Week 6: Follow Up to my Gift

Jules, You are right that I focused on how to assess the competencies, as that was part of my posed question I’ve been pursuing. I assumed that the lecture halls and labs for base knowledge and actual supervised client contact would not change in teaching, based on my proposed competencies. For the methods, I was assuming assessment, planning, intervention and evaluation were all to be modeled and taught, then measured against competencies for achievement. You also asked how I will assess professionalism and accountability. Professionalism is measured by following the policies, procedures and regulations set out by the health institution, the university and the CNO; it is also dress and hygiene, considerate language, behaviours showing respect for clients and other professionals and adhering to the Canadian Nurses’ Association, Code of Ethics document.

Ahmed, I could not find your commentary on my blog– sorry!

Anna, You asked how nurturing can be taught, where and how is it assessed. Although I consider nurturing to be more pronounced in some people, it is the role of the scholastic nurse educator to not necessarily engender this in students but to help make it overt behaviour within socially acceptable manners. I agree with you that professionalism does include ethics. Thanks for the CBC link!

Beth, Nurse leaders in Ontario at the time developed the CNO competencies, but I'm not sure when they initially came into existence It is interesting to consider the political climate at the time, as it actually was when nurses were lobbying for more rights for self regulation and autonomy in delivering health care, separate from physicians. You asked how I propose to assess nurturative behaviours and those are typically measured by attentive listening, open body language, hand holding, brow soothing, hugs, encouraging words, teaching behaviours and hand over hand guidance.

Thanks for all the feedback, Prof Potter. I want to address a few points you brought up. Bevis' theory includes the ideas of nurturative interventions (=nurturing), protective, which you equate with ethics and the third is generative interventions, where nursing attempts to stimulate growth and improvement. In the affective realm, protective nursing behaviours would certainly include ethics, such as the rights to privacy, confidentiality and self determination in healthcare decision making.

Regarding "competencies that reflect public service and professional self regulation," these would include lobbying, registration and licensing, ongoing education through reflective practice and discipline of errant members.  "Ethical practice" is stipulated in a document called the Canadian Nurses’ Association (CAN), Code of Ethics which defines ethical nursing practice.

I believe accountability is "necessary" in order to preserve client dignity, promote and improve health and ensure safety of clients. I agree that not all areas of proposed competencies overlap all three learning domains and you came up with the ideal argument (basic anatomy) for that!

You also suggested that I should be careful about the implications of tying professional practice to "evidence-informed ideas". Professional nursing practice has been closely tied with evidence! In order to “do” nursing in other words, practice it, the choices for action should be evidence based, thus professional nursing practice should be grounded in evidence wherever possible. This shift in nursing circles from the term “evidence-based” ideas to “evidence informed” opens up room for creativity and critical thinking and unique solutions for individualized problems.

Week 5: Gift of a Challenge...What no competencies?

My “gift of a challenge” was: “Say my discipline didn’t predetermine the competencies graduates are supposed to have, what competencies would I choose, why those particular ones, and how would I help students learn them?”

            For a starting point, I refer to the College of Nurses of Ontario’s mission and vision statements: “Our mission is to protect the public’s right to quality nursing services by providing leadership to the nursing profession in self-regulation;” Our vision is “excellence in nursing practice everywhere in Ontario.” The National Competencies document describes that quality care as being “safe competent and ethical”. There are 123 competencies that must be met for ongoing licensure.

            I would choose competencies that meet the core reason for the existence of nurses, premised on Em Bevis’ theory. A nurse’s role is to provide care in preventative, nurturative and protective ways. Any behaviours that reflect safety, nurturing and ethics would be a start for measuring competency. By also using the foundational systems theory of care, those 3 levels of care can be applied to individual clients, families, communities, nations and global health care.

            I would initially choose competencies that are more directed to the traditional role of bedside care, promoting preventive behaviours in clients and protecting vulnerable clients, all from a holistic viewpoint of bio-psycho-social-spiritual health.

            Safety competencies are the 1^st level competencies required in order to prevent errors, accidents and psychological harm. Student must demonstrate the ability to apply safety considerations and rules, plus establish trust in therapeutic client relationships. This is similar to the Hippocratic oath physicians are encouraged to adopt, essentially “to 1^st do no harm.”

            Professionalism and accountability must be established before anyone can practice the art and science of nursing with clients, so that is the next cluster of competencies to apply.

            Core facts and evidence-informed ideas are necessary to make quality health care decisions for clients, to increase chances of survival. Based on this, competencies that demand demonstration of basic anatomy, physiology, patho-physiology, pharmacology, psychology, sociology and spirituality would be a next step for competency demonstration.

            Next, competent application of knowledge needs to be measured, usually through the ability to identify prioritized nursing diagnoses, the development of collaborative plans of care and implementation of that plan, followed by ongoing evaluation of client care: the nursing process.

            Ethical practice cannot be overlooked and neither can competencies that reflect service to the public and professional self regulation.

            Whew! Now, how to help students learn these competencies on performative, cognitive and affective levels.

            Once learning outcomes incorporating these competencies have been set, I would establish assessment assignments with corresponding marking rubrics. Those assessment assignments would have to incorporate basic, progressing to advance level synthesis of information, theories and ideas via SOLO taxonomy levels. Teaching/learning theories and evidence point to problem solving and critical thinking as the desirable outcomes to any learning. To that end, case studies asking for students to synthesize information in order to suggest provision of holistic healthcare in preventative, nurturative and protective ways would be a start once basic evidence-informed data is learned. Performance of standardized skills in a lab is also desirable before students attempt to care for clients. I would model and discuss desirable professional behaviours. Written examinations testing recall of expected information would help to establish some evidence of basic knowledge. Supervised care of less vulnerable clients, progressing to more complicated clients as students progress through their nursing education is practical. The use of a variety of learning methods is desirable in order to meet learning styles and to give different perspectives on expectations of competency achievement.

Week 4: Measuring Learning in Nursing

In exploring my modified posed question “How can learning in nursing be measured cognitively, performatively and affectively?" I need to delve into the current methods of evaluating learning in nursing.

Tanner (2011) looks at various measurement methods utilized across nursing to evaluate nursing education.  She calls for an improvement in developing suitable measures for the evaluation of learning outcomes and refers to the situation as a “critical state”.

She identifies three broad categories of learning outcome assessments utilized in nursing education research.

Opinion surveys and self reports are used in simulation labs but create a lot of variation and include a lot of subjectivity. Having used these reports in our Faculty of Nursing, I agree with the author. We do not use the reports for scoring the students, but to critique how we can improve our simulation presentations and scenarios (case studies).

Tanner cites a second means of testing, standardized tests, as likely better than teacher-created exams because the in house “tests frequently lack psychometric evaluation beyond internal consistency reliability and minimal content validation.”  She points out that standardized tests “may not be sensitive to variations produced by educational interventions” and gives the example of ”interventions directed toward improving clinical reasoning, such as case-based instruction, may not affect content knowledge scores.”

This points to the necessity to ensure that all aspects of learning leading to critical thinking be addressed (cognitive, affective and performative). Can one assume that content knowledge is part of the cognitive realm?

Tanner suggests that although standardized tests might have a role in testing nursing learning, she criticizes their reliability as a standard for measuring specific nursing performance, such as clinical reasoning, or are sensitive to the style of nursing education interventions.

The third method is clinical skills checklists. We use skills checklists in evaluating performance based nursing skills and include critical thinking skills and questions for cognitive learning measurement and include criteria that involves affective learning such as addressing modesty, confidentiality, respect, sensitive communication and ethics. Tanner suggests there is some value in these methods of measurement.

Tanner holds out great promise for high-fidelity simulation, coupled with rating scales or assessment rubrics to test students’ ability to use relevant knowledge in particular contexts. She addresses the need for multiple scenarios and the constraint of high economic cost of such methods.

This article points to the concern that the current methods utilized in measuring nursing learning are not considered sufficient or comprehensive enough to warrant continued use. Tanner calls for the development of measures that are appropriate for a clinical practice discipline and that will reflect variations in educational approaches.

With my question, I believe this article echoes the concern that there might not be a ready answer to my question!

Reference:

Tanner, C. A. (Ed.)r(2011). The critical state of measurement in nursing education research. Journal of Nursing Education. Vol. 50(9): 491-492. DOI: 10.3928/01484834-20110819-01