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Documenting Gap Analysis:

A Thorough Assessment of the Education Need

Amy L. Charette, MS, RN

WMSD Nurse Peer Review Leader

education@westernmsd.org

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Gap Analysis

Why must we do this?

Why do we do this?

Why should we do this?

How do we do this?

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Part of the “Education Design Process”

outlines the process of developing and/or evaluating

individual educational activities according to ANCC

Accreditation Program criteria,

which ensure that individual educational activities are

effectively planned, implemented, and evaluated

according to educational standards and adult learning

principles.

Chapter 3 -- ANCC 2015 Accreditation Program Manual

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Starts with identifying a “problem”

Feedback on previous individual activity evaluations.

Learner requests, leadership requests.

Clinical data trends – patient outcomes

Quality/Risk Management data

Discussions with health care professionals including interdisciplinary feedback (as appropriate or available).

Colleagues and content experts.

Conducting assessment surveys, assessing changing trends in healthcare policy and the healthcare workplace.

References to standards, consensus statements, and published guidelines.

U. S. government statistics and websites (such as the Centers for Disease Control and Prevention).

Trends in literature: Review of various journals and websites providing information on clinical data, trends in quality management, health care literature, law, social issues, healthcare delivery and health care policy

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When “gap” is not yet a problem

At this step in the process, the Nurse Planner is determining what are the problems creating practice gaps.

There are times when the problem/learner need is for reinforcing knowledge, skills, or practices that are already satisfactory. There is not a “gap” in the form of a deficit, instead the need is to prevent a gap from occurring.

Or there may be opportunities for improvement – there is not a current problem in practice, but new data is available to support a modification of current practice to improve performance or patient outcomes.

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Selected the problem

What is:

35-50%

screenedWhat should

be: annual

dilated exams

Traditional

continuing

education

“Measure twice, cut once”

Problem in practice or opportunity for improvement

(professional practice gap)

How do you know it is a problem?

What data do you have to validate the problem?

What is the reason that the problem exists?

Is the problem a “professional practice gap”?

Gap Analysis

The Nurse Planner starts by analyzing data that validate the need for the educational activity.

This analysis forms the basis of a professional practice gap, or the difference between the current state of practice and the desired state of practice.

It is important to note that a professional practice gap may exist for registered nurses or health care teams, regardless of the practice setting.

Professional practice gaps are not limited to clinical practice and may also exist in areas of professional work such as administration, education, and research.

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Gap Analysis

• Every gap analysis starts with

introspection.

• ‘Current State’ you list out all the

attributes you’d like to see improved.

• Your focus can be wide (ex: the whole

facility) or narrow (ex: a dept. or shift)

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Gap Analysis

• The analysis can be quantitative (‘30 falls

per year; 2% nosocomial infections; 10%

faculty turnover)

• Can be Qualitative or both.

• The key thing is to be specific and factual

with an emphasis on identifying

weaknesses – “gaps”.

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Professional Practice Gap

Gap is the difference between the

current state of “what is” and the

desirable or achievable state “what

should be or desired”

Gap Analysis

Assessing Education Merit

The merit assessment has two parts:

1) does educational intervention have potential to

address the gap

2) does your organization agree the problem in practice

or opportunity for improvement is a priority for the

education resources to advance professional

development outcomes?

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Gap analysis worksheet

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Determining the underlying reason

➢Gap due to knowledge – doesn’t know

➢Gap due to skills – doesn’t know how

➢Gap due to practices – not able to show or

do in practice

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Miller’s Model of Clinical Competence

Knows: learner has knowledge about the topic/subject

Knows how: learner is capable of applying the knowledge

Shows how/does: learner is able to apply knowledge and skills in a

simulated setting (shows how) or the practice environment (does)

Miller’s

Model of

Clinical

Competence

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Assess knowledge (knows):

Simple knowledge tests (multiple choice or similar)

Assess skill (knows how):

Case studies/extended matching multiple choice

Case presentations

Essay questions

Assess practice (shows/does):

Simulation (Objective Structured Clinical Examination)

Observation in the practice setting

* ACCME uses the analogous terms knowledge, competence and performance

Educational Design Process

25Type of Gap Learning Techniques Evaluation Methods

Knowledge

(knows)

▪ Didactic

▪ Discussion

▪ Pre/post test

▪ Case studies

▪ Games

▪ Discussion/debriefing at the end

of the program

▪ Pre/post test

▪ Case study with group

discussion

Skills

(knows how)

▪ Case studies with group

discussion

▪ Demonstration/return

demonstration

▪ Simulation

▪ Case studies with group

discussion

▪ Return demonstration

▪ Simulation

Practice

(shows/does)

▪ Review of current practice

▪ Return demonstration

▪ Simulation

▪ Supervised practice

▪ Follow-up survey

▪ Interviews

▪ Return

demonstration/simulation

▪ Observation of practice

▪ Record audits

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Let’s practiceCurrent

state

Desired

state

Identified

gap

Evidence to

validate gap

Gap due to

knowledge, skill

and/or practice

Learning

outcome

Method of

evaluation

New

monitors

have been

purchased

for the ICU

Nurses

know how

to set up

and use

the

monitors

accurately

and safely

Nurses

currently

do not

know how

to use the

new

monitors

The majority

of nurses in

the ICU have

no experience

with the new

monitors; new

technology

Knowledge – have

not had exposure to

new monitor; do

not know basic

features of monitor

system

Skill – don’t know

how to use the new

monitor

Practice – have not

used the new

monitor in patient

care

Nurses will

successfully

demonstrate

knowledge

related to use

of new

monitoring

system

Nurses will pass

post-test with

score of 90% or

greater with

content focused

on safe use of

new monitoring

system.

28Learning Outcome

Describe Current State

Describe Desired State

Describe Identified State

Education Plan to Address Gap

Example: The Emergency Nurse will successfully pass a certification exam in emergency nursing.

Only 10% of our emergency department staff nurses are certified in emergency nursing.

Nurses will be able to successfully pass the CEN exam after completing an exam preparation course and engaging in appropriate study based on their individual learning needs.

Nurses lack the knowledge and skills to pursue emergency nurse certification.

Provide an emergency nursing certification review course, including an individualized self-assessment to help the nurse identify areas for additional study.

Example: The Nurse will be able to implement non-pharmacologic pain management strategies for patients experiencing arthritis pain.

The nurses on our unit have identified that they are not comfortable with recommending non-pharmacologic pain management strategies for patients with arthritis.

Nurses will be able to suggest at least two non-pharmacologic pain management techniques for patients with arthritis.

RNs may not be knowledgeable of, or feel empowered to suggest or provide alternative methods for pain management.

Review of basic principles of pain management, along with a skills lab for hands-on practice of pain management techniques. Including cold, heat, relaxation, and deep breathing.

Example: The Nurse will be able to describe the state nurse practice act as it relates to their current practice.

A recent discussion at our shared governance committee revealed that nurses were unfamiliar with the Nurse Practice Act in our state and could not identify rules and regulations pertinent to registered nurse practice.

Nurses will be able to access and explain the nurse practice act and relevant rules and regulations.

RNs are aware of the existence of the Nurse Practice Act, but my not be completely familiar with specific rules and regulations.

Nurses will participate in a facilitated review of the Nurse Practice Act led by a member of the nursing leadership, and will engage in roundtable discussions about specific rules and regulations related to nursing practice in our state.

Let’s practiceCurrent

state

Desired

state

Identified

gap

Evidence to

validate gap

Gap due to

knowledge, skill

and/or practice

Learning

outcome

Method of

evaluation

Pediatric

patients in

respiratory

distress are

placed on a

non-

rebreather

facemask

within 5

minutes of

presentation

to the

Emergency

Department

100% of the

time but

frequently the

facemask is

not applied

correctly

Pediatric

patients in

respiratory

distress are

placed on a

non-

rebreather

facemask

applied

correctly

within 5

minutes of

presentation

to the

Emergency

Department

100% of the

time

Frequent

inappropriate

non-

rebreather

facemask

application for

pediatric

patients in

respiratory

distress

Direct observation

by Clinical Nurse

Specialist;

comments from

respiratory

therapist in ED;

comments from

ED medical staff

Lack of skill in correctly

applying facemask to

pediatric patients in

respiratory distress

Registered nurses

in the Emergency

Department will

apply a non-

rebreather

facemask

correctly to all

pediatric patients

in respiratory

distress

Successful return

demonstration of

application of a non-

rebreather facemask

for pediatric patients

in respiratory distress

Let’s practiceCurrent

state

Desired

state

Identified

gap

Evidence to

validate gap

Gap due to

knowledge, skill

and/or practice

Learning

outcome

Method of

evaluation

40% of

patients 65

and older in

our

community

health clinic

are receiving

the

pneumococc

al vaccine

consistent

with national

guideline

100% of

patients 65

and older in

our

community

health clinic

receive the

pneumococc

al vaccine

consistent

with national

guideline

60% of

patients 65

and older in

our

community

health clinic

are not

receiving the

pneumococc

al vaccine

consistent

with national

guideline

Chart audit of

patient files;

interviews with

nurses; 75% of

nurses report

they are not

familiar with

updated national

guideline and

therefore were

not providing

information

about the vaccine

Knowledge – unaware

of updated guidelines

Registered

nurses will

demonstrate

they know the

updated vaccine

recommendatio

ns for all

patients 65 and

older

Complete post-test

with passing rate of

80% or greater

WMSD Resources

• WMSD Website

• http://www.westernmsd.org/MainMenu/CE

• WMSD Resources – Individual Activity Applications or

Approved Providers• Gap Analysis Worksheet and Examples

• WMSD Website FAQs

• http://westernmsd.org/MainMenu/CE/Frequently-

Asked-CNE-Questions

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