not clearly articulated in the courses, and quality improvement needs to be addressed in future curriculum revisions.
Implications for Education and Practice The gap analysis helped the faculty highlight areas of strength and identified deficiencies in competency development. Content redundancy was also apparent with this approach. The gap analysis process brought together educational and agency professionals to discuss expectations of entry-level practitioners and gave all participants clear language regarding learning expectations. Colleagues at practice sites have begun to reconsider content in orientation programs and continuing education offerings in light of the results of the gap analysis.
The dialogue has continued, leading to a systematic approach to curriculum building in collaboration with practice partners and affiliating agencies. For example, the concept of quality improvement (QI) was introduced to freshmen in the major in Introduction to Professional Nursing; sophomores used agency data to analyze nurse-sensitive outcomes that correlate to their course concepts (e.g., pressure ulcers, infection control and handwashing, and fall prevention); and juniors learned about ongoing QI projects from the agency quality manager. The following year, these students, as seniors, participated in a clinical conference in which unit-based data were provided for their analysis. The students were encouraged to consider the implications of the data and discuss possible approaches to the problem. The agency staff member then presented the findings of a unit-based initiative to address the problem. Evaluations of the activity indicated that students had a much better understanding of QI and its relationship to patient care than they had previously. The nursing faculty and affiliating agency staff intend to continue to develop student experiences targeting competency development.
Several factors need to be considered before assessing a curriculum using gap analysis. The first is awareness of the labor-intensive nature of the data mining required. Not only is it time-consuming to complete the systematic review of all course materials, it is also essential that faculty colleagues provide prompt support when additional information is needed. The data mining and recording of relevant information from 22 didactic and experiential courses required approximately 20 hours by each of the project team members, excluding the practice partner. Secretarial support was critically important for facilitating simultaneous review by the project team.
Clearly, there are critics of the competency-based approach used here. The most common criticism is that competency-driven curricula will result in rigid, skills-driven education (Tanner, 2001). However, the Massachusetts initiative outlines knowledge, attitudes, and skills without the reductionist approach of some models.
Content saturation is also an issue for faculty. Faculty and students often feel overwhelmed with the need to study increasing amounts of content in limited time periods (Tanner, 2007). The use of competency-guided curricula has the potential to decrease duplicative content and promote active learning. To consolidate content, several active learning strategies have been developed that incorporate a number of competency areas in one assignment. Examples include the development of unfolding cases, case studies presented in segments over time. In addition, the use of reflective journals can help determine students' depth of understanding.
Summary The gap analysis provided clear direction for curriculum revision. Nursing and other health profession educators face the challenge of creating educational curricula that address core competencies essential to practice and evaluating the achievement of those competencies on an ongoing basis. Ironside (2009) indicates that the need for nursing faculties to focus on the development of quality and safety competencies has never been greater. By doing so, nurse educators contribute directly to the promotion of a health care delivery system that minimizes risk to patients and health professionals through quality care.
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Kerry H. Fater, PhD, RN, CNE, is professor, Adult and Child Nursing Department, UMASS-Dartmouth, North Dartmouth, Massachusetts. Preparation of this manuscript was supported by funding from the Massachusetts Department of Higher Education and the Johnson & Johnson Promise of Nursing for Massachusetts Nursing School Grant Program. Its contents are solely the responsibility of the author and do not necessarily represent official views of the funding agencies. For more information, write to Dr. Fater at KFater@umassd.edu.
Table 1. Examples of Specific Behaviors in the Learning Domains of Knowledge, Attitudes, and Skills in the Curriculum Core Competency: Professionalism Behaviors in the Curriculum Knowledge: Describes legal, Critically examines the ethical, and regulatory factors social, political, and that apply to nursing practice economic factors that drive (MDHE, 2007, p. 15) the health care delivery system. Attitude: Values established Demonstrates attitudes, standards of professional practice values, and behaviors (MDHE, 2007, p. 15.) consistent with professional practice standards. Skill: Uses recognized standards of Designs and implements nursing professional nursing practice management strategies using (MDHE, 2007). nursing process consistent with American Nurses Association Scope and Standards of Practice. Core Competency: Communication Knowledge: Knows grammar, spelling, Completes multiple written and medical terminology (MDHE, assignments and an oral 2007, p. 23.) presentation based on topics in a health context. Attitudes: Accepts the Assumes full responsibility responsibility to provide effective for communication with communication MDHE, 2007, p. 23.) appropriate health care team, orally and in writing. Skill: Uses clear, concise, and Demonstrates professional effective written, electronic, and verbal, nonverbal, and written verbal communication (MDHE, 2007, communication skills. p. 23.) Note. MDHE = Massachusetts Department of Higher Education Table 2. Example of Knowledge, Attitude, and Skills in Courses in the Undergraduate Program Competency: Knowledge: Attitude: Skill Safety Describes the Appreciates the Demonstrates benefits/ tension between effectives use limitations of professional of strategies commonly used autonomy and at individual, safety standardization service, and technology. institutional (MDHE, 2007, p. levels to 27). reduce risk of harm to self and others. (MDHE, 2007, p. 27). 106 Introduction to Reports unsafe Professional actions in the Nursing clinical setting to instructor. 250 /251 Knowledge Foundations in Nursing 325/327 Nursing Provides safe Care of Adults/ delivery of Acute/Chronic parenteral Illness medications/ nutrition such as IV pumps) Note. MDHE = Massachusetts Department of Higher Education
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|Title Annotation:||NURSING EDUCATION RESEARCH / GAP ANALYSIS|
|Author:||Fater, Kerry H.|
|Publication:||Nursing Education Perspectives|
|Date:||Mar 1, 2013|
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