Education of professionals - is there a role for a competency-based approach?

by

Laurence J Walsh
School of Dentistry, The University of Queensland

 

Introduction

Curriculum reform has always been an explosive topic of debate in academe. Curricula have been described rather unkindly as "graveyards", with more and more material coming in and nothing going out. Over the past decade, there have been numerous reports of attempts to improve dental curricula both structurally and philosophically. Many have been stymied by entrenched resistance to change and beliefs that "all is well" or that changes are often made for the sake of change with little thought about tangible educational outcomes (Brown, 1986; Formicola, 1991). An excellent overview of the trends in curriculum change has been provided by Lisa Tedesco (1995), while Hershey (1986) has given a useful catalogue of the main factors that impede curriculum change in universities

• : individual personal behavior (fear, inertia, self-centeredness, lack of vision),
• organizational and environmental factors (structure, communication, direction), and
• * groups or constituencies (administration, curriculum committees, faculty, students, patients, boards, accreditation agencies, specialty organizations, and practitioners).

The definition of the perfect curriculum has proved evasive, with many universities (including our own) following a pattern of both cyclical extensive curriculum "revolution" followed by many years of curriculum "evolution" in the intervening periods. Writing in 1984, Allan Formicola described the evolution of tertiary education as consisting of four major periods: reorganization, the growth of research, the "golden era" (high levels of funding and expansion), and a time for reflection. Looking toward the future, he commented that universities and their professional schools faced difficult choices as they considered curriculum revision. One could add that the problems are even more acute in the present climate, as institutions grapple with reduced financial support in real terms while the costs of tertiary education continue to increase. Added to this is the challenge of maintaining an appropriate focus on teaching and learning in a research-intensive university (Arrow, 1996).

 

The urgency of curriculum change

With the explosion of information in the 1980's and 1990's, and the accompanying information technology revolution, it became clear that the "graveyard" problem in many areas was becoming unsolvable. In attempting to cram in increasing amounts of material (the "coveritis" syndrome), the time pressures on both educators and students became intolerable. This was particularly so in the basic sciences areas of professional health curricula, where often students perceived little relevance to clinical practice (Fischman, 1986; White, 1986). As educators began to look for ways of "decompressing" the overcrowded curriculum (Roth, 1986; Greene, 1990), it was suggested that the basic science areas needed greater focus, and that the curriculum should contain only two integrated science courses which would cover (1) the structure and function of the human body and (2) disease and reaction to disease in the human body (Garant, 1986). Others such as Katz (1986) proposed that the emphasis in the basic science area should be on developing students' skills in independent inquiry, rather than simple memorisation of facts. There were also clear calls for a shift in focus from training "professional technicians" to one of educating learned professionals (Santangelo, 1981).

It has become clear that one of the best ways forward through the minefield of the information explosion is to equip the students to be able to assess the literature and learn for themselves during their careers in practice, applying the principles of evidence-based practice when evaluating new information (Howell & Matlin, 1995). To improve skills in life-long learning, problem-based learning (PBL), which had been used successfully in medical education for many years, has been adopted in various forms by a number of universities (Aldred et al., 1997; Boud & Feletti 1997). It is expected that graduates of problem-based curricula will be more effective continuing learners and therefore better practitioners because of more positive beliefs about learning and their acquisition of self-directed learning skills (Ferrier, 1990; Barrows 1994; Townsend et al., 1997). Of particular importance in this regard is an enhanced ability to analyse situations and solve real-world problems (Forrest et al., 1997).

 

Achieving a balanced emphasis

At this juncture, it is necessary to crystallise some of the beliefs which underpin the educational process for a professional:

• Content is important, but sizeable components of the content will become obsolete in the foreseeable future
• Process is also important, and the educational experience should be designed to show knowledge being applied in its proper context. Knowledge is not a series of isolated facts but a cohesive framework of inter-related concepts.
• Certification and accountability: There must be some means of ensuring that a new graduate is fit for practice as a professional.

Combining these threads together, it can be argued that a modern curriculum must produce graduates who are

• competent to practice in a variety of settings
• able to anticipate and cope with changes (demographic, philosophical and technological) following graduation
• committed to self-improvement, and are equipped with skills for self assessment and life-long learning
• cognisant of community needs and the social milieu in which they serve their patients/clients needs
• willing to change to reflect best practice, in response to changes in the scientific foundations (the evidence base) of their profession.

This requires the appropriate balance of emphasis on educational content and educational process. The education of a professional is a lifelong process that begins at university and continues until retirement from active practice. Because of the lack of supervision in practice, graduates must develop skills in self assessment and an awareness of what constitutes acceptable performance under normal circumstances (Cohen, 1981).

With regard to the latter, in recent years there has been intense activity in program accreditation by bodies such as the Australian Medical Council, Australian Dental Council, and Institute of Engineers of Australia. In the health science areas, the work of such bodies has become linked intimately to that of the registration boards in each state, who now operate under uniform principles of mutual recognition. Both in Australia and elsewhere, the boards and the national accreditation bodies have a strong interest the extent to which new graduates are fit for practice (Allen, 1992; Badner, 1994).

 

Fitness to practice - the concept of competency

A competency-based approach to curriculum design and student assessment can promoting the development of curricula which meet the demand of the professions, registration boards and the public. For the new graduate, competency statements can be used for assessing "readiness for practice", while for the more experienced practitioner they can promote safe, effective and accountable practice. As quipped by Marchese (1994) , "The public want more than course-passers; it wants competent practitioners." It is essential however to avoid a narrow view of competency, which will restrict the learning activities of students to mastering "the 100 things we need to know".

In common usage and colloquial speech the definition of competency is a simple technical skill. This narrow definition of competency overlooks the context in which those skills are exercised, and in so doing is counter-productive to deep learning and understanding. By encouraging a superficial approach, the application of this narrow concept of competency in education can subvert opportunities for truly independent self-directed and self-motivated learning.

A wider definition of competency recognises the context of learning and its intimate link with the real world. This immediacy captures the imagination and attention of students and motivates them toward further learning - and it is the "love of learning" that makes for a learned profession. The wider definition of competency, in terms of its use in tertiary education, includes

• a skill (such as a psychomotor or cognitive skill), and
• an understanding of what is being done, * supported by professional values, and
• performed independently in realistic practice settings (Chambers, 1994).

Thus, every competency includes particular components of intellectual and interpersonal competence, and each of these are set within an environment of public, academic and professional expectations (Marchese, 1994).

Put simply, a competency is a behaviour expected of a beginning independent practitioner. It requires some degree of skill, speed and accuracy consistent with patient safety, comfort and well-being (e.g. it is clinically "acceptable"), but is not performance at the highest level possible. Framed in another way, competencies are what general dental practitioners do on a regular basis; they are not the special skills needed by specialists to manage difficult (and sometimes esoteric) problems and situations.

In dental education, the seminal work of David Chambers in the early 1990's on competency-based approaches has made a major impact on the underlying philosophies of curriculum design, particularly in North America. His many writings have stressed how curriculum design (and assessment) should reflect defined competencies, both at the undergraduate level (Chambers & Gerrow, 1994) and at the level of post-graduate training and continuing education. In both spheres, this has direct application to the process by which various programs can be accredited (Redding, 1994).

Philosophically, one could say that the education of a competent professional is a lifelong process that begins at university and continues over the next 40 or so years in independent practice until retirement. Because of the frequent lack of supervision in practice, graduates must develop skills in self assessment and "an awareness of what constitutes acceptable performance under normal circumstances". The latter is a legal benchmark which is applied to professionals across the health care arena (Collins, 1985).Competency statements can be helpful in assessing "readiness for practice", and can be an important tool in promoting safe, effective and accountable practice.

 

Why use competencies in curriculum design?

Competency statements can help to crystallize areas for student learning, which have specific learning outcomes. These are framed on what competent practitioners know and are able to do. To assess these outcomes, professional judgement will be necessary - both from the teaching staff during the course, and from the new graduates via self assessment. A corollary to this is that both groups need to adopt an ethic of continuous improvement (Woolliscroft, 1995). This point will be commented upon further below.

Using a competency-based approach, a curriculum can be designed which

• prepares the graduate for practice as a generalist (Formicola, 1990; Cohen, 1995)
• looks to the needs of the future, and is responsive to any clear need to change (Neidle, 1990)
• stresses critical thinking and problem-solving skills (McCann et al., 1998)
• sets the stage for lifelong learning to keep skills and knowledge updated
• takes an integrated rather than traditional, subject-based approach (O'Neill, 1994; Reynolds, 1995)
• has a strong contextual focus - for example in the health sciences, it employs clinically relevant education in basic sciences and scientifically based education in clinical care (Tedesco, 1990; Tedesco, 1992)
• has a focus on outcomes and evidence-based practice.

Prior to competency at graduation, several stages which precede competency are identified: the acquisition of foundation knowledge, and practice under controlled situations which leads eventually to foundation-level performance. These characterise major learning activities in the early years of most courses. Hard decisions are necessary about which areas of foundation learning are in fact necessary - "nice to know" material should not be included when it is self-serving to the academic staff but largely irrelevant to the practicing professional.

Specific advantages of using a competency-based approach to curriculum development which have been identified by educators in the health science areas include:

• It helps to identify inappropriate content and redundancies
• It places the focus on understanding and performance rather than on isolated facts
• It encourages an interdisciplinary approach to curriculum development
• It encourages integrated approaches to learning and assessment
• It is patient/client-centred and student-centred rather than teacher-centred.

 

New paradigms for assessment

In the final section of this paper, I would like to touch briefly on the impact of a competency-based approach on assessment.

A key concept in the competency-based approach is that education is a process ("How far has the student learned?"), rather than the collection of quanta of facts or a repertoire of skills over time ("What has the student learned?"). There is a clear process of transition from beginner to novice, competent, proficient, and expert. The ability to learn independently, indeed the competence to do so, is the point which signals one's transition at graduation from student to novice professional. Beyond this, a clear distinction can be made between competency for generalists and proficiency for specialists.

Competency statements can help to crystallise areas for student learning, which reflect specific learning outcomes. These are framed on what competent practitioners know and are able to do. To assess these outcomes, professional judgement will be necessary - both from the teaching staff during the course, and from new graduates via self assessment. A corollary to this is that both groups need to adopt an ethic of continuous improvement.

Acceptance of the philosophy of a competency-based approach requires an altered approach to student evaluation, since it requires the involvement of both teacher and learner in assessing competency. Heightened aspirations for both the students themselves and the profession which they have entered provide a powerful motivation to student learning during the course and following graduation. For the new graduate, life-long learning occurs through reflective practice, self assessment, and formal continuing professional education.

Competency statements can form the bridge between education and practice. An important caveat to this statement relates to how students demonstrate competency - stereotypical situations and simulations where there is a large input from supervisors and little independence cannot truly demonstrate competence, even though they may assist in developing skills. Assessment instruments used in competency-based programs must be valid, reliable, credible, feasible, and appropriate. There must be agreement as to what minimal level will be accepted, how often performance will be assessed, and how deficiencies in performance will be handled.

Defining the competencies for professionals has important applications beyond primary training programs, such as for

• assessing overseas-trained practitioners
• evaluating practitioners who have completed retraining programs after periods of extended absence from practice
• developing continuing professional education (CPE) programs for practicing professionals
• developing peer-review systems for practicing professionals.

A wide view of competency-based education (which includes cognitive as well as practical skills) can help align the educational process during and following graduation with the needs of the profession, both in the present and the future.

 

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