Throughout the world, millions of students go
to school every day. These students study
subjects such as science, language and
mathematics in courses usually scheduled to last the
duration of the school year. Because progression
through the various subjects in school is time-based,
at any given time during the year the teacher is
expected to be at a specific point in the textbook or
course content. While not every student may
progress at the same rate, the schedule typically
requires everyone to move at the same rate as the
teacher. Tests are administered periodically to ensure
students understand the concepts and principles. Test
scores often are compared to determine the grades of
the students. Unfortunately, when a student does not
do well on a test there often is little time for individual
assistance as the teacher must move on in order to
adhere to the established time schedule.
While traditional, time-based approaches to education
have met with varying levels of success over the
years, it is an ineffective system when the goal is to
train individuals to perform specific, job-related skills.
For example, an active, certified airline pilot is attending
a 3-week training course to learn to fly a new type
of aircraft. Will attending all sessions during the course
ensure the pilot can fly the plane? Of course not! If the
pilot is unable to attend 2 days of the course, does this
mean the pilot cannot fly the plane? Probably not.
After 4 days, the pilot does poorly on a written test.
Should the pilot immediately fail the course or should
the pilot continue with assistance and be given the
opportunity to be tested again? If the pilot can pass all
written tests does this indicate that the pilot can fly the
plane? No! In addition to assessing knowledge, an
evaluation of the pilot’s skills also is required.
Obviously, the time-based educational system used in
schools and universities is not appropriate when
conducting training. A more appropriate approach is
competency-based training (CBT).
In a traditional educational system, the unit of progression
is time and it is teacher-centered. In a CBT
system, the unit of progression is mastery of specific
knowledge and skills and is learner- or participant-centered.
Two key terms used in competency-based
training are:
- Skill—A task or group of tasks performed to a
specific level of competency or proficiency
which often use motor functions and typically
require the manipulation of instruments and
equipment (e.g., IUD insertion or Norplant ®
implants removal). Some skills, however, such
as counseling, are knowledge- and attitude-based.
- Competency—A skill performed to a specific
standard under specific conditions.
There appears to be substantial support for competency-based training. Norton (1987) believes that
competency-based training should be used as opposed
to the “medieval concept of time-based
learning.” Foyster (1990) argues that using the
traditional “school” model for training is inefficient.
After in-depth examinations of three competency-based
programs, Anthony Watson (1990) concluded
that competency-based instruction has tremendous
potential for training in industry. Moreover, in a 1990
study of basic skills education programs in business
and industry, Paul Delker found that successful training
programs were competency-based.
A competent clinician (e.g., physician, nurse, midwife,
medical assistant) is one who is able to perform a
clinical skill to a satisfactory standard. Competency-based
training for reproductive health professionals
then is training based upon the participant’s ability to
demonstrate attainment or mastery of clinical skills
performed under certain conditions to specific
standards (the skills then become competencies).
Norton (1987) describes five essential elements of a
CBT system:
- Competencies to be achieved are carefully
identified, verified and made public in advance.
- Criteria to be used in assessing achievement and
the conditions under which achievement will be
assessed are explicitly stated and made public in
advance.
- The instructional program provides for the
individual development and evaluation of each
of the competencies specified.
- Assessment of competency takes the
participant’s knowledge and attitudes into
account but requires actual performance of the
competency as the primary source of evidence.
- Participants progress through the instructional
program at their own rate by demonstrating the
attainment of the specified competencies.
How does one identify a competency-based training
program? In addition to a set of competencies, what
other characteristics are associated with CBT?
According to Foyster (1990), Delker (1990) and
Norton (1987) there are a number of characteristics
of competency-based programs. Key characteristics
are summarized in Table 1.
Table 1. Characteristics of Competency-Based Training Programs
- Competencies are carefully selected.
- Supporting theory is integrated with skill practice. Essential knowledge is learned to support the performance of skills.
- Detailed training materials are keyed to the competencies to be achieved and are designed to support the acquisition of
knowledge and skills.
- Methods of instruction involve mastery learning, the premise that all participants can master the required knowledge or skill,
provided sufficient time and appropriate training methods are used.
- Participants’ knowledge and skills are assessed as they enter the program and those with satisfactory knowledge and skills
may bypass training or competencies already attained.
- Learning should be self-paced.
- Flexible training approaches including large group methods, small group activities and individual study are essential
components.
- A variety of support materials including print, audiovisual and simulations (models) keyed to the skills being mastered are
used.
- Satisfactory completion of training is based on achievement of all specified competencies.
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One of the primary advantages of CBT is that the
focus is on the success of each participant. Watson
(1990) states that the competency-based approach
“appears especially useful in training situations where
trainees have to attain a small number of specific and
job-related competencies” (page 18). Benefits of CBT
identified by Norton (1987) include:
- Participants will achieve competencies required
in the performance of their jobs.
- Participants build confidence as they succeed in
mastering specific competencies.
- Participants receive a transcript or list of the
competencies they have achieved.
- Training time is used more efficiently and
effectively as the trainer is a facilitator of learning
as opposed to a provider of information.
- More training time is devoted to working with
participants individually or in small groups as
opposed to presenting lectures.
- More training time is devoted to evaluating each
participant’s ability to perform essential job skills.
While there are a number of advantages of competency-based training, there also are some potential
limitations. Prior to implementing CBT, it is important
to consider these limitations:
- Unless initial training and followup assistance is
provided for the trainers, there is a tendency to
“teach as we were taught” and CBT trainers
quickly slip back into the role of the traditional
teacher.
- A CBT course is only as effective as the process
used to identify the competencies. When little
or no attention is given to identification of the
essential job skills, then the resulting training
course is likely to be ineffective.
- A course may be classified as competency-based,
but unless specific CBT materials and
training approaches (e.g., learning guides,
checklists and coaching) are designed to be used
as part of a CBT approach, it is unlikely that the
resulting course will be truly competency-based.
Models and simulations are used extensively in
competency-based training courses. Airplane pilots
first learn to fly in a simulator. Supervisors first learn to
provide feedback to employees using role plays during
training. Individuals learning to administer cardiopulmonary
resuscitation (CPR) practice this procedure on
a model of a human (mannequin).
Satur and Gupta (1994) developed a model which
facilitates skill development in performing and evaluating
coronary anastomoses with an angioscope. The
results of their study indicate that models are proving
invaluable as a training tool. George H. Buck in a
1991 historical review of the use of simulators in
medical education concluded that “Given the
developments in this technology within the last 50
years, it is possible that the use of simulators will
increase in the future, should the need arise to teach
new concepts and procedures at set times to large
groups of individuals” (p. 24). Researchers in two
different experimental studies involving training people
to perform breast self-examinations (BSE) compared
several methods and found that using models was the
most effective training method (Campbell et. al., 1991
and Assaf et. al., 1985). In a multicenter evaluation of
training of physicians in the use of 30-cm flexible
sigmoidoscopy, Weissman et al (1987) found that they
were easily trained by first practicing on plastic colon
models.
Norton (1987) believes that participants in a competency-based training course should learn in an
environment that duplicates or simulates the work
place. Richards (1985) in writing about performance
testing indicates that assessment of skills requires tests
using simulations (e.g., models and role plays) or
work samples (i.e., performing actual tasks under
controlled conditions in either a laboratory or a job
setting). Finally, Delker (1990) in a study of business
and industry found that the best approach for training
involved learner-centered instruction using print,
instructional technology and simulations.
Evaluation in traditional courses typically involves
administering knowledge-based tests. While knowledge-based assessments can certainly be used in CBT
to measure mastery of information, the primary focus
is on measuring mastery of skills. In keeping with this,
Thomson (1991) reports that the decision to recognize
a performance as satisfactory and to determine
competence should be the basis for success of a
competency-based program. Moreover, Foyster
(1990) argues that assessment in competency-based
programs must be criterion-referenced with the
criterion being the competencies upon which the
program is based. Finally, Richards (1985) indicates
that simulation and work sample performance tests
should include a checklist or some type of rating scale.
In a 1990 study of three operating competency-based
programs, Anthony Watson identified a number of
implications for organizations considering implementing
a CBT system:
- Organizations must be committed to providing
adequate resources and training materials.
- Audiovisual materials need to be directly related
to the written materials.
- Training activities need to match the objectives.
- Continuous participant interaction and feedback
must take place.
- Trainers must be trained to conduct competency-based training courses.
- Individuals attending training must be prepared
for CBT as this approach is likely to be very
different from their past educational and training
experiences.
JHPIEGO Corporation has adopted a competency-based
approach to conducting clinical training in
selected reproductive health practices. Based on the
principles summarized in this paper, JHPIEGO’s
approach to CBT involves key activities which occur
during the design, delivery and evaluation of training
courses. These activities are summarized here and
explained in detail in JHPIEGO’s Clinical Training Skills
for Reproductive Health Professionals and Advanced
Training Skills for Reproductive Health Professionals
reference manuals.
The key activities around which JHPIEGO’s competency-based training is built include design, delivery
and evaluation activities. The components of each are
summarized in Table 2 and Table 3.
Table 2. Design Activities
- Identification of the specific clinical skills (e.g., IUD, Norplant implants, counseling, infection prevention or
minilaparotomy) that will form the basis of a competency-based training course.
- Identification of the conditions (e.g., using models, role plays, clients) under which the skills must be demonstrated.
- Development of the criteria or standards to which the skills must be performed.
- Development of the competency-based learning guides and checklists which list each of the steps and sequence (if
necessary) required to perform each skill or activity.
- Development of reference manuals which contain the essential, need-to-know information related to the skills to be
developed.
- Development of models (e.g., Zoe pelvic model, Norplant implants training arm) to be used during training.
- Development of training objectives which outline what the participant must do in order to master the clinical skills.
- Development of course outlines which match a variety of training methods and supporting media to course objectives.
- Development of course syllabi and schedules which contain information about the course and which can be sent to
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Table 3. Delivery and Evaluation Activities
- Administration of a precourse questionnaire to assess the participants’ knowledge and attitudes about course content.
- Administration of precourse skill assessments using models to ensure participants possess the entry level skills (e.g., able
to perform a pelvic exam if learning to insert IUDs) to complete the course successfully and role plays to determine the
level of their communication (counseling) skills.
- Delivery of the course by a trainer/facilitator using an interactive and participatory approach.
- Transfer of skills from the trainer to the participants through clinical and counseling skill demonstrations using slide sets,
videotapes, models, role plays and finally, clients.
- Development of the participants’ skills using a humanistic approach, which means participants acquire the skill and then
practice until competent using anatomic models and role plays.
- Practice of the skills following the steps in the learning guide until the participant becomes competent at performing the skill.
During this time the trainer functions as a coach providing continuous feedback and reinforcement to participants. Only when
participants are assessed and determined to be competent on a model do they work with clients.
- Presentation of supporting information and theory through interactive and participatory classroom sessions using a variety of
methods and audiovisuals.
- Administration of a midcourse questionnaire to determine if the participants have mastered the new knowledge associated
with the clinical skills.
- Guided practice in providing all components of the clinical service.
- Evaluation of each participant’s performance (i.e., knowledge, attitudes, practice and clinical skills) with clients. The
evaluation by the trainer is performed using competency-based checklists. The participant is either qualified or not qualified
as a result of the knowledge, attitude and skills assessments.
- Presentation of a statement of qualification which identifies the specific clinical service the individual is qualified to provide.
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JHPIEGO uses a four-step process to transfer specific
clinical skills and knowledge from experts to service
providers. These steps are part of the process of
developing a family planning training system within a
country. The four steps include:
- Standardizing provision of clinical services and
modifying and adapting JHPIEGO training
materials as necessary
- Training service providers to provide these
services competently, according to the approved
standards
- Identifying and preparing proficient service
providers to function as clinical skill trainers so
they are able to train other service providers
- Identifying and preparing clinical skill trainers to
function as advanced and eventually master
trainers so that they are able to train other
clinical skill trainers, evaluate training and
develop or revise course materials
The first step is to standardize the clinical skill(s) to
be used in the delivery of family planning services. For
example, in a country there may be a need to train
clinicians to perform IUD insertions and removals.
The first activity conducted is to identify and observe a
group of clinicians who are performing these procedures.
The steps the clinicians perform are observed
and compared to the standard approach outlined in
JHPIEGO’s competency-based IUD learning guides
and checklists. This observation process gives
JHPIEGO trainers an idea of the skill levels of those
who will be trained to be service providers. As
necessary, JHPIEGO’s learning guides and checklists
are modified to meet the specific service delivery
standards or norms within the host country. The
standardized procedure then forms the basis for the
service provider training courses conducted within the
country.
The second step is to train a specific group of
service providers to perform the standardized clinical
skills. The clinical skills course is based on a training
package (see Figure 1) consisting of a reference
manual, supporting audiovisuals, anatomic models,
and trainer and participant handbooks (which contain
the learning guides and checklists based on the
standardized procedure). Following the clinical skills
course, these competent service providers provide
clinical services to clients. After providing services for a
period of time, a group of the most proficient service
providers who have demonstrated an interest and
willingness to become clinical trainers undergo training
skills training.
The third step in the transfer process is to prepare a
group of proficient service providers to be clinical skill
trainers. These service providers attend a clinical
training skills course which also is based on a training
package. During this course, participants will have
their clinical knowledge updated and skills assessed
and standardized to ensure they are proficient at
performing the clinical skill. Participants will then learn
how to demonstrate clinical skills, transfer knowledge
and skills during training, function as clinical coaches,
and use competency-based learning guides and
checklists to assess participant performance. Following
the clinical training skills course these clinical skill
trainers conduct service provider training courses.
During their first service provider course they either
co-train with an advanced (or master) clinical trainer
or are observed by a training skills trainer.
The final step in the process of transferring skills is to
prepare a small group of proficient clinical skill trainers
to become advanced trainers. These clinical skill
trainers attend an advanced training skills course which
is also based on a training package. During this course,
participants learn how to conduct needs assessments,
design training courses, facilitate the group dynamics
occurring during a course, and evaluate training.
Following the advanced training skills course these
advanced trainers conduct clinical training skills
courses. During their first several training courses they
cotrain with a master trainer. After successfully
delivering several training skills courses these individuals
can be qualified to function as a master trainer.
Based on the concepts and principles presented in this
paper, the key features of JHPIEGO’s approach to
training include:
- Development of competencies (knowledge,
attitude and practice) is based on national
standards.
- Quality of performance is built into the training
process.
- Emphasis of the training is on development of
qualified providers, not on the number of
clinicians undergoing training.
- Training builds competency and confidence
because participants know what level of
performance is expected, how knowledge and
skills will be evaluated, that progression through
training is self-paced, and that there are opportunities
for practice until mastery is achieved.
Assaf AR et al. 1985. Comparison of Three Methods of Teaching Women How to Perform Breast Self-Examination.
Health Education Quarterly Fall: 259–272.
Buck GH. 1991. Development of Simulators in Medical Education. Gesnerus (48): 7–28.
Campbell H et al. 1991. Improving Physicians’ and Nurses’ Clinical Breast Examination: A Randomized Controlled Trial.
American Journal of Preventive Medicine 7(1): 1–8.
Delker PV. 1990. Basic Skills Education in Business and Industry: Factors for Success or Failure. Contractor Report,
Office of Technology Assessment, United States Congress.
Foyster J. 1990. Getting to Grips with Competency-Based Training and Assessment. TAFE National Centre for Research
and Development: Leabrook, Australia. ERIC: ED 317849
Norton RE. 1987. Competency-Based Education and Training: A Humanistic and Realistic Approach to Technical and
Vocational Instruction. Paper presented at the Regional Workshop on Technical/Vocational Teacher Training in Chiba City,
Japan. ERIC: ED 279910.
Richards B. 1985. Performance Objectives as the Basis for Criterion-Referenced Performance Testing. Journal of
Industrial Teacher Education 22(4): 28–37.
Satur CMR and Gupta NK. 1994. Angioscopy-Guided Training Model of Coronary Artery Anastomosis. Annals of
Thoracic Surgery 57(5): 1343–1345.
Thomson P. 1991. Competency-Based Training: Some Development and Assessment Issues for Policy Makers. TAFE
National Centre for Research and Development: Leabrook, Australia. ERIC: ED 333231
Watson A. 1990. Competency-Based Vocational Education and Self-Paced Learning. Monograph Series, Technology
University: Sydney, Australia. ERIC: ED 324443
Weissman GS et al. 1987. Multicenter Evaluation of Training of Non Endoscopists in 30-CM Flexible Sigmoidoscopy.
Cancer Journal for Clinicians 37(1): 26–30.
JHPIEGO Strategy Papers are designed to summarize JHPIEGO’s experience
in reproductive health, with a focus on education and training. The papers
are intended for use by program staff of JHPIEGO, USAID and its cooperating
agencies and other organizations providing or receiving technical assistance
in the area of reproductive health training.
©Copyright 1995 by JHPIEGO Corporation. All rights reserved.
Financial support for this publication was provided in part by the United States Agency
for International Development (USAID). The views expressed in this report are
those of the authors/editors and do not necessarily reflect those of USAID.
JHPIEGO, an affiliate of the Johns Hopkins University, is a nonprofit organization
dedicated to improving the health of women and families globally.
NORPLANT® is the registered trademark of the Population Council for subdermal
levonorgestrel implants.
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