Navigating Competency-Based Education through Simulations in Nursing Curriculum - Part 1

In part one of this two-part episode of NLN Nursing Edge Unscripted, host Dr. Raquel Bertiz from the National League for Nursing’s Center for Innovation in Education Excellence is joined by Dr. Laura Klenke-Borgmann from the University of Kansas School of Nursing. The discussion explores the integration of competency-based education (CBE) into nursing programs, focusing on initiatives at the University of Kansas School of Nursing led by Dr. Klenke-Borgmann. They implemented the "SimZones" framework, which progressively develops students' skills through simulations mapped to Miller's Pyramid of competency. This approach involves iterative evaluations, such as Objective Structured Clinical Examinations (OSCEs), to ensure students achieve proficiency through deliberate practice and reflective feedback. The program emphasizes transparency in evaluation and addresses challenges like shifting both student and faculty mindsets away from traditional pass/fail grading models. Outcomes from the pilot showed that 100% of students eventually reached competency, and their reflections highlighted the value of iterative learning and the pride in their development.

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Transcript

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[Music][Music] Hello everyone I am Raquel Bertiz from the NLN Center for Innovation in Education Excellence.  And today I'm very excited to chat with a fellow nurse educator and literally a fellow from our  2022 NLN Sim Lead fellowship program and let me introduce Dr. Laura Klenke-Borgmann. She's  currently the director of the University of Kansas School of Nursing Simulation Center and she is a  clinical associate professor of the same program as well. She had published and presented various  works in nursing education such as a clinical judgment, nurse educator competencies, and currently  also a several projects on competency based education. But I really admire Laura's fashion  and work in simulation education. More recently, the work that was acknowledged by the Clinical  Simulation in Nursing journal as article of the year in 2023 was that work on transferability  of clinical judgments learned via simulations in the classroom to clinicals. Yeah, that's right.  The transability of that to their actual clinical practice. Right. So there is so much to talk about  in nursing education and simulations today but I am very interested to learn and I'm sure many of  you are as well, our listeners, about initiatives in operationalizing competency based education  in curriculum and nursing programs such as the one Laura and I will talk about today. So Laura,  welcome. Thanks Raquel. Always good to chat and catch up with you as my fellow fellow. Right.  Yeah. So yeah. So the nursing education has so many questions on how to implement competency  based education and of course the 2021 AACN Essentials so I would start with with these  questions. So what projects or initiatives have you implemented in your nursing program and what  were your reasons for doing so. Well, other than we know it's the 2021. Yeah. Other than we  need to. Right. We need to do. Right. Yeah, well thank you so much and I like I said, I really appreciate  being here. I could talk forever on these topics as you know as well. So one of the things to your  question that we really have been working on and implementing as a new initiative here at  the university, the KU School of Nursing, is we did see the need to increase the presence of  competency based education and competency based evaluation within our simulation curriculum. And  again, like you said, all based on that 2021 AACN Essentials and saw specifically the SimZones  approach as the perfect theoretical framework in which to do it. So last spring, spring of 24 ,we implemented  for the very first time in our curriculum and specifically in our sim curriculum, the  SimZone's approach to competency based evaluation through an SOCE, so an objective structured clinical  examination for our third year students at the end of the, at the end of the semester, at  the end of the year. So I hear a SimZone's approach here and many of  our listeners may know it or may not know it, but I'm curious about it. So can you talk a little bit  more about the SimZones framework? Yes, absolutely. So  originally the SimZones approach was published  by Roussin and Weinstock and then more recently it's been kind of modified for specifically the  nursing curriculum and education. And basically it is a framework that we chose because when mapped  together, SimZones and actually if people are familiar with Miller's pyramid of competency  based evaluation, it's a really strong scaffold for what authentic learning looks like, specifically in  a longitudinal simulation curriculum. So basically, to evaluate what learners can do, not necessarily  what educators teach them or tell them, right. So the SimZones system is an organization for  longitudinal simulation based learning and it's comprised of basically five zones, in which the  authors talked about how there's specific learning goals in each zone. And as I mentioned, additionally,  those zones were mapped to Miller's pyramid for competency assessment. So you start at the  bottom of the pyramid or bottom of the SimZones and you just worry about what your students know  right. So basically requisite knowledge - what do learners need to know from didactic courses,  from their previous Knowledge from readings, to be able to then elevate them through the next zones. So zone zero basically of the SimZones talks about that of just what requisite knowledge  do they need to know. Then after they know, you kind of take it one step up into zone one and  that's basically what they know how to do. So through the lens of SimZones and through the  lens of sim, that's talking about things like you know repetitive deliberate practice of just  like the psychomotor skills. So once they have that requisite knowledge and zone zero you can  move them through the next zone of repetitive deliberate practice. Then once they sort of have  been in that zone for a while you can move them to zone two, which is more contextual learning. So now  we can actually kind of start to throw them into simulation based experiences because they have  that other knowledge from the other zones. But you can still kind of stop and start them and  provide feedback along the way and that's kind of the contextual learning that happens in zone two.  In zone three that's what we think of the type of learning that happens in a simulation where they  start the simulation, they do the entire simulation and then they stop and we debrief them, so there's  not that stopping and starting. This is that traditional, when you think of sim, you know,  stopping and not stopping until the simulation is over. And then the last zone, zone four  is basically taking all of that knowledge that you've accumulated throughout those zones and  being able to actually do in practice. And so this is actually like evaluation that would happen in  the clinical practice setting, in the wild so to speak. So for this project that we did last spring,  we specifically used principles of backward design through the lens of those SimZones that  I just described to ensure that our curriculum met the desire outcomes for our students. So our  focal point was that individual OSCE, a comprehensive evaluation to that we use to assess the clinical  competence of our learners, but worked backward from that through backward design throughout to  create an entire semester long curriculum that moved them through those SimZones to ensure that  they were prepared to be successful in that end of semester OSCE. Yeah so there's a lot of elements  of competency based education to digest from what you just said, so you definitely  mentioned backward design, which is of course, you know, is almost synonymous with competency based  education. But I hear some elements there as well. So in terms of what you said about OSCE, so I'm  thinking, hmm, formative assessments, summative evaluations, right, and of course the simulations are teaching  and learning modalities as well, right. So would you want to expound on how you did your OSCEs, right. Yeah! OSCEs, what were they for and what came afterwards. Yeah, absolutely,  for sure. So to your point of talking about, you know, we kind of covered the topic backward  design already, but I would like to kind of piggy back onto what you talked about regarding like  formative and summative evaluation throughout this process. So as I mentioned, our initial step was  kind of a thorough analysis of zone zero, basically we assessed our students baseline knowledge and  did a preliminary analysis that revealed gaps which kind of  told us how to tailor our instructional sessions accordingly. And next a curricular road map was  essentially created that enabled our learners to achieve the necessary competencies that we wanted  them to be able to do by that end of semester OSCE. So the road map basically included preparatory lab  sessions that aligned with each SimZone framework zone for our learners. So for example, we held an OSCE prep lab one toward the beginning of the semester that we sort of envisioned as being in that zone  one of our SimZone. So that was held one month before the summit of OSCE and it was a two-hour  session that incorporated some small group practice where students focused on deliberate  practice of some of the psychomotor skills that were going to be required later in the semester  in the OSCE. So specifically things like primary and secondary IV tubing setup, doing a physical  assessment, doing ISBAR and a handoff, communicating with the healthcare team, doing safe IV medication  administration. And in these two-hour sessions, in this OSCE prep lab one, in zone one, learners were able to do deliberate practice of those things and received real time facilitator  and peer feedback throughout that session. Then two weeks after OSCE prep lab one, students returned back  to the lab for what we referred to as OSCE prep lab 2. So again we envisioned OSCE prep lab 2 occurring  in that zone two of the SimZones. So this time, this two-hour session for the learners allowed  them to engage in small group practice scenarios designed to mimic what the final OSCE simulation  was going to look like. So students were allowed to kind of pause and stop and ask questions of  the facilitators along the way. And again, the simulation that they actually participated  in was very close to the one they were going to do for their more summative evaluation, but it  allowed them to stop and start and continue to get feedback, so again that contextual learning in SimZone 2. And then what we referred to as zone three involved the actual summative measurement of those  nursing competencies through that individual simulation that each student did at the end of  the semester for the actual OSCE and every student took care basically of the same patient. It was a post-operative patient experiencing some post-op complications. So does that kind of answer your  question about how we moved through those zones to prep them for that final evaluation? Yeah, it  makes sense, right. So if you have the SimZones as your frame for moving your students through  like maybe zero or no knowledge to eventually, oh at the end of this time frame, whatever that time  frame was they need to be able to do all of these things, which of course goes back to our prior  conversation of backwards design, where while in the beginning we need to know where they would  be at the end of a certain time frame, which traditionally for many of us it's a semester  or a trimester, half a semester, whatever that is right. So right. Right and yeah. And yeah interesting.  So and then I would like to circle back to your reasons or your aims for this final project.  Yeah, yeah so essentially we had two major aims for this pilot project. One the first aims was  to evaluate the individual clinical competencies of these third-year pre-licensure baccalaureate  nursing students who were going to be in a primary nurse role while caring for this post-op patient.  So we as the faculty involved created a faculty- designed checklist where the students either did  or did not complete observable tasks that we were going to be looking for and evaluating throughout  that OSCE. And it was the expectation that the learners demonstrated competence for every line  item on that evaluation checklist to be determined quote unquote competent in the OSCE itself. So to be  clear, the final version of this checklist that we designed had four subscales. So really we were  looking specifically at behaviors that would fall into categories of patient safety, clinical  judgment, physical assessment and communication, with obviously required observable behaviors in  each one of them. And so measurement we for every one of these students they came in and did a 35  minute simulation caring for this patient for which we measured then these competencies on this  checklist. And this is this was the interesting part, Raquel. So performance was determined as  either competent or developing competency so to be in alignment and use that same language as  the AACN is putting out for their competencies. And if students were deemed still developing  competency this was not a good/bad, pass/fail kind of evaluation. This was just, okay, great, you know  you're still developing competency. So then if that was the case, they were brought back to the lab one  week later for additional deliberate practice and then did another summative OSCE and this process,  sort of an iterative process, was repeated on a weekly basis as many times as necessary until  competency was reached for all of the learners. And in total this process was completed over a  three-week time frame. So we were able to get 107 of our learners through this iterative process of  you know doing the OSCE, coming back if they were still developing competency, working with them a  little bit more and then having them do another OSCE and it it took three weeks, so not as long as  maybe we thought it maybe would take. That, that's amazing right. So and I hear the words like all  students and like individual students and I also hear certain activities on the end of the faculty  in terms of the creating the road map, designing the checklist, evaluation checklist, determining behaviors. That sounded a lot of work and so therefore and of course like oh three weeks  right, oh were you able to do all of that in three weeks! So I'm curious to know, how did you get this  to work? So your faculty for example, I'm curious about that. Yeah, sure, absolutely. So 100% it was a  lot of work and a lot of work to make sure that we did the process right from the very beginning  right so that we were setting ourselves up to be successful all along the way. And we  definitely gained valuable insight into not only the challenges that we as faculty faced  but challenges that student faced with competency based evaluations along the way as well. So one of  the things I will tell you is that very quickly in the process the faculty recognize the importance  of transparency regarding the evaluation process for our learners. You know, so we made sure from the  very beginning that we provided students with a really clear description of how evaluations would  be conducted. We covered that checklist that I just told you about that we designed. We  covered the checklist criteria with the students from the beginning. I think a lot of  us in education sometimes are a little worried about sort of quote unquote teaching to the test  but I think transparency and competency based evaluation is actually really, really important  and we were transparent with the students at the very beginning of the whole process from the first  day of one of those OSCE prep lab ones. We provided the students the evaluation checklist that they  were going to be evaluated on at the end so they had that checklist through all of those prep labs  and all of their learning so that they were, it was very transparent to them what they were going  to be evaluated on and what competencies we were specifically looking at. We learned that was really  important. We also provided timelines for feedback to students and reinforced that student data would  be used to develop personalized learning plans for them and this message was repeatedly communicated  to students throughout the entire semester so that's the one thing I can share with you that we  as faculty learned really quickly of how important transparency is all along the way for learners in  this new methodology. The other thing we learned really quickly was unlike traditional, like as  I kind of as I mentioned before, like unlike traditional pass/fail or A-F grading  systems, competency evaluations were a new concept for many students. You think about the way they've  learned since kindergarten, right. Good/bad, pass/fail, get a 97% on your test. This shift  and assessment methodology was met with certainly a range of emotional responses from students and I  imagine and one of the ways we sort of came to know this was they also had to once they were  deemed competent in their evaluation we had them watch the recording of themselves doing the OSCE and fill out a guided written reflection. And in that written reflection we heard a lot of comments  from students including stress, obviously anxiety, uncertainty, with this type of evaluation process  because as many time even though we told them over and over again throughout this process this is not  good/bad, pass/fail this is either your competent or your developing competency and we'll bring you  back they still thought in their head when they were told on the day of evaluation that okay  great, you're still developing competency several of them still saw it as, oh I failed, and that was a  really hard hurdle to overcome with their level of sort of understanding of competency evaluation.   So that was really important to us as faculty as a learning piece as well. And so I'll say  despite the faculty efforts to create a really supportive environment, many students still did  equate developing competency as like receiving a poor letter grade and that wasn't the case at  all, right. So that was one thing that, that's a big thing that we really learned moving forward  is how important that language is for this shift in methodology of how students will be evaluated.  Yeah, I can imagine if our students had gone through years and years of our traditional  education and suddenly we're shifting them to this new way of well of course evaluation is  is the biggest I would say component there and I am used to getting a grade, like what you said. Yeah.  Or pass/fail and I can sleep at night knowing I pass, but then right what do I do if you tell  me I'm still developing competency. And of course I can't imagine the cascade of activities that would  happen afterwards to get to my competencies, get competence, but the first thing I would say is the  acceptance of, what do you mean I am not competent yet? Right. Yeah. So I kind of like get what  you're saying there in terms of, oh, let's not forget our students here. Right. Yeah. We're  all very excited about developing our road maps and curriculum and yes we have a nice well-written  program here but what about our learners right. But okay, so let's circle back to your faculty  though and I heard earlier that you said that the faculty understood the importance of this  process. Yeah. So what about the learning curve of faculty, if there is such right. Yeah. Yeah. No,  absolutely, and you know I will definitely call out my team that I did this project with.  They were fantastic. We were, you know, always in tight communication. Communication  and collaboration throughout this process was huge. And I think it's in beyond just  your team of faculty. You have to think about the faculty at large as well, right. And so you know  historically OSCE were oftentimes thought to be these very like high stakes pass or fail type of  competency evaluations. Exactly. Because that's what we went through. That's right, right. And so  I guess my question to that and my little push back to that is - do they have to be, right? To  better capture the essence of competency based evaluation I think we in nursing education should  maybe consider reimagining quote unquote what an OSCE is, right, to include iterative coaching and  several opportunities for learner success like the approach that we did in this project. And so  I think that's one of the things for faculty development at large, not just obviously here  at my institution but at large is it'll also take a little bit of retraining the way we  think about some of the ways that we evaluate in the past right. Right. And to our listeners  I would like to kind of like point out what you said in terms of transparency of learning  and how it goes in contrast to our traditional belief that we should not be teaching to that  test. Right. Which is why not. Right, exactly. So if we're testing them we want them to be able to pass  the test, but of course not to take it literally to teach them what's in the test, but what  should we be thinking about as educators for our students to get there successfully get there and  and then of course, again, I'm not sure if the is the professional culture in nursing and of  course I digress a little bit, but the anxiety and fear of learning which occurs so often. Yeah.  Right. Right. In our, I would say, roles as faculty and future faculty development initiatives, I think  we should also be taking into consideration a kind of like reflection at our own culture  as teachers, educators, and faculty and I think that's a huge element of initiating any change,  which we often forget because we dive in, right, into oh this is what needs to be done, but like we  leave ourselves alone for introspection which is necessary. We would like to be conscious of  our time boundaries here and I know that this conversation can go on and on and it will. We  will end this part one now with the conversation of CBE and simulation based education. Thank you  for your time and we hope to see you in our next episode. Bye for now and see you in part two.[Music]