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Construction and validation of competency frameworks for the training of nurses in emergencies* * Paper extracted from doctoral dissertation “Construção, validação e utilização dos Marcos de Competências e Entrustable Professional Activities (EPAs) para formação em enfermagem no ensino e avaliação do atendimento às urgências e emergências do paciente adulto em ambientes clínicos simulados”, presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

ABSTRACT

Objective:

to build and validate competency frameworks to be developed in the training of nurses for the care of adult patients in situations of emergency with a focus on airway, breathing and circulation approach.

Method:

this is a descriptive and methodological study that took place in three phases: the first phase consisted in a literature review and a workshop involving seven experts for the creation of the competency frameworks; in the second phase, 15 experts selected through the Snowball Technique and Delphi Technique participated in the face and content validation, with analysis of the content of the suggestions and calculation of the Content Validation Index to assess the agreement on the representativeness of each item; in the third phase, 13 experts participated in the final agreement of the presented material.

Results:

the majority of the experts were nurses, with graduation and professional experience in the theme of the study. Competency frameworks were developed and validated for the training of nurses in the airway, breathing and circulation approach.

Conclusion:

the study made it possible to build and validate competency frameworks. We highlight its originality and potentialities to guide teachers and researchers in an efficient and objective way in the practical development of skills involved in the subject approached.

Descriptors:
Nurses; Clinical Competence; Education; Education, Nursing; Nursing Assessment; Emergencies

RESUMO

Objetivo:

construção e validação dos marcos de competências a serem desenvolvidas na formação do enfermeiro para a assistência de pacientes adultos em situações de urgência com foco na abordagem das vias aéreas, ventilação e circulação.

Método:

estudo descritivo e metodológico que ocorreu em três fases: na primeira, realizou-se uma revisão da literatura e uma oficina composta por sete experts para a construção dos marcos de competências; na segunda, participaram 15 experts para a validação de aparência e conteúdo por meio da Snowball Technique e da Técnica Delphi, realizada a análise de conteúdo das sugestões e calculado o Índice de Validação de Conteúdo para aferir a concordância quanto à representatividade de cada item; na terceira fase, participaram 13 experts, na qual houve a concordância final do material apresentado.

Resultados:

os experts em maioria eram enfermeiros, com pós-graduação e atuação profissional na temática do estudo. Foram construídos e validados marcos de competências para a formação do enfermeiro na abordagem das vias aéreas, respiratórias e circulatória.

Conclusão:

o desenvolvimento do estudo proporcionou a construção e validação dos marcos de competências. Ressalta-se sua originalidade e potencialidades para orientar docentes e pesquisadores de maneira eficiente e objetiva no desenvolvimento prático das competências na temática.

Descritores:
Enfermeiros; Competência Clínica; Educação; Educação em Enfermagem; Avaliação em Enfermagem; Emergências

RESUMEN

Objetivo:

construcción y validez de los marcos de competencias a ser desarrollados en la formación del enfermero para la asistencia de pacientes adultos en situaciones de urgencia con enfoque de las vías aéreas, ventilación y circulación.

Método:

estudio descriptivo y metodológico que se dio en tres fases: en la primera, se realizó una revisión de la literatura y un taller compuesto por siete experts para la construcción de los marcos de competencias; en la segunda, participaron 15 experts para la validez de apariencia y contenido por medio de la Snowball Technique y la Técnica Delphi, realizado el análisis de contenido de las sugerencias y calculado el Índice de Validez de Contenido para comparar la concordancia sobre la representatividad de cada ítem; en la tercera fase, participaron 13 experts en la cual hubo una concordancia final del material presentado.

Resultados:

los experts en su mayoría eran enfermeros, con post-graduación y actuación profesional en la temática del estudio. Fueron construidos y validados marcos de competencias para la formación del enfermero en el enfoque de las vías aéreas, respiratorias y circulatorias.

Conclusión:

el desarrollo del estudio proporcionó la construcción y validez de los marcos de competencias. Se resalta su originalidad y potencialidades para orientar docentes e investigadores de manera eficiente y objetiva en el desarrollo práctico de las competencias en la temática.

Descriptores:
Enfermeros; Competencia Clinica; Educación; Educación en Enfermería; Evaluación en Enfermería; Urgencias Médicas

Introduction

There are numerous challenges in the training of health professionals in the educational institutions of the different professional categories when it comes to promoting the training of students, preparing them to society to become qualified professionals who meet not only the expectations of the health system, but mainly the real needs of the population.

One of the main aspects that may hamper the achievement of this goal is possibly the difficulty to make the necessary changes in the curricular matrices of the health courses within the institutions to overcome traditional education and incorporate teaching and learning methodologies based on competencies, which have their major advances described in the teaching of American medicine11 Bollela VR, Castro M. Program evaluation on health professions education: basic concepts. Medicina. [Internet]. 2014 Sept [cited Jan 15, 2018];47(3):332-42. Available from: revista.fmrp.usp.br/2014/vol47n3/12_Avaliacao-de-programas-educacionais-nas-profissoes-da-saude-conceitos-basicos.pdfevista.fmrp.usp.br/2014/vol47n3/12_Avaliacao-de-programas-educacionais-nas-profissoes-da-saude-conceitos-basicos.pdf.
revista.fmrp.usp.br/2014/vol47n3/12_Aval...

2 Gruppen LD, Mangrulkar RS, Kolars JC. The promise of competency-based education in the health professions for improving global health. Hum Resour Health. 2012;10:43. doi: 10.1186/1478-4491-10-43.
https://doi.org/10.1186/1478-4491-10-43...

3 Fernandes CR, Farias A Filho, Gomes JMA, Pinto W Filho A, Cunha GKF, Maia FL. Competency-based curriculum in medical residency. Rev Bras Educ Med. [Internet]. 2012 Jan/Mar [cited Jan 15, 2018];36(1):129-36. Available from: http://www.scielo.br/pdf/rbem/v36n1/a18v36n1.pdf .
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4 Leung K, Trevena L, Waters D. Development of a competency framework for evidence-based practice in nursing. Nurse Educ Today. 2016;39:189-96. doi:10.1016/j.nedt.2016.01.026.
https://doi.org/10.1016/j.nedt.2016.01.0...
-55 Klamem DL, Williams RG, Roberts N, Cianciolo AT. Competencies, milestones and EPAs- are those who ignore the past condemned to repeat it? Med Teach. 2016;38(9):904-10. doi:10.3109/0142159X.2015.1132831.
https://doi.org/10.3109/0142159X.2015.11...
. Studies on the development of competency frameworks such as the CanMEDS Framework66 Van der Lee N, Fokkema JPI, Westerman M, Driessen EW, Van der Vleuten CP, Scherpbier AJJA, et al. The CanMeds framework: relevant but not quite the whole story. Med Teach. 2013;35(11):949-55. doi:10.3109/0142159X.2013.827329.
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-77 Frank JR, Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach. 2007;29(7):642-7. doi: 10.1080/01421590701746983.
https://doi.org/10.1080/0142159070174698...
, the Milestones88 Korte RC, Beeson MS, Russ CM, Carter WA. The emergency medicine milestones: a validation study. Acad Emerg Med. 2013;20(7):730-5. doi:10.1111/acem.12166.
https://doi.org/10.1111/acem.12166...

9 Teherani A, Chen HC. The next steps in competency-based medical education: milestones, entrustable professional activities and observable practice activities. J Gen Intern Med. 2014; 29(8):1090-2. doi: 10.1007/s11606-014-2850-9.
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-1010 Ten Cate O, Chen HC, Hoff RG, Peters H, Bok H, Van Der Schaaf M. Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Med Teach. 2015;37(11):983-1002. doi: 10.3109/0142159X.2015.1060308.
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, the Tomorrows Doctors in the UK and the Scottish Doctor in Scotland started in the early 1990s1111 Van Loon KA, Driessen EW, Teunissen PW, Scheele F. Experiences with EPAs, potential benefits and pitfalls. Med Teach. 2014;36(8):698-702. doi:10.3109/0142159X.2014.909588.
https://doi.org/10.3109/0142159X.2014.90...
.

Competency frameworks are descriptions of the knowledge, skills, and attitudes pertaining to each competency expected during the students’ training. They are organized in a framework that shows the results of the progressive development of students based on competencies, since their insertion in the university until post-graduate training1212 Wancata LM, Morgan H, Sandhu G, Santen S, Hughes DT. Using the ACMGE milestones as a handover tool from medical school to surgery residency. J Surg Educ. 2016; 74(3):519-29. doi:10.1016/j.jsurg.2016.10.016.
https://doi.org/10.1016/j.jsurg.2016.10....
-1313 Lamba S, Wilson B, Natal B, Nagurka R, Anana M, Sule H. A suggested emergency medicine boot camp curriculum for medical students based on the mapping of Core Entrustable Professional Activities to emergency medicine level 1 milestones. Adv Med Educ Pract. 2016;7:115-24. doi:10.2147/AMEP.S97106.
https://doi.org/10.2147/AMEP.S97106...
.

In a narrative way, they describe the competencies that must be repeatedly demonstrated during curricular schedules in clinical environments with different levels of complexity1414 Krupat E, Pelletier SR. The development of medical student competence: tracking its trajectory over time. Med Sci Educ. [Internet]. 2016; Mar [cited Nov 22, 2017];26(1):61-7. Available from: https://link.springer.com/article/10.1007/s40670-015-0190-y.
https://link.springer.com/article/10.100...
, allowing the possibility of a feedback to stimulate changes in observed behaviors, as well as a greater precision in the application of evaluative scales1515 Lomis KD, Russell RG, Davidson MA, Fleming AE, Pettepher CC, Cutrer WB et al. Competency milestones for medical students: design, implementation, and analysis at one medical school. Med Teach. 2017;39(5): 494-504. doi: 10.1080/0142159X.2017.1299924.
https://doi.org/10.1080/0142159X.2017.12...

16 Page C, Reid A, Coe CL, Beste J, Fagan B, Steinbacher, E et al. Piloting the mobile medical milestones application (M3App): a multi-institution evaluation. Fam Med. [Internet]. 2017; [cited Nov 20, 2017];49(1):35-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Piloting+the+Mobile+Medical+Milestones+Application+(M3App)%3A+A+Multi-Institution+Evaluation.
https://www.ncbi.nlm.nih.gov/pubmed/?ter...
-1717 Beeson MS, Carter WA, Christopher TA, Heidt JW, Jones JH, Meyer LE et al. The Development of the Emergency Medicine Milestones. Acad Emerg Med. 2013;20(7):724-9. doi: 10.1111/acem.12157.
https://doi.org/10.1111/acem.12157...
. Competency frameworks have been expanded in varied medical specialties such as General Surgery1212 Wancata LM, Morgan H, Sandhu G, Santen S, Hughes DT. Using the ACMGE milestones as a handover tool from medical school to surgery residency. J Surg Educ. 2016; 74(3):519-29. doi:10.1016/j.jsurg.2016.10.016.
https://doi.org/10.1016/j.jsurg.2016.10....
,1818 Lyle B, Borgert AJ, Kallies KJ, Jarman BT. Do attending surgeons and residents see eye to eye? an evaluation of the Accreditation Council for Graduate Medical Education milestones in general surgery residency. J Surg Educ. 2016;73(6):e54-e58. doi: 10.1016/j.jsurg.2016.07.004.
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-1919 Drolet BC, Marwaha JS, Wasey A, Pallant A. Program director perceptions of the general surgery milestones project. J Surg Educ. 2017;74(5):769-72. doi: 10.1016/j.jsurg.2017.02.012.
https://doi.org/10.1016/j.jsurg.2017.02....
, Pediatrics2020 Smith PH, Carpenter M, Herbst KW, Kim C. Milestone assessment of minimally invasive surgery in pediatric urology fellowship programs. J Pediatr Urol. 2017;13(1):110.e1-110.e6. doi: 10.1016/j.jpurol.2016.08.012.
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21 Bartlett KW, Whicker SA, Bookman J, Narayan AP, Staples BB, Hering H et al. Milestone-based assessments are superior to likert-type assessments in illustrating trainee progression. J Grad Med Educ. 2015;7(1):75-80. doi: 10.4300/JGME-D-14-00389.1.
https://doi.org/10.4300/JGME-D-14-00389....
-2222 Hicks PJ, Englander R, Schumacher DJ, Burke A, Benson BJ, Guralnick S. Pediatrics milestone project: next steps toward meaningful outcomes assessment. J Grad Med Educ. 2010;2(4):577-84. doi: 10.4300/JGME-D-10-00157.1.
https://doi.org/10.4300/JGME-D-10-00157....
, Urology2323 Swing SR, Beeson MS, Carraccio C, Coburn M, Iobst W, Selden NR et al. Educational milestone development in the first 7 specialties to enter the next accreditation system journal of graduate medical education. J Grad Med Educ. 2013;5(1):98-106. doi: 10.4300/JGME-05-01-33.
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, and specially Emergency1313 Lamba S, Wilson B, Natal B, Nagurka R, Anana M, Sule H. A suggested emergency medicine boot camp curriculum for medical students based on the mapping of Core Entrustable Professional Activities to emergency medicine level 1 milestones. Adv Med Educ Pract. 2016;7:115-24. doi:10.2147/AMEP.S97106.
https://doi.org/10.2147/AMEP.S97106...
,1717 Beeson MS, Carter WA, Christopher TA, Heidt JW, Jones JH, Meyer LE et al. The Development of the Emergency Medicine Milestones. Acad Emerg Med. 2013;20(7):724-9. doi: 10.1111/acem.12157.
https://doi.org/10.1111/acem.12157...
,2323 Swing SR, Beeson MS, Carraccio C, Coburn M, Iobst W, Selden NR et al. Educational milestone development in the first 7 specialties to enter the next accreditation system journal of graduate medical education. J Grad Med Educ. 2013;5(1):98-106. doi: 10.4300/JGME-05-01-33.
https://doi.org/10.4300/JGME-05-01-33...

24 Ketterer AR, Salzman DH, Branzetti JB, Gisondi MA. Supplemental milestones for emergency medicine residency programs: a validation study. West J Emerg Med. 2017;18(1): 69-75. doi: 10.5811/westjem.2016.10.31499.
https://doi.org/10.5811/westjem.2016.10....

25 Beeson MS, Warrington S, Bradford-Saffles A, Hart D. Entrustable professional activities: making sense of the emergency medicine milestones. J Emerg Med. 2014;47(4): 441-52. doi: 10.1016/j.jemermed.2014.06.014.
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26 Peck TC, Dubosh N, Rosen C, Tibbles C, Pope J, Fisher J. Practicing emergency physicians report performing well on most emergency medicine milestones. J Emerg Med. 2014;47(4):432-40. doi: 10.1016/j.jemermed.2014.04.032.
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-2727 Beeson MS, Holmboe ES, Korte RC, Nasca TJ, Brigham T, Russ CM, et al. Initial validity analysis of the emergency medicine milestones. Acad Emerg Med. 2015;22(7):838-44. doi: 10.1111/acem.12697.
https://doi.org/10.1111/acem.12697...
, in which worldwide advances in multiprofessional care occur2828 Meyer G, Shatto B, Delicath T, Von Der Lancken S. Effect of curriculum revision on graduates' transition to practice nurse educator. Nurse Educ. 2017;42(3):127-32. doi: 10.1097/NNE.0000000000000325.
https://doi.org/10.1097/NNE.000000000000...
. In nursing training, however, competency frameworks represent a topic yet to be explored, because the content taught often depends on the teachers’ conceptions and does not have a specific discipline to be approached2929 Filho LAM, Martini JG, Lazzari DD, Vargas MAO, Backes VMS, Farias GM. Urgency/emergency course content in the education of generalist nurses. Rev Min Enferm. 2017;21:e-1006. doi: 10.5935/1415-2762.20170016.
https://doi.org/10.5935/1415-2762.201700...
.

The situation is even more worrying when associated with the shortage of active learning methodologies and of opportunities for the practical experience of future professionals. Pedagogical strategies are essential to promote integrative construction of knowledge, reflexive observation and the closest possible approximation with the real environment, so as to promote the confidence of the students3030 Martins JCA, Baptista RCN, Coutinho VRD, Mazzo A, Rodrigues MA, Mendes IAC. Self-confidence for emergency intervention: adaptation and cultural validation of the self-confidence scale in nursing students. Rev. Latino-Am. Enfermagem. 2014;22(4):554-61. doi: 10.1590/0104-1169.3128.2451.
https://doi.org/10.1590/0104-1169.3128.2...
.

There is a lack of studies published in scientific journals specifically on professional competence of nurses in emergencies. According to the study3131 Holanda FL, Castagnari MC, Cunha IC. Professional competency profile of nurses working in emergency services. Acta Paul Enferm. 2015;28(4):308-14. doi: 10.1590/1982-0194201500053.
https://doi.org/10.1590/1982-01942015000...
, the theme is often exclusively directed to the management area.

In this context, it is essential to review the nursing education and ensure that these professionals have an effective participation in patient care during emergency situations. Patients with a compromised airway quickly become unstable and run the risk of cardiorespiratory arrest3232 Higginson R, Parry A, Williams M. Airway management in the hospital environment. Br J Nurs. 2016; 25(2):94-100. doi: 10.12968/bjon.2016.25.2.94.
https://doi.org/10.12968/bjon.2016.25.2....
. Recent studies3333 Helmerhorst H, Roos-Blom M, Van Westerloo D, De Jonge E. Association between arterial hyperoxia and outcome in subsets of critical illness: a systematic review, meta-analysis, and meta-regression of cohort studies. Crit Care Med. 2015; 43(7):1508-19. doi: 10.1097/CCM.0000000000000998.
https://doi.org/10.1097/CCM.000000000000...
-3434 Panwar R, Hardie M, Bellomo R, Barrot L, Eastwood GM, Young PJ, et al. Conservative versus liberal oxygenation targets for mechanically ventilated patients: a pilot multicenter randomized controlled trial. Am J Respir Crit Care Med. 2016;193(1):43-51. doi: 10.1164/rccm.201505-1019OC.
https://doi.org/10.1164/rccm.201505-1019...
emphasize the need to evaluate strategies for ventilatory support, because nurses need to have the knowledge, ability and competent clinical reasoning to anticipate, monitor and intervene when any complication arise from ventilatory support3535 Barton G, Vanderspank-Wright B, Shea J. Optimizing Oxygenation in the Mechanically Ventilated Patient: Nursing Practice Implications. Crit Care Nurs Clin North Am. 2016; 28(4):425-35. doi: 10.1016/j.cnc.2016.07.003.
https://doi.org/10.1016/j.cnc.2016.07.00...
. Critical hemodynamic events usually occur along with predictable progressive deterioration, with signs and symptoms anticipated by physiological changes3636 Kronick SL, Kurz MC, Lin S, Edelson DP, Berg RA, Billi JE et al. Part 4: Systems of Care and Continuous Quality Improvement. Circulation. 2015;132(18):s397-s413. doi: https://doi.org/10.1161/CIR.0000000000000258.
https://doi.org/10.1161/CIR.000000000000...
.

In situations of emergency, airway, breathing and circulation (ABC) approach must take place systematically and rapidly, with identification of possible disorders and onset of immediate treatment. This is applicable in all traumatic and non-traumatic emergencies, either in extra-hospital environments where there is usually no life support equipment for rescue maneuvers, or in more advanced settings such as pre-hospital mobile service, emergency rooms, general hospital wards, or in intensive care units.

The uniform adoption of the ABC approach among team members is capable of improving joint performance. The training of team members can have an impact on the outcomes, the recognition of professionals and the management of care for patients in acute or critical situations, allowing increased self-confidence and lower reluctance on the part of professionals3737 Thim T, Krarup NHV, Grove EL, Rohde CV, Løfgren B. Initial assessment and treatment with the airway, breathing, circulation, disability, exposure (ABCDE) approach. Int J Gen Med. 2012;5:117-21. doi: 10.2147/IJGM.S28478.
https://doi.org/10.2147/IJGM.S28478...
.

This study aims to build and validate competency frameworks to be developed in the training of nurses to provide care for adult patients in urgent situations with a focus on the ABC approach.

Method

Descriptive, methodological study of construction and validation of competency frameworks to be developed in the training of nurses regarding care for adult patients during ABC approach in situations of traumatic and non-traumatic urgency.

The study was developed in three phases: the first phase consisted in a literature review on the theme, with the search, synthesis and analysis of studies. Then, a workshop was held at a public university in the countryside of São Paulo, with seven experts to build the competency frameworks. The recruitment of experts was done by means of the “snowball technique”, in which a sample is created by means of indications of people who have in common characteristics that are of interest for the research3838 McGee JE, Peterson M, Mueller SL, Sequeira JM. Entrepreneurial Self-Efficacy: Refining the Measure. Entrepreneurship Theory Practice. 2009;33(4):965-88. doi: http://dx.doi.org/10.1111/j.1540-6520.2009.00304.x
https://doi.org/http://dx.doi.org/10.111...
-3939 Oliveira DC. Theme/category-based contente analysis: a proposal for systematization. Rev Enferm UERJ. [Internet]. 2008 Oct/Dec [cited Sept 10, 2017];16(4):569-76. Available from: http://www.facenf.uerj.br/v16n4/v16n4a19.pdf>.
http://www.facenf.uerj.br/v16n4/v16n4a19...
. Following this technique, one professional (key informant) indicated the name and the electronic address of six professionals that met the inclusion criteria of the study, to whom invitations were sent. The inclusion criteria for selection of experts were adapted from Fehring’s4040 Fehring RJ. Methods to validate nursing diagnoses. Heart Lung. [Internet]. 1987 Nov [cited Oct 11, 2017];16(6):625-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/3679856.
https://www.ncbi.nlm.nih.gov/pubmed/3679...
reference as follows: health professionals with at least one year experience in adult patient care in situations of emergency, in the context of care and/or teaching.

During the workshop, the seven experts participating in the study were trained for familiarization with the theme and they were requested to build the competency frameworks for the training of nurses in the adult patient care in traumatic and non-traumatic emergencies, using the ABC approach.

The experts were randomly distributed into three different groups, where each group was responsible for building the specific competency frameworks for each item of the ABC algorithm. They also filled a form for biographical and professional characterization and signed the Informed Consent Form (ICF).

In the second phase of the study, the competency frameworks prepared in the first phase were validated. The “snowball” technique was also used in this phase3838 McGee JE, Peterson M, Mueller SL, Sequeira JM. Entrepreneurial Self-Efficacy: Refining the Measure. Entrepreneurship Theory Practice. 2009;33(4):965-88. doi: http://dx.doi.org/10.1111/j.1540-6520.2009.00304.x
https://doi.org/http://dx.doi.org/10.111...
-3939 Oliveira DC. Theme/category-based contente analysis: a proposal for systematization. Rev Enferm UERJ. [Internet]. 2008 Oct/Dec [cited Sept 10, 2017];16(4):569-76. Available from: http://www.facenf.uerj.br/v16n4/v16n4a19.pdf>.
http://www.facenf.uerj.br/v16n4/v16n4a19...
. On expert (key informant) was requested to indicated the name and e-mail address of three professionals who met the inclusion criteria of the study. Every new participant was invited to do the same, i.e., indicate peers who could contribute to the study.

The Fehring4040 Fehring RJ. Methods to validate nursing diagnoses. Heart Lung. [Internet]. 1987 Nov [cited Oct 11, 2017];16(6):625-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/3679856.
https://www.ncbi.nlm.nih.gov/pubmed/3679...
criteria were adapted and used to select experts to be included in the study: being a health professional; being involved in care and/or teaching with at least one certificate of clinical practice (specialization) in the area of interest of the study; having master’s degree with thesis in the area of interest of the study; having PhD degree with dissertation in the area of interest of the study; having clinical experience of at least one year; having published relevant research in the area of interest and having published articles on the theme in reference journals. To be considered an expert, the participant had to meet at least one of the items above mentioned.

Seventy-six professionals were indicated through the “snowball” technique3838 McGee JE, Peterson M, Mueller SL, Sequeira JM. Entrepreneurial Self-Efficacy: Refining the Measure. Entrepreneurship Theory Practice. 2009;33(4):965-88. doi: http://dx.doi.org/10.1111/j.1540-6520.2009.00304.x
https://doi.org/http://dx.doi.org/10.111...
-3939 Oliveira DC. Theme/category-based contente analysis: a proposal for systematization. Rev Enferm UERJ. [Internet]. 2008 Oct/Dec [cited Sept 10, 2017];16(4):569-76. Available from: http://www.facenf.uerj.br/v16n4/v16n4a19.pdf>.
http://www.facenf.uerj.br/v16n4/v16n4a19...
and met the criteria adapted from Fehring4040 Fehring RJ. Methods to validate nursing diagnoses. Heart Lung. [Internet]. 1987 Nov [cited Oct 11, 2017];16(6):625-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/3679856.
https://www.ncbi.nlm.nih.gov/pubmed/3679...
.

The invitation to participate in the research was sent to all the 76 experts via e-mail with a web access link, which directed the person to the electronic form, made available through Google Docs Off line®. Upon clicking the link, the Informed Consent Form (ICF) was promptly opened for completion, being this step a mandatory condition for the opening of the following pages with the biographical and professional characterization forms, editing manual, and the competency frameworks for face and content validation.

The invited experts were requested to return the data collection instruments within a maximum period of 30 days. Fifteen (15) professionals responded to the validation of the material built. In this phase of face and content validation, we used the Delphi Technique, a method that represents a methodological research strategy whose objective is to obtain a maximum of agreement in a group of experts on a certain theme4141 Scarparo AF, Laus AM, Azevedo ALCS, Freitas MRI, Gabriel CS, Chaves LP. Reflections on the use of delphi technique in research in nursing. Rev Rene. 2012;13(1):242-51. doi: 10.15253/rev rene.v13i1.3803.
https://doi.org/10.15253/rev...
.

The third phase of this study occurred after the analysis of content of the considerations and suggestions provided by the experts for the material to be validated. Content analysis focuses on a set of techniques to perform analyses during the process of reading the results of the contributions of experts, systematized through essential concepts, described by: objectivity, systematicity, manifest content, registration units, context units, creation of categories, analysis of categories, inference, and conditions of production3939 Oliveira DC. Theme/category-based contente analysis: a proposal for systematization. Rev Enferm UERJ. [Internet]. 2008 Oct/Dec [cited Sept 10, 2017];16(4):569-76. Available from: http://www.facenf.uerj.br/v16n4/v16n4a19.pdf>.
http://www.facenf.uerj.br/v16n4/v16n4a19...
.

For content analysis3939 Oliveira DC. Theme/category-based contente analysis: a proposal for systematization. Rev Enferm UERJ. [Internet]. 2008 Oct/Dec [cited Sept 10, 2017];16(4):569-76. Available from: http://www.facenf.uerj.br/v16n4/v16n4a19.pdf>.
http://www.facenf.uerj.br/v16n4/v16n4a19...
, the data in the answers were categorized, classified and quantified for interpretation of the results. After an exhaustive reading of the primary categorization of the data, these were realigned to each competency framework related to each ABC framework and according to the topics expressed in the original messages provided by the experts. Then, data were related in meaning units and contextual units, which cover the messages in full length according to the participants.

After data organization, the main components were identified to compose the competency frameworks to be promoted in the training of nurses for adult patient care involving the ABC approach in situations of traumatic and non-traumatic urgency.

The Content Validation Index (CVI) was then calculated to assess the agreement among experts on the representativeness of each item in the tables. For this study, the minimum index of 0.80 for each item in the table was considered acceptable for calculating the CVI4242 Oliveira AKA, Vasconcelos QLDAQ, Melo GSM, Melo MDM, Costa IKF, Torres GV, et al. Instrument validation for peripheral venous puncture with over-the-needle catheter. Rev Rene. 2015;16(2):176-84. doi: 10.15253/2175-6783.2015000200006.
https://doi.org/10.15253/2175-6783.20150...
.

After analysis, a new version of the competency frameworks was created and, after that, a second round of opinions was requested4343 Gonçalves ATP. Content analysis, discourse analysis, and conversation analysis: preliminary study on conceptual and theoretical methodological differences. Adm Ensino Pesq. 2016;17(2):275-300. doi: 10.13058/raep.2016.v17n2.323
https://doi.org/10.13058/raep.2016.v17n2...
. The 15 participating experts received a new e-mail with the redesigned competency frameworks and were requested to return the material within a maximum time of 30 days. The participants of this phase were 13 experts, who characterized the agreement on the material presented. Data were collected from experts was from March to August 2017, through ethical authorization under Opinion 55082716.5.0000.5393.

Results

Table 1 describes the characterization of the participating experts in each validation phase of the competency frameworks.

Table 1
Characterization of the participating experts in each validation phase of the competency frameworks. Ribeirão Preto, SP, Brazil, 2017

In the first phase of the study, the experts participating in the workshop built the ABC competency frameworks to evaluate frameworks related to the progression of students, which were classified into three distinct levels: level 1 (student before immersion in the supervised curricular internship), level 2 (student immersed in the supervised curricular internship) and level 3 (nurse).

This classification of progression of students was established after a consensus of the experts based on Resolution CNE/CES No 3 of November 7, 2001, which establishes the National Curricular Guidelines of the Nursing Undergraduate Course1 1 National Council of Education. (2001). Opinion CNE/CES n. 3, from November 7, 2001. Provides for the National Curricular Guidelines of the Undergraduate Nursing Course [Internet legislation]. Brasília. http://portal.mec.gov.br/cne/archives/pdf/CES03.pdf , which states in Art. 7: “In Nursing training, in addition to the theoretical and practical contents developed during training, the courses are required to include in the curriculum a supervised internship in general and specialized hospitals, outpatient clinics, basic health service network, and communities in the last two semesters of the Undergraduate Nursing Course”.

Thus, as all Higher Education Institutions offering Nursing courses have adopted the Curriculum Guidelines*, the supervised curricular internship is mandatory in the last two semesters of training, characterizing it as the fundamental framework in the students’ progression and development.

In the following phases, the experts contributed to the validation using the Delphi technique4141 Scarparo AF, Laus AM, Azevedo ALCS, Freitas MRI, Gabriel CS, Chaves LP. Reflections on the use of delphi technique in research in nursing. Rev Rene. 2012;13(1):242-51. doi: 10.15253/rev rene.v13i1.3803.
https://doi.org/10.15253/rev...
. The suggestions received from the experts had their content analyzed, and it was concluded that there was a consensus on the content presented, resulting in the tables of competency frameworks presented below.

Agreement among experts on the representativeness of the items in relation to the content of the tables was presented through the CVI. In the third phase, some items from the first analysis presented a CVI below 0.80; thus, the comments and suggestions provided by the experts were considered for the possibility of adjustments, and then the material was returned to the participants, resulting in CVI values ≥ 85% for all items in the final analysis.

The final result represents the consensus among experts on the competency frameworks involving knowledge, skills and attitudes considered to be minimally necessary for nurses to prevent instabilities, contribute to the treatment and recovery of adult patients during ABC approach in traumatic and not traumatic urgencies.

Each cell in the table reveals a competency framework to be demonstrated by the students within their level of progression. Competency frameworks are present in greater number mainly at the initial levels of training, what is expected in relation to the students’ developmental needs. Thus, the level 3 (nurse) has consequently a higher level of empty cells.

Figure 1 below presents the competency frameworks prepared and validated for nursing care in airway approach in situations of urgency.

Figure 1
Competency frameworks prepared and validated for nursing care in airway approach in situations of urgency. Ribeirão Preto, SP, Brazil, 2017

Figure 2 below presents the competency frameworks created and validated for nursing care in the airway approach in situations of urgency.

Figure 2
Competency frameworks prepared and validated for nursing care in airway approach in situations of urgency. Ribeirão Preto, SP, Brazil, 2017

Figure 3 below presents the competency frameworks constructed and validated for nursing care in the hemodynamic state approach in emergency.

Figure 3
Competency frameworks built and validated for nursing care in the approach of hemodynamic state in situations of urgency. Ribeirão Preto, SP, Brazil, 2017

Discussion

The competency frameworks to be developed in nursing training in adult patient care in situations of traumatic and non-traumatic urgency focusing on the ABC approach aims to support the training and work of nurses in the most varied of situations experienced and referred in the clinical practice.

With the Competency frameworks, the ability to assemble measures in different contexts makes it possible to identify trends in student performance, revealing the need for improvement. They guide teachers in the process of developing their programs within the curricular matrix throughout the course, as well as in the evaluation process, generating a model that can be shared among diverse schedules regarding the expected knowledge, skills and behaviors of students1515 Lomis KD, Russell RG, Davidson MA, Fleming AE, Pettepher CC, Cutrer WB et al. Competency milestones for medical students: design, implementation, and analysis at one medical school. Med Teach. 2017;39(5): 494-504. doi: 10.1080/0142159X.2017.1299924.
https://doi.org/10.1080/0142159X.2017.12...
.

The data provided by the competency frameworks serve as indicators of curriculum performance. The results of the competency frameworks used for a student group show whether the results of the desired competencies are being achieved and is clearly useful as a source of data for discussions on improvements and monitoring of the potential impacts of curricular changes1515 Lomis KD, Russell RG, Davidson MA, Fleming AE, Pettepher CC, Cutrer WB et al. Competency milestones for medical students: design, implementation, and analysis at one medical school. Med Teach. 2017;39(5): 494-504. doi: 10.1080/0142159X.2017.1299924.
https://doi.org/10.1080/0142159X.2017.12...
.

It is important to note, however, that in other validation studies some experts have pointed out that although the content of competency frameworks is important for the training of health professionals and provides a structure for demonstrating the progression of the students, competency frameworks need a differentiation for each specialty, requiring time and physical and financial investments from educational institutions1919 Drolet BC, Marwaha JS, Wasey A, Pallant A. Program director perceptions of the general surgery milestones project. J Surg Educ. 2017;74(5):769-72. doi: 10.1016/j.jsurg.2017.02.012.
https://doi.org/10.1016/j.jsurg.2017.02....
.

In terms of application, it is discussed the context in which the competency frameworks will be specified and observed, the number of frameworks grouped within each level, or the total number of competencies and sub-competencies to be developed and evaluated, which may be detrimental to practice for the evaluation, and may need adjustments on the part of the educational institution1919 Drolet BC, Marwaha JS, Wasey A, Pallant A. Program director perceptions of the general surgery milestones project. J Surg Educ. 2017;74(5):769-72. doi: 10.1016/j.jsurg.2017.02.012.
https://doi.org/10.1016/j.jsurg.2017.02....
,2323 Swing SR, Beeson MS, Carraccio C, Coburn M, Iobst W, Selden NR et al. Educational milestone development in the first 7 specialties to enter the next accreditation system journal of graduate medical education. J Grad Med Educ. 2013;5(1):98-106. doi: 10.4300/JGME-05-01-33.
https://doi.org/10.4300/JGME-05-01-33...
. These questions led to the introduction of the concept of Entrustable Professional Activities (EPAs)99 Teherani A, Chen HC. The next steps in competency-based medical education: milestones, entrustable professional activities and observable practice activities. J Gen Intern Med. 2014; 29(8):1090-2. doi: 10.1007/s11606-014-2850-9.
https://doi.org/10.1007/s11606-014-2850-...
,4444 Ten Cate O. Nuts and Bolts of Entrustable Professional Activities. J Grad Med Educ. 2013;5(1):157-8. doi: 10.4300/JGME-D-12-00380.1.
https://doi.org/10.4300/JGME-D-12-00380....
-4545 Englander R, Carraccio C. From Theory to Practice: Making Entrustable Professional Activities Come to Life in the Context of Milestones. Acad Med. 2014;89(10):1321-23. doi: 10.1097/ACM.0000000000000324.
https://doi.org/10.1097/ACM.000000000000...
.

However, other studies present positive perceptions of trainers about this evaluation process when compared to systems previously used in some institutions, with emphasis on the benefits of the competency-based education strategy, students’ performance evaluation, and the ability to provide impartial feedback 1919 Drolet BC, Marwaha JS, Wasey A, Pallant A. Program director perceptions of the general surgery milestones project. J Surg Educ. 2017;74(5):769-72. doi: 10.1016/j.jsurg.2017.02.012.
https://doi.org/10.1016/j.jsurg.2017.02....
,2323 Swing SR, Beeson MS, Carraccio C, Coburn M, Iobst W, Selden NR et al. Educational milestone development in the first 7 specialties to enter the next accreditation system journal of graduate medical education. J Grad Med Educ. 2013;5(1):98-106. doi: 10.4300/JGME-05-01-33.
https://doi.org/10.4300/JGME-05-01-33...
.

A great current questioning among professional education scholars is that if we really want to transform nursing education and practice, we must believe and find proposals to implement the positive results of educational strategies directed to the environment of practice2828 Meyer G, Shatto B, Delicath T, Von Der Lancken S. Effect of curriculum revision on graduates' transition to practice nurse educator. Nurse Educ. 2017;42(3):127-32. doi: 10.1097/NNE.0000000000000325.
https://doi.org/10.1097/NNE.000000000000...
.

The discussion about the need for changes in the training of competent nurses has existed for more than three decades. However, the lack of standardization of essential competencies combined with a limited number of validated assessment tools has been a challenge4646 Leung K, Trevena L, Waters D. Development of a competency framework for evidence-based practice in nursing. Nurse Educ Today. 2016;39:189-96. doi:10.1016/j.nedt.2016.01.026.
https://doi.org/10.1016/j.nedt.2016.01.0...
which, in critical situations, can put both the patient and the professional at risk.

In the results found in this study, we saw that the proposed methodology made it possible to reach a consensus among experts in the assembling of essential skills for the training of nurses in the theme studied. The proposal is that these competency frameworks are influential in curricular training strategies, and some of these competency frameworks are probably taught in traditional curricula, but in disconnected and poorly integrated moments of training. The important point to note is that it must be considered that in order to develop each competency framework at each level of training progression, there is a previous and even simultaneous theoretical and practical context or even contextualized by the pedagogical plan of the course. Competency frameworks allow the students to visualize their current status and reflect on what behaviors are needed for their professional training2323 Swing SR, Beeson MS, Carraccio C, Coburn M, Iobst W, Selden NR et al. Educational milestone development in the first 7 specialties to enter the next accreditation system journal of graduate medical education. J Grad Med Educ. 2013;5(1):98-106. doi: 10.4300/JGME-05-01-33.
https://doi.org/10.4300/JGME-05-01-33...
,4747 Schumacher DJ, Englander R, Carraccio C. Developing the master learner: applying learning theory to the learner, the teacher, and the learning environment. Acad Med. 2013; 88(11):1635-45. doi: 10.1097/ACM.0b013e3182a6e8f8.
https://doi.org/10.1097/ACM.0b013e3182a6...
. Even more important than an evaluation process, competency frameworks allow the students to visualize a learning itinerary that must continue at each moment of their training1212 Wancata LM, Morgan H, Sandhu G, Santen S, Hughes DT. Using the ACMGE milestones as a handover tool from medical school to surgery residency. J Surg Educ. 2016; 74(3):519-29. doi:10.1016/j.jsurg.2016.10.016.
https://doi.org/10.1016/j.jsurg.2016.10....

13 Lamba S, Wilson B, Natal B, Nagurka R, Anana M, Sule H. A suggested emergency medicine boot camp curriculum for medical students based on the mapping of Core Entrustable Professional Activities to emergency medicine level 1 milestones. Adv Med Educ Pract. 2016;7:115-24. doi:10.2147/AMEP.S97106.
https://doi.org/10.2147/AMEP.S97106...

14 Krupat E, Pelletier SR. The development of medical student competence: tracking its trajectory over time. Med Sci Educ. [Internet]. 2016; Mar [cited Nov 22, 2017];26(1):61-7. Available from: https://link.springer.com/article/10.1007/s40670-015-0190-y.
https://link.springer.com/article/10.100...

15 Lomis KD, Russell RG, Davidson MA, Fleming AE, Pettepher CC, Cutrer WB et al. Competency milestones for medical students: design, implementation, and analysis at one medical school. Med Teach. 2017;39(5): 494-504. doi: 10.1080/0142159X.2017.1299924.
https://doi.org/10.1080/0142159X.2017.12...
-1616 Page C, Reid A, Coe CL, Beste J, Fagan B, Steinbacher, E et al. Piloting the mobile medical milestones application (M3App): a multi-institution evaluation. Fam Med. [Internet]. 2017; [cited Nov 20, 2017];49(1):35-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=Piloting+the+Mobile+Medical+Milestones+Application+(M3App)%3A+A+Multi-Institution+Evaluation.
https://www.ncbi.nlm.nih.gov/pubmed/?ter...
.

Study4848 Harding AD, Walker-Cillo GE, Duke A, Campos GJ, Stapleton SJ. A framework for creating and evaluating competencies for emergency nurses. J Emerg Nurs. 2013 May;39(3):252-64. doi: 10.1016/j.jen.2012.05.006.
https://doi.org/10.1016/j.jen.2012.05.00...
reinforces the need for proposals to objectively assess and record the competency of nurses in urgencies, stating that it is not appropriate to use a single method of competency development and evaluation. A recent Brazilian study4949 Holanda FL, Marra CC, Cunha IC. Construction of a Professional Competency Matrix of the nurse in emergency services. Acta Paul Enferm. 2014;27(4):373-9. http://dx.doi.org/10.1590/1982-0194201400062.
http://dx.doi.org/10.1590/1982-019420140...
presented a matrix of basic nursing and associated skills for to work in emergencies and highlighted the shortcomings in the national literature.

This study, although specifically related to the theme of urgency, may be a future reference for other nursing education areas, becoming a tool for teachers to reflect on the training processes, and the development and evaluation of curricula. Several authors regard competency frameworks as important to guide evaluators, resulting in a mental model that can be shared in all curricular programs as to the knowledge, skills and behaviors expected of students 1515 Lomis KD, Russell RG, Davidson MA, Fleming AE, Pettepher CC, Cutrer WB et al. Competency milestones for medical students: design, implementation, and analysis at one medical school. Med Teach. 2017;39(5): 494-504. doi: 10.1080/0142159X.2017.1299924.
https://doi.org/10.1080/0142159X.2017.12...
,1919 Drolet BC, Marwaha JS, Wasey A, Pallant A. Program director perceptions of the general surgery milestones project. J Surg Educ. 2017;74(5):769-72. doi: 10.1016/j.jsurg.2017.02.012.
https://doi.org/10.1016/j.jsurg.2017.02....
,2323 Swing SR, Beeson MS, Carraccio C, Coburn M, Iobst W, Selden NR et al. Educational milestone development in the first 7 specialties to enter the next accreditation system journal of graduate medical education. J Grad Med Educ. 2013;5(1):98-106. doi: 10.4300/JGME-05-01-33.
https://doi.org/10.4300/JGME-05-01-33...
,4747 Schumacher DJ, Englander R, Carraccio C. Developing the master learner: applying learning theory to the learner, the teacher, and the learning environment. Acad Med. 2013; 88(11):1635-45. doi: 10.1097/ACM.0b013e3182a6e8f8.
https://doi.org/10.1097/ACM.0b013e3182a6...
.

Regarding the limitations found in this study, it is important to point out that other investigations on the subject related to the development and evaluation of nurses were not identified, nor were they directed to the area of ​​urgency in the profession, which exalts its found, thus hindering the comparison of the results found here with other investigations. The methodological approach is characterized as a restriction of results, because the number of experts participating in the study was reduced in relation to the number of people invited. Another bias is related to the “snowball” technique, considering the fact that the people accessed by the method are the most visible in the participating population, which prevents the generalization of the results.

Given the potential presented, it is expected that this study contribute to the design of a matrix of development and evaluation of competencies in the theme proposed in the training of nurses. The study suggests the investment in further research to help in the creation of competency frameworks as proposed, not only in the area of ​​urgency, but also in other areas of nursing teaching and research.

Conclusion

The study resulted in different competency frameworks to be developed in the training of nurses regarding adult patient care in traumatic and non-traumatic urgencies in the ABC approach, with the potential to guide teachers and researchers in an efficient and objective way for practical development in the theme.

We hope that the competency frameworks complement the nursing training process by mutually collaborating with students and teachers in an objective and effective way to develop and evaluate competencies, as competency-based educational advances are increasingly needed to meet the needs of the population, impacting patient care and safety.

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  • *
    Paper extracted from doctoral dissertation “Construção, validação e utilização dos Marcos de Competências e Entrustable Professional Activities (EPAs) para formação em enfermagem no ensino e avaliação do atendimento às urgências e emergências do paciente adulto em ambientes clínicos simulados”, presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

Publication Dates

  • Publication in this collection
    2018

History

  • Received
    20 Feb 2018
  • Accepted
    02 Aug 2018
Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3451 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br