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Benchmarks: An Evidence-based Approach to Creating High Performing Nurses

Bobbi Martin and Ronda LaVigne  
Galen Center for Professional Development, 1031 Zorn Ave., Suite 400, Louisville 40207, KY, USA  

Abstract: Consensus is evident among influential professional organizations (American Nurses Association, American College of  Nurses, Institute of Medicine, National Council of State Boards of Nursing, World Health Organization, National Institute of Health,  Quality Safety and Education for Nursing and the American Association of Critical Care Nurses) as to essential core competencies for  healthcare providers. Although there is agreement among them, assessment and measurement of competence for RN’s in transition is  overly complex. Eleven benchmarks were developed as foundational criteria to determine readiness to practice through research of  national healthcare organizations position statements on competency and subsequently cross walked with identified core  competencies. This article introduces the concept of evidence-based benchmarks as a mechanism to determine readiness to practice  safely, competently and independently among novice and experienced nurses who are in transition.  


1. Introduction 

Nursing readiness for practice and competence is a  topic that strikes at the core of quality patient outcomes  and the patient’s perception of care; each affecting  criteria for payer reimbursement.  

Assessment and measurement of competence for  nurses in transition are overly complex and rely on  cumbersome checkoff lists and lengthy competency  performance evaluation packets. Preceptors are left to  determine when a nurse in transition is ready to  practice independently by their sense of readiness  rather than evidence of competence.  

Nurse Development Resources® (NDR)  Benchmarks are a standardized evidence based tool  for competency assessment and documentation of  transitioning nurses’ readiness to independently  manage a full patient assignment.  


2. Prevalent Transition Practices  

The immersion period refers to time spent caring  for a patient assignment with a preceptor and encompasses nurses in transition which include new  graduates, experienced newly hired nurses, and nurses  moving from one clinical area to another. 

Agreement is evident among leading healthcare  organizations as to essential core competencies for  healthcare providers (American Nurses Association  (ANA), American Association of Colleges of Nursing  (AACN), Institute of Medicine (IOM), National  Council of State Boards of Nursing (NCSBN), World  Health Organization (WHO), National Institute of  Health (NIH), Quality Safety and Education for  Nursing (QSEN) and the American Association of  Critical Care Nurses (AACCN)). These include  patient-centered care, evidence-based practice, quality  improvement, safety, teamwork, and information  technology [1-8]. Although there is agreement on core  competencies, ambiguity exists within nursing about  methods to evaluate competence [9].  

Assessment and measurement of competence for  transitioning nurses is complicated. Typically,  hospitals apply standard orientation times that range  from four weeks for experienced nurses to 18 or more  weeks for new graduate hires. However, there is no  evidence to support these as reliable time-frame check off lists in order to complete a validation  document.  

Debate and controversy about methods of competency  validation, diverse approaches to competency  validation by hospital organizations, regulatory agency  requirements, and financial constraints make  standardization of competency validation among  transitioning nurses untenable. As a result, the process  of transitioning nurses to independent practice  becomes fragmented, disorganized, and frustrating. An  evidence-based tool that determines the length of the  immersion period, has clear and concise criteria, and is  easily used during the precepted clinical experience is a  practical and sustainable solution.  

3. Competence, Competency and NDR  Benchmarks  

The terms “competence” and “competency” invoke  different meanings and assumptions among healthcare  providers [10]. The ANA differentiates competence  and competency by defining competence as the  demonstration of knowledge, skills, and attributes;  whereas competency is the expected criteria of  performance of knowledge, skills, and attributes. In  addition the ANA elaborates and states, “Competence  can be evaluated by using tools that capture objective  and subjective data about the individual’s knowledge  base and actual performance and are appropriate for  the specific situation and the desired outcome of the  competence evaluation” [4]. These definitions  encourage nurses to engage in meaningful learning  that is creative and facilitates the transfer of factual  knowledge into clinical practice.  

3.1 Competency Validation  

Donna Wright’s competency assessment model is  gaining wide acceptance across the nation as a best  practice approach to assessment and management of nurse staff competence [2, 10, 11]. Similar to the  definitions provided by the ANA, her work challenges the nursing workforce to think as innovators about  competency assessment. Competency evaluation is a  means to assure we are providing high quality and  safe patient care as opposed to surveyor and/or  credentialing approval. The first step to attain a  workforce with consistent performance is to clearly  define competency. The following definitions provide  example of the diversity that exists in nursing’s  definition of competency (p.7).  

• The knowledge, skills, abilities, and behaviors  needed to carry out a job.  

• Whatever is required to do something adequately  [12]  

• The ability to perform a task with desirable  outcomes under the varied circumstances of the real  world [13]  

• The effective application of knowledge and skill  in the work setting [14]  

Changeability in definition illuminates the need for  organizations to agree on a competency definition and  organize processes, policies, and competency  assessments based on their definition. Equally  important is deliberation and expansion of  competency validation methods. Wright outlines  eleven measurable and documentable approaches. Her  philosophy for measuring competence embraces  validation through a variety of demonstration methods  but underscores best outcomes occur when  verification methods align with the organizations’  definition of competency. See Wright’s Methods for  Competency Validation Figure 1.  

The next step after competencies are defined is to  distinguish between initial competency assessment and  ongoing competency development. Initial competency  assessment begins at hire and culminates with  independent practice. Initial competency assessment  focuses on job knowledge, skills, and attributes  necessary for independent practice during the first six  months to a year in the assigned clinical setting,

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On-going competency assessment builds on initial  assessments and reflects the ever-changing nature of  the job, organization, and practice environment.  


Clear differentiation between initial and ongoing  competency is important to ensure the workforce is  competent across the continuum. Traditionally the  workforce is segmented in such a way that  newly hired nurses and existing nurses follow  different competency tracts. Current structures  and processes complicate the end goal of creating a  clearly defined competency assessment process  and place arbitrary timeframes for competency  validation. The use of benchmarks provides an  evidence-based tool to accurately determine transition  timeframes.

3.2 Transition Timeframes  

The ability to accurately determine immersion  periods is crucial for a variety of reasons: patient  safety, quality patient outcomes, patient satisfaction,  nurse satisfaction (preceptor and preceptee), and fiscal  management of the immersion period. Presently  competency assessment and validation serve as  primary determinants of immersion periods—time  spent caring for a patient assignment with a preceptor.  Common practice uses 100% completion of assigned  competencies, preceptor feedback, and an educated  guess of immersion period timeframes. Few  evidence-based tools exist to help organizations determine immersion timeframes [14, 15]. There is a  paucity of evidence-based tools that provide clear and  concrete expectations with appropriate criteria for  assessment of knowledge transfer to the clinical  practice setting. Demonstration of foundational  principles that develop critical thinking and problem  solving are the core of Nurse Development  Resources® (NDR) Benchmarks, and equip  transitioning nurses with essential elements necessary  to independently care for a patient assignment. Using  NDR Benchmarks as a determinant of the immersion  period provides an evidence-based and standardized  approach that eliminates extensive orientation lengths  for nurses ready to independently practice but ensures  nurses who need additional time receive it.  

3.3 NDR Benchmarks  

The national conversation of how the profession  transitions nurses and manages competency  assessment is changing. Frameworks, criteria and  tools from American Nurses Credentialing Center  (ANCC) and Wright help fuel the shift by bringing  context and tools to the challenge. NDR Benchmarks  are part of this discussion and offer a fresh perspective  and viable solution for determining nurse transition  timeframes. NDR Benchmarks provide elemental  criteria that assist organizations in their assessment of  a transitioning nurse’s readiness for safe, competent,  and independent clinical practice and are intended for use with all nurses in transition, across all specialty  practice areas, and clinical environments. 

3.3.1 Process  

A 12-month multi-state, multi-hospital beta test was  conducted to implement, test, and refine NDR, which provides point-of-care reference for HACs and core  measures along with a medication calculator  

• Married State Preceptor Model (MSPM)  • Support group facilitation  

• Quality improvement mentorship  

Over 500 nurse leaders, preceptors, and  transitioning nurses were provided workshops on how  to use NDR. Early analysis of feedback from the beta  test revealed a major gap in transitioning nurses to  independent practice. In an effort to validate  competencies, transitioning nurses failed to  operationalize introductory principles necessary to  manage patient care such as delegation, prioritization,  and time management.  

Qualitative feedback revealed preceptors spent time  completing competency evaluation packets as opposed  to role modeling, coaching and evaluating  foundational nursing principles. This discovery served  as a catalyst for further research and resulted in the  development of NDR benchmarks. Benchmarks were  introduced into the beta test as a determinate of  readiness to practice independently of preceptor  supervision. Teaching methods for all participants  included onsite presentations, training videos, and  monthly hosted webinars. EngageSM, an electronic  management system, provided real-time progress of  NDR Benchmark achievement.  

3.3.2 Development  

Research of position statements from the previously  mentioned influential healthcare organizations on  

competency served as the NDR Benchmark  underpinnings (ANA, AACN, IOM, NCSBN, WHO,  NIH, QSEN, and ACCN). The research yielded  specific, consistently agreed upon core competency  criteria, including patient-centered care,  evidence-based practice, quality improvement, safety, 

teamwork, and information technology. The core  competencies were interwoven into eleven benchmark  categories that illustrate and encompass the  knowledge, skills, and behaviors necessary to manage  a full patient assignment independent of a preceptor.  The benchmarks eliminated reliance on complex  competency evaluation packets and/or check off lists  that distract preceptors and transitioning nurses from  the focus of patient care coordination and  management reducing fragmentation in the transition  process. See Benchmark Categories Figure 2. Instead  NDR Benchmark criteria provide observable actions  the preceptor can assess during the precepted  experience as the preceptor and transition nurse care  and manage a full patient assignment together. NDR  Benchmarks serve as guidelines that center the  transition nurse’s attention on necessary skills for safe,  competent and independent management of a patient  assignment.  

As a bedside nurse, precepting adds an additional  role with more responsibilities to an already full  workload. Preceptors must learn to manage extra duties  that require specific knowledge, skills, and attributes  for successful outcomes. Because a bedside nurse has  multiple and diverse obligations, competency assessment  tools are needed that are clear, comprehensive, and  easy to access. Preceptors are provided the rationale  and instruction on how to use the benchmarks with the  recommendation that the preceptor/preceptee dyad  manage a full patient assignment together, known as  the Married State Preceptor Model (MSPM) [16].  Traditionally, a patient assignment is divided between  the dyad, and the transitioning nurse misses key  opportunities to see critical thinking and clinical  reasoning when they occur. 

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4. Outcomes  

Competence is the intellect and attitude nurses must  possess, competency is demonstration in practice and  benchmarks are the evidence-based mechanism that  safely determines the length of time necessary for  nurses to practice independently. The relationship  between competence, competency and NDR  benchmarks becomes evident when operationalizing  competency management in clinical practice. Wrights  competency assessment model provides supporting  rationale and the MSPM provides an effective  precepting approach that enables easy use of the NDR  Benchmark tool.  

The impact and benefits of NDR benchmarks are  trifold and include the ability for organizations to  make informed strategic staffing decisions, have a  standardized evidence based tool for competence  assessment and documentation, and are consistent  

across clinical areas.  

4.1 Inform Strategic Staffing Decisions  

In light of the Institute of Medicine’s  recommendations of an 80% Baccalaureate-prepared  nursing workforce [19], trending educational  preparation data allows hospitals to hire nurses at  various levels of entry thus meeting their immediate  staffing needs while establishing partnerships with  colleges to extend continuing education and  professional development to all nurses.  

Because education and experience level data is  collected on each NDR user upon hire, hospitals can  trend data to determine an average time needed by  newly hired nurses to provide independent and safe  care for a full patient assignment. For example,  hospitals may hire new graduates from multiple area nursing colleges. By trending when new graduate  nurses’ complete benchmarks, which marks the time  they are placed in productive staffing, hospitals are able to make informed hiring decisions based on  evidence of actual performance. For example, nurses  from X College consistently achieve benchmarks at 6  weeks, whereas nurses from Y College consistently  require 12 weeks.  

This holds true for experienced nurse new hires and  nurses transitioning from one unit to another.  Hospitals can trend data to project the time an  experienced nurse with 5 years’ experience will take  to be placed into productive staffing in comparison to  a nurse with 2 years’ experience. Or nurses from a  medical/surgical unit require 8 weeks to transition to  an ICU whereas nurses from labor and delivery take  12 weeks to transition to ICU. NDR benchmarks  provide hospitals a tool to inform strategic staffing  decisions.  

4.2 Standardize Competence Assessment &  Documentation  

Inconsistent determination of transitioning nurses’  readiness to practice places patients is at risk.  Standardization reduces risk and can influence positive  patient outcomes. Nurse leaders, preceptors and  transitioning nurses benefit from a standardized,  evidence-based process. NDR Benchmarks are a  solution for overcoming these hurdles and promote  safe and individualized nursing transitions. Because  NDR benchmarks are foundational principles that can  be observed in daily management of a clinical  assignment, preceptors can determine the transitioning  nurses’ demonstration of knowledge transfer to clinical  practice. Preceptors report the concrete criteria within  each benchmark which gives them measureable  objectives they can discuss with their preceptee. The  benchmarks provide focus for discussion and enable  collaborative dialogue between the preceptor and  preceptee as to how they are meeting or not meeting the  criteria.  

4.3 Consistent Across Practice Areas  

A consistent and flexible tool is necessary for  application in a variety of healthcare delivery settings.  NDR benchmarks demonstrate flexible and  consistence capabilities regardless of specialty areas  including medical/surgical, progressive care, intensive  care, emergency, labor and delivery, and pediatric  departments. Discovery of this implication became  evident during the beta-test, when hospitals extended  benchmarks to specialty practice areas. NDR  Benchmarks require transitioning nurses to  demonstrate the ability to competently coordinate care  for a full patient assignment and focus attention on the  patient population being served.  

5. Summary  

The beta-test highlighted opportunity for  vocabulary clarification and assisted with adjusting  descriptions and articulation between the role of  benchmarks and competency validation in clinical  practice. A comprehensive but clear articulation is  NDR Benchmarks incorporate top health care  organizations’ core competencies as the standard point  of reference that outline expected levels of  performance and are used to determine readiness for  independent practice.  

Nursing readiness for practice and competence is a  topic that strikes at the core of quality patient  outcomes and patient’s perception of care, each  affecting criteria for payer reimbursement.  Organizations are challenged to demonstrate the  quality of their care and competency of their nursing  workforce to their community and regulatory agencies.  Barriers and challenges have been related to  vocabulary and methodology for competency  assessment illuminating a need for evidence based  measurement tools.  

Prominent national organizations’ core  competencies outline criteria expectations but  variance in methods for assessing competence in the  clinical setting remains a problem in evaluating desired outcomes. Evidence based tools that determine  readiness for independent practice is scarce. Although  the ANA has better defined competence and  competency, and Donna Wright provides a  comprehensive model to assess and manage ongoing  competencies, a gap remains as to how to determine  readiness of independent practice for nurses in  transition.  

NDR Benchmarks are an evidence-based,  predictable, and measureable tool that aids  organizations with the determination of nurse  readiness for independent practice. Although  benchmark completion indicates placement of the  nurse into the staffing mix, validation of assigned  competency sets continue. This is a paradigm shift  from past practices where 100% completion of  competency sets served as the primary indicator of  safe, independent practice. Informed strategic  decisions, standardized competence assessment and  documentation, and consistency across practice areas  are three distinct organizational advantages to using  benchmarks.  

Recommendations for future research include  deeper analysis of the use of benchmarks. Studies that  measure the influence of benchmarks on orientation  length, determinants of independent practice, and how  education and experience levels influence strategic  decision making will add to the national dialogue and  drive high quality care.  

“The nation’s health depends on nursing®” is a  core belief at the Galen Center for Professional  Development (GCPD). Confident the nation’s health  indeed depends on nursing makes the case for  empowering organizations with the use of an  evidence-based tool that determines a nurse’s safe and  competent transition to independent practice.  


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