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The Framework, Concepts and Methods of the

Competency Outcomes and Performance
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THE COPA MODEL:

A Comprehensive Framework Designed to Promote

Quality Care and Competence for Patient Safety
CARRIE B . LENBURG , COLLEEN KLEIN, VERONIC A ABDUR-RAHMAN,
TA M M Y S P E N C E R ,

uring the past decade, remarkable changes have

become evident in the areas of quality patient care
and safety (Hofler, 2008; Lenburg, 2008). Spurred by national initiatives, essentially all nursing organizations, agencies, and educational programs have increased their emphasis on patient safety
and competence in clinical practice. Organizations for specialty
areas of practice and nursing education at all levels have convened
frequently to explore the meanings, definitions, and specific wording of competencies and ways to improve their use among students
and practitioners (American Association of Colleges of Nursing,
2006; Byrne & Waters, 2007; National League for Nursing, 2005;
National Organization of Nurse Practitioner Faculties, 2002). The
emphasis on quality health care has become a high priority issue
for all health care professions, in essentially every clinical specialty and practice environment.
The impetus for this current interest in competencies was the
release in 1999 of the Institute of Medicine (IOM) report To Err Is
Human: Building a Safer Health System. Since its publication,
numerous, comprehensive initiatives have been introduced to promote patient safety and quality care. For example, Texas,
Massachusetts, and Vermont launched statewide quality initiatives
(Allen et al., 2008; Boyer, 2002, 2008; Massachusetts Board of
Higher Education, 2007). Recently, the Quality and Safety
Education for Nurses (QSEN) initiative (Cronenwett et al., 2007;
Sherwood & Drenkard, 2007), a national project funded by the
Robert Wood Johnson Foundation, challenged faculty in 15 prelicensure nursing programs to implement the IOM competencies
(Greiner & Knebel, 2003) with some changes by QSEN. In addition

ABSTRACT

AND

S U S A N B OYER

to many articles, a new book by Finkelman and Kenner (2009)

describes how IOM recommendations can be integrated into nursing curricula.
This article focuses on the Competency Outcomes Performance
Assessment (COPA) Model, which was developed in the early
1990s and is used by a number of schools and agencies as they
revise their curricula, delineate faculty and student roles, and
devise methods to validate outcomes (Lenburg, 1999a, 1999b,
2004, in press; Luttrell, Lenburg, Scherubel, Jacob, & Koch, 1999;
Redman, Lenburg, & Walker, 1999). Lenburg developed the COPA
Model based on 17 years of experience directing and consulting
with the clinical-assessment-based Regents College (now Excelsior
College) nursing programs and years of consultation with other
nursing programs (Lenburg, 1979, 1991, 1999b).
The COPA Model is designed and structured as a theoretical
curriculum framework to promote competence for practice. It is
based on the philosophy of competency-based, practice-oriented
methods and outcomes and is organized around four essential conceptual pillars: a) the specification of essential core practice competencies, b) end-result competency outcomes, c) practice-driven,
interactive learning strategies, and d) objective competency performance examinations in all courses. Effective implementation of
the COPA model requires that faculty resolve four fundamental
questions:
What are the essential competencies required for practice?
What are the most effective outcome statements that integrate
those competencies?
What are the most effective interactive learning strategies to

Patient safety and quality care are issues of major concern for nursing and all health care professions. Initiatives driven by these

concerns have been undertaken during the past decade by organizations and agencies at the local, state, and national levels. One comprehensive
framework used by many schools and agencies is Lenburgs Competency Outcomes and Performance Assessment Model (COPA). This article
explores the basic concepts and related principles that are fundamental in refocusing the curriculum to promote practice-based competence.The
framework emphasizes eight core practice competencies; competency-based outcomes; practice-driven learning; and competency performance
examinations. The article also highlights Kleins doctoral research, which compares the effects on teaching and learning in a sample of diverse
nursing programs, some of which use and some that do not use the model. Key findings are summarized with recommendations for further study.
The COPA Model also is briefly compared to an emerging competency initiative.

3 1 2 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s

COMPETENCY MODEL

promote achievement of the outcomes?

What are the most effective performance assessment methods to
validate achievement of outcomes and required practice competencies and subskills?

Ta b l e 1 . E i g h t C o r e P r a c t i c e C o m p e t e n c y C a t e g o r i e s a n d
Examples of Skills
1. Assessment and
Intervention Skills

Monitoring and data collection; physical assessment, therapeutic treatments

P i l l a r 1 : C o r e P r a c t i c e C o m p e t e n c i e s In the COPA Model, the

nursing knowledge and skills for any course can be clustered under
one or more of the eight universal core competencies listed in Table
1. Each competency must be learned and assessed individually, but
with increasing complexity of content and practice, several may be
integrated simultaneously into a single outcome. The framework
and competencies are applicable in varying degrees across all
didactic and clinical courses and within all levels of study and role
performance.
For each course, faculty identify specific, required subskills for
each competency category, consistent with the content, program
level, and patient settings. (See Table 1.) Some specific subskills
remain constant over all clinical courses, while others will vary.
Examples of constant subskills are:
Universal precautions (assessment and intervention skills)
Patient interactions (communication skills)
Critical decision making (critical thinking)
Professional role behavior (leadership skills)
Integration of evidence-based practice (knowledge integration).
By using the entire array of competencies, faculty ensure that all
are integrated to some extent in all courses. The omission of any
competency deprives the learner of experiences to develop essential skills and apply them in diverse settings and circumstances.
Because they focus on skills acquisition and the knowledge
required for actual practice, the competencies apply both to didactic and clinical courses.
The core competencies guide the development of outcome statements that structure and clarify course expectations, content and
essential skills, the integration of multiple interactive strategies,
and the development and implementation of performance examinations. They also function as an effective guide for evaluation and
ongoing quality improvement throughout the program.

2. Communication

a. Oral: interacting, listening, taking history,

reporting to other providers, discussion
b.Written: recording, writing reports, analyses,
memos, assigned papers
c. Computing: data entry, search for resources,
networking with other providers

3. Critical Thinking Skills

Using evidence for practice, integrating theory

into practice, problem solving, decision-making, scientific inquiry

4. Human Caring /
Relationship Skills

Cultural respect for others, patient advocacy,

patient-centered care, ethics, privacy,
confidentiality

5.Teaching Skills

Telling, showing, demonstrating health care

and promotion, instructing others, mentoring,
precepting

6. Management Skills

Planning, delegating, coordinating work of others, human and material resource utilization,
team work

7. Leadership Skills

Collaboration, coalition building, assertiveness,

informed risk-taking, creating alternatives,
professional accountability and continued
development

8. Knowledge
Integration Skills

Basing care on knowledge and standards, using

evidence-based resources for decision-making,
synthesis of information

Most objectives, as traditionally used in nursing courses, begin with verbs such as, discuss,
list, describe, recognize, and demonstrate, or combinations of two or
more verbs in a single objective. These verbs indicate directions for
suggested ways of learning and often have little in common with
actual practice. In contrast, outcomes are based on this question:
What do nurses actually do in practice related to content of the particular course? Do they merely describe, list, or explore some
aspect of nursing? Or do they integrate, implement, plan, or conduct aspects of actual practice?
In the COPA Model, traditionally worded objectives are converted to end-result outcome statements that are integral to practice and worded as practice expectations. They guide interactive
P i l l a r 2: C o m p e t e n c y O u t c o m e s

learning and assessment consistent with actual nursing practice.

Specific criteria are used to write all outcome statements, whether
for the program, courses, or learning assignments (Lenburg,
1999b). Table 2 (on following page) lists examples of some of the
most important criteria. A useful faculty exercise is to use the criteria to analyze course objectives and convert them to more practice-based competency outcomes.
P i l l a r 3 : I n t e r a c t i v e , P r a c t i c e - F o c u s e d L e a r n i n g Ways
of learning flow from and are integral to the competency outcomes.
Once the outcome statements are clearly worded and related to core
competencies, the necessary learning strategies become clearer.
They require the answer to the question: What are the most effective methods that help students achieve the outcomes and core
competencies? For example, if the outcome is Integrate critical

September / October 2009 Vo l . 3 0 N o . 5 3 1 3

COMPETENCY MODEL

Ta b l e 2 . S a m p l e C r i t e r i a f o r W r i t i n g C o m p e t e n c y
O u t c o m e S t a t e m e n t s a n d E x a m p l e s o f O b j e c t i v es
C o n v er t e d t o O u t c o m e s
Use a common stem to precede competency outcome statements that establish the verb tense for each statement; f
or example: At the conclusion of the course (or program)
the learner will be able to:
Begin each statement with the single, highest level verb that is
pertinent to the content and is objectively measurable.
Use the language of practice: What do nurses actually do?
Use language that is clear, concise, and relevant, and related
to the core competencies.
Put the most important action first, with conditions
or methods last.
EXAMPLES

(Outcomes are in italics)

At the conclusion of the (course, unit, etc.) the learner

will be able to:
Demonstrate knowledge of wellness concepts as a basis
for care provision.

Provide care to clients that incorporates concepts of wellness.

Discuss and critique the theoretical and practical implications of
various cultural backgrounds on illness.

Create plans of care to promote health and healing for patients

from diverse cultures.
Identify appropriate age-related health promotion, disease prevention, and health protection strategies in the delivery of primary care

thinking in plans of care, learning strategies might include:

Analyze case studies with specific requirements to integrate relevant data; and, Integrate evidence in making decisions about effective actions to take. If the outcome is: Teach patients methods to
promote health at home, learning strategies might include: Write a
teaching plan that lists clear directions in words the patient will
understand; role-play the scenario in the lab (or implement in the
clinical setting). If the outcome pertains to knowledge integration, a
learning strategy might be: Create nursing care plans (or concept
maps) for designated patients that are supported by evidence-based
practice or research.
The philosophy of performance-based, interactive learning is
focused on the learner and effective learning strategies, not on the
teacher and teaching methods. From this perspective, many emerging learning strategies are more effective than passive, teacherfocused lectures. Practice-based competencies and outcomes rarely
are achieved through lecture. Class time is more effectively used to
provide interactive feedback that helps students clarify and integrate concepts for application in practice. What students do not get
from reading and what they need most is clarification and confirmation that they understand a concept and can apply it in practice.
This shift to a learning-assessment paradigm places responsibility on faculty to: a) specify competency outcomes, b) determine
effective interactive, practice-based methods for learning, and c)
create and implement effective, structured performance examinations in all courses. Students are responsible for learning and
achieving the designated competencies. Faculty guide students in
learning by providing focused interactive instruction, coaching, and
direction to relevant learning resources. They create incentives to
stimulate student motivation to achieve competence and confidence. Effective learning results from effective interactions
between teacher and student, student and resources, and student
and student. These components are essential to achieve the outcomes and core competencies that prepare students for practice.

of children.

Implement primary care strategies for children that emphasize

age-related health promotion, disease prevention, and health
protection.
Appreciate personal moral development and its relationship to
professionalism and decision- making, including a brief introduction to
basic ethical concepts.

Integrate concepts of moral and ethical beliefs, professionalism,

and decision-making into a statement of personal and
professional role development.

3 1 4 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s

Pillar 4: Competency Performance Examinations and

A s s e s s m e n t s Standardized performance examinations to assess

competence are based on established psychometric concepts equivalent to those used for written examinations. The difference is that performance examinations are summative and criterion-referenced
rather than normative-referenced. They are predicated on several test
and measurement concepts, 10 of which are described as essential
(Lenburg, 1979, 1999b; Lenburg & Mitchell, 1991) and are listed in
Table 3. Together, these concepts comprise an interactive, basic constellation to guide development and implementation of standardized,
objective, and consistent performance assessment of competence in
any given situation. They prevent the bias, subjectivity, inconsistency, and inaccuracy that are often found in clinical evaluation
methods. Competence is established through predetermined specific
criteria that define how good is good enough for any particular course,
skill, or assignment (Lenburg, 1979, 1991, 1999b, 2004, in press).

COMPETENCY MODEL

Ta b l e 3 . Te n P s y c h o m e t r i c C o n c e p t s a s F o u n d a t i o n f o r
P e r f o r m a n c e E x a m i n a t i o n s v er s u s Tr a d i t i o n a l
Ev a l u a t i o n P r a c t i c e s
1. Examination (CPEs, CPAs)

vs.

Teaching-learning

2. Competencies, skills, abilities

vs.

Simple tasks

3. Critical elements

vs.

Steps in learning

4. Objectivity

vs.

Subjective opinions

5. Sampling

vs.

Total content

6. Acceptability

vs.

Idealism

7. Comparability

vs.

Inequality

8. Consistency

vs.

Variability

9. Flexibility

vs.

Rigidity

10. Systematized conditions

vs.

Spontaneous decisions

These criteria, which are called critical elements in the COPA

Model, are mandatory for each required skill. They are principles that
cannot be violated, rather than steps in a process or activity used during the learning period. Sequential steps are essential for learning the
skill, but different ways to accomplish certain activities (skills) are possible without violating the undergirding principles. Implementation of
these psychometric concepts and related processes is essential for more
valid and reliable performance examinations (evaluation).
After the learning period as determined by faculty, competency
performance examinations (CPEs) require the learner to meet the
established standards as defined by the critical elements and other
protocols. Critical elements are defined as single, discrete, observable behaviors that are mandatory for a given skill or ability. To meet
the standard for competence, therefore, all critical elements for each
skill must be met. Meeting a percentage of critical elements does not
equal competence as defined.
Because critical elements are mandatory, faculty need to scrutinize each element to determine whether it is an aspect of learning or
actually is essential for safe, effective practice (Lenburg, 1979,
1999b, 2004, in press). Policies determine methods of grading, number of performance examinations for each course, conditions for
repeating a failed CPE, and consequences of not meeting all criteria.
In the COPA Model, objective performance examinations are
implemented in all courses, didactic and clinical. CPEs pertain to
clinical courses with various aspects of patient care, whether actual
or simulated; therefore, they must meet required legal, ethical,
and professional standards of conduct. In didactic courses they
are named competency performance assessments (CPAs); the
competency outcomes and psychometric concepts, including critical elements, apply. The distinction is that CPAs do not involve
patients per se; they pertain to activities such as written assignments, presentations, plans, budgets, research analysis, and written tests. CPAs, like CPEs, ensure that evaluation is consistent,
objective, and accurate.

Implementation

and

Administrativ e

Considerations

Implementation of CPEs and CPAs requires policies and procedures related to role changes for teachers and learners. During
these examinations, teachers become examiners and learners
become examinees. This shift requires reorientation for all
involved; it also changes the dynamics of learning and teaching, despite potential threats imposed by change (Bargagliotti,
Luttrell, & Lenburg, 1999). The use of CPEs and CPAs with
clearly defined outcomes and criteria for competence stimulates learners to become more motivated to practice the designated skills and abilities throughout the course. CPEs and
CPAs are strong incentives for students to prepare more effectively for accountability at the end of the learning period; they
also encourage teachers to be more focused on strategies that
facilitate achievement of competence and confidence. These
changes enhance patient safety and quality care as students are
expected to implement all critical aspects of safe practice.
The COPA Model has been adopted by several nursing
schools and clinical agencies and their experiences illustrate
some of the faculty and student achievements and struggles
(Boyer, 2002, 2008; Klein, 2006b; Luttrell et al., 1999;
Redman et al., 1999). Sometimes the model is adapted to
accommodate particular issues, but it is essential that the four
pillars are kept intact as much as possible. The closer faculty
adhere to the COPA concepts and principles as designed, the
more likely their efforts will achieve the outcome of competent
students.
While some research efforts have been undertaken and some
are in process, more studies need to be conducted to support the
unique features of the COPA Model. Research that includes students, graduates, and employers would provide essential evidence
of effectiveness. In addition, comparisons with other existing competency approaches would provide useful directions for improvements in education and practice. Studies of similarities and differences in competency development might include the QSEN
initiatives.
Like COPA, the QSEN project (Cronenwett et al., 2007;
Sherwood & Drenkard, 2007) focuses on curricular change and
specific competencies for practice. The COPA Model requires
that end-result outcomes be established and that all eight core
competencies are included; specific nursing roles, skills, and
responsibilities are clustered under one or more of these competencies. Each competency category integrates relevant knowledge, attitudes and skills, depending on the course content.
QSEN designates six competencies and itemizes the specific knowledge, attitudes, and skills for each. The competencies
of each approach are comparable in some respects, although
differently worded and based on different frames of reference.
A core difference is that the QSEN does not yet include information on specific competency outcomes or performance
examinations.

September / October 2009 Vo l . 3 0 N o . 5 3 1 5

COMPETENCY MODEL

F i n d i n g s in S c h o o l s U s i n g t h e C O P A M o d e l One implication of the IOM report (1999; Greiner & Knebel, 2003) was that safe
nursing care is equated with competence, and that competencybased instruction must receive more emphasis. As health care
becomes increasingly complex, it is clear that safe patient care is
directly influenced by the quality of the education of practitioners in
health care disciplines (OLeary, 2005). From this perspective and a
review of the literature, it was determined that research to support
and guide curricular change is limited and that nursing studies
focused on instructional methods are needed.
Kleins initial work reported on the performance examination
aspect of the COPA Model (2006b); from this experience, she
designed her dissertation as an exploratory study to provide data
related to the influence of this curricular approach. An in-depth discussion of the study design, methodology, and findings are described
in the dissertation (Klein, 2006a) and in a subsequent article (Klein
& Fowles, 2009). A brief summary is offered here.
A comparative, cross-sectional survey method was selected to
study senior students near the point of graduation from different
nursing education programs (diploma, associate, and baccalaureate
degree). Students were also divided by the curricular approach used
by the nursing program, COPA versus non-COPA. The aim of the
study was to explore unique differences in programs and determine
if these differences could be attributed to a particular curricular
framework. Thirteen of 20 schools agreed to participate in the study;
five schools had the COPA Model in place. The schools were in similar geographic areas. The sample consisted of 391 generic, full-

time, senior nursing students, 101 faculty, and 10 administrators.

Schwirians (1978) Six-Dimension Scale of Nursing Performance
was selected to measure nursing student competence. This instrument is comprised of 52 randomly ordered items that address six
aspects of nursing practice: a) leadership, b) critical care, c) teaching/collaboration, d) planning/evaluation, e) interpersonal relationships/communication, and f) professional development. Researchergenerated questionnaires were used to obtain information from students, faculty, and administrators.
Scales were derived from the factor analysis: the Klein Scales and
the Klein Competency Construct Scales. The Klein Scales contain
three subscales that relate to the COPA Model (COPA Indicators,
Student-Focused Strategies, and Simulation/Skill Verification) and a
subscale for Traditional Methods of Instruction. Using a split database of COPA and non-COPA students, a linear regression analysis
was completed controlling for effects such as age, previous and current work experience, gender, ethnicity, and independent skills/laboratory practice time. The COPA curricular process was found to
positively influence the six dimensions of nurse performance in four
areas. Those scales that most directly influenced competence scores
were the COPA Model Indicators and the Student-Focused
Strategies.
Mean scores for both scales were significantly higher among the
COPA students and faculty, lending support to the uniqueness of the
COPA <odel and its contribution to student learning. Students and
faculty from both types of schools were congruent in their interpretation of the curricular processes used for instruction and evaluation of

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COMPETENCY MODEL

learning. Administrators from COPA schools reported slightly higher NCLEX-RN five-year average pass rates (93.4 percent vs. 91.5
percent at non-COPA schools).
This brief summary provides some insight into the use and influence of the COPA Model by schools of nursing. The types of clinical
experiences within nursing programs needs to be examined to determine their impact on student learning and competency development.
Other studies are needed to determine the effectiveness of different
competency models in education and practice environments. The
most relevant studies are those that focus on the evaluation of competence once graduates enter professional practice to determine if
preparation for the role is enhanced by specific models, such as
COPA or QSEN, or any other models in development. Collaborative
research including education and practice components will provide
the most productive evidence-based findings for the promotion of
practitioner competence that ensures patient safety and quality care.
S u m m a r y The COPA Model requires significant changes in traditional educational attitudes and methods in nursing programs to
promote competent, effective, professional practice and patient
safety. It is guided by a framework of concepts that establish competency outcomes, effective learning of core competencies, and
standardized methods to validate competency performance essential for actual practice. The model, or major components of it, has
been adopted effectively by many nursing programs and clinical
agencies. With guidance and persistence, faculty work through the
challenges of change and ultimately observe remarkable differNursing. Retrieved from www.nursingworld.org/
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and methods of the Competency Outcomes and
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ences in student performance.

The COPA model is an example of efforts to confront the need
for more competent nurses and ensure patient safety at a time when
both are in jeopardy. To paraphrase an observation by futurist Alvin
Toffler: The unprepared of the 21st century will not be those who
cannot read and write, but those who cannot learn, unlearn, and
relearn. Nurse leaders, educators, and students are caught in the
struggle of shifting from past practices to contemporary requirements, of unlearning and relearning, of shifting from a past-to-present dimension to an informed present-to-future practice. The challenge, as always, is how to bring about productive change. COPA is
an effective alternative to promote competent nursing practice,
both in educational and practice environments. NLN
NLN

A b o u t t h e A u t h o r s Carrie B. Lenburg, EdD, RN, FAAN,

ANEF, is president of CLAS, Inc., Roan Mountain, Tennessee.
Colleen Klein, PhD, RN, FNP-BC, is director, Professional Nursing
Practice, OSF Saint Anthony Medical Center, Rockford, Illinois.
Veronica Abdur-Rahman, PhD, RN, is Texas director, Pre-licensure
BSN Program, Western Governors University, Salt Lake City, Utah.
Tammy Spencer, MS, RN, is senior instructor, University of Colorado
at Denver College of Nursing. Susan Boyer, MEd, RN, is executive
director, Vermont Nurse Internship Project, Windsor. Contact Dr.
Lenburg at clenburg12@gmail.com.
K e y Wo r d s Practice Outcomes Competencies Performance
Examinations Patient Safety Clinical Evaluation

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College of DuPage Press.
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of outcomes:The design and use of real and simulation nursing performance examinations. Nursing and
Health Care, 12(1), 68-74.
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