Increasing demands on nurses and the role of the nurse educator: Developing nursing competencies

Submitted by Jill E. Toledo, MSN, RN, CPON

Tags: Competency Nurse Education Nurse Educator patient care patient outcomes patient safety performance

Increasing demands on nurses and the role of the nurse educator: Developing nursing competencies

Share Article:

Today’s healthcare environment is becoming more challenging with the introduction of evidence based practice, higher patient acuity, increased nurse to patient ratios, and the need to provide culturally competent care within a challenging and fast paced environment that demands positive patient outcomes and increased patient safety.  The Institute of Medicine (IOM) determined that 2%-3% of patients encountered adverse events during hospitalization (Miltner, Patrician, Dawson, and Jukkala, 2012).  Healthcare professionals practicing within this healthcare environment, require ongoing education and review that appropriately prepares them for the challenges of 21st century nursing.  

Nurses are a diverse group with different cultural, educational backgrounds and generational differences.  As an educator in such a diverse care setting it is important to recognize the educational and generational gap that may exist. Utilization of teaching methods and techniques that engage the different generations and varying learning needs is essential to success. It is of increasing importance to understand the multigenerational differences and expectations of the learners so that the education provided does not create barriers or misunderstandings and allows the learner to reach their maximum potential and learn effectively (Hawala-Druy and Hill, 2012). When leading an educational initiative it is important to understand the values of the generations, their different approaches to learning, communication styles, expectations of learning, personal values and even views about authority in the workplace when working with and teaching a diverse group (Hu, Herrick and Hodgin, 2004).

Healthcare has become more challenging, as it is occurring within a technologically advanced environment. Nurses have increased accountability and are required to care for diverse patient populations with specific cultural needs.  Nurses are expected to provide evidence-based, patient centered care while utilizing quality improvement techniques.  Training competencies need to identify the needs of the nurses while providing them with the education to meet the increasing demands for quality, safe and effective patient care that in turn results in positive outcomes.  In order to meet those increasing demands, hospital based nursing education must provide the direct caregivers at the bedside with education that ensures that they can meet the minimal standards of nursing competence (Hsieh and Hsu, 2013).

Within many acute care settings, protocols and processes changed quickly, acuity fluctuates and increasing demands of clinicians contribute to an environment where appropriate techniques, double checks in place to ensure patient safety fail and can compromise patient safety, impact positive patient outcomes and increase hospital costs.  Nurses are the primary caregivers in an inpatient setting, they are the frontline staff that have continuous patient involvement and implement direct patient care.  In today’s healthcare environment, nurses are in the ideal position to influence patient outcomes.  According to Lenburg, Abdur-Rahman, Spencer, Boyer, and Klein (2011) competencies and utilization of the Competency Outcomes and Performance Assessment Model (COPA) can prepare nurses with core clinical behaviors that demonstrate competence. The Institute of Medicine (IOM) in 2002 identified core competencies that would increase the quality of patient care and safety (Forbes and Hickey, 2009).  Topics identified are to provide patient centered care, work within an interdisciplinary team, utilization of evidence based practice, quality improvement and use of informatics.  

Another concern regarding patient care are the unique challenges facing new graduates.  As discussed by Anderson, Hair, & Todero (2012), some challenges faced by new graduate nurses occur when they transition from a nursing program to the professional role. Those challenges are attributed to reduced orientation, increased stress that correlates with high patient acuity, short staffing, lack of confidence and concerns related to giving medications and causing patient harm.  

Educators have a responsibility to teach students and nurses alike to develop and strengthen their skills in order to become competent and safe practitioners while assisting them to transform knowledge into practice (Doane and Brown, 2011).  Armstrong, Spencer, & Lenburg (2009), states that the Quality and Safety Education for Nurses (QSEN) determined that core competency and knowledge is essential and plays a vital role in the provision of safe patient care.  Evidence based practice also plays a critical role in promotion of quality health care, increasing the reliability of care, promotion of positive outcomes all while decreasing costs (Melnyk, Gallager-Ford, Long and Fineout-Overholt, 2014).

According to Melnyk et al. (2014), competencies are a process that consists of psychomotor, knowledge and affective skills that enable nurses to provide quality care.  In order to promote restoration of health, influence positive outcomes and decrease length of stay nurses must be appropriately educated in order to carry out medical orders and practice autonomously.  Nurses, who are not appropriately educated and trained, may not be able to practice independently or safely and can potentially contribute to adverse patient outcomes.  

Utilization of appropriate learning models and learning theory is also essential when developing teaching competencies. Two successful models are the Competency Outcomes and Performance Assessment Model (COPA) and the Knowles Adult Learning Theory.  

The COPA Model is an effective model for competency development as it clearly defines the learning need(s), course objectives and necessary competencies that help the learner achieve the necessary skills to perform the task.  Competence is a complex concept where the nurse can perform the actual task appropriately, but also adopt a belief that quality, safety and evidence based practice improves patient outcomes.  The COPA model provides us with a framework that is a self-regulatory process that determines that the provider is able to demonstrate safe practice once the competencies are completed.  It gives reassurance to the patient, institution and nurse that the care provided is safe, effective and evidence based.  According to Klein and Fowles (2011), the COPA model expects the learner to be actively involved, requires the program to identify learning outcomes, competencies and strategies in teaching to assist in the development of competent providers.  In recent years the utilization of the COPA model has become more common because it helps identify existing health problems and the necessary competencies that nurses must possess in order to meet those health needs (Kim, 2012).  Utilization of the COPA model in nursing education prepares students and practicing nurses to effectively provide care to patients because they have appropriate knowledge and developed core clinical behaviors (Lenburg, Abdur-Rahman, Spencer, Boyer & Klein, 2011).

Knowles Adult Learning Theory can also be applied competency development as all of learners within the hospital setting are adults. Adult learners are nurses who are task and goal oriented. They further want to meet the needs of the patients as well as their own needs. The patients need a competent provider who can perform skills effectively and the nurse needs the skills to save time, skills that can be easily applied and incorporated into their daily routine.  According to the adult learning theory, adult learners can become frustrated if they cannot see that the new information being covered is relevant to what task are being performed (Kenner and Weinerman, 2011). During competency instruction it is important to show the staff that the information being provided can decrease patient morbidity and mortality.  Adult learners also have the desire to become partners with the educator and have a cooperative relationship (Kenner and Weinerman, 2011).  As an educator for adult learners it is crucial to understand how adults learn and how learning is applied to their prior experiences as a nurse and understand their motivation to learn new or revised techniques.  Adult learning is problem focused, incorporates prior experiences and is easily applied to everyday life (Onyon, 2012).

With the numerous demands of nurses within the complex healthcare environment there is an increasing need to support, reinforce and educate nurses on the skills needed to provide safe effective care to complex patient populations.  QSEN’s global nursing initiative developed competencies that allow nurses now and in the future to improve the quality and safety within the healthcare system where they work (Melnyk et al., 2014).  Educators have taken on that challenge and embrace the opportunity to support bedside nurses in their daily provision of care.


  1. Anderson, G., Hair, C., and Todero, C. (2012). Nurse residency programs: An evidence based review of theory, process and outcomes. Journal of Professional Nursing 28(4), 203-212.
  2. Armstrong, G.E., Spencer, T.S., and Lenburg, C.B. (2009). Using quality and safety  education for nurses to enhance competency outcome performance assessment: A  synergistic approach that promotes patient safety and quality outcomes. Journal of Nursing Education 48(12), 686-693.
  3. Doane,C.H., and Brown, H. (2011). Re-contextualizing learning in nursing education: Taking an ontological turn. Journal of Nursing Education 50(1), 21-26.
  4. Forbes, M. O. & Hickey, M. T. (2009). Curriculum reform in baccalaureate nursing education: Review of the literature. International Journal of Nursing Education Scholarship, 6(1), 1-16.
  5. Hawala-Druy, S., and Hill, M.H. (2012). Interdisciplinary: Cultural competence and culturally congruent education for millennials in health professions.  Nurse  Education Today 32, 772-778.
  6. Hsieh, A.I., and Hsu, L.L. (2013).  An outcome-based evaluation of nursing competency of baccalaureate senior nursing students in Taiwan.  Nurse Education Today 13, 1536-1545.
  7. Hu, J., Herrick, C., and Hodgin, K.A. (2004). Managing a multigenerational nursing team. The Health Care Manager 23(4), 334-340.
  8. Kenner, C., and Weinerman, J. (2011). Adult learning theory: Applications to non-traditional college students. Journal of College Reading and Learning 41(2), 87-96.
  9. Kim, H.S. (2012).  Outcomes-based curriculum development and student evaluation in nursing education. Journal of Korean Academic Nursing 42(7), 917-927.
  10. Klein, C.J., and Fowles, E.R. (2009).  An investigation of nursing competence and the competency outcomes performance assessment curricular approach: Senior students’ self-reported perceptions. Journal of Professional Nursing 25(2),109-121.
  11. Lenburg, C.B., Abdur-Rahman, V.Z., Spencer, T.S., Boyer, S.A., and Klein, C.J. (2011).  Implementing the COPA model in nursing education and practice settings: Promoting competence, quality care and patient safety.   Nursing Education Perspectives 209-296.
  12. Melnyk, B.M., Gallager-Ford, L., Long, L.E., and Fineout-Overholt, E. (2014). The   establishment of evidence bases practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings. Proficiencies to improve healthcare quality, reliability, patient outcomes and cost. Worldviews   on Evidence Based Nursing 11(1), 5-15.
  13. Miltner, R.S., Patrician, P.A., Dawson, M., and Jukkala, A. (2012).  Incorporating quality and safety education into a nursing administration curriculum.  JONA: The Journal of Nursing Administration 42(10), 478-482.
  14. Onyon, C. (2012). Problem-based learning: A review of the educational and psychological  theory. The Clinical Teacher 9, 22-26.