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The Texas model of differentiated entry-level competencies of graduates of nursing programs.

ABSTRACT The Board of Nurse Examiners and the Board of Vocational Nurse Examiners for the state of Texas updated the state's competency-based education model in collaboration with stakeholders in nursing service, state nursing organizations, and the deans and directors of the state's 82 board-accredited professional nursing programs. Based on this collaborative effort, 14 differentiated entry-level competencies with associated knowledge and clinical behaviors/judgments were identified that set standards for graduates of vocational, diploma, associate, and baccalaureate degree programs.

Key Words Competency-Based Education--Nursing Education--Differentiated Competencies--Entry-Level Nursing

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IN 1988, the Texas legislature mandated that the Texas Higher Education Coordinating Board convene a nursing study committee to conduct a comprehensive study of nursing education issues and concerns related to the nursing shortage, career mobility among nursing programs, and collaboration among schools in geographic proximity. An outcome of this mandate was the 1993 publication of Essential Competencies of Texas Graduates of Education Programs in Nursing (1). These competencies identified the knowledge, judgment, skills, and professional values that were expected of graduates of undergraduate nursing education programs. > The competencies varied in complexity, depth, and breadth, reflecting general education and nursing studies across vocational, diploma, associate degree, and baccalaureate nursing education. Following publication, an independent analysis conducted by the Council on Education of the Texas Nurses Association determined that the competencies were inclusive of the knowledge and concepts essential for the safe practice of nursing and were appropriate with regard to concepts, knowledge, and clinical decision making. > The 1993 document was adopted by the Board of Nurse Examine, (BNE) and the Board of Vocational Nurse Examine, (BVNE) for the state of Texas. The BNE developed rules that required incorporation of the essential competencies into ADN, diploma, and BSN nursing curricula of BNE-accredited nursing programs. Likewise, the BVNE required that schools for vocational nursing education include the essential competencies in their curricula. > Since 1994, all nursing programs in the state have completed curriculum revisions in compliance with the competencies and the associated knowledge, behaviors, and judgments required for achievement of each competency. In addition, both the BNE and BVNE have used the essential competencies to review new nursing programs. Because the 1993 competencies were focused on describing current educational outcomes and these outcomes were not necessarily predictive of future needs, it was considered timely after seven years to reassess the document's currency and relevance.

Purpose Nursing practice in Texas progresses along a continuum from the licensed vocational nurse (LVN) to the doctorally prepared registered nurse. Basic educational preparation for LVN education is at the vocational level; programs are provided through community colleges, hospitals, or proprietary schools and are approved by the BVNE.

Educational preparation for the RN licensure examination may be obtained through diploma, associate degree, or baccalaureate degree programs. Each program provides the necessary preparation for practice as a registered professional nurse and is approved by the BNE. The curriculum of each type of nursing program differs, resulting in differentiated entry-level competencies for graduates. This article describes the process of updating the competencies and their associated knowledge, clinical behaviors, and judgments for entry-level nursing practice for LVNs and RNs educated in diploma, associate degree, and baccalaureate degree nursing programs.

One assumption of the project was that the competencies for each educational level would build on the previous level(s). A goal was to increase awareness of the differentiated entry-level competencies within the health care industry.

Method STAKEHOLDER INVOLVEMENT In January 2000, the BNE charged the Advisory Committee on Education (ACE) to review and revise the 1993 essential competencies (1). ACE formed a subcommittee chaired by a member of the BNE. The subcommittee included five nurses who represented diploma, ADN, and BSN education, the Texas Organization of Associate Degree Nursing, and the Texas Organization of Baccalaureate and Graduate Educators. In addition, members of two professional organizations, the Texas League for Nursing and the Texas Organization of Nurse Executives, were included. Representatives of the BNE and BVNE attended all meetings.

The subcommittee requested that all nursing programs involve health care agencies in reviewing the 1993 document and making recommendations for change. The purpose was to strengthen the document by ensuring contributions from diverse agencies throughout the state. ACE encouraged schools to engage in dialogue with agencies to increase awareness of the differentiated practice guidelines and to ease the transition of new graduates to early nursing practice experiences.

Employers of nurses and representatives of schools of nursing submitted written recommendations, comments, and suggestions for revisions to ACE. The BVNE conducted a parallel process, surveying vocational programs for review and revision of the competencies and joining with ACE to finalize the process.

The ACE subcommittee analyzed various documents: the Essentials of Baccalaureate Education (2), Educational Competencies for Graduates of Associate Degree Nursing Programs (3), and the PEW Health Professions Commission "21 Competencies for the 21st Century" (4). The framework of the 1993 document provided for inclusion of this content. The subcommittee noted that although the 14 competencies had not changed substantially, major changes had taken place in the knowledge and clinical behaviors/judgments that were expected to demonstrate achievement of the competencies at each level of education.

THE REVIEW PROCESS When the ACE subcommittee met, committee members who represented a particular level of education provided a description of that level based on a common template. Curricular requirements in relation to general education and nursing courses, licensure requirements, qualifications for entry-level practice, and the primary roles of entry-level graduates were all discussed.

It was noted that one of the major differences among the three levels of educational preparation is the target client, beginning with the individual as client at the vocational level and broadening to the family and group at the baccalaureate level. Although society as client was included for BSN graduates in the 1993 version, feedback from deans and directors and other stakeholders resulted in its omission in the revised version. The deans and directors of BSN programs indicated that their graduates were not being prepared to perform at this level.

Committee representatives defined practice for experienced vocational, ADN/diploma, and BSN graduates based on continuing education and expertise. Descriptions of the level of practice concluded with entry-level competencies sorted into three categories: provider of care, coordinator of care, and member of the profession.

The next step was to review the competencies in each category. After reviewing the literature on differentiated practice, the committee established priorities for promoting quality improvement in the knowledge and clinical behaviors/judgment portions of the competencies. Areas targeted for updating included evidence-based practice, health promotion and illness prevention, community-based practice, care of vulnerable populations, and management and leadership. Knowledge/clinical behavior and judgment statements relating to the health care delivery system were revised to reflect changes in federal and state legislation, the expanded use of technology, and other dynamic changes that have taken place in health care delivery.

The chair of the committee empowered the representatives for each educational level to be experts for their areas of responsibility. With mutual respect among all committee members, open and honest dialogue was possible. For example, if an ADN representative stated that the knowledge and clinical behaviors/judgment of a particular competency were taught at the ADN level and expected upon graduation, BSN representatives were encouraged to describe the additional breadth and depth of knowledge expected at the BSN level. When there were disagreements, committee members referred to published documents to see how others had addressed particular competencies.

After two years of regular meetings, the committee provided a draft edition to deans and directors of schools of nursing and requested feedback. The final version of the Differentiated Entry Level Competencies of Graduates of Texas Nursing Programs was unanimously approved by ACE in January 2002 and presented to the BNE and BVNE at their spring meetings (5,6). Both boards unanimously approved the document. In autumn 2002, the BNE and BVNE notified educational programs of the updated competencies, instructing them to revise their curricula to be consistent with the new document.

How the Competencies Are Structured The 14 differentiated entry-level competencies are written for nursing programs to meet the approval criteria established by both Texas boards of nursing. Competencies are defined as "effective demonstration, by the time of graduation, of knowledge, judgment, skills and professional values derived from the nursing and general education content" (6, p. 45). Nurses who have been in practice and have progressed beyond the novice level are not affected.

The competencies are organized according to provider of care, coordinator of care, and member of a profession. Fourteen broad competency statements, which describe the expected behaviors of the graduate, serve as guidelines for employing graduates in practice settings and developing plans for building on competencies (e.g., orientation programs, job descriptions, clinical ladders).

The competencies are further described in terms of "knowledge needed to achieve the competency" and related "clinical behaviors and judgments." One of the major differences among the competencies for the three levels of educational preparation is the target client, beginning with the individual at the vocational level and broadening to families and groups at the BSN level. The 14, entry-level competencies for diploma/associate degree graduates and baccalaureate graduates are outlined in Tables 1 and 2. Competency 2 in the category "provider of care" is provided with associated knowledge in Table 3 and related clinical behavior and judgment expectations of LVN, diploma, ADN, and BSN graduates in Table 4.

Significance This new publication has far-reaching potential. Along with its influence on teaching methodologies and learning assessment, it has the potential to affect educational mobility and articulation among programs while providing a basis for program development to bridge the gap between education and practice. In addition, it can provide direction for public policy development.

TEACHING METHODOLOGIES AND LEARNING ASSESSMENT Embedded in the competencies is the development of critical thinking, accountability, problem solving and decision making, and management competencies. The competencies include working with vulnerable populations in a variety of settings and provide a broad structure for curricular innovation, problem-based learning, and learner-focused self-mastery of competencies. They serve as a foundation for preparing students for unpredictable environments, flexibility, reflective thinking, and evidence-based practice.

As students are assessed in the development of competencies, they become familiar with practices for promoting quality improvement in individual performance. The community focus and emphasis on wellness and health promotion promote a change in focus for nursing through the educational process (7).

EDUCATIONAL MOBILITY AND ARTICULATION The competencies are designed to serve as a foundation for articulation agreements among Texas schools of nursing. They have been distributed to nurse educators throughout the state and have been incorporated into nursing curricula. Therefore, education mobility is smoother, requires less validation, and allows for development in the next level of education. The competencies are used to define and evaluate outcomes of graduates and to design seamless progression from vocational nursing to ADN to BSN curricula.

BRIDGING THE EDUCATION TO PRACTICE GAP New graduate orientation programs, externships, and internships are methods used to address the gap that takes place naturally between the completion of a basic nursing education program and novice-level practice. By clearly defining educational outcomes, the competencies serve as a starting point for the development of programs to support new graduates and develop novice practitioners into advanced beginner nurses.

Career ladders can he derived from the knowledge and clinical behaviors and judgments outlined in the competencies and provide for consistency in expectations for professional growth. Employers can use the competencies to create incentives for professional development and recognize and reward educational advancement of nurses within their agencies. The competencies have the potential for driving strategies to create more effective work environments for nurses with appropriate responsibilities according to education and ability (8,9).

RECRUITMENT AND PUBLIC EDUCATION As educational programs refine their use of the differentiated competencies, clear messages about the continuum of practice in nursing will be communicated that are helpful to prospective students in selecting programs. These messages have the potential to clarify the public message about the profession that is communicated in recruitment materials directed toward high school, community college, and university career counselors and others. In addition, information about the continuum of practice serves as a basis for informing consumers of the roles of nurses within health care delivery systems.

POLICY DEVELOPMENT Differentiation of practice in nursing has implications/or promoting public policy relating to the nursing workforce. Policies designed to promote efficient care delivery and case-mix usage in staffing patterns can be designed to enhance effectiveness in the health care system. In Texas, the nursing shortage has led to a need for case-mix models that maintain the quality of care while addressing cost efficiency and the prioritization and distribution of resources.
Table 1. Entry-Level Competencies of Texas Graduates of
Diploma/Associate Degree Nursing Programs

PROVIDER OF CARE

* Determine the health status and health needs of clients based on
interpretation of health data and preventive health practices in
collaboration with clients and interdisciplinary health care team
members.

* Formulate goals/outcomes and plan of care based on nursing
diagnoses in collaboration with interdisciplinary health care
team members.

* Implement plan of care within legal and ethical parameters,
including scope of practice, in collaboration with the client
and interdisciplinary health care team to assist client in
meeting health care needs.

* Develop and implement teaching plans for clients concerning
promotion, maintenance, and restoration of health.

* Evaluate clients' responses and outcomes to therapeutic
interventions.

* Provide for the care of multiple clients either through direct
care or assignment and/or delegation of care to other members of
the health care team.

* Use critical thinking approach to analyze clinical data and
current literature
as a basis for decision making in nursing practice.

COORDINATOR OF CARE

* Coordinate human and material resources for the provision of
care for clients.

* Collaborate with clients and the interdisciplinary health care
team for the planning and delivery of care.

* Refer clients to resources that facilitate continuity of care.

* Function within the organizational framework of various health
care settings.

MEMBER OF A PROFESSION

* Assume accountability and responsibility for the quality of nursing
care provided to clients.

* Act as an advocate to promote the provision of quality health care
for clients.

* Participate in activities that promote the development and practice
of professional nursing.

NOTE. Client refers to the individual and family.

Table 2. Entry-Level Competencies of Texas
Graduates of Baccalaureate Degree Nursing Programs

PROVIDER OF CARE

* Determine the health status and health needs based on expanded
interpretation of health-related data and preventive health
practices in collaboration with clients and the interdisciplinary
health care team.

* Formulate goals/outcomes and plan of care using an evidence-based
and theoretical analysis of available data in collaboration with
clients and interdisciplinary health care team members.

* Implement plan of care within legal and ethical parameters,
including scope of practice, in collaboration with clients and
interdisciplinary health care team to assist clients in meeting
health care needs.

* Develop and implement comprehensive teaching plans to meet the
learning needs of clients.

* Evaluate clients' responses and outcomes to therapeutic
interventions.

* Provide for the care of multiple clients either through direct
care or assignment and/or delegation of care to other members of the
health care team.

* Use an evidence-based analytical approach as the basis for
decision making in practice.

COORDINATOR OF CARE

* Coordinate human and material resources for the provision of care
for clients.

* Collaborate with clients and the interdisciplinary health care
team for the planning and delivery of care.

* Refer clients to resources that facilitate continuity of care.

* Function as a facilitator within the organizational structure of
various health care settings.

MEMBER OF A PROFESSION

* Assume accountability and responsibility for the quality of
nursing care provided to clients.

* Serve as health care advocate in monitoring and promoting access
to and quality of health care for clients.

* Act as a leader in promoting nursing as a profession.

NOTE. Client refers to individual, individual's family, and groups.

Table 3. Knowledge Required for Achievement of Competency No. 2
Related to Provider of Care

 DIPLOMA/ASSOCIATE
VOCATIONAL NURSE DEGREE BACCALAUREATE DEGREE

Assist in the Formulate goals/ Formulate goals/
formulation of outcomes and plan of outcomes and plan of
goals/outcomes and a care based on nursing care using an
plan of care in diagnoses in evidence-based and
collaboration with collaboration with theoretical analysis
clients, their clients and of available data in
families, and interdisciplinary collaboration with
interdisciplinary health care team clients and
health care team members. interdisciplinary
members. health care team
 members.

Knowledge Additional Knowledge Additional Knowledge

A Dynamics of the A Principles of A Models for
 nurse-client establishing nurse- understanding the
 relationship. client relationship. dynamics of the
 nurse-client
 relationship.

B Written, verbal, B Techniques of B Communication
 and nonverbal written, verbal, and theory.
 modes of nonverbal
 communication communication
 including including
 information information
 technologies. technologies.

C Fundamental C Principles of C Principles of
 principles of disease prevention, epidemiology and
 disease health promotion, genetics.
 prevention, health education, and
 promotion/ rehabilitation for
 restoration for clients.
 clients.

D Basic D Clinical practice D Interdisciplinary
 interventions to guidelines as a interventions,
 support the client basis of including nursing
 and family during interventions to care across all
 life stages, support client settings.
 including end-of- throughout the
 life care. lifespan, including
 end-of-life care.

E Relationships E Collaborative E Collaborative
 between the aspects of the aspects of the
 nursing plan of relationship between relationship between
 care, the the nursing plan of the nursing plan of
 therapeutic care, the care, the plan of
 regimen, the plan therapeutic regimen, interdisciplinary
 of inter- the plan of health care team
 disciplinary interdisciplinary members, and cost
 health care team health care team factors in multiple
 members, and cost members, and cost settings.
 factors. factors.

F Criteria for F A systematic F A variety of
 setting priorities approach for setting systematic
 in planning and priorities and approaches for
 evaluating care. strategies for problem solving and
 coordinating plan of decision making for
 care. care planning.

G Steps and G Strategies for G Research findings
 procedures in collaborative related to nursing
 discharge planning discharge planning. care and
 process. collaborative
 discharge planning.

 H Principles of H Relationship of
 humanities and humanities and
 natural, social, and natural, social, and
 behavioral sciences behavioral sciences
 as applied to care as applied to care
 planning for planning for
 clients. clients.

NOTE. Each educational level assumes previously stated competencies.

For vocational nursing, client refers to the individual. For diploma
and associate degree nurses, client refers to the individual and the
individual's family. For baccalaureate degree nurses, client refers
to the individual, individual's family, and groups.

Table 4. Clinical Behaviors/Judgments Demonstrating Achievement of
Competency No. 2 Related to Provider of Care

 DIPLOMA/ASSOCIATE
VOCATIONAL NURSE DEGREE BACCALAUREATE DEGREE

Clinical Behaviors/ Additional Clinical Additional Clinical
Judgments Behaviors/Judgments Behaviors/Judgments

A Identify short- A Identify short- and A Establish short- and
 term goals/ long-term goals/ long-term goals/
 outcomes, select outcomes, select outcomes and plan
 basic interventions, and care with clients
 interventions, and establish priorities and
 establish for care in interdisciplinary
 priorities for collaboration with team.
 care in client.
 collaboration with
 client.

B Contribute to the B Use current B Assist in
 development of technology and development of
 nursing plan of evidence-based clinical practice
 care. information to guidelines and
 formulate and modify coordinate plans of
 nursing plan of care with
 care. interdisciplinary
 health care team.

C Identify obvious C Contribute to the C Collaborate with
 conflicts between interdisciplinary multiple providers
 nursing plan of plan of care. to plan for
 care and plan of obtaining diverse
 interdisciplinary services for client.
 health care team
 members.

D Participate in D Communicate plan of D Collaborate in
 discussion of plan care to nurses and developing goals
 of care with other for community-based
 interdisciplinary interdisciplinary programs whose
 health care team health care team primary goal is
 members. members. health promotion or
 health restoration.

E Assist in the E Initiate discharge E Participate in
 discharge planning planning in research process and
 of selected collaboration with use interpreted
 clients. interdisciplinary research findings to
 health care team. plan, implement, and
 evaluate discharge
 plans.

F Recognize cost of F Implement cost- F Demonstrate fiscal
 care for nursing effective care. accountability for
 interventions. health care.

 G Integrate theory and
 research-based
 knowledge from arts,
 humanities, and
 sciences for direct
 and indirect
 delivery of client
 care.

NOTE. Each educational level assumes previously stated competencies.
For vocational nursing, client refers to the individual. For diploma
and associate degree nurses, client refers to the individual and
individual's family. For baccalaureate degree nurses, client refers
to the individual, individual's family, and groups.


References

(1.) Board of Nurse Examiners for the State of Texas and Texas Board of Vocational Nurse Examiners. (1993). Nursing Education Advisory Committee (NEAC) report, Vol. 1: Essential competencies of Texas graduates of education programs in nursing. Austin, TX: Authors.

(2.) American Association of Colleges of Nursing. (1998). Essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.

(3.) National League for Nursing. (2000). Educational competencies for graduates of associate degree nursing programs. New York: NLN Press.

(4.) Bellack, J. P., & O'Neill, E. H. (2000). Recreating nursing practice for a new century: Recommendations and implications of the Pew Health Professions Commission's final report. Nursing and Health Care Perspectives, 21(1), 14-21.

(5.) Wilson, R. (2002). Board adopts differentiated entry level competencies of graduates of Texas nursing programs. RN Update, 33(4), 1-2.

(6.) Board of Nurse Examiners for the State of Texas and the Texas Board of Vocational Nurse Examiners. (2002). Differentiated entry level competencies of graduates of Texas nursing programs. Austin, TX: Authors.

(7.) Brady, M., Leuner, J. D., Bellack, J. P., Loquist, R. S., et. al. (2001). A proposed framework for differentiating the 21 Pew competencies for level of nursing education. Nursing and Health Care Perspectives, 22(1), 30-36.

(8.) Lanser, E. G. (2001). A model workplace: Creating an effective nursing environment. Healthcare Executive, 16(4), 6-12.

(9.) Rick, C. (2003). Differentiated practice: Get beyond the fear factor. Nursing Management, 34(1), 11.

Elizabeth Poster, PhD, RN, FAAN, dean of the University of Arlington School of Nursing and a member of the Board of Nurse Examiners (1997-2003) representing baccalaureate degree nursing programs, was chair of the Advisory Committee on Education. Phyllis Adams, EdD, RN, CNS, FNP, represented the Texas Nurses' Association. Cora Clay, MA, RN, represented the Texas Board of Vocational Nurse Examiners. Blanca Rosa Garcia, PhD, RN, represented the Texas Organization of Associate Degree Nurses. Annette Hallman, PhD, RN, represented diploma programs. Brenda Jackson, PhD, RN, represented the Texas League for Nursing. Linda Klotz, PhD, RN, represented the Texas Organization of Baccalaureate and Graduate Nurse Educators. Robert Lumpkins, MS, RN, CNAA, represented the Texas Organization of Nurse Executives. Helen Reid, EdD, RN, represented the Texas Organization of Associate Degree Nurses. Pamela G. Sanford, MSN, RN, C, CNS, represented the Texas League for Nursing. Kendra Slatton, MSN, RN, CDE, represented the Texas Organization of Nurse Executives. Nancy Yuill, PhD, RN, represented the Texas Organization of Baccalaureate and Graduate Nurse Educators. The authors thank Virginia Holmes, MSN, RN, Cara Mueller, MSN, RN, and Robbin Wilson, MSN, RN, nursing consultants of the BNE, for their work and support of the committee, and Ferne Kyba, PhD, RN, for her contributions to the ethics section.
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Author:Poster, Elizabeth; Adams, Phyllis; Clay, Cora; Garcia, Blanca Rosa; Hallman, Annette; Jackson, Brend
Publication:Nursing Education Perspectives
Date:Jan 1, 2005
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