Establishing the Standards for Nursing Competencies in Higher Education
Nursing education is most challenging during
these times. With ever changing demand for quality and safe nursing practice,
as well as the emergence of innovation in technology in health care settings,
educators are faced with a myriad of issues that surround the quality of
learning that reflects certain standards and describe essential attributes
vital for transforming a novice to an expert. When the healthcare professionals
are required to deliver an acceptable performance within the context of the
standards identified by the regulatory bodies, the academe is commissioned to
train the students in such a manner that the outcome of learning exhibits the
proficiency expected from the students. Moreover, the challenge for better
results which is faced by the educators is defined as responsibility requiring
imperative actions that create positive outcomes for various factors of
Educational institutions lay down the
foundation of knowledge, skills, and attitude. When the student enters the
academic walls of an institution, they carry with them aspirations and high
expectations regarding the training they acquire, more than suffice the
competencies required by them before entering the workforce. The patients
directly affected with such performance and the employers of nursing graduates
assume that performance outcome is directed towards safe and quality nursing
practice. The nursing program provides a clear direction to the components of
competencies embedded in the method of instruction through the curriculum
offered within the course of training. While educators continue to reinvent and
innovate, the initial step which points towards revisiting the curriculum and
modelling the competency framework remains a challenge and is often the aspect
As the call for quality nursing care expands,
the need for educational institutions to develop the nursing curriculum is
emphasized. King Saud University (KSU) College of Nursing moved towards the
direction of achieving nurse clinicians that provide a safe, competent and
ethical nursing care to Saudis. This article will introduce the concept of the
National Nursing Competencies and their relevance to nurses and others by
relating it to clinical scenarios. It will examine various designs and
framework of nursing competencies related to approaches utilized by
institutions in response to the needs of the academic and clinical environment.
Furthermore, it will provide a description of what constitutes nursing
competency, as well as will take cognizance of the importance of identifying and
developing competencies in the profession. Predominantly, it will discuss the
process involved in establishing a competency-based curriculum. Furthermore, it
will provide a platform to the process and methods by which student learning
has been evaluated throughout their five academic years at King Saud University
College of Nursing.
Axley (2008) 1 discussed that competency is
essential to the profession of nursing, and providing a clear theoretical
definition of competency is only the first step. Competency, as discussed in
the Competency Standards approach to professional education and Practice, is
explained as a combination of attributes enabling performance of a range of
professional tasks to the appropriate standards 2. Davis (2010) 3 accentuated
that the heightened levels of public concern regarding safety are also a major
factor which mandates that health professionals demonstrate clinical competence
prior to entering the clinical setting.
Nurse professionals have a distinct commitment
to develop and implement the standards of nursing practice through continuous
acquisition of pertinent knowledge, attitude and skills, application of
critical judgment, and the evaluation of such as essential to quality care.
Dolansky, Mary, Moore, & Shirley (2013) 4 emphasized that a safe and
high-quality system of care requires that health professionals take
responsibility to learn and apply skills associated with improving a wider
system of care. Nurses are accountable and are held liable for their actions in
the clinical field. The assurance of continued competence is an essential
element through which commitment should begin. Decker, Utterback, Thomas,
Mitchell & Sportsman (2011) 5 expressed that continuing competence is
ongoing professional nursing competence according to the level of expertise,
responsibility, and domains of practice.
However, competency encompasses more than just
psychomotor skills. Competency specifies the level of achievement expected and
the tasks and contexts of professional practice in which we may see the
competency demonstrated 2 Nurses know that psychomotor skills are important
but without the requisite of knowledge, it does not constitute nursing.
Knowledge of health and disease process is of little use with the appropriate
nursing skills to apply. Planning and organizing capabilities are of little
benefit to the clients if the attitude that nurse should value (such as caring
and patience) is not present. Therefore, the integration of the three domains
is essential for understanding and eventually performing nursing care with
competence. The Canadian Nurses Association (2010) 6 further emphasized that
safe, competent, and ethical nurse practitioner practice require the
integration and performance of many competencies simultaneously.
Competency is demonstrated in varied levels of
care. Often, this exhibits a minimum acceptable level or standard. Definitely,
beginners, for instance, do not achieve the expert level, but they can be competent
when they perform a wide range of nursing tasks well and systematically. They
might be slow but can develop further skills and speed up with time. On the
other hand, the experienced competent nurse works quickly and with competence,
able to care for a highly complex and dependent patient in the critical care
unit, as well as having ability to care about highly dependent patients in a
busy surgical or medical ward. In the community settings, nursing skills of
assessment and decision-making are often visible, but are reflected in the
delivery of patient care.
Hill (2010) 7 pointed out that an important
factor that contributes to nursing quality is the nurse’s years of experience
in nursing. Multiple experiences of observing cues, and recognizing patterns
related to patient status that need to be acted on in specific ways, lead to
higher levels of clinical performance. Expert practitioners’ supplement formal
learning with mature knowledge is based on the progress which has taken years
to take place.
Students have innate abilities and attitudes
that they carry upon entry into the nursing program. This is where the process
of education begins. As soon as the courses are introduced, the knowledge and
skills specific to nursing are presented. Within these times, the students and
the educators engage in various activities that integrate knowledge and skills
for caring to inculcate the desirable competency required by the learners.
Wykoff, Khoury, Stoots, & Pack (2014) 8
discussed that recent research has demonstrated that new graduates are not well
prepared for their duties in the field. Moreover, Redman, Lenburg, & Hinton
Walker (1999) 9 also emphasized that it took approximately eight months of
clinical experience before new BSN graduates felt confident and competent in
their clinical judgments. As the nursing education to tertiary settings is
progressing, the nature of the learning and application has also been altered.
Nursing courses for enrolled and registered nurses remain on the basis of
knowledge; skills and attitudes that nurses are expected to demonstrate in the
workplace in a wide variety of contexts and settings 10. Thus,
competency-based Education has been introduced to some professional programs
and courses such as nursing.
Lenburg, Klein, Abdur-Rahman, Spencer, &
Boyer (2009) 11 narrate that a competency based approach requires the
analysis of relevant and current environment and needs from which they
determine content ant competencies to be achieved in the instructional program.
This provides a foundation of the competency outcomes together with adult
education, interactive and student focused learning strategies, as well as
outcomes and assessment of performance competencies. Competency based education
or training emphasizes on assessment in real-life settings and situations. The
evaluation is formed on how the learner is able to create judgment and
demonstrate the knowledge based on the clinical scenario. Tilley (2008) 12 accentuated
that competency-based performance evaluation assess a participant’s actual
ability to meet a predetermined set of performance standards under controlled
conditions and protocols and is focused on knowledge and principles essential
for effective implementation of required skills.
Process: Establishing the KSU-CON competency-based curriculum
King Saud University College of Nursing aims to
provide safe, competent and ethical nursing care to Saudis. To accomplish this
goal, KSU-CON identified the need to establish a new approach. Within the guidelines
of the curriculum that was developed, a committee was commissioned by the
higher administration of the college which consisted of people with various
educational background and specialties. Working as a team, the committee was
tasked to establish the competency-based curriculum by groups.
A multi-step process was utilized to define the
set of nursing core competencies for KSU CON. Firstly, the group identified and
created competencies from other countries and current trends and standard
practices in USA. A review of the Quality and Safety Education for Nurses model
(Quality and Safety Education for Nurses (QSEN), 2010) 13 was done. The
committee conducted a review of literature, comparing the set of core
competencies against internationally accepted models, guideline and standards.
The preliminary set of competencies was also compared to the Essentials of
Baccalaureate of Education (American Association of Colleges of Nursing, 2008)
14, the Competency Outcomes and Performance Assessment (COPA) model (Lenburg,
Klein, Abdur-Rahman, Spencer & Boyer, 2009) 11, and the National League
for Nursing’s educational competencies for graduates of associate degree
nursing programs (National League for Nursing (NLN), 2000) 15.
The first dynamics resulted in defining the
competency framework of the BSN curriculum. This laid down the foundation of
the competency to be implemented and described the importance of these
competencies to the college. Seven (7) competencies are recognized as 1)
patient-centered (caring competency), 2) professionalism, 3) communication, 4)
leadership, 5) safety, 6) research, and 7) teaching and learning (see Fig. 1.).
Fig. 1 – Competency Framework
Insert figure here
competency model addresses the current need of the nursing education
specifically in the Saudi Nursing Curriculum. To develop the nursing
competencies, the committee identified a set of assumptions to serve as a
framework for its work and as guiding principles for the design of a
competency-based education and practice partnership model (see table 1).
The second group was
tasked to specify and delineate these competencies by defining them and
categorize the skills relative to each competency (see Table 2). Lastly, the
third group developed the assessment tools applicable for the competence
the Standards of the Profession
Having identified and clear core competencies,
it is essential to integrate these competencies into the training provided for
the KSU-CON students. It is requisite of all courses that all KSU nursing
students should be able to meet their respective competencies for the beginning
practitioner. Redman, Lenburg, & Hinton Walker (1999) 9 discussed that
multiple requirements for competent nursing practice in the health care system
have been established by national associations and agencies. The Joint
Commission for Accreditation of health care Organizations obliges that the
clinical competence should be assessed, maintained, demonstrated, and
Taking these clear set of standards, these form
a basis for those within the specialty, and other collaborating part of the
academe to understand the competencies required for practice. The
competency-based standards offer a basis for judgments to be made for entry
into the profession, such as accreditation, registration, or enrolment as a
nurse. They also provide clear guidelines for judging progression within the
role, and as such can be used to make decisions about awards, classifications,
promotions, and for general staff appraisal purposes.
As part of the multi-step approach, the
committee proposed guidelines for the competency-based curriculum. Purpose,
policy, procedure, remediation, professional behaviors, clinical safety policy,
and list of clinical skills are components of the guidelines. Primarily, the
purpose of the competency is to evaluate and assess student’s skill competency
level. The main policy generalizes that all nursing students will be required
to demonstrate competencies in; 1) medication administration, 2) nursing
skills, and 3) professional documentation.
In the guidelines, a detailed description of
the competency testing is provided. First, it is scheduled through the nursing
skills laboratory. Secondly, it must be scheduled and completed during the
semester prior to the return. A successful completion of these and other
competencies is required. Lastly, remediation and re-testing will be required
if it is not completed successfully. In addition, as postulated in the
procedure section of the guidelines students will demonstrate competencies at
the pre-novice level at the end of each year in four main parts as following;
a) pharmacologic math, b) medication administration, c) clinical nursing
skills, and d) professional medical terminology and documentation.
Remediation is defined as a practice required
for all unsuccessful skill testing (check – offs). This addresses concerns for
students who demonstrate unsatisfactory completion of the competency test 16.
There are three main steps of remediation and each of them has a specific guideline.
However, after the third remediation, if the students are unsuccessful, they
will be considered to be failed in the course. To evaluate a student’s clinical
practice that whether it is safe or not, the clinical safety policy is
established. It is expected that all students will deliver nursing care in a
safe manner. Unsafe conduct in the clinical area is defined as psychological
and/or physical behaviors by the side of the student that can threaten the
health and/or well-being of a client. Nevertheless, unsafe clinical performance
is defined as a behavior which falls into one or more of the following
categories, which are: a) inconsistent level of knowledge base and performance
in the clinical area, b) inability to apply nursing theory in clinical practice,
and c) inappropriate or incorrect clinical behavior.
Evaluation of learning and the concomitant
exploration and development of appropriate models and techniques for
assessment, have always been a significant component of the curriculum within
the School of Nursing at King Saud University college of Nursing. Regardless of
whether the unit is theoretical or practical, our students are provided with a
unit outline specifying rationale and aims, and objectives, content, teaching
learning design, assessment requirements, and criteria for assessment. The
learning goals, instructional design and evaluation of learning methods are all
linked and clearly visible.
As claimed earlier, the KSU College of nursing
competency standards form the basis of our Clinical Performance Evaluation
Tool. This tool is currently designed around seven competency clusters;
patient-centered (caring competency), professionalism, communication,
leadership, safety, research, teaching, and learning. A guide providing the
details against which a student’s clinical performance is evaluated accompanies
each Tool. Each student must achieve a satisfactory level of performance in
each of the competencies contained in the seven clusters. Identified indicators
are used by the evaluators to judge the level of performance.
Today, our Clinical Performance Evaluation Tool
is the primary means of evaluating student clinical performance. In earlier
years, we evaluated a student’s performance using a list of discrete behaviors
or skills according to behavioral criteria. However, now the criteria are more
holistic and developed in such a way that expects to raise student performance
levels with each practicum.
The challenges associated with evaluation of
student clinical performance will no doubt continue to offer opportunities for
further transformations of our methods. To facilitate these transformations, we
closely monitor not only learning opportunities and environments within the
university and the wider clinical arena, but also education literature related
to all aspects of health education. At the School of Nursing, KSU, we will
increase our conscious about the central role evaluation significant in student
We have become aware that the evaluation tasks
help to direct student learning, rather than lists of objectives or contents.
We will no doubt continue to refine our methods for evaluating student learning
to meet future education challenges. For instance, it is probable that lifelong
learning strategies and information literacy skills will be increasing in
demand as the knowledge explosion continues, and knowledge of today becomes
obsolete tomorrow. It is also probable that personal and interpersonal skills
as well as those skills associated with critical thinking and problem solving
will be needed more than ever.
Internationalization, globalization, and
ongoing scientific and technological advances raise the likelihood of an
increase in the use of technologically mediated teaching and learning. All
these factors suggest a very challenging future for all aspects of nurse
education, not only the curriculum rather also how the student learning is
evaluated. Competency-based curriculum approach for nursing bachelor students’
had been successfully established in CON, KSU. The model, core competencies,
and guidelines have been described in detail. Faculty staff was involved in the
implementation that it should carefully comprehend the concept of
competency-based curriculum. Further tasks are still needed to evaluate the
competency model in KSU College of nursing curriculum.
for practice and research
Educators must choose the teaching methods that
are proper and effective for what they teach.
The comparison between the two teaching methods
(simulation and traditional) indicated no significant differences in
electrocardiogram (ECG) interpretation sessions.
Future research could use different complex
teaching contents and examine the effectiveness of simulation.
This project was supported by a grant from the
“Research Center of the College of Nursing”, Deanship of Scientific Research,
King Saud University. The sponsoring agency was not involved in the study
design; in the collection, analysis, and interpretation of data, as well as in
the writing of the report, and in the decision to submit the paper for
Conflict of interest
The manuscript has not been previously
published and is not under consideration in the same or substantially similar
form in any other journal. All those listed as authors are qualified for
authorship and all who are qualified to be authors are listed as authors on the
byline. To the author’s knowledge, no conflict of interest, financial or other
exists. Each author has participated and contributed sufficiently to take
public responsibility for appropriate portions of the content.