By Tammy Franqueiro and Jean Shinners
ICE blog readers may have read previous posts on Competency Based Medical Education (CBME) which is largely structured under the guidance of the Accreditation Council for Graduate Medical Education (ACGME) supporting the link between education and postgraduate clinical practice to document the progress of an individual’s competence of identified knowledge, skills, attitudes and performance on six core competencies of patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and system-based practice. Competency-based education (CBE) is a general education model that moves from seated time, credit hours, and grade-points and is consistent with CBME as the learner demonstrates their knowledge and ability to perform skills at the point of care. This approach has generated quite a bit of interest over the last several years as a method to ensure individual and collective competence. As educators and practitioners, we know that individuals may possess the necessary knowledge to care for patients, yet have difficulty integrating that knowledge into their daily performance in today’s complex healthcare environments. A CBE model has been used in medical continuing education for years. Nursing also uses CBE in some academic settings appreciating the importance of the relationship between academia and practice to elevate performance and improve outcomes.
CBE and the Interprofessional Clinical Learning Environment (IP-CLE)
In 2017, one of the authors, Jean Shinners, had the privilege of participating in a two-day symposium, Achieving the Optimal Interprofessional Clinical Learning Environment, hosted by the National Collaborative for Improving the Clinical Learning Environment (NCICLE) as a representative of the American Nurses Credentialing Center (ANCC). One of the goals of NCICLE is to promote interprofessional (both clinical and administrative) conversations on innovative strategies that enhance the quality of learning in clinical environments and across organizations. The purpose of the symposium was to investigate and identify the key characteristics of an optimal, interprofessional clinical learning environment (IP-CLE). Six characteristics were identified:
- Patient centeredness
- Commitment to a continuum of learning
- Reliable communications
- Team-based care
- Shared accountability
- Evidence-based practice centered on interprofessional care.
These characteristics serve as a foundation to create an optimal IP-CLE, supporting the practice of CBE while enhancing the experience for the educator, the practitioner, and ultimately, the patient and their family/support system. NCICLE organized a follow-up workshop in 2019 to deliver actionable items for healthcare leaders’ use across practice environments to improve the IP-CLE. Workshop results highlight the chance to identify shared language regarding collaboration across professions while maintaining professional identity. Identified strategic and operational initiatives can assist organizations to optimize IP-CLEs.
How does it work?
By employing the principles of a collaborative learning environment, CBE can be implemented to meet the educational needs of an interprofessional workforce. With its focus on acquisition of knowledge, skills, and abilities (KSAs) rather than a required amount of seated time in a classroom environment, CBE prepares the learner for professional practice. The American Nurses Credentialing Center (2020) describes CBE as practice-based learning (PBL) noting PBL is “learning that takes place in the workplace setting under the guidance of preceptors, mentors, or other experienced healthcare professionals, or a combination thereof, and promotes the process of investigating and evaluating professional practices in the context of best-available evidence to continuously improve outcomes” (p. 19). In this context, the preceptor, mentor, or other experienced healthcare professional assumes the role of educator.
Challenges and benefits to implementing CBE within or across professions identified by Koster et al. (2017) include:
Challenges
- Time-consuming.
- Requires agreement on the knowledge, skills/competencies, and behaviors for the role(s).
- May require a change in perspective of involved stakeholders and participants on goals, expectations, and learning strategies.
- Consensus on language (terminology) and contents needed across professions while recognizing different roles and responsibilities across practice.
Benefits
- Ensures each individual is competent and responsible to practice.
- Makes the clinician accountable for their performance.
- When used across professions, ensures the collective competency of the group (Shinners & Franqueiro, 2017).
- Promotes interprofessional knowledge, attitudes, skills, and behaviors.
The following table illustrates the steps to implement CBE using an IP-CLE:
| Steps | CBE and IP-CLE Example |
| 1. Gap Assessment compares current knowledge, skills, and attitudes against an identified competency framework. May include: needs assessment or surveyobserved performance (at point of care or in simulation)other ways to identify a learning gap | Interprofessional education meeting participants receive feedback that learners have a need to develop KSAs regarding a specific competency (e.g., patient-centered relationships). Continuum of learning fostered throughout one’s career within the organization. Interprofessional values are integrated and reinforced inclinical workflowpreprofessional, undergraduate, and graduate education. |
| 2. Key Interprofessional Stakeholders Provide input on topic Participate as part of educational planning team | Various stakeholders included in educational planning. It is critical that team works together to plan and develop educationEach team member provides a unique perspective as defined by interprofessional education and collaboration. |
| 3. Tailored Learning Review competency related to learning needIdentify specific performance criteria to establish expectations and outcomesIdentify optimal educational opportunities for individual and interprofessional teamIndependent review of articles/resourcesLive class eventSimulation event Clinical immersion | Principles of shared accountability for interprofessional learning and collaboration: Communicate competencies supported by desired behaviorsProvide opportunities for experiential learning with measurable outcomes. |
| 4. Competency Validated at the Point of Care once education is completed by participant, which may vary in time needed. This is the real benefit of CBELearners demonstrate their ability to apply their knowledge, skills, and abilities in the authentic environment | For some clinicians, it may take several attempts to reach safe, independent practice. Moving to a CBE model can save time and money as well as increasing participant satisfaction and competence (Shinners & Deasy, 2021). |
| 5. Debriefing and Program Evaluation is completed and reviewed by planning team – Iterative process focuses on: meeting learner needsidentifies potential revisionsplan future offerings | High-functioning IP-CLEs have structures and processes in place to ensure shared accountability for evaluating, improving, and maintaining an interprofessional approach to learning and collaborative practice. |
The use of a competency-based model founded on the principles of an optimal clinical learning environment is a step in the right direction to ensure both individual and collective interprofessional competence. Learners need to gain experience to demonstrate higher critical thinking skills necessary for problem-solving and decision-making. An interprofessional CBE approach supports an optimal clinical learning environment for the learner to successfully obtain the skills needed in the practice environment.
For more information on using CBE in practice, check out a previous ICE Blog which includes a 2-part series on Key Principles in Programmatic Assessment.
Photo credit: Wikimedia Commons
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