HealthSeptember 19, 2022

Implementing three Cs to inform competency-based nurse staffing

As COVID-19 hospitalizations stabilize and state and federal emergency funding dries up, hospitals are examining how best to drive new revenue and simultaneously cut costs as they face expenses that remain at historic highs. The most obvious place to look? Staffing.

As of June 2022, the healthcare industry saw the highest levels of job cuts than any other industry. Staff reductions were up 54% over the same time period last year, and nurses make up a good majority of these reductions.

It’s an ironic data point given nurses have been on the front lines throughout the pandemic. But is there a different path forward? One that doesn’t base staffing needs on straightforward nurse-patient staffing ratios but is instead based on acuity of patients, and perhaps just as importantly, nurse competency? There has been enough research to suggest the answer is clear: Staffing should not be based solely on hours per patient day, beds alone, or even average daily census. Competency should inform staffing.

Hospitals that are on a path to cut staff in order to navigate the current environment run the risk of poor patient outcomes and higher rates of adverse events. But they also need to consider how far they can push nurses who remain before they reach their breaking point. Given the record number of nurses leaving the profession due to dissatisfaction, burnout, or retirement – the latest report from the American Association of Critical-Care Nurses suggests 67% of nurses want to quit over the next few years – health systems stand to make a bad situation worse if they end up losing their most experienced nurses. The other unintended consequences? A change in the skill mix of the remaining nursing staff and potentially added costs and resources to train nurses who may not have the necessary competencies to practice in a particular unit or across units.

Yet moving to a competency-informed staffing model is not an easy task. The good news is that progress is being made to make the shift. Respondents in a 2022 Wolters Kluwer and UKG nurse leader survey revealed that most predict competency will inform their nurse staffing over the next year. Almost 80% reported that they would need to implement competency-informed shift coverage. It’s a move that’s encouraging but not happening fast enough. Most health systems do not have adequate competency management programs that can inform their staffing, processes that can transform checklists into nursing professional practice competencies, and the appropriate underlying infrastructure so all of the software systems can seamlessly communicate with each other.

How is nurse competency defined?

Competency is defined by the American Nurses Association (ANA) as an expected level of performance that integrates knowledge, skills, abilities, and judgments (ANA, 2014). Competency is a key component of the new American Association of Colleges of Nursing Essentials and it’s how undergraduate and graduate nursing students are taught – with the goal of producing competent, practice-ready nurses after they complete an orientation or nurse residency program. Novice nurses are not the only ones who need additional education and training to be competent. Nurses who are experts in some areas of practice may not be fully competent in others.

By aligning staff competencies with organizational goals, health systems can:

  • Ensure staff demonstrate sufficient expertise
  • Help recruit and select staff more effectively
  • Identify skill and competency gaps more efficiently
  • Provide more individualized training and professional development
  • Plan sufficiently for succession
  • Make change management processes more efficient
  • Standardize preceptor work
  • Improve competency documentation, tracking, and reporting

Developing a competency management program

A competency management program should align nurses’ skills and behaviors with clinical and organizational goals. Competency needs to be routinely measured and documented, and this information needs to be readily available for surveyors and nursing leadership. In reflecting on the key pillars in the ANA Leadership Competency Framework, the building blocks of competency management include three Cs: 1) communication, 2) compliance, and 3) competence activity.

1. Communication activity

Communication activities are activities that bring awareness to relevant safety or other important information. Examples include policy review, course attendance, downtime procedures, and resource information.

2. Compliance activity

Compliance activities are activities that meet a regulatory or accreditation requirement to provide and document training. Examples include fire safety, workplace violence prevention, adverse event reporting, and patient advocacy.

3. Competency activity

Competency activities are observable activities that serve to measure possession of a sufficient level of expertise. Examples include IV insertion, basic ECG interpretation, prioritizing care, recognizing and seeking assistance for situations beyond own skill level, and self-defense techniques.

To support competency management programs, organizations should utilize enabling technology and integrated solutions, to ensure skills, qualifications, competencies, certifications, orientation processes, and workforce plans are interoperable and where procedures and policies, and documentation are seamlessly made available.

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