Developing and Refining a Competency-Based Assessment Tool for Abortion Care Training in Certified Nurse-Midwifery Education

Aubrey Meunier, University of Illinois Chicago

DOI: 10.58117/wa7q-6236

Introduction

Competency-based education (CBE) has become a central organizing framework in advanced nursing education, emphasizing observable performance, progressive skill acquisition, and transparent evaluation of learner readiness outcomes (ten Cate & Scheele, 2007; ten Cate & Taylor, 2020). In procedural and high-stakes areas of practice, effective assessment is essential to supporting learner development and ensuring patient safety. Despite this emphasis, many nursing education programs continue to rely on informal or inconsistent methods for evaluating procedural competence, particularly in clinical areas where training opportunities are limited or socially stigmatized.

Abortion care training for Certified Nurse-Midwives (CNMs) represents one such area. Although CNMs are increasingly recognized as essential providers of comprehensive reproductive health care, including abortion services, educational pathways for abortion training vary widely. Inconsistent assessment practices may contribute to learner uncertainty, variability in faculty feedback, and inequities in evaluation across training environments. The absence of standardized, competency-based assessment tools further complicates efforts to ensure consistent educational quality and readiness for independent practice (American College of Nurse-Midwives [ACNM], 2023; Fleming et al., 2022). Prior work in midwifery education has emphasized the importance of structured approaches to achieving and assessing abortion care competency (Levi et al., 2012).

Access to abortion care in the United States is increasingly constrained. A 2022 study by Jones et al. found that 89% of U.S. counties did not have a facility providing abortion services, and 38% of individuals of reproductive age lived in these counties (Jones et al., 2022). Expanding the clinical workforce capable of providing abortion care is therefore a critical strategy for improving access, particularly in rural and underserved areas. CNMs, with appropriate training and privileging, are well-positioned to help address these gaps. Their role in abortion care is supported by national organizations and aligns with the profession’s emphasis on holistic, patient-centered reproductive health (ACOG, 2022; ACNM, 2023). However, the absence of standardized, evidence-based tools to assess CNM competency in abortion care remains a significant barrier to expanding training and ensuring quality.

Within CBE frameworks, assessment tools function not only as evaluative instruments but also as pedagogical supports that clarify expectations, structure feedback, and promote reflective learning (ten Cate & Taylor, 2020). Developing such tools requires alignment with clinical standards, educational theory, and the realities of live training environments. Early-stage methodological work focused on tool development and feasibility is therefore a critical step in advancing equitable and effective nursing education practices.

The purpose of this project was to develop, pilot, and iteratively refine a competency-based assessment tool designed to support abortion care training for CNMs. Rather than evaluating learner outcomes or tool effectiveness, this study focused on feasibility, clarity, and usability through initial pilot feedback to inform iterative refinement and broader dissemination.

Methods

Design

This project employed a methodological quality-improvement design guided by the Plan–Do–Study–Act (PDSA) framework, a widely used model for iterative improvement in educational and clinical settings (Institute for Healthcare Improvement [IHI], 2017). The focus was on developing and refining an assessment method through stakeholder feedback rather than testing hypotheses or evaluating clinical outcomes.

Setting and Context

The project was conducted within a university-affiliated abortion care training program supported by the RADIANT Fellowship (Reproductive Autonomy and Abortion Integration for Nurse-Midwifery Training), a federally-funded initiative designed to expand abortion care training within midwifery education. The training program provides structured educational and supervised clinical experiences in abortion care for licensed providers, including CNMs. The training curriculum was established prior to this project; the present work focused exclusively on the assessment component of training.

Participants

Participants included five faculty evaluators responsible for supervising abortion care training and ten CNMs engaged in first-trimester abortion care education. All participants acted within their professional or educational roles. Participation was voluntary.

Assessment Tool Development

During the Plan phase, faculty input was solicited to identify essential competency domains and practical requirements for real-time assessment. Domains were intentionally organized to reflect distinct but interrelated dimensions of clinical competence, including technical procedural skill, clinical judgment, communication, and professionalism. This structure was selected to support targeted feedback and to reduce the tendency toward global or impression-based evaluations that can obscure specific areas for learner growth.

The assessment tool was developed by synthesizing stakeholder input with established educational frameworks, including principles of competency-based education and national nursing and midwifery education standards (American Association of Colleges of Nursing [AACN], 2021; Akintade et al., 2023; American College of Nurse-Midwives [ACNM], 2023). Observable behavioral descriptors were prioritized over abstract rating scales to promote clarity, inter-rater consistency, and shared understanding of performance expectations. This design choice reflects recommendations within competency-based education literature emphasizing the importance of explicit, observable criteria in procedural skills assessment (ten Cate & Scheele, 2007; ten Cate & Taylor, 2020).

Tool feasibility was a central design consideration. The assessment tool was intentionally designed to be concise, intuitive, and usable in real-time without disrupting clinical flow. The tool also aligned with established abortion training curricula that emphasize progressive skill acquisition and formative feedback (Fleming et al., 2022).

Pilot Implementation

Version 1 of the assessment tool was piloted during simulated and/or supervised abortion care training encounters involving five faculty evaluators and ten Certified Nurse-Midwife trainees. Faculty evaluators used the tool in real-time across multiple training sessions to guide observation and to structure formative feedback during training encounters. Pilot implementation across multiple faculty evaluators supported assessment of the tool’s feasibility, clarity, and usability within real-world instructional contexts.

Data Analysis

Feedback collected during the pilot phase was analyzed using a rapid qualitative review approach appropriate for quality-improvement and methodological studies. Informal faculty and trainee comments from post-training debriefings and written notes were reviewed inductively to identify recurrent patterns related to feasibility, clarity, and usability. Given the project’s quality-improvement focus, formal qualitative coding was neither necessary nor appropriate for the study aims.

Results

Initial Pilot Feedback

Initial pilot feedback indicated that the assessment tool was feasible for real-time use during training encounters. Faculty evaluators reported that the structured format supported clearer documentation of learner performance and facilitated more consistent formative feedback.

Trainees described the tool as helpful in clarifying performance expectations and supporting reflective learning. Explicit competency descriptors were perceived as contributing to a shared understanding of performance standards between evaluators and learners.

Clarity and Content Organization

Pilot feedback identified opportunities for refinement. Participants noted overlap across competency domains and recommended clearer differentiation between technical procedural skills, clinical judgment, and communication competencies. Simplification of language and reorganization of domains were suggested to reduce cognitive load during live assessment. For example, faculty evaluators reported that tasks such as cervical preparation and aspiration technique were sometimes evaluated alongside decision-making behaviors, such as recognizing inadequate dilation or determining when additional analgesia was indicated. Separating these elements into distinct domains allowed technical execution and clinical reasoning to be assessed independently.

Participants also noted that communication behaviors were embedded within multiple domains, making it difficult to consistently assess learner performance in patient-centered counseling and intra-procedural communication. For instance, supportive language used during cervical dilation was variably documented under professionalism, communication, or technical skill domains. Reorganizing communication competencies into a standalone domain clarified expectations and reduced cognitive load during real-time assessment.

Tool Refinement and Version 2 Development

Findings from the pilot directly informed revision of the assessment tool. Version 2 incorporated streamlined language, reorganized domains, and clearer behavioral descriptors to improve usability and reduce overlap between competency areas. Key revisions included more explicit differentiation between technical skill, clinical judgment, and patient-centered communication domains. The revised Abortion Care Competency (ACC) Tool is organized into three clinical tracks: medication abortion (MAB), procedural abortion (PAB), and emergency management, each with domain-based competencies tailored to the clinical context. Core competencies include counseling on medication abortion regimens, follow-up planning (e.g., ultrasound, telehealth, or urine pregnancy testing [UPT]), and completion of Risk Evaluation and Mitigation Strategies (REMS) documentation, as required for mifepristone prescribing. Additional competencies include preventive and sexual health care, such as sexually transmitted infection (STI) testing and counseling, as well as assessment of psychosocial and logistical factors that may impact care. The overall structure and domain organization of the revised Abortion Care Competency (ACC) Tool are summarized in Table 1.

Table 1. Structure of the Abortion Care Competency (ACC) Assessment Tool

In addition to the domain-specific competencies outlined above, Version 2 emphasizes core domains of performance that are assessed across clinical contexts. These include clinical knowledge and technical skill, patient communication, and the ability to identify and address logistical and social barriers using a trauma-informed approach. These domains reflect key components of competency-based clinical performance and support more consistent and meaningful evaluation across learners and settings. Domain-level performance criteria and rating structure are summarized in Table 2.

Table 2. Global Performance Domains and Rating Structure

The updated tool also incorporates a simplified 3-point ordinal rating scale (0–2) for both item-level and domain-level assessment. This scale was selected to enhance clarity, reduce evaluator burden, and improve consistency in scoring, particularly in fast-paced clinical and simulation environments. In addition to domain-level ratings, a separate overall performance classification (Developing, Competent, Accomplished) is assigned to capture clinical integration and progression toward independent practice. Scoring criteria and performance anchors are presented in Table 3.

Table 3: ACC Tool Rating Scale and Overall Performance Classification

The revised tool is currently in use within the training program, with additional evaluation planned.

Discussion

This project describes the development and early refinement of a competency-based assessment tool for abortion care training in Certified Nurse-Midwifery education. Initial pilot feedback supported feasibility and usability including its suitability for real-time use during training encounters and its ability to clarify performance expectations for both faculty and learners. Faculty evaluators reported that the structured format facilitated more consistent documentation of learner performance and supported focused, formative feedback. Trainees described the tool as helpful in understanding competency expectations and in guiding self-reflection following training encounters.

Actionable areas for improvement were also identified through pilot feedback. These included overlap across competency domains, ambiguity in differentiating technical procedural skills from clinical judgment, and inconsistent placement of communication behaviors across multiple domains. Revisions addressed these issues by streamlining domain structure, clarifying behavioral descriptors, and reorganizing competencies to better align with observable performance during live assessment. The iterative revision process highlights the importance of stakeholder engagement in educational assessment design, particularly in procedural training contexts where clarity and usability are essential.

Although developed within a single training program, the assessment framework and methodological approach are transferable to other nursing education contexts involving procedural skill development. For example, this approach may be applicable to assessment of procedures such as intrauterine device insertion, cervical ripening techniques, manual vacuum aspiration for miscarriage management, or obstetric emergency skills, where clear differentiation between technical execution, clinical decision-making, and communication is critical. Prior work in competency-based education underscores the value of clearly defined performance expectations and structured assessment tools in promoting consistency and learner development across training environments (Ten Cate & Scheele, 2007).

The demonstrated feasibility and usability of the assessment tool developed and refined during this project suggest that early-stage, stakeholder-informed methodological work can meaningfully support the implementation of competency-based assessment practices in nursing education, even in complex and high-stakes clinical training environments.

Implications for Nursing Education

Competency-based assessment tools play a critical role in promoting transparency, consistency, and equity in nursing education. In procedural training environments, particularly those involving sensitive or stigmatized care, clear assessment expectations can support psychological safety by reducing ambiguity and aligning faculty and learner understandings of competence (Levi et al., 2012). Structured assessment tools may also mitigate variability in feedback quality across evaluators, supporting more equitable training experiences and more consistent learner development across training contexts (Ten Cate & Scheele, 2007).

Abortion care training represents a particularly salient context for competency-based assessment, given variability in institutional support, clinical exposure, and faculty comfort. The assessment approach described in this project offers a practical framework for operationalizing competency-based principles in real-world training settings. By emphasizing observable behaviors and formative feedback, the tool supports learner development while maintaining flexibility for diverse educational contexts.

Limitations

This project was limited by a small sample size and reliance on informal qualitative feedback. These limitations reflect the project’s methodological and quality-improvement focus rather than deficiencies in study design.

Future Directions

Future evaluation will assess the revised Version 2 assessment tool using larger samples and additional metrics, including inter-rater agreement, usability across clinical settings, and longitudinal assessment of learner progression. Planned data collection beginning in January will inform further refinement and support evaluation of the tool’s role in standardizing assessment practices across training sites. Subsequent iterations may also explore adaptation of the framework for additional reproductive health procedures.

Ethical Review

This project was reviewed by the University of Illinois Chicago Institutional Review Board and determined to constitute quality improvement and educational program evaluation; therefore, institutional review board approval was not required.

Funding

This project received no external funding.

Conflict of Interest

The author declares no conflicts of interest.

Generative AI Disclosure

AI-assisted tools (ChatGPT, OpenAI) were used for language editing and structural refinement. All final content decisions, interpretations, and conclusions are the responsibility of the author.

AUTHOR ORCID: 0009-0008-1800-0144

References