Pre-Licensure Nursing Student Perception of Competency-Based Education: A Phenomenological Study

Background

The healthcare environment is becoming increasingly complex, and without quality nursing education, new graduate registered nurses (NGRN) will not be prepared to meet the demands of the job by providing safe, quality care or meet the public’s expectations for health care [1]. Kavanagh and Sharpnack [2] report that NGRNs are not efficient in essential nursing skills and clinical judgment; the percentage of NGRNs who were deemed safe to practice has significantly dropped from 35% in 2005 to a staggering 9% in 2020 [2]. Regulatory bodies and professional organizations such as the Institute of Medicine, the American Association of Colleges of Nursing (AACN), and the Accreditation Commission for Education in Nursing (ACEN) are requesting major changes in nursing education, including a focus on clinical judgment [3]. Competency-based education (CBE) in nursing is one recommendation for ensuring quality nursing education and preparing NGRNs to transition to practice. The goal of CBE is to determine how effectively students apply the knowledge and skills gained from nursing education [4].

Purpose

Gaining insight into the students’ perception of competency-based nursing education will inform faculty in creating strategies to support learning through CBE and give insight into the uniqueness of the student experience. This qualitative study used a hermeneutic phenomenological approach to understand the lived experiences of pre-licensure junior and senior baccalaureate nursing students in competency-based nursing programs. This study was limited to pre-licensure nursing students in a CBE program in their junior and/or senior year of the baccalaureate program of study.

The central research question was: What is the essence of the lived experience for pre-licensure junior and senior baccalaureate students in a competency-based nursing education program? This study employed van Manen’s [6] method to analyze the lived experience of the students, focused on the students' initial experience with CBE in nursing. This method guided the research through semi-structured interviews that gathered the interpretative meaning of CBE in nursing using the four existential themes described in the method. van Manen’s [6] six-step approach to interpretive phenomenology was employed to interpret the material collected through the interview process. This research design helped to fully understand how CBE impacts students' emotions, study habits, and progression through the nursing program.

Data Collection Procedures

Data was collected from 20 universities that agreed to allow their students to participate in the study on a voluntary basis. A total of 22 students reached out to participate; of those, one was ineligible because they were a sophomore. Those who indicated interest and were eligible to participate were emailed the letter of informed consent to review and sign. The signed letter was received from 9 students, and 8 students completed the interview process. Each student was given a unique identification code (such as Student Nurse A or SNA, Student Nurse B or SNB, and so on) to use throughout the data collection process. The only identifying information saved during the interview was the student’s level in the nursing program. Other contact information obtained to schedule the interviews was deleted once the interviews were completed.

Interview Process

The initial interview was conducted via Zoom with the student’s camera off and their identification code on the screen to protect privacy. The interviews were recorded for data analysis, transcribed through Zoom, and saved on an external hard drive used only for this study. The initial interview was semi-structured with open-ended questions developed by the researcher. An interview guide was used to ensure similar information was collected from each participant and included the core question and other associated questions to gain a rich description of the student’s experience. Handwritten notes were taken during the interview to enhance analysis of the collected data. The written notes, thoughts, and anecdotes provided a framework for reflecting on and interpreting the interview.

Following the initial interview, the students were given the transcript of the interview for review and reflection [6]. The student was asked to verify the accuracy of the transcript and had the opportunity to add further material related to their experience with CBE to clarify it. The students were asked to provide a word image describing their lived CBE experience, consisting of 3-5 words. The word image was used to validate the interpretation of the interview material, provided a foundation for the themes, and substantiated step two of van Manen’s [6] method to “investigate experience as we live it” (p. 30).

Data Analysis

The interviews, transcribed via Zoom, were read after each interview and before the next to gain a general sense of the interview and its content [5]. The researcher considered students' perspectives and their explanations of their lived experiences with competency-based education. Their perspective was analyzed to provide a rich description of their CBE lived experience using van Manen’s [6] methodical structure of human science research. van Manen’s [6] methodological structure includes six research activities or steps: 1) turn to a phenomenon of interest; 2) investigating the lived experience of the phenomenon; 3) reflect on themes and concepts of the phenomenon; 4) writing and rewriting; 5) maintain a strong relation to the phenomenon; 6) balancing the research considering parts and whole. Although these are described as steps, the researcher is not required to follow them in order; they may be incorporated intermittently or simultaneously throughout the process [6].

To realize step one of van Manen’s [6] method, the researcher recognized that the lived experience of baccalaureate pre-licensure nursing students in CBE is of interest, given the recent AACN requirement to incorporate CBE into the nursing curriculum to obtain or retain accreditation. The lived experience of CBE is essential to creating a competency-based curriculum that will not only lead the nursing student to pass the NCLEX but also lessen the transition-to-practice gap. Understanding the essence of the student’s perception of CBE will provide nursing faculty with an interpretation of the student experience to formulate a curriculum and experience that will benefit the student and foster an atmosphere conducive to learning and skill demonstration. This was incorporated into the lived space existential and will guide hermeneutic reflection in step three [6].

To investigate the experience as we live it, which is step two of van Manen’s method [6], a description of the lived experience of CBE was collected from junior and senior pre-licensure nursing students through semi-structured interviews. The description of their lived experiences helped the researcher become more invested in the phenomenon and develop a deeper understanding of CBE in nursing. The interview was conversational to help the student feel comfortable during the process and focused on gathering the lived-experience material, such as stories, anecdotes, and descriptions of experiences [6]. The follow-up with each student was more reflective, and the students were asked to provide a word image of their experience. The interview incorporated the lived body and lived time existentials; the student is “bodily in the world” of CBE, and their experience is a personal life history of lived time [6]. The interview and follow-up also revealed the lived human relation, an existential perspective, by describing their experiences with faculty and peers in CBE and through the conversation with the researcher [6].

Hermeneutic-phenomenological reflection, step three, was implemented to gain an understanding of the student’s lived experience in CBE and to identify themes of the experience [6]. Themes were created through reflection of the interview transcripts, written notes, and the student’s word images. Identifying the themes involved reflection using the four existentials as a guide and, through the process of insight, interpreting the interview content, helped discover and disclose a deeper meaning of the lived experience of CBE through the eyes of the student [6].

The goal of hermeneutic phenomenological writing, step four, is to make the phenomenon, in this study, the student’s lived experience of CBE, understandable [6]. Writing and rewriting required the researcher to be sensitive to the students’ experiences and to reflect on the essence of those experiences to formulate a rich interpretation of the students' experience.

Maintaining a strong, well-oriented relation (step five) involves setting aside bias, opinions, and preconceptions to focus on the phenomenon [7]. van Manen [6] gives four conditions for accomplishing this: the text should be oriented, strong, rich, and deep. The oriented text focuses on developing the answer to the research question: What is the lived experience of prelicensure nursing students in CBE nursing? A strong text reveals the best interpretation of the material through reflection and hermeneutic-phenomenological writing. A rich text is a concrete description of the phenomenon, the lived experience of CBE in nursing. Finally, a deep text was created to reflect the meaning of the prelicensure students' lived experience through an open and honest description, giving it dimension.

Balancing the research context by considering parts and the whole (step six) is the culmination of disseminating the meaning of the lived experience of the prelicensure student in CBE. This includes all aspects of the research process, including thematic analysis, reflection, writing, investigating, and interpretation of the material.

The steps in the research process were continually evaluated to ensure each played a role in the overall study [6]. The dissemination of the findings included every aspect of the research design and a rich interpretation of the meaning of the lived experience of pre¬licensure nursing students in CBE.

Rigor, Reliability, and Validity of the Study

Rigor in qualitative research includes confirming that the appropriate research method was used, that the method addressed the research question, that the strength of the research design was maintained, and that the researcher was free from bias during the study. Rigor ensures the researcher’s role was free from bias and the conclusions are strong, rich, and deep along with being related to the research question [8,9]. Reliability, validity, authenticity, and transparency are used to establish rigor in a study.

This study used interviews of pre-licensure nursing students with a standard set of questions to build reliability of the data collected. Follow-up questions were asked pertaining to the answer when more clarity was required to understand their thoughts.

To confirm the validity of this study, an audit trail was created to guide others in replicating the study and validating the findings [10]. Note-taking and the researcher’s feelings are vital to confirming validity. During the notetaking process, essential observations and insights were documented along with keywords from the student perspectives to help the researcher develop themes and ultimately describe the lived experience of CBE [11]. The researcher’s insights and reflections on CBE gave the reader a clearer vision of the findings and interpretation of the data collected.

In this study, the two assessments used to obtain concurrent validity were the interview and a word-image. The students reviewed their interview transcript to verify their thoughts and feelings and were given an opportunity to clarify or to add information. The students were asked to provide three to five words describing their lived experience in CBE after reviewing the interview transcript. These words were compared with their interview transcripts to add validity to the study and the interpretation of the individual interviews.

Ethical Considerations

The study was submitted and approved by an Academic Institutional Review Board and was determined to be a minimal risk study. The study participants were fully informed of the purpose of the study, the procedures of the study, potential risks and benefits, and how the data would be used and disseminated. The interviews were conducted virtually while the interviewer was in a closed office to protect privacy and confidentiality. The only personal information collected was the participant’s name and level or year in the nursing program. Each participant was assigned a code, a unique identifier, for data transcription and analysis.

Discussion of Findings

Six themes were identified through the analysis of the findings. The themes were categorized into van Manen’s [6] four existentials: Lived Space, Lived Body, Lived Time, and Lived Other (relationality). The students' specific thoughts are identified through their unique identification code, SNA, SNB, SNC, and so on. See Figure 1 for Conceptual Model.

The Lived Space existential focused on how the space that the students found themselves in affected their emotions and feelings about the phenomenon. The first theme identified was: “Students are in the lab space consistently to practice skills.” The students mostly discussed their lab and simulation experiences and how these experiences shaped their learning and knowledge of nursing skills. The students stated they had regular lab days, such as Tuesdays, Thursdays, and Fridays. Several students said their skills days were “jam packed” into the second and third semesters so they could be prepared to participate in clinicals. One student stated that in the senior year, they did not have “structured lab hours,” but they could review and practice any skill they felt needed attention throughout the semester. Overall, the students had a positive experience and were in the lab and participated in simulations on a routine basis throughout the beginning of their nursing programs, with the exception of one student who did not have required lab time during the senior year.

The second theme, “Students are adapting to CBE in nursing without too much difficulty,” came through when students answered questions about the teaching styles in their nursing courses. The students did not specifically state a difference between their experience in the CBE nursing courses and general education courses. The students stated that the teaching strategies in the nursing courses were generally lectures, exams, demonstrations, quiz applications (such as Kahoot), lab days, and simulations. They seemed to adapt to the CBE curriculum without difficulty.

The Lived Body existential focused on the interaction with others: students with other students, and faculty with students. The third theme identified was “The faculty do not have knowledge of or are not willing to explain CBE to students,” and the fourth theme was “Students are not made aware of the difference between skills and competencies, nor the definition of competency.” Upon analyzing the interview transcript and listening to the recordings, it became clear that these two themes are closely intertwined throughout the interactions between students and their peers, as well as between students and faculty.

The students stated that the words “competency” or “competencies” were briefly mentioned, used interchangeably with “skills,” or not mentioned at all. When asked how the students are made aware of the required competencies for a course, most stated that the competencies were reviewed on the first day of class. Three of the students, SNA, SNB, and SNG, had a more definitive understanding of CBE, but still did not describe their perception of CBE as being truly competency-based. It was interesting to note that these students attended three different schools. SNA mentioned the lab was more "skills-based,” and her perception of CBE as a whole is that it is more hands-on rather than competency-based. SNB stated that the competencies were related to assignments in the course. Her perception of CBE was critical thinking and relying on knowledge learned in the classroom. SNG stated that the faculty mentioned being competent, and they have “competency check-offs.” SNG’s perception of CBE was that it is “critical thinking and connecting ideas.” The other five students were either unaware of or minimally aware of the program's competencies, only that skills checkoffs were mandatory. SND stated they needed to “prove to somebody” that they could perform the skills correctly and was not aware of competencies in the program. SNE felt CBE was being checked off to move on to the next skill, and SNJ mentioned that CBE was helpful for exams. SNF stated it was a different level of learning, and SNI stated it gave her confidence in her ability to perform skills.

The Lived Time existential focused on the experience of being in the world or considering past experiences and how they impact the current lived experience; specifically focusing on the students' experiences in the general education courses and their current experience in CBE nursing courses. The fifth theme identified was, “The students notice a difference in the teaching strategies and study/practice time between general education courses and CBE nursing courses.” Half of the students stated that the CBE nursing courses were more “hands-on” than the general education courses. The different teaching strategies used in CBE nursing courses included HoloLens and OSCEs, along with different teaching props. Two students mentioned the use of quiz applications, such as Kahoot, in the courses. Several students mentioned that the nursing lectures go fast and have more information included in the lectures that they need to know. Study habits and time were increased with the CBE nursing courses. SNA stated she spent 90 minutes in the lab to practice a skill, then practiced at home with a friend. SNB noted she studied up to 3 hours after each lecture. SNJ stated her study habits for nursing courses were “more time consuming” and that she was “not learning the way she did before.” The major difference between the two types of courses is the hands-on approach that nursing courses incorporate.

The final existential, Lived Other (relationality), focused on the experience of relationships with others, including those between students and their peers and those between students and faculty. The sixth, and final, theme identified was “Students find comfort and support from their peers and instructors.” SNA mentioned that senior students would come to class or lab days to assist with skills. SNA and SNB mentioned that the faculty were available to answer questions. SNB went on to say that the instructors got to know the students “pretty well.” SND shared that there is a lot of collaboration at her school with peers and faculty. SNF stated there was a lot of collaboration with peers and faculty. She noted that she enjoyed being with the nurse or instructor to learn about their “real life experiences” and have her own “real-life” experiences with their guidance. Her comfort came from knowing she wasn’t alone in her struggles, as her peers had the same “knowledge level.” The students overall felt that working with their peers and faculty was a positive experience, and relationships were formed with each other for collaboration and brought comfort and encouragement to each other.

Figure 1: Conceptual Model

Recommendations for Nursing Education

The faculty provides the knowledge base for the students, and they should be able to describe to students the difference between the competencies and skills. Therefore, the faculty need to be educated in CBE, including the difference between competency and skill, and the importance of the assessment of the student’s critical thinking, attitude, and skill set, along with encouraging students to self-reflect on their skills and how to improve throughout the program. Competency and skill assessments should be completed multiple times throughout the nursing program to help students become practice-ready and build a foundation of confidence in their skills.

Recommendations for Future Research

Recommendations for future research include faculty-focused studies to understand the extent to which faculty understand CBE and the challenges they face when transitioning to a CBE curriculum. For example, comparing the faculty in established CBE nursing programs (more than 5 years) with those in programs that have been implemented for 1-3 years. What differences do they see? Are faculty more engaged in teaching CBE? What is the difference in the understanding of CBE between the two groups? Another study could be a continued study of students in a CBE nursing program after the transition to CBE has been implemented for more than a year. How are they understanding CBE? How are they adapting to CBE? A longitudinal study that compares CBE-educated nurses to non-CBE-educated nurses to measure the impact CBE has on new graduate nurses. A final recommendation is to research the differences between veteran nurses in the hospital and new nurses coming in from a CBE program. Is there a difference in their readiness or knowledge of nursing?

Conclusion

The findings of this study revealed that students are adapting to the CBE nursing curriculum without significant disruption. However, the student-based meaning of competencies and CBE remains undetermined, as students are not fully aware of the true definition of CBE in nursing and its relationship to their learning about nursing and nursing practice. Students indicated that the terms "competency" and "skill" are used interchangeably. Finally, the students indicated that they found comfort and support from their peers and their instructors in the respective CBE nursing programs.

Limitations

The limitations of this study included a small number of institutions (20) willing to allow their students to participate. The majority of email requests were unanswered. The study was limited to the Midwest and Southeast United States. Expanding the territory for data collection may have increased the number of institutions and participants in the study.

References