Competency-Based Education in Action: Rethinking Clinical Learning

In this episode of NLN Nursing EDge Unscripted, hosts Drs. Kellie Bryant and Raquel Bertiz are joined by Dr. Rose Rossi and Dr. Stephanie Jeffers to explore leadership and innovation in nursing education. The conversation centers on competency-based education (CBE) as a framework for rethinking and redesigning clinical education in undergraduate nursing programs. Drs. Rossi and Jeffers discuss how clinical competencies are defined, assessed, and aligned with program outcomes to better support student readiness for practice. They highlight the role of academic leadership, faculty collaboration, and data-informed decision-making in advancing competency-based approaches. Together, the discussion offers practical insights for nurse educators seeking to modernize clinical education while maintaining quality, consistency, and meaningful outcomes.

For additional insights on Widener University’s approach to competency-based clinical education, visit Dr. Stephanie Jeffers’ faculty page on the Widener University website, where her contact information is available: https://www.widener.edu/about/faculty-directory/stephanie-jeffers.

Dedicated to excellence in nursing, the National League for Nursing is the leading organization for nurse faculty and leaders in nursing education. Find past episodes of the NLN Nursing EDge podcast online. Get instant updates by following the NLN on LinkedIn, Facebook, Instagram, Bluesky, and YouTube. For more information, visit NLN.org.

Transcript

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Welcome to another episode of the NLN podcast, Nursing EDge Unscripted. We are your hosts for today's episode. I'm Dr. Kellie Bryant and I'm joined here by my colleague, Dr. Raquel Bertiz from the National League for Nursing. In this episode, we will be talking about a very hot topic and a timely topic. Nursing education's continued drive for excellence and competency based education. And this conversation is going to focus in particular on clinical education. Before we dive into the full conversation, let's share some of our reflections right after the taping. We're always looking for practical solutions on how to operationalize CBE and obviously from the conversation they do offer like the concrete steps. So how do you do this? Yeah, that was a very, very informative podcast. I really enjoyed speaking to Rose and and and Stephanie. What I loved about it the most was that when they started talking about the process, you know, it wasn't that they just jumped into creating this tool that the fact that they had this two-day workshop where they kind of mapped out their curriculum to figure out which competencies or outcomes belong in whether it's didactic, clinical or simulation and then were able to come up with, you know, the the the behaviors and and this this tool. I think that was an important first step and the fact that they also involved faculty. the faculty kind of owned it and then even had student input. I thought that was a great way of making sure that, you know, they got that buy in, right? I like their emphasis on involving clinical instructors and that clinical instructors are are vital to any nursing program implementation and how they need to be prepared. And and I think that brings us back to many of our issues with clinical instructor preparation where we ask them to okay go ahead and swim and but also yeah it also gave us a new perspective on how to conduct clinical evaluation because let's face it a lot of us you know at our universities have this this long, 10 page tool with the med partially met and all these outcomes which are like they were saying are very broad you You know, I love the fact that now it's based off of competencies and students add their input and they're able to identify, you know, the behaviors that met that competency and they have an input along with the faculty. So again, having more of that student centered focus, I think, is is where we need to move when it comes to clinical evaluation. So, it's nice to have a new model, a new way of thinking, approach to clinical evaluation because I do think we've been stuck in our our old ways. Let's turn from our reflections to the experts driving this important conversation. Our guests today are from Widener University School of Nursing who have developed an innovative model in which students use a competency-based clinical evaluation tool each week as part of their clinical evaluation. Our guests today are Dr. Rose Rossi, Professor Emmeritus, and Dr. Stephanie Jeffers, associate dean of undergraduate programs at Widener University School of Nursing. I want to welcome Rose and Stephanie. Thank you for joining us today. Thank you for having us. Thank you. All right. So, I'm just going to dive right in and start with tell us a little bit about how you came up with this idea to start this competency based assessment in the clinical setting. Give us the background on that. Well, I think first the first thing that we realized at Widener was we wanted to get all of the faculty buy in as we were moving to the new AACN essentials. So this really started by us having a full faculty meeting at workshop where we laid out all the domains and all the competencies and the all the sub-competencies and we asked our faculty to a map where all of these occurred in each of their courses and then so that was sort of part one but part two then we said what does this look like? what does this look like for your students based on your courses? So asking faculty to really begin to think about this in from a competency perspective as opposed to just a knowledge perspective I think was a good jumping point and Steph could really talk about her own course which is where she did a lot of this work. Well, I would like to say that when Rose said that we mapped everything out, we literally mean mapped it out. There were poster boards, papers, we had Post-it notes so that, you know, we could tag different areas, different domains, what goes with which competency. And the faculty would write down on each of those slips of paper behaviors that were associated with the competency that they would expect students to achieve competency in by the end of the semester in clinical. As far as the courses at the time, I was faculty in both junior level and senior level medical surgical nursing. And so with our faculty that t taught in those courses, we came up with behaviors that were associated with each domain and then posted them on all of the corresponding areas on the map. The other thing that was really nice as we did this is that we broke out which of these behaviors would we want to measure in clinical in simulation and which of these behaviors would we measure in more objective ways objective testing. So having faculty really begin to break that down I think helped put it in perspective for them and then for us. So that was really step one. What this did, I think, was help the students then own that that this behavior, these behaviors were theirs to create and theirs to develop. And it wasn't, I'm just going to sit back and be a sponge. It was, oh, I now have to seek out opportunities to try and meet this behavior. And I think that really helped engage the students in a way that were sometimes a little more passive than we would have liked them to be. That sounds very interesting. I'm I'm sure I'm pretty sure that we're always looking for more student engagement and from what you've said, it sounds like a lot of things you have done to get to where you are right now. So I'm curious what were your biggest challenges with implementing this new approach? I would say the biggest challenge was educating clinical instructors. So we had to present it to them as a new instrument and let's be honest everybody has difficulty with change. So just providing that education and saying look this is how we're going to measure competency the and then we provide examples under each domain. So for example, if somebody needed to meet interprofessional collaboration competencies, how did they interact with inter the interprofessional team? Did the student describe interactions in the clinical setting with the patient? And so we just had to provide that education to the clinical faculty and myself, I was a course coordinator for junior level medical surgical nursing when we implemented this instrument. And I provided a lot of support because sometimes the clinical instructors weren't sure if they were doing the right thing or providing the right feedback to the student. How are they evaluating what the student is writing in their instrument weekly? So at the beginning it was a little difficult but they sort of picked it up pretty quickly. And the students also I will say initially they were focused on tasks and skills. Today I did a Foley insertion. Yesterday I took vital signs. Whatever the skill was, they were mostly focusing on that. But with some prompting from the clinical instructors, the students began to really reflect. So when you're reflecting, you're thinking about what you're doing. You're not just doing a skill. And by the end of the semester, I could really I would read some of these clinical evaluation tools just to make sure that they were completing them correctly. And it really seemed like the students had pride in what they were doing now because they're like, "Oh, I did this for my patient. My patient had difficulty breathing and I assessed them. I changed their position or I talked to them if the patient was having anxiety and it seemed like they were really more invested in their education as far as completing behaviors and thinking about what they're doing at clinical. The other challenge we had which I think was interesting and we didn't quite anticipate this was the use of technology in our learning management system because ultimately what we wanted was one document where students could see their progression each week. And that was really difficult to do because we wanted one document where they could write their, you know, under their behaviors each week or under each domain each week what they did so they could see it and then faculty could comment. And we couldn't quite get there with our LMS. So, we ended up having to be a little bit more creative in how that happened. Because we wanted our instructors to be able to say, "Oh, on week one, this is what the students said when they addressed this behavior and on week 10, this is what they said." And you could see the growth over time. So that was a little bit of a challenge that we tried a couple different things and and we were doing those things even before we rolled this out. So we had a number of our faculty who were clinical, you know, who were the students and I was the instructor and we'd be like fill this in and let's see how this goes. So I if I had my wish I would figure out a different LMS system where this might work a little bit easier. But I think what we have is workable and usable and we're not changing our LMS anytime soon. That's for sure. Yes. So you just described a beautiful student centered approach to learning that the students are active in, you know, assessing where they're at and how they're meeting their clinical outcomes, which I love. One question I have is a little bit more specific about the tool. So, can you tell me a little bit more about what this tool looked like and how it was implemented? Meaning, did the students fill it out first and then the faculty kind of make comments to it, you know, after the clinical day? And and my other question is, and what happens at the end of the semester where there may be some gaps where the students weren't able to, you know, demonstrate a certain behavior? How did you address that? So, the students needed to complete the clinical evaluation tool where they would address one or two domains per week. Obviously, you're not going to meet all of the domains every single time the students in clinical. So one or two things that really stood out to them and so they had to reflect on what the behaviors were that were required or suggested for that particular domain, write some examples, and then the clinical instructor would then provide feedback on that. And there's a little rubric in the in the learning management system that says meets expectations or, you know, needs improvement, that kind of thing. So if the student was too short with their response or they didn't provide a lot of detail, instructors would encourage them to do so for the next time. Or sometimes it ended up being more like a discussion post. So like there was conversation back and forth with the instructor and the student. It was more than the instructor just saying,"Hey, great job." It was the instructor sort of reflecting back on the student what the student achieved and identifying those skills and behaviors that were required for that particular competency. And if there was an area where maybe the student get a lot didn't get an opportunity but for example they never encountered an ethical dilemma. The instructors would then say, "Okay, you didn't encounter an ethical dilemma, but what would you do if?" And then they would give them a scenario or a situation and have them reflect on that situation. And that way we weren't saying, "Oh, well, there were no ethical dilemmas that the students encountered, therefore we're not going to address this domain." They provided them, you know, scenarios or opportunities to then discuss what would you have done if this scenario happened or you know what would you have done if you thought the nurse was giving the wrong medication? What would you have done if this event happened? And I think even in the feedback which the instructors were wonderful in is they would they would say okay so you talked about this what would you do next time to further expand what you did and giving students an opportunity to really think about those things differently and say okay well okay you did this this is great this was a great start what's your next step what would you do after that allow the students to really begin to think about how they will continue to grow as a professional nurse. That sounds really interesting. And I think I was going to ask you this question but since you started on that note my curiosity is all about because you're doing this competency based evaluation and use of the clinical teaching tool. How has your clinical teaching kind of like expanded if that's the right term for that or or shifted? So, because we're evaluating them this way, I'm curious, so how are we teaching them now to get there? I think that clinical instructors are doing more debriefing with students now and encouraging reflection to assist students with identifying areas of strength and areas where the student might have to improve. And I think that is helpful to have a dialogue with the student because you're encouraging them to think about the rationale for their interventions or the rationale for particular assessment. And that is really kind of the key to the competency based education is you're doing more thinking than doing tasks and skills. So I think that this shift is more having more conversations and encouraging more reflective thinking with the students as far as the clinical instructors go and to and to add to what Steph is saying, you know, one of the big struggles that clinical instructors often have is they don't want to upset a student by, you know, giving them poor feedback and they don't they're not always comfortable giving giving that constructive feedback or they don't quite know what to say. When a student has written something down like that and they have something to work on, it's much more collaborative. It's not, oh, me as the clinical instructor saying you didn't do a great job. And I think it's helped our clinical instructors be more comfortable in their role when and and they're great practitioners and sometimes what happens is you have an amazing nurse and now they've stepped into that clinical instructor role and they're trying to learn that skill set of how to be a strong clinical instructor. And this gives them the opportunity to learn how to provide feedback in a way that's positive and constructive and collaborative and doesn't feel negative and punitive to the student because we never want a student to walk away feeling like, "Oh my god, my clinical instructor thinks I'm not smart and I'm not cut out to do this." And the instrument, I think, really helps that collaboration in a way that we didn't have before. other our other tool was truthfully you know did you exceed you know or meet or didn't meet like this behavior and then the other thing that we did because these behaviors make sense and I'm going to be totally transparent our prior clinical evaluation tools were so vague apply the natural social and sciences and humanities to the care of the patient And the instructors were like, "What does that mean? How do I evaluate that?" And now we have an instrument that's very clear like we have very specific behaviors we expect our students to do. And so now they understand what their role is. The other thing I think that was really helpful in this when we met with all the faculty is that we were able to scaffold behaviors in a way so that we weren't double dipping. So and it was helpful in particular in Steph's situation where she was in junior med surge and senior med surge. So the behaviors for the junior students were different than the behaviors of the senior students. And because of that, we could see the growth over time. And we're very fortunate at Widener, we were not in an environment that was very much a top down. Everything comes from the dean rolling down. And because of that I think engaging the faculty in this really made the difference because without engaging the faculty this would never have happened. Well we all worked together during that workshop and so doing that together as a team the faculty now own the clinical evaluation tool especially for their particular specialty area. So they have the input into it and so they know that this is something that they have helped to create and so I feel like that helps them but that's the buy in to have people involved they'll be more vested in they'll be more likely to to implement it. So the fact that you went to the faculty and had to develop it that was that was great and also I love the fact that you involved students too because it sounds like you even had the student you know buy in. So if you ever want to implement something, yeah, those are the steps. And we were really lucky because our sim faculty came, right? Then they got and and I also have to say, you know, we have several of our faculty teach across undergrad and grad, but we have a significant number of faculty who just teach at the graduate level. and they came to the undergrad meeting with us to kind of give us support and come up with suggestions and help people who were struggling of writing you know objectives and you know behavioral outcomes. So I think what Steph is saying is right that whole team approach you know it made it better and I was in Steph's role before Steph was in it and I don't want to be the person being saying this is how you have to do things like that was just never my approach. So I loved the collaborative experience and I have to say by the end of day two we were tired. It was exhausting. Yeah. I was I was going to ask you cuz when you talked about the process, how you mapped out everything to say, you know, which outcomes are met in simulation, didactic versus clinical, how long did it take you? This was like a two day full day. It was two full days. So the first day we literally were mapping out where things were and then we were writing objectives that we were going to use in our syllabi. Right. Right. And then day two we were then developing the behaviors everywhere where we said, "Oh, this lives in clinical." Then day two, we were writing the behavior. So by the end of day two, we were all pretty done. And this was at the end of the semester, right? We were done. Yeah. We were like,"All right, we're done. We've had Excellent." So I believe when we had a prior conversation, you have just started this pilot. Was it this summer or last? Yes. So tell me now that you have you know a few semesters under your belt using this new model. What were those aha moments? Was there anything that surprised you whether it's you know logistically how you rolled this out or when you looked at the data from this you know the valuations was there anything that kind of you know surprised you that you weren't expecting? I would say for me it was reading what the students were writing. Over time it became more detailed, a lot of depth, a lot of emotion in it too. Especially if they were dealing with situations that were challenging such as, you know, the patient was a rapid response or somebody there was quite a few students that had patients that were aggressive or you know there was safety concerns with the staff and so they really addressed it in a very professional manner and I was happy about that. thing, but also like the way they reflected on what they thought they needed to do as far as interventions or doing assessments really showed me their growth over a period of time. So, I was pleased with that. This semester over the fall we have all of the specialties and meds surge doing their own clinical evaluation tools. So the specialties tweaked their own examples for competencies or they use the same domains but the examples would be different you know for maternity or pediatrics. So I'm waiting until finals are over to review all of those. And I've required requested feedback from faculty about is there anything that we need to change in the language of the document? How did it work for your clinical instructors? And so that we can move it forward. Well, yeah, all of this really sound exciting and so if you could leave your our fellow nurse educators with one takeaway about competency based clinical education, what would it be? I think actively engaging the clinical instructors. They're our biggest assets and we want them to feel like they're a vital part of everything we do. And I think by actively engaging them in this process, they feel like they're our partners now and not just this, you know, group on the side. Steph, what do you think? I would say focus on thinking not just doing because competence is about clinical judgment and not just tasks or skills. Oh, what a wonderful way to to end our podcast. I can't believe the 20 minutes went by so quickly. I feel like we can go on and on on this topic. So, I want to thank you both Rose and Stephanie for such a wonderful conversation on a very timely and important topic. I again want to say thank you for joining us and sharing your innovative approach to evaluating in the clinical setting. And for those of you that are joining us today, thank you for listening to our podcast and we look forward to you joining us on our next podcast. Thank you and take care. Thank you.