Nurses get best results with hands-on assessments

Preparation and interviewing are favored trends

After years of uneven oversight, regulatory agencies are getting tougher on nurses. States are asking providers for proof of workplace competency, while pressuring hospitals to set meaningful standards on clinical proficiency.

Nursing organizations are feeling the heat. In critical care, where morbidity rates generally run high, the stakes are daunting, according to veteran ICU nurses.

It’s no place to gamble with hunches that your staff will pass muster, says Georgiann Homuth, RN, MS, CCRN, a critical care clinical nurse specialist at Swedish American Health System near Chicago.

Rightly or wrongly, many licensing and accreditation entities, among them the Joint Commission on Accreditation of Health Care Organizations, are linking their concerns over medical mistakes to cases of poor clinical judgment.

Medical mistakes linked to hospital deaths

Recently released figures from the Harvard University School of Public Health in Cambridge, MA, linked medical mistakes to some 120,000 annual hospital inpatient deaths. While Harvard officials didn’t single out any one factor as responsible, including nurse proficiency, experts have long argued for better staff training and assessment as a way to reduce hospital adverse events.

But assessing nurse competency hasn’t been easy. A running debate over how to design and implement competency assessment tools has given way to confusion and inaction, say many advanced practice nurses.

Observation tests are preferred

In many busy, overworked ICUs, the written test has been the cornerstone of most competency assessment exams. However, a growing number of nurses generally condemn written exams.

"How do I know whether you can really do something unless you actually do it?" asks Homuth, who advocates observation tests over written exams.

Although there is no one way to design the ultimate competency assessment tool, some experienced practitioners advocate devising a combination of approaches, including written and observational, with an overriding focus on practical, real-life knowledge of bedside care.

Hospitals that have taken this integrated approach appear to achieve better results, according to their own officials. What follows are examples of two different approaches taken by markedly different hospitals:

Department of Veterans Affairs Medical Center, West Palm Beach, FL.

At the Department of Veterans Affairs Medical Center in West Palm Beach, FL, managers designed a multifaceted tool that combined a written portion and a verbal, task-focused interview component.

The interview covers aspects of a nurse’s clinical and technical abilities. But it also tests cognitive, intellectual, and social skills that are routinely used in the ICU, says Sara Moore, RN, MSN, CCRN, a former ICU manager, who now works with the medical center’s imaging services.

Moore designed the tool while assigned to the ICU and won a National Teaching Institute’s Creative Solutions award in 1997 from the American Association of Critical Care Nurses (AACN) in Aliso Viejo, CA.

The test is divided into two sections:

I. KSA (knowledge, skills, and abilities): Assesses a nurse on formal technical and clinical patient care matters, such as understanding hemodynamic parameters and accurate interpretations of blood gas level readings.

II. WOF (work-orientation factors): Focuses on professional collaboration, decision making, interpersonal relations, and social skills involving patients and family members.

Parts of each section involve a written portion in which the nurse is given a problem-solving scenario and is assessed on a narrowly defined series of expected responses. (For a sample question from each category, see the box on p. 7.)

The management staff developed the questions on the basis of what they felt were important areas for nursing expertise, Moore says. But managers can also devise the questions based on problem areas by targeting, for example, patient types or diagnoses that pose serious problems for nursing care.

Providers differ on testing styles

Important areas for the hospital included working with patients on conscious sedation and ventilator-dependent cases, Moore says. The obvious places to look are those that involved high-risk patient cases and highly volatile outcomes and bedside management protocols.

Moore says the hospital administers the test to new and rank-and-file nurses annually as part of a twice-a-year "skills fair" that involves booths and games in which nurses can test their skills in fun ways.

The two-hour test is given in a classroom setting. Individual nurses can choose when to take the exam, but all the nurses are interviewed during the same designated block of time, Moore says. Floaters or extra nurses are called in to cover the floor.

The tests are graded by a series of nonnumerical values that fall into four categories: negative (-), neutral (0), positive (+), and double positive (++). Moore says the scoring system reduces a tendency toward subjectivity and focuses on strengths and weaknesses, instead.

Swedish American Health System, Rockville, IL.

With two large, 10-bed ICUs and a staff of 50, competency assessment should be anything but easy at Swedish American Health System. But management has been able to evaluate its nurses by focusing on sound preparation and actual hands-on skills, says Homuth.

The unit uses two different assessment tools, one to test tenured nurses and another for staff with less than three years of experience. Usually, the emphasis has been to test on important procedures that for some nurses are less-frequently performed.

A typical example might be the removal of a femoral sheath from a patient’s groin area, which due to the three maneuvers involved may be a tricky procedure for nurses who don’t routinely perform the procedure, Homuth says.

To choose the best procedures, Homuth says administrators begin with a list of basic skills such as starting an intravenous line or inserting a nasogastric tube.

A second list is compiled for skilled nurses with less than three years of experience, which might include assisting in a pericardiocentesis or monitoring a cerebral ventricular drainage, Homuth adds.

'Education Days' strengthen nurses’ skills

In March of each year, the unit holds a set of "Education Days," two full days of nursing skills review that include a list of 29 must-know items and a 3½-hour session with a nurse verifier.

Tenured nurses (with more than three years of experience) undergo 2½ days, with a much shorter list every other year. For tenured nurses, the emphasis is on technical competency, but critical thinking skills are highlighted, Homuth adds.

In December, the managers usually send a list by e-mail around to staff nurses asking for input and changes to the list. Other resources are also consulted, including advice from preceptors, benchmarking data, the unit’s clinical policies and procedures manual, and the AACN practice guidelines.

A packet of required skills is distributed in advance that includes the list of questions, their answers, and any updates or new information nurses are required to know.

The emphasis of the assessment involves observation of each nurse, either in a hypothetical or actual patient-care situation. Regardless of the case, the nurse conducting the observation looks for real-life capabilities beyond formal technical knowledge of the procedure or protocol, Homuth says.

During observation, the nurses are evaluated for each procedure on a pass/fail basis. A report is issued on each nurse identifying the procedure, the date of observation, and the final grade. Nurses who fail an observation are retested later.

"The key to competency testing is to ensure that the nurse can function fully in an actual situation," Homuth adds.