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1. NURSING
COMPETENC
Y PROGRAM
Ahmad Thanin

2. OBJECTIVES To demonstrate continued competence through
structured program.
To set minimum acceptable clinical performance
criteria.
To ensure that competence of all Nursing staff are
assessed, maintained & demonstrated.
To facilitate continuous performance improvement.
To meet the JCI & Central Board Accreditation
Healthcare Institution (CBAHI) Standards on Staff
Competency.

3. WHY DO WE
NEED TO
DEVELOP A
COMPETENCY
PROGRAM?
To demonstrate continued competence through a
structured program.
To set a minimum acceptable clinical performance
criteria.
To ensure that competence of all Nursing staff are
assessed, maintained & demonstrated.
To facilitate continuous performance improvement.
To meet the Joint Commission International (JCI) and
Central Board Accreditation of Healthcare Institutions
(CBAHI) Standards on Staff Competency.

4. DEFINITIONS COMPETENT
• A person performs assigned duties &
responsibilities in job description
correctly.
COMPETENCE
• A combination of skills, knowledge,
attitudes, values & abilities that underpin
effective performance as a nurse.
COMPETENCY
• Ability to demonstrate knowledge, skills
& attitude to perform a specific job.

5. NURSING COMPETENCY
PROGRAM
IN ORDER TO ENSURE
THAT THE COMPETENCE
OF ALL NURSES IS
ASSESSED,
MAINTAINED,
DEMONSTRATED, AND
IMPROVED, A
CONTINUOUS
COMPREHENSIVE
NURSING COMPETENCY
PROGRAM THAT:
Consists of competency standards that applies to clinical
procedures within the health and wellbeing dimensions.
Starts from the new hire orientation period in which
mandatory competencies are initiated.
Continues through general and unit-specific competencies
as soon as the nurse is assigned to a unit or a clinic.
Ongoing evaluation of the employee’s competence through
entire employment period.
The competency assessment is in conjunction with the
knowledge, skills & attitude framework.

6. NURSING
COMPETENC
Y PROCESS
The mandatory competencies for new employees are initiated and assessed
in the Nursing Education Unit and then follow on the general and the unit-
specific competencies of the assigned unit or clinic.
The progress of the new employee is to achieve the competencies
documented on the competency form.
If the new employee is unable to meet the objectives, an individualized
performance improvement plan will be developed by the head
nurse/supervisor with the assistance from the nursing education and others
as applicable, with the employee.
Ongoing competency assessment of employees through mandatory and
annual competencies. Each employee should be periodically evaluated on
their knowledge, skills, and attitude specific to their patient population.
If changes in assignment, such as floating, transfers, and modifications are
made for type of service, a competency-based orientation is provided.

7. NURSING
COMPETEN
CY
PROCESS

8. NURSING COMPETENCY PROGRAM
COMPONENTS
MANDATORY, GENERAL, UNIT SPECIFIC,
AND
ANNUAL
COMPETENCIES

9. MANDATORY
COMPETENCIES
1. Emergency Response
2. Environmental Safety
3. Hazardous Material
4. Infection Control

10. GENERAL COMPETENCIES
Age Related
Care
Pain
Management
Blood
Administration
Moving and
Handling
Medication
Administration
Patient
Teaching
Respiratory
Therapy & O2
Administration
Wound
Management
Documentation Falls Precaution

11. THE GENERAL
ORIENTATION
COMPETENCIES
THAT ARE
COMMON TO ALL
NURSING AREAS
THAT ARE:
designed to assess the performance of the new
employee/orientee
common to all technical and professional nurses
who are providing direct patient care. Learning
about these competencies starts in new hire
orientation and continues on the assigned unit as
the new hire nurse works with the preceptor:
There are 10 identified general competencies.

12. SPECIFIC
COMPETENCI
ES
Competencies are unique to a
nursing unit/clinic based on the
scope of service & practice, job
description & high-risk procedures.
Examples for the Pediatric Unit:
• Immunization
• Conscious Sedation

13. ANNUAL
COMPETENCIES
• Annual competencies are designated by the
management of each unit/clinic based on low
volume-high risk procedures, Quality Improvement
results & Job performance standards.
• In addition to the (4) mandatory competencies, the
annual competencies can be selected from any
general and/or unit specific competencies, but not
more than two competencies, which makes a total
of 6 competencies per year.

14. COMPETENCY FORMS
The form is used to document assessed
competencies that include :
• Competency statements describes a general category of
performance and describes employee’s attitude that is
observable and measurable.
• Performance criteria includes sufficient description of the
knowledge and skills.

15. HOW DO WE
ASSESS
KNOWLEDGE,
SKILLS, AND
ATTITUDES?
Through observation in the daily work, clinical
situations, drills, etc. where the nurses critical
thinking can be evaluated.
Multiple choice tests, verbal response question
and case studies could be used.
Competency Process options are suggested
resources/activities listed on all Competency
forms to assist the staff members to gain the
knowledge, skill, and appropriate attitude
required to meet the competency statements.

16. WHO CAN DO
THE
ASSESSMENT
AND
DOCUMENTATIO
N?
The nursing educator, or a
preceptor or a senior staff nurse
identified as being competent,
such as Clinical Resource
Nurse (CRN) if available.
A competency form is
maintained in the employee unit
file annually.

17. INFECTION
CONTROL
AN EXAMPLE OF A MANDATORY
COMPETENCY

18. MEDICATION
ADMINISTRATIO
N AN EXAMPLE OF A GENERAL
COMPETENCY

19. PATIENT
ASSESSMENT
AN EXAMPLE OF A UNIT SPECIFIC
COMPETENCY

20. ROLES &
RESPONSIBILITI
ES
DIRECTOR OF
NURSING &
DESIGNEE:
Ensures the Competency
Program is in place & meets
high standards of patient care
to achieve “Best Practice”.
Monitors & guides the
competency program.
Identifies, reviews & updates
pertinent hospital’s services of
related competencies as
indicated.

21. ROLES &
RESPONSIBILIT
IES
NURSING
SUPERVISOR:
Participates in the monitoring &
implementation of the nursing
competency program.
Identifies annual competencies in
conjunction with low volume high risk,
quality indicators, changes in
practice/standards or policy & other
relevant information/events.

22. ROLES &
RESPONSIBILITIE
S
NURSE
EDUCATOR/
CLINICAL
INSTRUCTOR:
Initiates mandatory competencies
during the new hire orientation
period.
Provides required
education/training programs
based on competency
assessment outcomes.
Reviews mandatory and general
competencies periodically.

23. ROLES &
RESPONSIBILITI
ES
HEAD NURSE:
Ensures identification of preceptors & Clinical
Resource Nurses.
Supervises & evaluates performance of all nursing
staff assigned to the clinical area.
Provides coaching, counseling & develops a
performance improvement plan based on the result
of the nursing competency assessment.
Maintains current competencies on employees' files.

24. ROLES &
RESPONSIBILITI
ES
Nurse Preceptor/Clinical Resource
Nurses:
• Validates nurses’ competence.
• Communicates assessment findings with the
assessed nursing staff and head nurse/
supervisor.
Nursing Staff:
• Completes the required departmental
competencies.
• Promotes and provides professional competence
in all aspects of nursing care.

25. THANK
YOU