Transition to Practice--Part 2 Implementing an Ambulatory Care Registered Nurse Residency Program: Competency--It's Not Just a Task.
In 2005, the Robert Wood Johnson Foundation funded the Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett et al., 2007) with the goal of addressing known gaps in the curriculum for pre-licensure students and preparing those students to provide quality and safe patient care. After reviewing the literature and working with leaders in nursing, the QSEN faculty identified six core competencies which include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). QSEN competencies assist in moving quality and safety from care at the individual level to a systems level. Systems thinking promotes the identification of care failures and best practices in patient care. This shift in thinking allows nurses to more fully identify patterns and relationships in care (Dolansky & Moore, 2013). The ambulatory care setting also requires nurses to apply systems thinking to address the complex care coordination needs of patients.
While QSEN competencies were initially developed for undergraduate and graduate student education, these competencies can strengthen quality and safety practices for all of nursing. The American Nurses Credentialing Center (ANCC) Practice Transition Accreditation Program recommends cross walking program competencies with QSEN and the IOM Interprofessional Competencies when developing program content (ANCC, 2016). QSEN competencies are also being translated from academic settings into nursing practice.
The American Nurses Association (2013) defines competency as "an expected level of performance that integrates knowledge, skills, abilities, and judgement" (p. 3). QSEN competencies integrate knowledge and skills, but have replaced "abilities" with "attitudes." Attitude plays a fundamental role in supporting quality and safe care. As an example, a nurse has the knowledge, skill, and ability to use two patient identifiers when implementing a treatment, but may not perform the process. This scenario may occur because he or she does not entirely embrace the safety practice, especially when faced with time constraints. It is supported by the number of patient misidentification events that continue to occur in healthcare settings. By incorporating knowledge, skills, and attitudes (KSAs) into each of the six competencies, QSEN sets the stage for comprehensive competency assessment that reinforces safe and quality care (see Table 1).
Bloom's taxonomy, created in 1956, is widely accepted as a method to measure competence (Bastable, 2008). Bloom's three learning domains are cognitive (knowledge), psychomotor (skill), and affective (attitude). The cognitive domain involves the development of intellectual skills and ranges from being able to recall or restate information to evaluating the information. The psychomotor learning domain involves learning new skills and moves in complexity from observing a skill to being able to adapt a skill related to a specific situation. The affective domain involves the development of behaviors that surround feelings, values, and appreciation (Bastable, 2008). Developing robust KSAs is essential in ensuring the learner has the abilities and characteristics needed to perform all the duties of the job safely.
Typically, knowledge is addressed using lectures and assigned reading, acquisition of fine motor and gross motor ability addresses skills, and caring interactions are associated with attitudes. However, one isolated teaching strategy or learning activity does not support comprehensive competency achievement by the targeted learner. When developing competencies, integration of all the learning domains is essential. The use of various teaching strategies and validation tools can assist in integration of the learning domains. According to Wright (2005), using only one method of competency verification compromises the ability to assess whether or not a person can carry out all the skills needed to perform the requirements of the job or position. Established methods that can be used to substantiate competency are listed in Table 2.
Ambulatory Care RN Residency Program Competencies
In an effort to align with the recommendations of the IOM and current accreditation standards for transition-to-practice programs, the American Academy of Ambulatory Care Nursing (AAACN) Ambulatory Care Registered Nurse Residency Program Task Force selected QSEN as a framework for building the program (AAACN, 2017). Many of the residency program sections support the development of KSAs as depicted in Figure 1. This integration of sections and learning experiences supports the program goal of improving quality and safety, and assuring competency and confidence of the new or transitioning RN in ambulatory care (Levine, 2017).
During the process of identifying key proficiencies needed for the Ambulatory Care Registered Nurse Residency Program (AAACN, 2017), both procedural and professional competencies were developed to ensure that a nurse new to ambulatory care would be able to perform safely in all aspects of this unique care setting. All six QSEN competencies in Table 1 were used as the building blocks for the residency program's comprehensive list of procedural and professional competencies.
Many of the procedural skills align with the QSEN Safety competency. The procedural competencies are designed much like skills checklists; however, supplementary content was built to address critical thinking and clinical reasoning ability. It is important to consider that being able to perform an isolated task, such as blood glucose point of care testing on a patient with diabetes, does not demonstrate that the new ambulatory care registered nurse (RN) can competently care for a patient with diabetes. The addition of case scenarios or critical-thinking questions to the procedural competency allows for a higher level of assessment and also addresses learner knowledge and attitudes. An example might be having the ambulatory care RN work through an unfolding case scenario involving a noncompliant patient experiencing hyperglycemia. This permits competency assessment that addresses more than the psychomotor domain. The case scenario may be built to address the ambulatory care RN's knowledge of the pathophysiology of diabetes; signs, symptoms, and treatment of hypo and hyperglycemia; and differences in insulin types. To address the knowledge portion of the KSA, one might develop a critical-thinking question such as: "What would be the plan of care for a patient, seen in clinic, with a blood glucose level less that 70 mg/dl who is experiencing headache, dizziness, and diaphoresis?" Additionally, the case scenario could identify how the ambulatory care RN uses motivational interviewing to promote positive patient decision making, and use of teach-back to assess patient understanding.
Professional competencies in the residency program were developed to align with the Scope and Standards of Practice for Professional Ambulatory Care Nursing (AAACN, 2010). The professional role of the ambulatory care nurse not only highlights the nursing process, but addresses additional professional behaviors and roles that promote quality, safe patient care (AAACN, 2010). The role of the ambulatory care nurse also encompasses ethical practice, lifelong learning, quality improvement, evidence-based practice and research, collegiality and collaboration, and leadership (AAACN, 2010). The Scope and Standards of Practice can be easily cross-walked with the QSEN competencies, providing the framework for developing ambulatory care specific professional competencies. A list of professional competencies suggested for the ambulatory care RN is provided in Table 3.
Identifying and developing competencies may appear to be a labor-intensive process. However, there are guiding principles that may help in moving from a long list of competencies to a shorter list that is comprehensive yet meaningful. Clearly understanding the role or job description of the new ambulatory care nurse will help identify key competencies that need to be developed. Develop only those competencies that align with the job description of the RN and organizational standards. Additionally, regulatory standards may need to be considered in identifying required competencies. Keep in mind, QSEN provides a framework to support development of competency statements that reflect the clinical setting in which the nurse is working. The development of robust KSAs, using various validation methods, guides the assessment of competency. An example from the residency program of a developed competency related to advocacy is shown in Figure 2.
The QSEN initiative has played an important role in transforming how nursing can improve quality and safety in education and practice. The six QSEN competencies support a paradigm shift in how competency is determined. Assessing whether a nurse is competent to perform the duties of his or her job role involves more than completing a skills checklist. Evaluating for knowledge, skills, and attitudes related to patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics supports a shift from individual actions to systems improvement (Sherwood & Zomorodi, 2014). The AAACN Ambulatory Care Registered Nurse Residency Program used the QSEN framework to support development of competencies that will provide the new nurse to the ambulatory care setting with the knowledge, skills, and attitudes to provide safe, quality care.
American Academy of Ambulatory Care Nursing (AAACN). (2010). Scope and standards of practice for professional ambulatory care nursing (8th ed.). Pitman, NJ: Author.
American Academy of Ambulatory Care Nursing (AAACN). (2017). Ambulatory care registered nurse residency program. Pitman, NJ: Author.
American Nurses Association. (2013). Competency model. Silver Spring, MD: Author.
American Nurses Credentialing Center (ANCC). (2016). 2016 application manual: Practice transition accreditation program. Retrieved from www.nursecredentialing.org/PTAP-AccreditationManual
Bastable, S.B. (2008). Nurse as educator: Principles of teaching and learning for nursing practice (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., ... Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131. doi:10.1016/j.outlook.2007.02.006
Dolansky, M.A., & Moore, S.M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. Journal of Issues in Nursing, 18(3), 1-15. doi: 10913734
Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy of Sciences.
Institute of Medicine (IOM). (2000). To err is human: Building a safer health system. Retrieved Washington, DC: National Academy of Sciences.
Institute of Medicine (IOM). (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academy of Sciences.
Levine, J. (2017). Transition to practice--part 1. Implementing an ambulatory care nurse residency program: The importance of a structural framework. Nursing Economic$, 35(5), 267-271.
Levine, J., More, L., & Jones-Bell, J. (2017). Ambulatory care RN residency program: Implementation strategies. Paper presented at American Academy of Ambulatory Care Nursing 42nd Annual Conference, New Orleans, LA.
Sherwood, G., & Zomorodi, M. (2014). A new mindset for quality and safety: The QSEN competencies redefine nurses' roles in practice. Nephrology Nursing Journal, 41(1), 15.
Wright, D. (2005). The ultimate guide to competency assessment in health care (3rd ed.). Minneapolis, MN: Creative Health Care Management, Inc.
LAUREL MORE, MS, RN-BC, CPN, is Clinical Education Specialist, Children's Hospital Colorado, Aurora, CO; and AAACN Ambulatory Residency Task Force Member.
NOTE: This column is written by members of the American Academy of Ambulatory Care Nursing (AAACN) and edited by Kitty Shulman, MSN, RN-BC. For more information about the organization, contact: AAACN, East Holly Avenue/Box 56, Pitman, NJ 08071-0056; (856) 256-2300; (800) AMB-NURS; FAX (856) 5897463; Email: email@example.com; Website: http://AAACN.org
Caption: Figure 1. Program Sections Supporting Knowledge, Skills, Attitudes
Table 1. QSEN Competency and Definition Competency Definition Patient-centered "Recognizes the patient of designee as the care source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs." Teamwork and "Functions effectively within nursing and collaboration inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care." Evidence-based "Integrate best current evidence with clinical practice expertise and patient/family preferences and values for delivery of optimal health care." Quality "Use data to monitor the outcomes of care improvement processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems." Safety "Minimize risk of harm to patients and providers through both system effectiveness and individual performance." Informatics "Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making." SOURCE: Cronenwett et al., 2007, pp. 123-129 Table 2. Validation Methods and Learning Domains Validation Method Learning Domain Case studies Cognitive (K) Affective (A) Demonstration Cognitive (K) Psychomotor (S) Exemplars Cognitive (K) Affective (A) Gaming Cognitive (K) Group discussion Cognitive (K) Affective (A) Instructor-led Cognitive (K) class Knowledge Cognitive (K) assessment test On-line modules Cognitive (K) Portfolio Cognitive (K) Affective (A) Reflection Cognitive (K) Affective (A) Self-assessment Affective (A) Simulation Cognitive (K) Psychomotor (S) Affective (A) Table 3. Professional Competency Topics Professional competency topics Communication Ethical practice Advocacy Teamwork and collaboration Informatics Evidence-base practice, quality improvement, and research Leadership Lifelong learning SOURCE: AAACN, 2017 Figure 2. Example: Advocacy Competency Employee Name (print): __ Date: __ QSEN Competency(s): Patient-Centered Care (Recognizes the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.) Subject: Advocacy Type of Evaluation:  Orientation;  Annual Competency;  Other: __ Evaluation Methods: (Indicate all that apply in third column for each competency statement.)  A: Audit/Chart Review;  CS: Case Study;  DO: Direct Observation/ Demonstration;  E: Exemplars;  KAT: Knowledge Assessment Test;  L/D: Lecture/Discussion;  P/P: Policy & Procedure Review;  P: Presentations;  QI: QI Monitors;  R: Reflection;  SA: Self-Assessment;  S: Simulations;  SL: Skills Lab;  Other Competency KSA (Knowledge/ Evaluation Unable Statements Skills/Attitudes) Methods to To Meet Perform Competency When performing Knowledge a comprehensive * AAACN Scope and assessment of Standards of each individual Practice for patient, the RN Professional takes into Ambulatory Care account: Nursing physical, * Core Curriculum for psychosocial, Ambulatory Care spiritual, Nursing, Chapter 8: cultural, Patient Advocacy financial, and Use of cognitive, and Community Resources literacy as * Care Coordination part of the and Transition comprehensive Management, Chapter assessment 2: Advocacy * Discuss how health literacy, culture, values, spiritual affiliation may impact care delivery (Joint Commission Standard) Skills * Identifies signs of domestic violence, child/elder abuse * Uses comprehensive assessment to develop an individualized plan of care * Assesses learning readiness and provides education that takes into account psychosocial, spiritual, financial, cognitive, and cultural aspects of patient/family Attitude * Values patient/ designee preferences, values, and needs when performing a comprehensive assessment Competency KSA (Knowledge/ Performs Performs Statements Skills/Attitudes) with without To Meet Coaching Coaching Competency When performing Knowledge a comprehensive * AAACN Scope and assessment of Standards of each individual Practice for patient, the RN Professional takes into Ambulatory Care account: Nursing physical, * Core Curriculum for psychosocial, Ambulatory Care spiritual, Nursing, Chapter 8: cultural, Patient Advocacy financial, and Use of cognitive, and Community Resources literacy as * Care Coordination part of the and Transition comprehensive Management, Chapter assessment 2: Advocacy * Discuss how health literacy, culture, values, spiritual affiliation may impact care delivery (Joint Commission Standard) Skills * Identifies signs of domestic violence, child/elder abuse * Uses comprehensive assessment to develop an individualized plan of care * Assesses learning readiness and provides education that takes into account psychosocial, spiritual, financial, cognitive, and cultural aspects of patient/family Attitude * Values patient/ designee preferences, values, and needs when performing a comprehensive assessment SOURCE: AAACN, 2017
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|Title Annotation:||Perspectives in Ambulatory Care|
|Date:||Nov 1, 2017|
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