Inside Syllabus: Q&A with Dr. Robert Englander

Syllabus Issue March-April 2023

Inside this Syllabus Edition:

• Q&A with Dr. Robert Englander
• 2023 Deans Annual Meeting Highlights
• Discover AACN's New Climate Survey
• AACN Conferences
• Upcoming AACN Award Deadlines
• ...and more!

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Q&A with Dr. Englander

How do you define competency-based education (CBE)?

The simplest and best definition comes from an article by Frank et al. in 2010,1 a sentinel article in Medical Teacher for anyone wanting to understand CBE. “Competency-based medical education is an outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies.” This represents a major shift from the structure/process education of the 20th century. In structure/process, the timing of the education is fixed (such as a 2-year or 4-year pre-licensure program), and the curricular content is the focus and determines the learner’s outcomes. In CBE, the outcomes, driven by the needs of the public, are the focus and they determine the curriculum and assessment. Learners then get to the expected levels of competence in a time-variable fashion.

How is competency-based education being implemented across the health professions?

CBE is being implemented to varying degrees across most health professions. I can perhaps speak best to physician education and training, where the Accreditation Council for Graduate Medical Education was the driving force to change the paradigm. As a result, graduate medical education is 20 years into implementation with varied success. We certainly are much closer to the delineation of the requisite competencies of an early 21st century physician and the levels of performance or milestones for those competencies. The assessment challenges have been formidable, but I think we are making progress there as well. Undergraduate medical education was slower to the table but is moving more consistently to CBE. In nursing, the publication of the Essentials is a requisite and great first step. Now the delineation of their performance levels and the curricular and assessment tools that are required for implementation will be the next exciting phase for the community of nurse educators to tackle together. Other health professions, such as veterinary medicine and physical therapy, are working as communities towards defining the requisite competencies for their graduates and the essential activities in day-to-day activities (or Entrustable Professional Activities) that require the integration of those competencies.

What are Entrustable Professional Activities (EPAs)?

In an article we wrote in Medical Teacher that focused on a shared language for CBE, we proposed this definition of an EPA: “An essential task of a discipline (profession, specialty, or subspecialty) that a learner can be trusted to perform without direct supervision and an individual entering practice can perform unsupervised in a given health care context, once sufficient competence has been demonstrated.”2 So… they are essential day-to-day tasks across a specialty or profession that can be observed in the clinical work environment, and require the integration of multiple competencies from those delineated by the profession.

What is the relationship between competencies and EPAs?

As just noted, while competencies are abilities of individuals, EPAs are essential tasks that those individuals must perform and that require the integration of competencies to successfully complete. EPAs thus serve as a framework for curriculum and assessment in a program where the outcomes are competencies.

What are some of the biggest challenges associated with competency assessment?

There have been four major conundrums in competency assessment. The first is that competencies are context-independent. They do not require actual patient care to assess, and this decontextualization can allow some with less ability than ideal to get through. The second is related to the granularity of competencies. Arriving at a way to measure the competency often requires its deconstruction to the point that the actual ability being assessed is meaningless in isolation and without context. The third conundrum is simply logistics. Some of the tenets of competency-based assessment include emphasis on formative assessment, multiple assessors, and multiple assessments. If, as in the Essentials, you have 45 competencies (and multiple sub-competencies), and each one requires multiple observations or other non-observational assessments, let’s say 10, the number of assessments can be daunting. Forty-five competencies with 10 assessments over the course of training, with 100 students per year is 45,000 assessments per year for a 4-year program. This also has faculty development implications. Fourth, CBE is criterion-referenced, and we in education have lived in a norm-referenced world for over a century. It is hard to move from the notion of a bell-shaped curve to the notion of a threshold that all learners can achieve, given the resource of time. But it is essential, especially if we want to address bias in assessment. It’s time to set clear outcomes and then move to pass/fail, or as noted professor Carol Dweck says, “pass/ not yet” for all of our learners.

How can schools of nursing accelerate CBE implementation efforts?

The two lowest hanging pieces of fruit are to align the curriculum and assessments with the Essentials. To start, schools can look at all their course learning objectives and “map” them to the Essentials competencies and sub-competencies. If some objectives do not match, the school can decide either to save the objective and include outcomes outside the Essentials, or to eliminate the objective. Then, the assessments for each course should also be aligned to the competencies that the curriculum represents. In the meantime, national efforts can continue to try to better delineate the performance levels for the Essentials competencies and help with assessment development that may be used across programs.

What is the biggest misconception about CBE?

The biggest misconception about CBE is that the shift requires a change to time-variable education and training. It is true that CBE should allow one to demonstrate threshold competence in a time-variable manner, but that does not necessarily mean we have to change the time frames of education. For example, we can provide additional responsibilities and advanced training to learners who arrive more quickly at the requisite competencies. More importantly, going back to the “why” of CBE, we need to ensure that 100% of graduates are competent, even if that means keeping individuals beyond the initial required timeframe. This might also mean novel approaches to funding health professions education!

How important are AACN’s Essentials to shaping the future of nursing education?

If the nursing profession is going to make the shift to CBE, then the Essentials are essential (pun intended). The first step to CBE is to delineate the requisite domains and their competencies through a consensus process across the profession. You cannot proceed without it!

How critical are academic-practice partnerships in the transition to CBE?

No matter how you decide to approach competency assessment, it represents a true change from the past regarding the place of the direct clinical supervisor in providing feedback and assessment. Because the primary mode of assessment stems from direct observation in the clinical (or simulation) space, you need to have your clinicians on board with the process. This seems impossible absent a strong academic-practice partnership. This also means more faculty and staff development and resource support from the academic home.

What impact will moving to CBE have on the nursing profession and healthcare delivery?

I don’t know that I can speak to the impact it will have, but more to the impact it aspires to have. First, the “why?” behind the paradigm shift. In health professions education, there is near uniformity in agreement that the 20th century educational paradigm was inadequate in that it did not address the breadth of competencies or the guarantee of graduate competence across almost every health profession because of its structure. CBE holds the promise of doing both—addressing the complex array of competencies and ensuring through rigorous programs of assessment that every graduate has demonstrated those competencies.

References 

1. Frank JR, Snell LS, Cate OT, Holmboe ES, Carraccio C, Swing SR, Harris P, Glasgow NJ, Campbell C, Dath D, Harden RM, Iobst W, Long DM, Mungroo R, Richardson DL, Sherbino J, Silver I, Taber S, Talbot M, Harris KA. Competency-based medical education: theory to practice. Medical Teacher, 2010; 32(8):638-45. doi: 10.3109/0142159X.2010.501190. 

2. Englander R, Frank JR, Carraccio C, Sherbino J, Ross S, Snell L; ICBME Collaborators. Toward a shared language for competency-based medical education. Medical Teacher, 2017; 39(6):582-587. doi: 10.1080/0142159X.2017.1315066.