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COMPETENCY ASSESSMENTIn the Operative and Invasive Procedure SettingJoyce A. Cox, MBA, CNP, CRNFA, OCNContributing AuthorsDawn Whiteside, BSN, RN, CNOR, RNFAJames X. Stobinski, PhD, RN, CNOR

INTRODUCTIONOperative and invasive procedures requiring the use of sterile technique are nolonger performed only in the operating room (OR). Advances in technology andtechniques have facilitated the performance of procedures in non-traditionalsettings beyond the OR. These include settings such as cardiac catheterizationlabs, physician offices, gastrointestinal labs and interventional radiology suites.This white paper provides definitions germane to the field and also addressescompetency assessment for members of the nursing team and those supportingthe delivery of care in the operative and invasive procedure suite.Patient safety and positive outcomes are the number one priority in operative andinvasive procedure settings as the expectations of healthcare consumers and otherstakeholders continue to rise in regard to nursing care. This complex environmentmust meet regulatory requirements from agencies such as the Occupational Safetyand Health Administration (OSHA)1, Centers for Medicare and Medicaid Services(CMS)2, The Joint Commission (TJC)3, Agency for Healthcare Research andQuality (AHRQ)4, licensure boards, certification boards and other federal andstate regulatory bodies.Over the last 15 years, the methods of measuring and assessing competency havemarkedly improved, offering tools that truly measure an individual’s performancein a specific situation. Competency assessment is one of the tools healthcarefacilities can use to build a culture of quality patient care and potentially reduce thenumber of adverse outcomes. Within the operative and invasive procedure setting,it is one means of determining if nurses, surgical technologists and other staffmembers, including physicians and anesthesia professionals, are proficient andcan demonstrate the technical, critical thinking and interpersonal skills necessaryto provide safe patient care relevant to their specific role function.Competency assessment may be viewed as a professional responsibility and acommitment to our patients to practice in a safe manner. Engaging in ongoingprofessional development, of which competency assessment is but one part,fulfills an obligation to the patient to provide high quality care. Competencyassessment is a methodology to provide a higher level of assurance to our patientsregarding our proficiency. Ideally, nurses and other healthcare professionalswould each have a meaningful professional development plan to include periodiccompetency assessment and lifelong learning. In the absence of such plans, theemployer assumes some responsibility and liability for the level of competencyof those working at the facility. Thus, competency assessment becomes part ofworkplace activities.Competency assessment is not simply a list of tasks that are observed and checkedoff at a specified period of time. Previously, healthcare facility managers usedchecklists of tasks annually to document competency. While skills checklists may bepart of the larger scheme of competency assessment, these lists may no longer serveas the sole source of measuring competency. The days of using checklists as the1Competency Assessment in the Operative and Invasive Procedure Setting

only measurement of competency are long gone, and facilities still using a singlemethod such as an annual skills assessment do not truly evaluate competency.Donna Wright, BS, MSN, RN, a well-known author in the competencyfield, states:Competency assessment is only meaningful when itreflects the dynamic nature of the job. This meansyou will not have one list of competencies or skillsidentified for a job that you will simply check off overand over each year; instead your competencies willbe a collection of skills, abilities, and behaviors thataddress the changing nature of the job for a givenperiod of time.5(p 2)This paper provides definitions of the various terms used in the field ofcompetency assessment and addresses competency assessment for members ofthe nursing team as well as those supporting the delivery of surgical care in theoperative and invasive procedure suite. The results of Montogmery’s PerioperativeNurse Competency Continuum Study,6 carried out in conjunction with a jobanalysis for perioperative nursing, reinforced current thinking on this subject. Ajob analysis is integral to the certification examination process and produces taskand knowledge statements that delineate the role being studied. These task andknowledge statements may also fill another purpose in that they can be used in thecompetency assessment process.DEFINITIONS2Inconsistent methods of defining and measuring clinical competency createthe biggest obstacle in measuring competency assessment. Levine and Johnsonstate “there is no common definition of competence and no evidence for onebest method to assess competence”7(p.58) Secondary to the issues regardingdefinitions of competency, many healthcare facilities focus on measuring theindividual’s ability to perform a given skill, not on their ability to perform in apractice setting. When applied to perioperative nursing, this approach reinforcesthe misconception that perioperative nursing is but a collection of tasks. Thisdetracts from the complexity of perioperative nursing and denigrates the criticalthinking skills so crucial in the profession. The definitions and methods describedin this educational offering may assist perioperative managers striving to assesscompetency and move beyond the simplistic notion of annual skills fairs. With thegoal of assessing competency in mind, establishing definitions of relevant terms isa priority. A collection of those terms follows.Competency Assessment in the Operative and Invasive Procedure Setting

CompetenceCompetence refers to a potential ability and/or a capability to function in agiven situation.8 While the terms competence and competency are often usedinterchangeably, there is a distinct difference. Competence is the capacity toperform specific to a role and includes other behavioral attributes that makesomeone successful in that role.9CompetencyBefore competency can be assessed, it must first be defined. The followingdefinitions capture the essence of competency. Competency, as described byStobinski,10 is what a nurse is capable of doing and is manifested in measurableactions and behaviors. It is one determinant of performance, but the relationshipbetween competence and competency is not direct, and the exact contribution anindividual’s capability to the larger picture of performance is unknown.Wright5(p 8) defines competency as the application of knowledge, skills andbehaviors that are needed to fulfill organizational, departmental and worksetting requirements under various real world circumstances. Schroeter makesa defining statement in this field, stating, “Competency focuses on one’s actualperformance in a situation. This means competence is required before one canachieve competency.”8(p.2) Specific to the OR, AORN defines competency as theknowledge, skills, and abilities needed to fulfill the professional role of an RN inthe OR.11,12Continued CompetenceCompetency Assessment3Continued competence, as defined by the Hospice and Palliative CredentialingCenter (HPCC) is “the on-going commitment of a registered nurse to integrateand apply the knowledge, skills and judgment with the attitudes, values andbeliefs required to practice safely, effectively and ethically in a designated roleand setting.”13 The concept of continued competence has recently come to theforefront as a means to demonstrate ongoing learning, professional developmentand to protect patients. Lateef states that one salient reason to address the issueof measuring competency is to keep pace with the accelerated evolution oftechnology and increased consumer expectations.9 The credentialing industry,of which certification programs such as the CNOR certification is but one part,has become a discipline with a more structured, principle-based approach tocontinuing competence and credentialing. From that standpoint of a principlebased approach, we can consider Knapp & List’s14 2009 definition of continuingcompetence as the ability to perform a role at specified levels of knowledge andskill not only at the time of initial certification but also throughout an individual’sprofessional career.Wright5 describes competency assessment as a dynamic ongoing process whereskills are obtained in three distinct phases: when hired, during initial practiceand on-going practice. The competencies are different at each level of practiceand correspond to phases where skills are obtained. This clearly has parallels tothe work of Benner who described a novice to expert continuum.15,16 Stobinski10discusses the relationship of performance to competency assessment and howthis can be used to identify areas of professional development and educationalCompetency Assessment in the Operative and Invasive Procedure Setting

needs. This allows managers to align competencies with patient care needs. Thus,competency assessment, in a well-designed program, can be seen as a key elementin a professional development program designed to continually elevate knowledgeand skill levels.SKEDGLEOWKNILLSTHE COMPETENCYCONTINUUMATTITUDESIn one commonly used framework (the KSA model), the three components ofcompetency are described as knowledge, skills and attitudes.17 This KSA frameworkprovides a helpful perspective through which the process of competency assessmentmay be viewed. For example, knowledge acquired through formalized educationand training is usually gained in a didactic mode. This classroom experienceprovides a significant contribution to knowledge levels.In the perioperative setting, employee roles are diverse; however, there arethree primary groups of non-physician providers that comprise the majorityof personnel in the OR: Registered nurses (RNs), surgical technologists (STs)and central processing technicians (CPTs). Each of these types of employeeshas a base of knowledge that must be mastered for their specific job role. Thiseducation on the basic scientific knowledge of the profession, often provided ina didactic setting, is then combined with relevant experience and skills training.The key remaining ingredient in the KSA model is that of attitude, which maybe influenced by the education and training the individual receives; but this areais typically not a centerpiece of competency assessment. The sum of these threecomponents ultimately yields a level of competency for that individual.18Competency assessment is necessary to evaluate individual and group performance.It helps identify challenging issues, serves as a cross reference to the performanceappraisal process, identifies if reportable quality measures are being met, andensures compliance with standards set by organizations such as OSHA. Theprocess of competency assessment is also overseen by entities such as the JointCommission, which accredits healthcare facilities. Competency assessment alsomay identify the contribution of employees to the overall financial stability of theorganization. This concept will be explored in more detail in the discussion ofvalue based purchasing (VBP).ASSESSINGPERIOPERATIVECOMPETENCYPatricia Benner is a nursing theorist and a prolific and influential author. She is bestknown as the author of the classic 1984 work, From Novice to Expert: Excellence andPower in Clinical Nursing Practice.15 In this book, she describes and applies the DreyfusModel of Skill Acquisition,19 with its stages of learning and skill acquisition, to thenursing profession. This five-level model describes the process of skill developmentfrom novice to expert (Table 1). This table is adapted from this seminal work byBenner.15 When designing competency assessment tools this model can provideguidance in tailoring assessment methods that are appropriate to the experience level ofthe practitioner.Clinical competency is not evaluated similarly for all practitioners, and a one-size-fitsall assessment tool has little practical use. Rather, clinical competency must be evaluated4Competency Assessment in the Operative and Invasive Procedure Setting

according to the practitioner’s level of skill acquisition and role expectations.20 Asthe Dreyfus19 model demonstrates, no one begins at a competent level. To attain thecompetent level of skill acquisition, typically a clinician must gain experience, knowledgeand skills over a two to three-year time period in the same practice area. Competencyassessment validation tools must be appropriate to the level of skills of the person beingassessed, including knowledge, psychomotor, technical and cognitive skills.For example, the job description for a novice nurses in the OR may include providingpatient care as an RN circulator. In this instance an area identified in the perioperativenursing job analysis with the heading of “Preoperative Patient Assessment andDiagnosis” could be the focus for competency assessment because this is a basic skill thateven a novice or advanced beginner must master early in his or her career path. Theexpert nurse may have additional roles identified such as “Transfer of Care” requiringextensive coordination of interdisciplinary care services such as nutrition or woundcare services.DREYFUS & DREYFUS MODEL OF SKILL ACQUISITION1-3Novice5The novice nurse has no previous experience on which tobase knowledgeable decision-making. Persons at this level seekconcrete rules to follow and find it difficult when the rulesdo not apply to the situation encountered. When workingwith novices, it is important to be concrete and provide basicknowledge that can be applied to actions in practice.AdvancedBeginnerThe advanced beginner nurse has some previous experiences onwhich to base decisions. This nurse is able to see “gray” aspectsin previously perceived black-and-white rules or procedures.Although this person acknowledges that situations may vary andactions cannot always be predicted, they usually have a difficulttime anticipating subtleties in a situation and prioritizing nursingactions. Nurses at this level are reactive rather than proactive.CompetentThe competent nurse has worked at least two to three years inthe same practice area. Experience enables this nurse to discerncommonalities and act toward meeting long-term outcomes orgoals. Organization is a characteristic of this nurse and can betypically manifested in his or her deliberate plan for managingpatient care priorities.ProficientUnderstanding the complete context of a situation rather thanfocusing on isolated tasks or pending actions is the hallmarkof the proficient nurse. This nurse prioritizes easily and reliesless on concrete rules and more on perceptions based onexperience. Another characteristic is the ability to easilydifferentiate between the expected and the unexpected.ExpertIntuitive knowing is a key characteristic of the expert nurse.Vastexperience and cognition enables this nurse to provide highquality nursing care by sensing subtle changes in the patient’sconditions and acting swiftly in response to these changes.References1. Novice to Expert:The Dreyfus Model of Skill Acquisition. http://www.sld.demon.co.uk/dreyfus.pdf. Accessed February 5, 2015.2.Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984.3.Benner P, Tanner CA, Chesla CA. Expertise in Nursing Practice: Caring, Clinical Judgment and Ethics. New York, NY: SpringerPublishing; 1984.Competency Assessment in the Operative and Invasive Procedure Setting

Managers may use the competency assessment process to facilitate the professionaldevelopment path for the perioperative nurse. A timeline can be formulatedfor nurses depending on their knowledge and experience. For instance, a newgraduate hired into the OR will be assessed on different competencies than aperioperative nurse with ten years’ experience who is practicing at the expert level.The manager can guide the employee in a successful career path in the OR usinginformation gathered from the competency assessment process.Benner’s Novice to Expert Continuum15 may also be used to compare thecharacteristics of an individual nurse’s practice against the observable behaviorsdescribed in the chart above. Differences or shortfalls in clinical performance,which are identified in this comparison, can be used as teaching points and alsoto establish learning and growth opportunities. For example, a nurse with fiveyears’ experience should be capable of performing at the competent level of skillacquisition as described by Benner.15 This level of performance assumes thenecessary clinical learning experiences and a supportive learning environmenthave been present. If the competency assessment process provides evidence thatthe nurse exhibits behaviors characteristic of an advanced beginner, there is anopportunity for additional learning and professional development activities.The manager can supply mentoring and educational opportunities for theRN to safely function in his or her specific role. The RN’s professional careerpath includes his or her own goals and those expected of the nurse by themanager and administrators in the facility. Areas of professional development,which may foster increased skill acquisition, may include additional clinicallearning experiences, specialty certification, academic education and advancednursing degrees.For the nurse who desires to stay in the scrub or circulating role throughouthis or her career, there are an abundance of educational and professionaldevelopment opportunities that may facilitate the desire to provide handson care. This example points out the importance of tailoring a professionaldevelopment path to the needs and goals of the individual. Not all staff membersaspire to certification or to additional academic education. An astute leader willrealize these differences and facilitate professional development that meets theneeds of both the organization and the individual.DESIGNING THECOMPETENCYASSESSMENT TOOL6Wright5 has done extensive work on the subject of competency assessment. A basicpremise of her work is for individuals to use as much evidence of their daily workas possible in the process of competency assessment. She believes that peopleshould not be testing on tasks that are performed on a daily basis. This may seemconfusing at first, but consider this perspective. For a task that is readily observed,frequently performed and the competency assessment is straightforward, thattask may just require occasional observation by a peer possessing competency.Additional instruction or refresher training on this task would not be the mostproductive choice as it is frequently performed and readily observable. The timeCompetency Assessment in the Operative and Invasive Procedure Setting

spent on additional training would be best spent on tasks that are infrequentlyperformed and that have a recent history of errors or substandard performance.Developing a department-wide competency team to identify job position functionsis a great start to a meaningful competency assessment process. To identify jobfunctions for each position, a brainstorming session can help. This process shouldinclude those who are not part of the competency team by emailing a spreadsheetof job positions and functions and asking them to add any omitted items andreturn their additions to the team.Information from a Job Analysis may also inform this process. Job Analysisfindings exist for some of the roles performed in the OR setting as the Job Analysisor Role Delineation Study is part of building a certification examination. Many ofthe organizations that administer certification examinations share these findingswith the public. Job Analysis findings are available for the role of the perioperativenurse, perianesthesia nurse, surgical technologist and central processingtechnicians. The use of Job Analysis findings is discussed in the next section ofthis paper.This list of competency assessment needs should include the following: New procedures, policies, initiatives; Changes in the above that affect the job; High-risk aspects of the job (i.e., those that would cause harm or even death); Problematic aspects of the job identified through quality improvement (QI)data, surveys from patients and staff, reports; and Regulatory requirementsThe next step is to write competency statements using action verbs. Table 2 is acondensed version of a table of action verbs.TABLE 2: EXAMPLES OF ACTION ussDemonstrateClassifyCombineChooseReference1. Bloom’s Taxonomy of Action Verbs. Clemson University. %20Action%20Verbs.pdf. AccessedFebruary 6, 2015.7Competency Assessment in the Operative and Invasive Procedure Setting

Using the table of action verbs, an example of a competency statement in theperioperative setting could be:Nurse Jones will confirm patient identity using two patient identifiersthroughout the patient’s perioperative experience.This statement establishes the behavior that will be assessed; however, a method ora choice of verification methods must be established to facilitate the competencyassessment process. Faced with a need to designate verification methods, many willsimply default to the well-known skills fairs and checklists; however, these do notallow for complete verification. Skills fairs only measure a point in time, and theevaluator can coach the employee until satisfactory results are achieved. Accordingto Wright,5 several verification methods are appropriate for assessing competency(Table 3). These include case studies, return demonstrations, observation of dailywork, discussion groups, presentations to department members, post-tests, mockevents, exemplars, peer reviews, self-assessments and QI monitors. Whateverevaluation method a manager chooses, a check sheet can be devised documentingthe learner, job position, work area, task, evaluation method, date and observer.TABLE 3. COMPETENCY ASSESSMENTVERIFICATION METHODSPOST TESTSMethod Post tests only measure cognitive skills and knowledge (e.g., written, oralexams, puzzles, worksheets, surveys, quizzes). These tests do not measure behavioral, performance, or psychomotor skills.Perioperative Example Rhythm recognition Documentation requirementsRETURN DEMONSTRATIONMethod Demonstrates to an experienced, qualified observer how to safelyperform a task.Perioperative Example Prove competency to regulatory body by:»» testing blood glucose»» foley catheter insertion»» performing surgical prep8Competency Assessment in the Operative and Invasive Procedure Setting

CASE STUDIESMethod Measure critical thinking skills. Provide situations and ask individuals to explain their responses tothe situation.Perioperative Example Malignant hyperthermia (high risk, low volume, time sensitive) Respiratory arrest in the ORPEER REVIEWSMethod Written and face-to-face reviews Measure:»» critical thinking skills»» interpersonal skills Must be safe for the persons giving the feedback, receiving thefeedback, and interpreting the feedback.Perioperative Example Phone etiquette Communication skills Customer service Dealing with an unexpected change in the surgical procedure Ability/flexibility to deal with change Behavior in an emergency situation Accountability/individual responsibility9Competency Assessment in the Operative and Invasive Procedure Setting

EXEMPLARSMethod Measure»» critical thinking skills»» interpersonal skills The individual writes a story of a situation he or she has or mayhave experienced. The story describes the choices made in the situation with the rationalebehind those decisions.Perioperative Example Presentation of assisting with induction. Summarize how to use a new piece of equipment. Describe caring for patient who has terminal cancer; assisting andcomforting family members; present facts about what happened andhow it happened. Describe hand overs and transitions of care. Demonstrate customer service.SELF-ASSESSMENTSMethod Assess values, beliefs, opinions, and attitudes. Encourage employee reflection. Provide a means for employee to documents thoughts that influenceday-to-day judgments.Perioperative Example Circulating RN facilitates room running on time. Scrub tech or nurse anticipates conversion of a laparoscopic procedureto an open procedure by having all the necessary supplies in the room.EVIDENCE OF DAILY WORKMethod Measures technical skills. Assesses skill of activities performed on a daily basis.Perioperative Example Positioning Administration of IV antibiotics Insertion of IV catheters Cleaning equipment Documenting patient assessment in computer software10Competency Assessment in the Operative and Invasive Procedure Setting

QI MONITORSMethod Measures knowledge, critical thinking, technical skills, andinterpersonal relations. Monitors patient care environment and outcomes. Used to monitor compliance with policies/protocols. Monitors benchmarks desired vs. achieved outcomes.Perioperative Example Chart audits Documentation audits Infection control policy compliance Blood glucose monitors and other equipment cleaning and calibration Checking emergency cart, documenting it Setting up and tearing down equipmentPRESENTATIONSMethod Assess knowledge and understanding.Perioperative Example Posters Presentations»» Oral»» Group Individual Teaching a class Explaining a process change or introducing a new process.DISCUSSION GROUPSMethod Often used with mock events Measures critical thinking skillsPerioperative Example Debrief Analyze a sentinel event Discuss hypothetical events Introduce new equipment or new process such as new computerizedprogram/charting11Competency Assessment in the Operative and Invasive Procedure Setting

MOCK EVENTSMethod Assess responses in daily work. Simulate real situations. Measure the ability to function under stress. Used for high risk, infrequent tasks.Perioperative Example Simulation: malignant hyperthermia:»» Where is the dantrolene?»» How is it mixed?»» Where can more be obtained, if needed? Cardiopulmonary resuscitation Airway management Point-of-care testing: blood glucose testing/calibration of machineReference1.Wright D. The Ultimate Guide to Competency Assessment in Healthcare, 3rd ed. Minneapolis,MN: Creative Healthcare Management, Inc; 2005.The perioperative job analysis discussed in the next section identifies the ninemajor practice areas specific to the current perioperative RN job role. Theseareas are sometimes referred to as domains when used as a basis for a certificationexamination. One component of the job analysis is the task and knowledgestatements. The full listing of the current task and knowledge statements are foundin the appendices of this resource. These statements can be used to formulatecompetency assessment statements. A discussion of recent research effortsregarding perioperative nursing job analysis processes provides additional depth tothe competency assessment discussion.JOB ANALYSISFINDINGSJob analysis studies are regularly performed to support high-stakes testing infields such as certification and licensure. Common examples would be licensureexaminations for entry into the nursing profession and certification examinationssuch as those for the CNOR and CRNFA certifications. These periodic jobanalyses validate that the tasks identified in the study or examination are performedby a nurse with a given level of experience. For example, to sit for the CNORexamination the nurse must have two years of practice experience.In 2006, the Competency and Credentialing Institute (CCI) commissioned LindaMontgomery Thomson of Prometric, the company that administers the CNORcertification examination, to conduct a research study.6 Specifically, Montgomeryand other Prometric staff conducted a job analysis/perioperative nurse competencycontinuum study. More than 1,500 individuals participated in different phasesof this multi-method survey which yielded descriptive information about the tasks12Competency Assessment in the Operative and Invasive Procedure Setting

performed by perioperative RNs and the knowledge and skills needed to adequatelyperform those tasks.6 A nationwide sample of perioperative nurses were asked torate their: current competency level in performing 103 perioperative nursing tasks, years of preoperative nursing experience in performing the 103 tasks, point of acquisition of 64 perioperative nursing knowledge/skills, and professional development needs across the 64 perioperative knowledge/skills.6(p. 6)This study reinforced some of the basic precepts of the work of both Wright5and Benner15,16 regarding competency and skill acquisition. More importantly,for nurses working in the OR setting, these findings were focused closely on therole of perioperative nursing. The study was timely and now serves to buttress theconcepts underlying the increasingly important process of competency assessmentin the perioperative setting.The Connection toWright and BennerThe Montgomery study sought to validate the tasks, knowledge, and skillsnecessary to the role of the perioperative RN at three levels: novice, intermediateand experienced.6 This methodology also exceeds the periodic job analysisprocess that supports the CNOR credential which only seeks to validate task andknowledge levels for perioperative RNs at one point in their

Donna Wright, BS, MSN, RN, a well-known author in the competency field, states: This paper provides definitions of the various terms used in the field of competency assessment and addresses competency assessment for members of the nursing team as well as those supporting the delivery of surgical care in the operative and invasive procedure suite.