Beyond Survey: Creating a Culture of Staff Competency

Nurse Jones is a seasoned registered nurse who has been an employee of Horse Springs Meadow Senior Living for seven years. But when a new admission arrives with a long list of medications, many of them newly on the market, and with a wound treatment prescribed that Nurse Jones has never seen demonstrated, are you sure this nurse can competently care for him?

As nurse leaders, we often take for granted that staff have the necessary skills and knowledge to adequately and safely care for the diverse needs of all our residents, especially new admissions. But do you know without doubt that your facility leadership has provided staff with all appropriate education and assessed competency thereafter?

The survey team, during its several days on-site, will evaluate staff competency as required by the Sufficient and Competent Nurse Staffing mandatory task—observing staff members’ hands-on care as it’s provided to residents. But what about the other 360 days of the year? Year-round, staff competency is at the core of providing proper care for residents with complex medical needs, achieving optimal resident outcomes, and lowering length of stays. Although it may seem daunting, it is possible to put a systematic plan in place to assess, monitor, and ensure the competency of staff on a regular basis. Here’s how to make staff competency an ongoing, integral part of your facility’s culture and values.

Understand knowledge-based versus competency-based education.

In order to provide effective staff education, it is crucial to know the difference between knowledge-based and competency-based education. Knowledge is the understanding we gain through formal education, training, and experience. Knowledge-based education provides the learner with information. Competency, according to the State Operations Manual (SOM), is a “measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.” Someone may have knowledge about a topic, but this person must be able to apply that knowledge in a measurably consistent way in order to be considered competent. So if, for example, you provide personnel with only a short in-service on a specific care need during which they review a handout, it’s not enough.

In fact, the SOM specifically explains that competency may not be demonstrated by documenting that staff attended a training, listened to a lecture, or watched a video. Rather, a staff member’s ability to use and integrate the knowledge and skills that were the subject of the training, lecture, or video must be assessed and evaluated by staff already determined to be competent in these skill areas. The SOM provides the following examples for evaluating competencies (not an inclusive list):

  • Lecture with return demonstration for physical activities
  • Pre- and post-tests for documentation issues
  • Demonstrated ability to use tools, devices, or equipment that were the subject of training and used to care for residents
  • Reviewing adverse events that occurred as an indication of gaps in competency
  • Demonstrated ability to perform activities that are in the scope of practice for which an individual is licensed or certified

Think beyond the nursing staff.

The SOM discusses competency requirements for all, not just for nursing staff, and calls attention to the context of behavioral health in particular. When facility staff are tasked with caring for those with mental illness, psychosocial disorders, or a history of trauma or post-traumatic stress disorder (PTSD), all staff need to keep their eyes and ears open for indications that a resident might be unwell.

Insufficient competencies have the potential to result in citations under the following tags:

  • F741, for any staff caring for residents with dementia or a history of trauma and/or PTSD
  • F801, for food and nutrition staff
  • F826, specialized rehabilitative services
  • F839, administration for any other staff not referenced above

Know your residents’ care needs.

It has been over a year since the requirement for the facility assessment (under F838) was implemented, but many nurse leaders have yet to harness its data as a tool for improvement. The fundamental purpose of the facility assessment is to help facility leaders identify competency and training needs that are specific to the resident population to ensure quality of care. At a minimum, an analysis of updated facility assessment data is required; beyond the minimum, leaders should be using its data to make strategic and practical training decisions.

Consider the following situation: A facility assessment shows a high prevalence of infections throughout the facility. The data also shows that there are a number of urinary tract infections (UTIs) and that the number of residents on a toileting program has decreased from the prior year. ADL assistance has also increased year after year. This information can be used to build a competency-based educational program that addresses the specific needs of the resident population. In this example, overall infections and UTIs have increased. This is an opportunity for competency-based education that centers around infection prevention and control. Next, toileting programs have decreased while ADL support has increased, presenting an opportunity to do a root-cause analysis to get to the real reason for this trend. This could be an opportunity to provide education on restorative programs that support residents’ function as well as on the importance of toileting programs, including their role in decreasing incontinence and thereby decreasing UTIs.

The above scenario is just a simple example of how data from the facility assessment can be used to help address educational needs and improve staff competency in resident care.

Let resident outcomes drive the focus of education.

Facility leaders can determine staff competency deficits by examining resident outcomes. Poor outcomes in a specific care area likely signal a lack of competency and an opportunity for education. For example, if a number of residents have been transferred to the emergency room due to a change in condition, training on how to recognize and address condition changes may be needed to help lower the rate of emergency room visits and may even lower hospital readmissions.

Additionally, initiatives taken through the quality assurance and performance improvement (QAPI) or quality assessment and assurance (QAA) program pinpoint competency-based educational needs, as these programs monitor care areas for improvement. For example, the QAA committee may be monitoring the number of medication errors in the facility. Providing competency education can help to lower the medication error rate, which in turn will improve resident safety and more quickly reduce the problem. Past survey deficiencies may also highlight care areas that need focused training.

Set expectations for staff that training is required and ongoing.

It’s important to act on the observations of educational needs—taken from QAA meetings, for example—and train promptly. At a minimum, plan to offer ongoing competency-based education each month; this ensures a scheduled time block with staff in which to focus on necessary areas for improvement. Also remember that during each training there should be an opportunity to apply the skill under review. If the topic is the staging of pressure ulcers, for example, require staff to demonstrate they are able to use the knowledge by having them stage wound examples. Set the expectation with staff that they should regularly attend these training sessions and that they will be required to demonstrate the covered skill.

Never stop auditing for accuracy.

All training has a life cycle—that is, for every training provided, an audit should always follow. Audits are imperative because they ensure the skills covered in trainings are being put to use when it counts—during care delivery. Choose care areas such as handwashing, incontinence care, and medication administration for audit on a weekly basis. In addition to auditing promptly after training, audit for skills that haven’t been reviewed recently to ensure best practices are being followed. Repeat skills training as necessary.


In a facility that has a culture of safety and prioritizes resident outcomes every day of the year, education and training aren’t just boxes to be checked, they are an ongoing goal that requires an honest skills inventory that drives staff improvement. Staff competency, although it may seem like an ambiguous goal, is clear as day in the light of resident outcomes.


Topics: Advocacy , Articles , Leadership , Resident Care , Staffing