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https://www.infirmiere-canadienne.com/blogs/ic-contenu/2024/08/12/damelioration-de-la-qualite-nicaragua-partie-1

CNA Certification Program competencies used to improve hospital care

By Maybel López, Karen Herrera Castro, & Michele Trask
August 12, 2024

Editor’s note: This is the first in a three-part series on a Nicaraguan hospital’s quality improvement initiative that began with implementing specialty competencies from the CNA Certification Program. These articles were originally written in Spanish (abstract available below). Part 2 will be published on August 19. Part 3 will be published on August 26.

CNA certification competencies used abroad

In 2023, a military and urban teaching hospital in Nicaragua launched a quality improvement project to enhance the person- and family-centred care it offered. A further aim of the project was to strengthen overall quality of care by increasing the scope of practice for nurses in Nicaragua.

To help achieve this goal, the facility looked abroad for an existing program that would help nurses develop their specialty expertise. The renowned Canadian Nurses Association (CNA) Certification Program was an obvious choice. CNA provided free access to three of its certification specialty competencies along with permission to translate them into Spanish. The competencies that were shared were critical care, nephrology and paediatrics (neonatology).

About the hospital

Hospital Militar Escuela Dr. Alejandro Dávila Bolaños is a military and urban teaching hospital that provides tertiary care. The nurses and physicians are trained in Managua, Nicaragua. The hospital is a referral centre that offers treatment and training for 11 specialties and eight subspecialties. It holds Diamond Level Status with Accreditation Canada, its highest level of accreditation. The hospital prioritizes quality and patient safety and seeks to promote these values nationally.

The nursing staff at the hospital are trained to varying levels of education, ranging from technical to bachelor’s and master’s qualifications. Despite the hospital’s university degree-granting status, it has not yet developed nursing specialties as an academic offering. Nurses working in various specialties were seeking additional training, a structure to help them learn and grow, and a way to establish consistency in care.

A core objective of the project was to create a professional profile, in the form of a competency-based assessment tool, for each nursing specialty. This tool was designed to equip each nurse to integrate and apply knowledge, skills, and attitudes in care practice to respond to the needs of patients and their families. Their improved clinical management and leadership could enhance both patient experience and morale for the entire health-care team. The assessment tool could also help to provide measurable consistency in care as well as a transparent career progression pathway for nurses aspiring to leadership roles (Baldin, Clark, & Fulton, 2009). (Contact author Michele Trask for a copy of the competency-based assessment tool.)

Methodology

A master's-prepared nurse leader was selected to lead a quality improvement project to implement the CNA competencies in three of the hospital’s specialties: critical care, nephrology and neonatology. Support was provided by the hospital’s CEO and executive leadership as well as the human resources, academic education, and quality teams.

The project team included several support roles, a Canadian nurse facilitator, and representation from nursing and medical leaders who partnered on the initiative. The model for improvement was used to guide the quality improvement process. The team established objectives and metrics, as well as plans for evaluation, communication, and engagement of subject matter experts.

A risk assessment was carried out to identify the risks, probable impact, mitigation strategies, and contingency strategies. Incorporating this work into the project plan helped ensure its success.

Workshops on creating competency-based assessment tools were held and, through many plan-do-study-act (PDSA) cycles, these tools were trialed and refined for each specialty. This was an important undertaking, to ensure that the quality improvement gains would be sustained beyond the life of the project.

The main goals for the project were established:

• Measure patient satisfaction by anonymous surveying of patients and families
• Measure team satisfaction by surveying the medical and nursing teams anonymously
• Create competencies by specialty relevant to the practice setting at the hospital
• Include a competency for person-centred care in each competency-based assessment tool
• Develop nurses’ confidence, experience, and communication skills
• Evaluate skills, abilities, and resources and create new experts using the competency assessment tools
• Identify nurses with potential who want to be experts within a year

Results

Of 21 nurses in the neonatal ICU and 21 in intensive care, 52.4% and 57.1% were evaluated as nurses with the desire and potential to be experts, and 19% in each specialty identified themselves as proficient/expert nurses. In the case of 12 hemodialysis (renal) nurses, these percentages were 66.7% and 33.3%, respectively.

In the first survey, opportunities for improvement were identified in effective communication between doctors and nurses and the level of trust when sharing information. In addition, the nurses who were surveyed reported little to no knowledge of their level of competence in their specialties. Strategic actions were then carried out, and the final survey showed that these weaknesses were overcome. Medical and nursing interactions were strengthened, training was delivered in the simulation centre, and other work sessions were successfully carried out.

Competencies for adult intensive care (ICU), pediatric care (neonatal ICU), and hemodialysis (renal) were created by integrating CNA’s specialty standards into the national and institutional regulatory framework. The skills and abilities of the nurses were evaluated effectively in the simulation centre.

Related article

Application of the nursing process in a complex health care environment

Competencies that were newly suggested from use of the CNA tools were analyzed, from which the project team suggested 38 changes to the hospital management. Twenty of these were accepted, resulting in expanded nursing practices and competencies.

Within the framework of involving users as part of the health team, patients and families were included in the competency evaluation process by participating in an anonymous survey. Their suggestions and recommendations were all incorporated.

Discussion

Since 2000, the International Council of Nurses (ICN) has recommended the use of established nursing competencies. Such competencies help clarify the functions of nurses and support professional practice in each country. ICN defines competencies as “a level of performance demonstrating the effective application of knowledge, skill and judgment” (ICN, 1998, p. 44). ICN and the World Health Organization encourage nursing competencies to be discussed, interpreted, and developed within the context and current needs of each country’s workforce (ICN, 2023).

The project discussed in this article used several tools, including a project tracker, risk register, evaluative instruments, and multiple surveys. These allowed the project team to monitor the planned tasks and identify new opportunities for improvement. Use of such tools enabled the experience, knowledge, skills, and abilities of specialist nurses to be shared in each session.

The surveys were particularly revealing. Perhaps most importantly, patient and family surveys were conducted by the three specialty units to evaluate the quality of person- and family-centred care. The results were overwhelmingly positive, with participants congratulating the institution and staff on the initiative and the improvement of quality in nursing care. The survey results indicated that empathy and human connection were prized by patients and families as key pillars of patient care. In light of this, person-centred care was added as a key competency to each of the competency assessment tools.

Conclusion

The project was an overwhelming success: all identified goals were achieved, and a bonus added value was the interprofessional collaboration that resulted in the increased scope of nursing practice. The project management team proposed 38 changes, 20 of which were accepted to expand both nursing practice and competencies. In addition to improved patient care, this led to an enormous boost of morale among nurses.

The project led to the design of a competency-based curriculum that promotes quality and warmth in nursing care and outlines the standards of excellence required for patient safety.

References

Baldin, K., Clark, A., Fulton, J., et al. (2009). National validation of the NACNS clinical nurse specialist core competencies. Journal of Nursing Scholarship, 41(2), 193–201. https://doi.org/10.1111/j.1547-5069.2009.01271.x

International Council of Nurses. (1998). ICN on regulation: Towards 21st century models. Geneva: ICN.

International Council of Nurses. (2023). International Council of Nurses and the WHO Competency Framework. https://www.icn.ch/news/international-council-nurses-welcomes-whos-new-competency-framework-world-health-worker-week

Maybel López, BN, MHA, has 12 years of clinical experience and is a leader in the nursing department at the Hospital Militar Escuela Dr. Alejandro Dávila Bolaños

Karen Herrera Castro, MD, PhD, MPH, is chief of the quality department at the Hospital Militar Escuela Dr. Alejandro Dávila Bolaños and is a surveyor for Accreditation Canada.

Michele Trask, BSN, MIPH, RN, FCAN, CHE, EDAC, is an adjunct professor at the University of British Columbia’s School of Nursing.

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