Harold G.J. Bok and A. Debbie C. Jaarsma
Faculty of Veterinary Medicine, Utrecht University, The Netherlands
Faculty of Medical Sciences, University of Groningen, The Netherlands
After graduation, veterinary professionals need to possess relevant attributes to face society’s current and future needs. Therefore, designing veterinary curricula that guide students’ competency development on the trajectory from novice student to veterinary professional is one of the major responsibilities of any veterinary school. In this chapter we will describe what such a competency-based training program could look like and provide some design and implementation guidelines based on our own experiences with competency-based veterinary education.
The Changing Role of Veterinary Professionals in Healthcare
Up until the beginning of the twentieth century, veterinary medicine was mainly focused on curative medicine concerning cattle and horses, relevant to transportation and agriculture. From the 1950s on, companion animal veterinary medicine became an important part of daily practice, as was already forecast by Christian Petersen in 1937 in his sculpture The Gentle Doctor (Prasse, Heider, and Maccabe, 2001). Due to changing societal needs and global interdependence during the last decades, veterinary professionals increasingly have been placed in a central position in the relationship between animal health and welfare and public health (Summerlee, 2010). It was as early as the late eighteenth century that Claude Bourgelat, founder of the first college of veterinary medicine in Lyon, France, claimed that a veterinarian needed a variety of skills in order to serve the public by monitoring food animal production, maintaining food quality and safety, controlling zoonosis, and preserving the environment and biodiversity. Nowadays, this is referred to as the “One Health approach,” an integrated approach to animal, human, and environmental health. Preparing veterinary students for this new role will be a major challenge for veterinary schools now and in the future (Willis et al., 2007; AVMA, 2008).
Over the last decades, numerous reports and scientific papers have been published in the veterinary literature about relevant graduate abilities (Brown and Silverman, 1999; Cron et al., 2000). One of the studies that led to significant advances in veterinary education is known as “Future Directions for Veterinary Medicine” and was conducted more than 25 years ago by the Pew National Veterinary Education Program (Pritchard, 1988). This report emphasized the importance of fostering problem-solving skills and self-learning abilities among students. Several other reports and scholarly evidence published in recent years underline the importance of increasing the attention to so-called non-technical competencies (e.g., being able to collaborate effectively with colleagues, veterinary nurses, and third parties, within or outside one’s own organization), in addition to domain-specific technical competencies in training programs (Lewis and Klausner, 2003; Jaarsma et al., 2008). In addition, over the past few years accreditation bodies in veterinary medicine have begun to accredit programs based on their ability to deliver education in a competency-based manner (AVMA, 2014; EAEVE-ESEVT, 2016). Therefore, competency-based education (CBE) is increasingly becoming a standard in veterinary education (Bok, 2014; Hodgson, Pelzer, and Inzana, 2013).
In 1978, McGaghie et al. commented in the medical literature: “The intended output of a competency-based programme is a health professional who can practice medicine at a defined level of proficiency, in accord with local conditions, with local needs” (p. 18). Aligned with this description, and based on an extensive literature review, the following definition of CBE for healthcare professions was recommended by Frank et al. (2010, p. 636): “Competency-based education is an approach to preparing professionals for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs.” Therefore, CBE aligns with a mastery learning approach in which educational progress is based on demonstrated performance rather than on curricular time (McGaghie, Barsuk, and Cohen, 2015).
For a competency-based approach to be successful, it is essential to align the curriculum constructively. Therefore, in healthcare education, competency frameworks are increasingly being used to structure program outcomes across the curriculum. These frameworks help to align content, educational strategies, teaching methods and assessment to enhance longitudinal expertise development (Harden and Laidlaw, 2012; Watling et al., 2013; Van der Zwet, 2014). Furthermore, supervisor continuity and a supportive feedback culture is crucial as they stimulate the exchange of performance-relevant information. Longitudinal integrated clerkships (LICs) therefore have recently received increased attention (Van der Zwet, 2014).
In their review in 2002, Carraccio et al. concluded that despite the growing adoption of CBE, schools struggled to implement competency-based programs successfully. In their opinion this mainly was caused by a lack of reliable and valid assessment instruments that help to determine whether a student has reached a predefined threshold. More than a decade later we are seeing interesting developments with respect to methods and tools that could be helpful. However, despite these new instruments and educational innovations, schools still struggle to implement CBE successfully (Bok et al., 2013; Heeneman et al., 2015). Increasingly, it is realized that this is probably an implementation problem caused by ineffective translation of CBE into teaching, learning and assessment strategies in practice. There is no need for additional or different assessment instruments, as the success of CBE lies in the users and not in the instruments or methods applied. Therefore, thoroughly explaining the principles, goals, and philosophy behind CBE to its users is of crucial importance.
Outcomes, Competencies, and Frameworks
Before continuing, it is important to tease apart how we define “competence” and “competency frameworks.” In this chapter we support the view that competence can be seen as “the ability to do something successfully” (Soanes and Stevenson, 2005). In this definition “successfully” can be seen as performing above a desired threshold. The ability to perform competently requires the integration of knowledge, skills, and attitudes with respect to one’s specific context. Recently, veterinary curricula have been developed that identify areas specific to the profession and relevant for students to develop performance in as competency domains or roles. In the veterinary literature there a number of examples that provide competency frameworks for either undergraduate or postgraduate education. To a certain degree, these frameworks emphasize the same competencies, as well having their own distinct features. One example is the VetPro competency framework, which consists of seven competency domains (Bok et al., 2011). These seven domains are used in veterinary curricula (e.g., in the Netherlands and Hungary) to serve as a foundation for CBE. In the United Kingdom, the Royal College of Veterinary Surgeons (RCVS) and the Quality Assurance Agency for Higher Education (QAA) have defined a framework of “Day One Skills,” which veterinarians should be able to perform immediately on graduation (RCSV, 2015). In 2011 the Association of American Veterinary Medical Colleges (AAVMC) introduced the NAVMEC competency framework (Hodgson, Pelzer, and Inzana, 2013). In accreditation procedures concerning veterinary curricula, the accreditation committee of the American Veterinary Medical Association (AVMA) used a set of competency standards similar to the VetPro and NAVMEC frameworks. Whatever framework is used, for CBE to be successful it is essential subsequently to apply the framework as the foundation to align all teaching, supervising, and assessment strategies (van der Vleuten et al., 2012).
When reviewing the literature for evidence that supports CBE, Frank et al. (2010) found four overarching themes: a focus on outcomes; an emphasis on abilities; a de-emphasis of time-based training; and the promotion of learner centeredness. We will briefly discuss these four themes.
A Focus on Curricular Outcomes
In a time of increased emphasis on the social accountability of the veterinary profession, veterinary schools need to ensure that every graduate is sufficiently prepared to enter practice. Contemporary veterinary curricula have been criticized for failing to train graduates on all relevant domains of their intended practice. In reaction to these demands, many veterinary schools improved their curricula by defining the outcomes that are required at graduation. However, this paradigm shift toward curricula focused around outcomes demands a radical change in didactic approaches. As described by Biggs and Tang (2011), for outcomes-based teaching, learning, and assessment to be successful, some important preconditions are required.
Learning outcomes, or attributes, such as communication skills, technical skills, personal development, and scholarly skills, should be internalized in the curriculum. In other words, the outcomes that students should have achieved after graduation should steer the development of all learning, teaching, and assessment strategies. After defining which outcomes are most important, proper assessment strategies enable both students and faculty to compare performance to the criteria defined in an outcome statement. Therefore, in CBE assessment is usually criterion referenced.
In CBE the focus is on what students need to learn and how, instead of what the teacher wants to teach. Therefore, the intended learning outcomes need to specify the topic that is to be learned, how it is learned, and to what level (standard) it should be learned. To operationalize the learning outcomes, they need to be written in such a way that they include an activity. Subsequently, this activity (e.g., taking a history) is constructively aligned through the learning and teaching activities (e.g., providing a lecture on interview techniques, simulating an interview with a peer student, and interviewing a patient owner). The activity can then be included in assessment activities to judge whether or not a student performs the outcome at the desired level.
A constructively aligned program is also more effective at optimizing consistency throughout the curriculum, because all the “building blocks” in the program focus on the same outcomes and support each other. This is in line with Hattie’s statement that “any course needs to be designed so that the learning activities and assessment tasks are aligned with learning outcomes that are intended in the course. This means that the system is consistent” (Hattie, 2009, p. 6). However, the term ‘intended learning outcomes’ is broader since learning, teaching and assessment activities also should allow desirable ‘unintended’ learning outcomes. In a student-centered, competency-based program, where students are responsible for their own learning and where they co-create their own learning and development, these unforeseen outcomes will inevitably occur.
An Emphasis on Abilities
In CBE, learning experiences are designed to incorporate prior learning elements continuously and to emphasize observable abilities (McGaghie et al., 1978; Carraccio et al., 2002). Curricular elements are structured based on outcomes, and defined as a matrix of activities juxtaposed with related competencies. Even though preparation for CBE can happen in a classroom setting, full implementation requires a workplace environment. Over the last decades, scholarly research about what happens in workplace learning have led to improvements in its quality and effectiveness as a learning environment (Dornan, 2006; Teunissen, 2009). Previously, most workplace learning theories were grounded in social learning theories (situated learning/situated cognition) that emphasized the interaction between the learner and the learning environment (Durning and Artino, 2011). More recently, theories based on experiential learning, cognitive apprenticeship, and legitimate peripheral participation within a community have demonstrated the importance of authentic activities and social interaction to the quality of workplace learning (Kolb, 1984; Lave and Wenger, 1991; Collins, 2006).
A workplace learning environment can be defined as a set of authentic experiences “that fosters the acquisition of competencies that are necessary to act as a professional” (Ten Cate et al., 2015, p. 984). A fundamental feature of CBE is that learners are defined as competent when they have passed a certain threshold that allows them to enter practice. In essence, it is a mastery learning approach, with its emphasis on accountability for learners’ progress toward predefined outcomes in preparing them to provide high-quality and safe patient care (Lineberry et al., 2015). In a mastery learning approach, learners’ competencies need to be placed in the context of workplace practice. However, mastery of abilities in individual domains does not imply that learners are competent across domains, or that they can translate those abilities to different contexts or circumstances, or that they can apply those abilities to patient care. Therefore, increasingly calls have been made to more explicitly frame performance outcomes, and subsequent programs of assessment, with authentic learning activities (Frank et al., 2010). Over the last decade, entrustable professional activities (EPAs) have been introduced as a way to bridge the gap between assessing and fostering graduate abilities and authentic patient care in a workplace environment (Ten Cate et al., 2015).