Navigating Competency-Based Education through Simulations in Nursing Curriculum – Part 2

In part two 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] Welcome back. Last episode we talked to Laura about competency based education and simulations.  Thank you for your time and listening to part one. So now let's continue our conversation  with Laura. I want to know some more so in terms of your plan implementation. So I hear  that this is a successful process so far. So I want to know what were the the enhancers? Yeah.  Yeah. Well, like as I mentioned, really tight teamwork and communication between all of  the faculty that were involved from creating that faculty designed competency checklist to actually  creating the simulation itself for the OSCE, you know, ensuring that all of the Healthcare  Simulation Standards of Best Practice were used, from the way that we communicated and being  in lock step with the words and the language that we use to students, you know. You can imagine if  that if you had a bunch of faculty on different pages not using this sort of same shared mental  model and giving students throughout this process different messages or saying different things, you  can imagine that you'd be in a mess. Yeah. And that's that's so important that the faculty  was truly in lock step. We were really supporting each other and making sure that we were consistent  with everything that was happening along the way because if not, that creates a mess and  then you start to lose student trust and student buy-in the situation. So huge call out to all of  my...all the faculty who were on the team. That was never the the case and because of it, it was  definitely an enhancer as you asked. And then again, the other thing that I would add is the  transparency to students all along the process. I think everyone involved did a great job with  that as well and again, that really helped, with even though students, this was new for students  and this evaluation process was very different for them, as I had mentioned a little a few minutes ago,  the fact that we were as transparent as possible did indeed help with trust from the students. So  that was really key, for sure. Right, so I was thinking about that as well. We need to have  the trust of all stakeholders so to speak. Yes And our students for that matter. So what about, and I hate to kind of like point them as barriers, but did you  encounter any barriers to implementation because I'm sure our listeners was like so how do you  navigate those right. Right, right. And you know, as we kind of have talked about already one  of the biggest barriers was like, I said before, getting both students and faculty to change their  mental models about evaluation and about iterative learning, right. And so, you know, competency based  education truly, the true essence of it is about what the learner can show us, what the learner  can do. Not...so basically it's about the output, right? What can they do not about what the input is,  not about what we're telling them or teaching them, but what they can actually show us. And so identify  strategies for students who may move at different paces within the curriculum requires using  different or additional resources for mastery or for competency. And so when student pacing does  vary and making that personalization of their process attainable for them, that can  certainly be a barrier. That takes time, that takes resources. When you're thinking about students not  all moving through the curriculum or through that continuum at the same time and at the same pace.  I love that about competency based education, but it definitely can be a barrier because it  is increased time, increased resources that that need to be applied for iterative learning. And  then the last thing I would just say is, again, we've said it already, but a barrier can certainly  be moving away from that mental model of good, bad, pass, fail way of thinking about evaluation  both for student students and for the faculty as well. And from what you said and I  I don't think it's only going to be in your program that we would encounter the similar  barriers, but all across nursing education in terms of implementing CBE. And in our  traditional..I would say educational environment of being tied into semesters or quarters. Yeah. right.  Or even credits, right, or the confines of credits and then the process of development  may not be the same for all students and therefore what would be that cap that we  would put in there in terms, oh time's up, or even going to be putting times up and there are all  maybe conversations happening all over the country as well. I can imagine that and  definitely we're going to be looking for forward to your articles later on in terms of these are  the barriers and these are potential solutions. I would be excited to hear that from your  team eventually. So for you and your program, what are the lessons learned from this  experience? Yeah, well so many. Let me start with the top the top few. The language used  to explain competency based education and evaluation to learners is really important and you  know I think you said it before as we were kind of starting out here today was gosh, we know that  competency evaluation is the way to go and you know we've got a lot of guidelines through the  AACN with the new Essentials and the competencies, but I think what we all need to consider is  that even with really clear, you know, once we start to develop really clear road maps and really clear  curriculums based on the essentials there is indeed a ripple effect of what that actually  means for understanding. So there's going to be some increased development needs for faculty and  also for students. It's not, you just create these road maps and hit play there's a lot of ripple  effects about what that means for students' understanding of how this works and how this  plays out. So that's the one thing is that the language that we use is going to be continue  to be huge moving forward. It's also essential to emphasize as we continue to grow in our competency  based education to students the importance of students keeping details of their competency based  evaluation experiences confidential from their peers. You know, if you think about students  going in for increasingly more simulations or some type of experiential learning where they have to  demonstrate their competencies we have to make sure that the evaluation process is consistent  and that students who do like let's say an OSCE a couple of days before another student doesn't  share with them the details of the case or the evaluation preventing obviously undue advantage  for students who take OSCE, you know, a day or so later than other learners. So I think that's also  something that we really need to consider with this kind of move to more experiential evaluation. You're right, so a lot of thoughts there in terms of really challenging the traditional or  old ways of us educators doing things and what I get from this conversation, in this later part,  is really the the evaluation piece of it right. Yeah. How do we evaluate students and OSCE and the  traditional way we do OSCE. Is there a room for change or changes, modifications and so on and  so forth. So. Yeah and consistency is a huge thing. It's almost similar to us deploying  written exams and how do we make sure that those exam items don't get out and provide and undo  advantage to others. And it really challenges the validity and reliability of our testing tools.   One thing that I'm also thinking as you talk about checklist and evaluation tools would be,  like eventually, would we be, in nursing education, be able to produce like standardized tools   to measure these competencies that we want for our nursing students to be professional  nurses? Because I know that, and, well, we're all on the same boat here. We design our own checklist.  Yes. But then we expect all our graduates to practice in the same professional environment  later on. Right. So why is there a need for us to have like all different checklists? But I  truly understand also variability of curriculum and context and so on and so forth. So eventually  I think the balance .. where's the balance there? Yeah. With that, I get to my next questions of  so what are your next steps for your curriculum, for your... Yeah. Could you like talk a little bit about faculty  development and what to consider there. What are your thoughts on these? Yeah, sure. So you know assessment in  competency based education you know should be planned for the program as a whole, right, so  not just one semester. So yes, we definitely piloted this sort of SimZone's curricular approach across  the semester just as a pilot but definitely 100% I see the value and basically the necessity that  assessments like this and this sort of curricular road map needs to happen across an entire program,  not just a semester. This avoids obviously focusing the assessment on just a few competencies in a  course, which could lead to potential gaps in assessment, gaps in the curriculum, and failure  to address development of proficiency across courses and experiences. So I think you know  the lessons that we learned from this pilot in one semester we can now begin to extrapolate  across all of our semesters in the entire program. And just ensure that basically I mean,  in my, in my vision, you could essentially create a simulation curriculum like the one we did  in this semester and every semester where you start at SimZone zero and you work the learner  up through SimZone 3 and every semester all the while keeping in mind that with every semester  as you march forward you kind of level up right. So you kind of every semester you're sort of starting  through the SimZones with the understanding that you're starting at a higher level every time if  that makes sense. Yeah. Yeah. I can imagine what you're saying in terms of well, you can all you  can actually apply the SimZones framework not just for a course, but for the entire program. The entire  program. And in essence I'm also thinking you can actually backward design the entire curriculum  as well, right. Right. So and then like intersperse your simulations and your OSCEs all throughout  the semester and have a broad overview of, okay. And you be able to give that to the students and  say this is our curriculum, this is your curriculum at the end of your program you're gonna get there.  But how. Yes. Right. That would be. Yes. Exactly. Exactly Raquel. That's what I'm talking about.  That would be lovely right there and the students would like have this one pager of like, oh, where  would I be at the end of this program, right? The essentials. Right. So the essentials and goals  of this backward design. Right. You think about the essentials and you think about the 10 domains  and the eight concepts that you have to you know make sure that your curriculum gets aligned to. And  you know, as I talk to other educators and as we start to think about redesigning curriculum based  on the the concepts in the domains of these new essentials, you know, one thing I hear a lot from  a lot of educators not just at my institution, but just friends throughout the  country, colleagues that I know, is gosh, you know, every one of those domains has competencies and  subcompetencies underneath of them and how will we ever be able to evaluate each one of those  item subcompetencies? And of course that's a challenge and that's definitely be a way we  have to rethink the way we do things, but one of the solutions that I think is that through  these kind of experiential simulations at the end of a semester or at the end of a you know  a period of time in a curriculum, my goodness, you can bundle so many of those subcompetencies into  one simulation. Right! So you do a competency based evaluation at an OSCE at the end of the  semester, at the end of the program, there's a lot of those line items of the checklist that can be  those subcompetencies that you're banging out 10 competencies in one experience for students.  And I think that's one way we can kind of get a handle on all of these subcompetencies is bundling  them into these experiential simulations in which students get evaluated in. And yeah, right, and that  shows us the value of simulations in CBE. Right. And we're talking about learning. We're talking  about evaluation. We're talking about what would be best strategies to do all of these. We're  looking at a solution that is being presented to us right now which is simulation based education  and really I think moving forward it's really about like well how about we plot our curriculum  according to the SimZones, right. Right. Right. Right! And that's what I love about the SimZones you  know. And that it's also really aligned with if people, like I said before, if people are familiar  with Miller's Pyramid of moving through those levels of competency of knows, knows how, shows,  and then shows how and does. And so it's like, yeah, we can't expect our students to just go  do if we didn't work them through those levels and those zones of learning and of competency.  So it's a great framework to really kind of start to organize your thoughts about curricular mapping  and getting students ready for competency. Yeah, so I can see you and your program doing a lot more  work in the future, right. And then finally one more question. So what are the students outcomes  though of this pilot project? So I'm curious about that. Yeah. Yeah. So I'm really excited to talk a  little bit about that and share what the student outcomes were. So as I told you, it really took us  three rounds if you will to get all of these 107 learners through this competency based OSCE. So  you know to be like, I'm really excited to share that around 64% of the students after working  through these SimZones and these OSCE prep labs were competent upon their first summative OSCE and I can  tell you the most kind of critical items that were missed during that first round that would have  someone come back and have to do a second OSCE were things like errors in their physical assessment,  demonstration errors, and safe med administration and then like communication like missed parts of  like performing an ISBAR or a handoff. But by then, so again, of those 30 or so percent of  students who didn't reach competency in that first round, they came back they had some more deliberate  practice and we did another OSCE with them. After that second round, 92% of the entire cohort were  competent. And then again if they weren't, we had them come back we worked with them,  we practiced with them, and they did a third. And by the third round 100% of that cohort were competent  after that continued deliberate practice and their third summative OSCE. And then as I mentioned, we  also did once they were competent, we had had them watch the recording of themselves and had them  fill out a reflective worksheet about asking them questions about clinical judgment  questions, you know, what did you notice about your patient, how did you interpret that, what  did you do about it, how did you reflect on it. We also asked them questions of things like  what have they learned about themselves throughout this process, what will you take with  you into your future practice? And we really saw three major themes that were identified when we  after we got done reading all the students sort of post OSCE reflections. And it really was, they  they were very proud, which was really cool to see, especially after their apprehension of this whole  competency based journey. They were really proud to watch themselves and see how far they've come  when watching their recording. They could see and have a desire to still continue to  refine nursing skills, so they could see they still had ways to go in terms of their growth but were  very proud of themselves. And then lastly, they did see the value in competency based education.  They saw the value of that iterative process of... this doesn't have to be a one and done, I have to be perfect the first time. I have to get everything right. They started to come around to  see the value of that iterative competency based way of learning so that was really cool to see,  especially after some of the apprehension and some of the difficulty at the beginning of the  process with them quite not understanding. "Now we're doing what and how many times can I try  to take this OSCE" and you know all of those kinds of questions. It was cool to see them come it all  come together in those reflections of like, oh good. They're getting it. They understand  what this process is supposed to be about. And it is really supposed to be about the  the optimizing learning for them. So that was cool to see. Right and it's really an effort to shift  our students' thinking of valuing learning for learning sake. Yes. Well said. Rather than  a grade, which goes to my next question and I know I said last question, but I just got to. So how  will their transcript look like and I'm just like, oh, you know how we're transcript based,  GPA based. So how will this translate in transcripts? Well that's a great question and I think that's  still something that we all need to in nursing education kind of make those decisions and decide  what that will look like. I mean, I can tell you in our specific example for this pilot in our program  in our current curriculum, all of their simulation experiences occur sort of under the umbrella of a  clinical course so all their simulations happen in the same course in which they're going out into  clinical and we have a very sort of pass fail kind of evaluation for our clinicals. They don't  necessarily get a number grade for their clinical courses. And so for us, it just kind of tied right  into that, that we would just ... it was just going to be basically competency for the sake of  competency sake and it wouldn't necessarily be tied to a course in which there was a grade in  the first place, if that makes sense. Right. Right. Right. And eventually I'm imagining  that even our courses that are tied to number grades so to speak would eventually kind of like  shift towards the idea of competency based because as I listen to you and you're talking about like  competency development of that 64%, I'm imagining all of these competencies had to be tied up with  prior earlier zones, which required knowledge. Right. And that's right. Those basic knowledge are  learned in like lecture courses. In your grade based courses. Right. In your grade  based courses. And therefore we cannot just take it off in simulations without having to kind of like  link our students and them realizing that this is not an isolated event of learning. This would  be the culmination of all the other courses that I have taken previously. Yes, very well said,  So when when we finally get that all together as educators and our students will understand this is  not one thing, that's not another thing, these are all in the same I would say container for lack  word. Yes. Yeah. Yeah. So exciting times in nursing education! Definitely so and I'm encouraged to  know that many educators like you Laura are facing the challenges of transforming nursing education  as well but leveraging these challenges with what we have, simulation education, technology  Innovations, right. And of course let's not forget developing the competencies of our faculty  as well. So thank you very much for this time today. Yeah. Yes. Absolutely. This was great.  I really appreciate the opportunity to share. I think the more that we can share and the more  that we can not keep what we're all doing at our own individual institutions quiet, but rather reach  out and share and talk, the more we will learn about each other, the more we'll learn about other  tips and tricks that other people are doing and as you were saying before, the more that we  do this and the more that we share this knowledge, the more we'll be able to get a little bit more  consistent in our approaches and kind of start to think about ways that we're not having to recreate  the wheel at every institution, but rather kind of learning from each other about what works well and  refining those approaches and those methodologies. So yeah. And I do in that in the spirit of that,  I do want to share that we'll have a publication on this entire process currently in  press right now. So that'll be hopefully published really soon for people to actually be able to read  a little bit more in detail about basically the the chat that you and I just had Raquel. And do you have a title that we can search for that article? Yes, yeah. So the title the title of the article is  going to be the SimZones Approach to a Competency Based Objective Structured Clinical Examination.  And it's going to be published in Nurse Educator. Oh perfect. That's where people can find it  shortly. And I also want to do a a call out to my co-author so that'll be out there very shortly  in Nurse Educator right. And again, kudos to all your team and faculty as well. Oh yes, yes.  It truly takes a village and I'm very blessed to have a great village because this makes all the  difference in the world when you can be consistent and on the same page. And also, just really honestly,  the team that put this, that made this happen not only were we consistent and collaborated well,  but people were really excited and passionate about it as well. And that makes a huge  difference so definitely want you know all of the faculty who played a part in this process  last spring to know and hear how much it's appreciated and what a huge difference it makes.  Right, right. And calling all administrators to make sure our faculty are motivated and  passionate about the work that they're doing for nursing education. And so with that, we would  like to thank you again for joining us. Until the next episode, and bye for now. Bye bye.[Music]