Master Competency in Entry-Level Nursing Education Through Scaffolded Learning

Abstract

Background:

The 2021 American Association of Colleges of Nursing (AACN) The Essentials: Core Competencies for Professional Nursing Education was the accelerant for moving nursing academia toward competency-based education (CBE). CBE is grounded in ongoing mastery with consistent progression throughout the program. Resources are needed for integrating the new Essentials into nursing programs.

Method:

A team of nurse educators worked to gain understanding of the Essentials and CBE. The end product was development of a scaffolded learning tool (SLT) to guide faculty.

Results:

The SLT incorporates outcome statements reflecting introduction, reinforcement, and mastery for each subcompetency. Each subcompetency has an exemplar of teaching strategies for nurse educators to use within their courses, with suggested curriculum placement.

Conclusion:

The SLT serves as a guide for nurse educators to apply the Essentials through integration of Bloom's taxonomy to prepare competent nurses.

Since the introduction of the American Association of Colleges of Nursing's (AACN; 2021) The Essentials: Core Competencies for Professional Nursing Education, nursing education called for the move to a competency-based education (CBE) model, preparing practice-ready nurse graduates. CBE, as outlined by AACN (²⁰²¹), emphasizes ongoing mastery and progression. The Essentials framework includes 10 domains, 45 competencies, 230 subcompetencies, eight key concepts, and four spheres of care for outcome-based assessment. The Essentials integrates values, as well as knowledge, skills, and attitudes (KSAs), into nursing practice while incorporating six competencies from Quality and Safety Education for Nurses Institute (^{AACN, 2023}).

Each nursing program upholds professional standards set by accrediting and governing bodies, such as the state Board of Nursing, AACN, National League for Nursing Commission of Nursing Education Accreditation, National Council of State Boards of Nursing, Accreditation Commission for Education in Nursing, and National League for Nursing, requiring the incorporation of the Essentials as a guiding document for curricula. In addition, nursing programs integrate their respective university's mission, vision, values, and philosophy to guide the development of learners into the profession. The release of the Essentials created a need for nurse educators to envision a process to integrate this new theoretical approach to nursing education.

The Competency-Based Nursing Education (CBNE) Network encourages discovery and discussion of both the Essentials and CBE. The CBNE Network is divided into regional networks; the East North Central (ENC) CBNE is composed of nurse educators from Michigan, Ohio, Indiana, Illinois, and Wisconsin. The ENC CBNE will be referred to as “the team” throughout the document. Nursing programs varied in size, workforce, resources, understanding expectations, and integrating CBE, which was further evident with the types of nursing curricula, engagement, mapping, and knowledge of curriculum design. Fundamentally, no one really knew where to start. The team delved into several areas of discussion, primarily relating to the Essentials and applicability to curriculum design, CBE, and scaffolded learning. A need exists to create resources for integrating the new Essentials while focusing on building competency.

Literature Review

Curriculum Design

Each nursing program uses a framework of key concepts guided by the program's mission and philosophy to develop their curriculum (^{Billings & Halstead, 2024}). The program learning outcomes focus on the identified skills in the organizing framework. Each program learning outcome should be measurable using demonstration of the expected achievement.

Once the framework and the program outcomes are identified, the courses are developed. The design of the courses and sequence of the classes are organized using specialty focus, concept-based, or leveled competencies (^{Billings & Halstead, 2024}). The challenge of specialty curriculum design is the risk of moving students through the program at a knowledge level without the skills to apply the content in practice. A concept-based approach reflects disciplinary knowledge grounded in research and provides structure for teaching, learning, and curricular design (^{Giddens, 2020}). Curriculum design shifts learning from content to the KSAs learners must achieve.

During curriculum revision, a gap analysis showed that the content focus of lectures, clinical, written papers, and testing left little time for students to master competencies needed in practice (^{Bokonjić et al., 2019}). The concern of nursing graduates being unprepared for practice has created a call for CBE.

Competency-Based Education

The shift of nursing education to CBE focuses on learners demonstrating competency for entry to practice. Giddens (²⁰²⁰) defined competency as the KSAs needed to competently complete a function. Competencies are measurable, observable behaviors that define what learners know and what they should be able to do over time with multiple assessments and within varied contexts (^{Frith, 2022}; ^{Giddens, 2020}). CBE focuses on intentional, rigorous student learning to enable flexibility without reducing quality.

AACN (^2024b) defines CBE as “a system of instruction, assessment, feedback, self-reflection, and academic reporting that is based on students demonstrating that they have learned the knowledge, attitudes, motivations, self-perceptions, and skills expected of them as they progress through their education.” CBE encourages learners to move from lower-order skills to increased complexity, building skills needed for nursing practice (^{Muraraneza & Mtshali, 2018}). Moving toward a competency-based model requires alignment with nursing practice standards, using evidence-based practice learning strategies, and adherence to community practice needs (^{Brownie et al., 2018}). The course content and learning activities are then sequenced and scaffolded to help the learner meet the competency-based learning outcomes (^{Cline & Rinaldi, 2023}).

Scaffolded Learning

Scaffolded learning moves the learner from baseline comprehension to achievement of desired skills through progressive practice (^{Coffman et al., 2023}). Scaffolding requires learners to develop proficiency of skills to advance to the next application level (^{Bobo et al., 2023}). Achievement of each level ensures that the learner has foundational knowledge and the desired learning outcomes.

Competency is achieved by gradual progression through introduction, reinforcement, and demonstration of the competencies. Scaffolding ties the skills to the why: why does the learner need to know this, why does the learner need to do this. By making this connection, the learner can visualize mastery of skills. Connecting the why to the skill enables learners from diverse backgrounds and experiences to engage in competency progression at their proficiency level. Terms, such as mastery, demonstration, and competency, embody CBE, where learners learn in an authentic manner (^{DeRosier & Atwell, 2024}). Several approaches exist to foster scaffolding within curricula, such as the use of Vygotsky's theory of learning and development, Bloom's taxonomy, and CBE.

Vygotsky's theory of learning and development supports scaffolding by focusing on where the learner currently resides with knowledge and skills by assessing the learner's cognitive and metacognitive development and interactions within the classroom (^{Kozulin et al., 2003}). The learner advances from the actual level of performance to potential level of performance. During progression, supervision is gradually removed as the learner demonstrates knowledge and skills independently.

Integrating Bloom's taxonomy scaffolds learning of the subcompetencies to create a crosswalk to specific learning activities and evaluation of progression indicators (^{Armstrong, 2010}). It is important that progression of learning matches the learners' cognitive and metacognitive development, supported by Bloom's taxonomy. Learners often start at a lower level of Bloom's taxonomy, such as identifying and discussing the competency path. Integrating Bloom's taxonomy into scaffold learning prepares students to apply nursing skills, such as prioritizing care, self-reflection, clinical decision making, and confidence (^{Bobo et al., 2023}). Furthermore, scaffolding is associated with students performing at higher levels in testing, engagement, conceptual comprehension, and authentic experience (^{Coffman et al., 2023}).

Challenges Integrating the Essentials Into Entry-Level Programs

The Essentials is an involved and comprehensive document that has taken a great amount of time to unravel. Nurse educators have discussed multiple challenges with interpretations and strategies to implement the Essentials into nursing programs. Nurse educators struggled with the lack of scaffolding for learning, development of educators, student motivation, and the standardization of assessments. The team's ongoing discussion regarding integration of the Essentials has been engaging, overwhelming, and controversial at times.

The challenge comes with coupling the Essentials with the theoretical integration of CBE. How do programs prime the Essentials in a way that addresses each domain, competency, and subcompetency while layering in opportunities for students to demonstrate competency when ready? The shift needed for integration is not an impossible task but requires strategy. Scaffolding is a CBE approach that naturally levels learning approaches and challenges programs to consider where introduction, reinforcement, and mastery of specific domains should be achieved.

However, it is impossible to transform every nursing program into an authentic CBE, but each program will be able to embrace certain CBE concepts. Authentic CBE provides flexibility that creates a unique learning plan for each student, offering multiple attempts to demonstrate mastery within their own time and pace. The challenge is embracing CBE within the constraints and rigor of traditional academic institutions. Each program will need to determine progression indicators, remediation opportunities, and how much time students have to meet expectations.

Purpose

To effectively unpack the volume of information provided in the Essentials, nurse educators must closely examine the subcompetencies to identify how to implement them in the program. Scaffolded learning creates a more manageable approach to creating teaching and learning strategies for learners. The team's purpose was to help guide faculty and programs with the shift to CBE and integration of the Essentials, which resulted in the development of the entry-level scaffolded learning tool (SLT).

Developmental Process

The team began working on the Essentials by exploring entrustable professional activities (EPA). EPAs are operational definitions of KSAs that outline the expectations of competency achievement (^{Al-Moteri, 2020}). While reviewing the relevant competencies, the team attempted to develop an EPA tool that integrated multiple competencies and subcompetencies. During creation of the EPA templates for each domain, there was a sense of something missing. Each EPA template did not seem measurable or attainable for learners. The EPAs often overlapped in competencies and subcompetencies, requiring a different viewpoint to adopt this approach to CBE. The team went back to the drawing board.

During ongoing meetings, the team explored what exemplars would demonstrate competency. Several exemplars of competency were brainstormed, including those from our nursing programs and the AACN (^2024a) Essentials Tool Kit. While the team compiled a list of exemplars, discussion ensued regarding operationalization in various programs. The team selected flexible exemplars that align with multiple subcompetencies while discussing how to implement them across various programs. The team continued to come back to the two following questions: How will learners meet each sub-competency? and How do we bridge learners from little to no knowledge to competent KSAs?

The next step of exploration included using Bloom's taxonomy to scaffold the subcompetencies. The subcompetencies are at the application level, and the need exists to bridge learners from little to no knowledge to competency during the nursing program. The team applied Bloom's taxonomy to level each subcompetency of 2.1 and 2.2, reflecting introduction, reinforcement, and mastery with progression indicators (Table ^A; available in the online version of this article).

Table A
Bloom's Taxonomy and Scaffolding

Bloom's TaxonomyScaffolding

Remember	Introduction
Understand	Introduction/Reinforcement
Apply	Reinforcement/Mastery
Analyze	Reinforcement/Mastery
Evaluate	Mastery
Create	Mastery

Adapted from Armstrong, P. [2010]. Bloom's taxonomy. Vanderbilt University Center for Teaching. https://cft.vanderbilt.edu/wp-content/uploads/sites/59/Blooms-Taxonomy.pdf

At the introduction level, the learning outcomes are at the remember and understand level of Bloom's taxonomy. During the reinforcement level, the learning outcomes are to understand, apply, and analyze as learners progress. The team leveled the subcompetency for the learner to demonstrate competence while ensuring learning outcomes are achievable and measurable. Each scaffolded outcome is paired with an exemplar demonstrating the student's achievement of each subcompetency. Additional exemplars can be pulled from the AACN (^2024a) Essentials Tool Kit.

Outcome

The final product created by the team was the SLT in which each subcompetency is leveled with outcome statements. The SLT in Table ^B (available in the online version of this article) includes domain 2, competencies 2.1 and 2.2, and the corresponding subcompetencies. As shown in Table ^B, scaffolding guides undergraduate programs on integrating the competencies stepwise into the nursing curriculum using progression indicators through the introduction, reinforcement, and mastery of subcompetencies. Each step toward competency includes exemplars of activities and assessments with possible curricular placement in the nursing program.

Table B
Scaffolded Learning Tool

Domain 2: Person-Centered Care	Person-centered care is holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriate.
Person-centered care is the core purpose of nursing as a discipline. This purpose intertwines with any functional area of nursing practice, from the point of care where the hands of those that give and receive care meet, to the point of systems-level nursing leadership. Foundational to person-centered care is respect for diversity, differences, preferences, values, needs, resources, and the determinants of health unique to the individual.
Competency	Subcompetency	Scaffolding (Introduction, Reinforcement, Mastery)	Related Courses	Exemplars
2.1. Engage (apply) with the individual in establishing a caring relationship	2.1a. Demonstrate (apply) qualities of empathy	Identifies qualities of empathy	Foundational Theory	Watch the video and discuss components of care: https://www.youtube.com/watch?v=1Evwgu369Jw (3 minutes)
		Discusses how you would demonstrate empathy in a patient care situation	Foundational Theory	Students reflect on the video and discuss how they would engage in therapeutic communication (empathy, compassionate care, and mutual respect)
		Provides empathy within a patient care situation	Clinical Application	Engage in patient care activities while using therapeutic communication (empathy, compassionate care, and mutual respect); demonstrate therapeutic communication in multiple situations (e.g., case studies, simulation, clinical)
	2.1b. Demonstrate (apply) compassionate care	Discusses what constitutes compassionate care	Foundational Theory	Watch video and discuss components of care: https://www.youtube.com/watch?v=1Evwgu369Jw (3 minutes)
		Identifies compassionate care within patient care scenarios	Foundational Theory	Students reflect on the video and discuss how they would engage in therapeutic communication (empathy, compassionate care, and mutual respect)
		Provides compassionate	Clinical Application	Engage in patient care activities while using therapeutic

		care within a patient care situation (e.g., case studies, simulation, in clinical setting)		communication (empathy, compassionate care, and mutual respect); demonstrate therapeutic communication in multiple situations (e.g., case studies, simulation, clinical)
	2.1c. Establish (apply) mutual respect with the individual and family	Discusses the importance of mutual respect with the individual and family	Foundational Theory	Watch video and discuss components of care: https://www.youtube.com/watch?v=1Evwgu369Jw (3 minutes)
		Identifies ways to establish mutual respect with the individual and family	Foundational Theory	Complete one of the following educational modules: https://www.journeyforteams.org/educational-modules/
		Demonstrates mutual respect with the individual and family (e.g., case studies, simulation, clinical setting)	Clinical Application	Engage in patient care activities while using therapeutic communication (empathy, compassionate care, and mutual respect); demonstrate therapeutic communication in multiple situations (e.g., case studies, simulation, clinical)
2.2. Communicate (apply) effectively with individuals	2.2a. Demonstrate (apply) relationship-centered care	Identifies relationship-centered care	Foundational Theory	An interactive site of nine women who faced stigma; helps recognize how stigma can impact the health care and support women need, seek, and receive: https://beyondla-bels.marchofdimes.org/beyond-labels-stigma-stories-laura.html
		Discusses the importances of relationship-centered care	Foundational Theory	Based on the videos, discuss why it is important to establish relationship-centered care
		Establishes a therapeutic relationship with the health care team and patient	Clinical Application	Engages in patient care while establishing a therapeutic relationship with the health care team and patient (e.g., case studies, simulation, clinical)

	2.2b. Consider (analyze) individual beliefs, values, and personalized information in communications	Identifies beliefs and values that are different from one's own	Foundational Theory	Use of various case studies with potentially differing perspectives on care. Reflect and journal on personal beliefs and values in relation to providing and receiving care.
		Discusses what beliefs, values, and forms of personalized information in communications may occur	Foundational Theory	Assessment Technologies Institute: Nurse's Touch Professional Communication: addresses cultural, age, developmental considerations, roles and responsibilities, conflict, and negotiation; also includes a case study
		Identifies ways to incorporate one's beliefs, values, and personalized information in communication	Clinical Application	Reflect on how one's beliefs, values, and personalized information may impact communication through case studies, simulation, and clinical setting
	2.2c. Use (apply) a variety of communication modes appropriate for the context	Identifies different types of communication and modes of communication	Foundational Theory	Complete interactive modules from the undergraduate QSEN Learning Module Series to learn and explore various types of communication and modes of communication: https://www.aacnnursing.org/our-initiatives/education-practice/teaching-resources/qsen-learning-modules
		Discuss how communication and mode of communication may vary based on patient, situation, etc.	Foundational Theory	Complete interactive modules from the undergraduate QSEN Learning Module Series to learn and explore various types of communication and modes of communication: https://www.aacnnursing.org/our-initiatives/education-practice/teaching-resources/qsen-learning-modules
		Use appropriate mode of communication within a given scenario	Clinical Application	Use appropriate modes of communication based on scenarios of case study, simulation, and clinical setting
	2.2d. Demonstrate	Discuss types of	Foundational Theory	Use this to guide discussion about different types of

	(apply) the ability to conduct sensitive or difficult conversations	communication and environment/setting to engage in sensitive or difficult conversations		communication and environments: https://www.cdc.gov/sti/hcp/clinical-guidance/taking-a-sexual-history.html
		Identify situations where a sensitive or difficult conversation may occur	Foundational Theory	Use this to guide difficult conversations with students: https://blog.diversitynursing.com/blog/handling-difficult-conversations
		Engage in a sensitive or difficult conversation within a case study, simulation, or clinical setting	Clinical Application	Based on this video, apply the principles to engage in a productive conversation with the family: https://youtu.be/ey-GHFm-1s0Y?si=tWg4CSqQj-jpsHhK (5 minutes)
	2.2e. Use (apply) evidence-based patient teaching materials, considering health literacy, vision, hearing, and cultural sensitivity	Consider evidence-based teaching topics that may be integrated into teaching	Foundational Theory	UptoDate, DynaMed, CDC, Merck Manual, Plain Language: https://www.plainlanguage.gov/guidelines/
		Discuss various types of evidence-based patient teaching materials	Foundational Theory	Search for two different sites for evidence-based patient teaching materials on the same; compare and contrast the appropriateness based on health literacy, vision, hearing, and cultural sensitivity
		Use evidence-based teaching materials within case studies, simulation, and clinical settings	Clinical Application	Provide patient education using evidence-based patient teaching materials while considering health literacy, vision, hearing, and cultural sensitivity
	2.2f. Demonstrate (apply) emotional intelligence in communications	Define emotional intelligence	Foundational Theory	Review article on emotional intelligence; discuss self-awareness, self-management, social awareness, and relationship management: https://www.myamericannurse.com/ei-emotional-intelligence-takes-practice/

		Discuss the importance of emotional intelligence in communication	Foundational Theory	Complete LinkedIn Module on emotional intelligence; dis-cuss these tools with peers and instructors: (specific to nursing) https://www.linkedin.com/advice/0/what-some-best-practices-assess-improve
		Demonstrate emotional intelligence within case studies, simulation, and clinical setting	Clinical Application	Engage in difficult conversations regarding patient plan of care with a peer, health care professional, patient, etc.

Note. CDC = Centers for Disease Control and Prevention; QSEN = Quality and Safety Education for Nurses Institute.

Discussion

As the team worked to create the SLT, the team developed a deeper understanding of CBE and embraced a theoretical shift in thinking of how our curriculum functions to educate future nurses. The subtle switch to considering what learners can demonstrate or do moves programs away from the educator-centered approach (^{Altmiller, 2023}). The SLT integrates Bloom's taxonomy to prepare students to apply nursing skills, such as prioritizing care, self-reflection, clinical decision making, and confidence (^{Bobo et al., 2023}). The SLT provides progression indicators for multiple exemplars for learners to demonstrate mastery through repetitive attempts at learning, which is a foundation for CBE. Scaffolding allows students to perform at higher levels in testing, engagement, conceptual comprehension, and authentic experiences (^{Coffman et al., 2023}). The SLT guides nursing programs to integrate the Essentials's 230 subcompetencies by demonstrating examples for leveling and placement in the curriculum.

Conclusions

The 2021 AACN Essentials was the accelerant for moving nursing academics toward competency-based assessment via CBE and scaffolded learning. The Essentials encouraged nurse educators to explore student-centered learning in new ways to authentically meet the learner where they were rather than where they should be. The SLT serves as a guide for nurse educators to integrate the Essentials into nursing education to prepare competent, practice-ready nurses.

Author Affiliation

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