Competency Days Help Ensure Nursing Knowledge

Hospitals with ANCC Magnet Recognition Program® (MRP) designation are always seeking better ways to educate their nurses to ensure quality outcomes. For many facilities, part of this education process comes in the form of competency days. And for some, such as Saint Francis Hospital and Medical Center in Hartford, CT, these competency days turn out to be a raging success.

Saint Francis is in its third year of using competency days for nursing education, and, according to Erica Siddell, PhD, RN, director of nursing education and professional development in Saint Francis' Center for Nursing Education and Practice Innovation, most of the bugs have been worked out.

The competency days are hosted once per month. The sessions are about four hours long, and each session will see about 100 nurses pass through.

The competency days began when the nursing education structure at Saint Francis was evolving at the same time.

"It was a different organizational structure prior to 2005," says Marge Freeland-Wasel, APRN, ACNS-BC, a clinical nurse specialist at Saint Francis. "We were the Department of Nursing Clinical Excellence, composed of all nurse specialists, no nurse educators."

The nurse specialists had many roles, and one of them was nursing education. However, they were torn between these many roles.

"The clinical nurse specialists in a particular unit would say they were going to run some competency days for my units, but there was no mandate that 100% of the staff would get there, or remediation if they didn't attend," says Freeland-Wasel.

The other issue was time—the clinical specialists could only provide so much education when torn between several roles. And it wasn't just the clinical specialists who were short on time.

"Surgery did their own competency days, medicine did their own, critical care—they were run on the unit. Staff would come out and still be thinking about patient care during the education," says Freeland-Wasel. "They had to get back to patient care."

And if the nurses still had patients waiting in the wings for them, it was very difficult to make these education days educationally sound. But then the educational council took on the responsibility, and shared governance went live.

"The educational council and the education fair happened around the same time," says Lynn Morris, RN, MSN, nurse educator at Saint Francis. The initiative came out of the council.

"At the time, my mother was working in another hospital out of state and used to send me flyers if she thought they might be of interest," says Morris.

One of those flyers was for a full-day educational fair for all employees. The concept was different from what Saint Francis would eventually implement, but it sparked an idea.

"We decided we needed to do something away from the bedside," says Morris.

Planning
It took a full year of planning before Saint Francis piloted the fair. It was extremely well received by staff members, says Morris, giving them a full eight-hour day away from patients to focus on education.

The first question, of course, was how to get nurses away from the bedside and still maintain patient safety.

"Initially, we had to get permission to get staff in off their scheduled hours," says Morris.

They looked at the number of employees, how many employees they could manage in a given day's fair, and how many fairs they could manage in a year. Staff was responsible for signing up.

They also figured out how to make sure employees showed up to the competency day.

"I think one of the drivers of our success is that in the last couple of years, attendance has become an enforced expectation," says Siddell.

Prior opportunities for education were offered and staff members were supposed to attend, but there really were no repercussions if they skipped out. Starting in 2008, however, if staff did not attend the mandatory session, it affected their ability to get their annual raises on time. The impetus behind this was tied to The Joint Commission's requirement for annual competency testing of staff, says Siddell.

Who's involved
As previously discussed, over the past few years, there has been an evolution in the nursing shared governance structure at Saint Francis. When the competency day program began, the education department was a more collaborative practice of clinical nurse specialists, says Siddell. They had direct care consultants as advanced practice RNs (APRN), but they were also responsible for unit-based education.

When a new CNO arrived in 2006, she mandated structural changes—one of these being a requirement that nursing education become a collaborative process with nurse educators and clinical nurse specialists to support the new shared governance structure.

"We were looking at the way the nursing council worked," says Siddell. "This new approach had to be vetted by our nursing management council, and some discussions were had with human resources and also at the director level to drive down accountability and make sure staff were attending. It was a cultural shift for us."

Structure
All nurses come through the competency day at some point during the year. They are scheduled away from their work area.

"We house it all in the educational department," says Kathy Urban, RN, MSN, nurse educator at Saint Francis. "The educators are responsible for different stations."

Aside from a pacemaker company that Saint Francis requested send a representative for competency education, all other stations are managed in-house, says Urban.

"One of the things Kathy did that was very successful was create a steering committee of nurse educators," says Siddell. "We've had to go back to Joint Commission requirements looking at high-risk/high-frequency, high-risk/low-frequency types of activities. We've worked with colleagues to come up with standard templates for each [education] area."

They have also looked at key skill areas and knowledge bases for various groups—critical care, for example, has competency requirements that look different from behavioral health, which are different from women and children, and so on.

"Each year, we look at what's been going on in the hospital and decide where we want to focus across the board," says Siddell. For example, the hospital purchased smart pumps in 2007 and found some knowledge gaps in the equipment at first, so they made competency training a requirement for everyone. Other years, there may be a type of medication error that needs to be focused on. Restraints are often a focus point.

"When we first went to the department about the steering committee, we asked, 'How do we define competency?' There wasn't any defined method of doing that in the department," says Urban. "What we did was made a definition, created a mission statement, developed a policy with human resources on competency, and determined who is responsible for what."

The steering committee meets with educators, managers, and representation from HR, and the group looks globally at what nurses need to be validated on to have their core competencies covered.

To keep requirements reasonable, the committee determined that there would be no more than 10 core competencies covered to avoid overwhelming the staff. These 10 can be made up of a combination of core competencies required globally, as well as those for individual units. This year, for example, the steering committee decided on six core competencies, leaving four additional competencies to be identified for individual units.

Those requirements are identified after the core competencies, when educators go back to speak with managers to discuss what areas they feel nurses need to be validated in to ensure competency.

Scheduling challenges
Timing and resources are everything when planning a competency day. Making sure you have the resources to man the stations and identifying the number of offerings you need to have can be a challenge.

"It takes time," says Freeland-Wasel. "We needed to go back to see how many could go through the fair at the same time."

"One of our struggles at first was scheduling; the mandatory nature of it," says Siddell. "We were setting up approximately three days a month, and during the first part of the year, they were not well attended."

Then, when staff members realized they still needed to attend a competency day, attendees would swell to unmanageable numbers. The education department went back to examine exactly how many attendees it could handle at once. It then went back to managers to organize the number of staff who would be scheduled to attend each fair.

"Doing this helped us push the issue about being more proactive about how they were scheduled," says Siddell.

Another issue was that Saint Francis originally scheduled some point-of-care testing during the competency days, and it was a struggle at first to get managers and staff to plan accordingly.

The hospital has seen a massive jump in staff finishing their competencies since taking on a more structured scheduling process, says Urban.

"We probably had around 40% finishing their competencies at first, and now we have over 90%," not including nurses on maternity leave, leaves of absence, or other excused absences, says Urban.

It all ultimately ties into the MRP journey, Siddell says. With St. Francis' focus on revamping the shared governance structure and some of these core processes, the ultimate goal in mind is the highest quality education and training.

One piece of advice for a hospital just starting to revamp its competency training: Don't go at it alone.

"I would say to someone starting from scratch: Talk to a hospital that is already doing it," says Urban. "Starting from square one, it took us from 2005. It's a process."