Competency domains of educators in medical, nursing, and health sciences education: An integrative review

Abstract Purpose Competencies for educators of healthcare professionals are important for demonstrating accountability, defining roles and responsibilities, structuring activities for training and development, defining standards, quality assurance, performance reviews, career development, and promoting the professionalisation of teaching. The frameworks and domains of educator competencies have not previously been reviewed or systematically described. Through this integrative review, the authors sought to identify an inclusive structure for competency domains that may be applied to educators. Methods Keywords were identified in a pilot search, followed by a multi-database search strategy of records published from 2000 to January 2020 with subsequent backward and forward reference searches. We included all record types that listed or described educator competency domains in medical, nursing and health sciences education. We excluded records that described ‘ideal traits’ or ‘characteristics of good teachers/educators,’ presented competencies as part of a larger curricular framework, and teaching assessment tool content. Results The multi-database search retrieved 2942 initial citations. From a full-text review of 301 records, 67 were identified as describing educator competency domains eligible for analysis. Documents contained a median of six domains (interquartile range = 5–7) and 14.9% incorporated at least one overarching element across their domains. Following an inductive thematic analysis, six distinct domains of educator competence were identified: Teaching and facilitating learning; Designing and planning learning; Assessment of learning; Educational research and scholarship; Educational leadership and management; Educational environment, quality, and safety. The two latter domains contained sub-themes that were able to be further categorised. Documents and frameworks were described for a wide variety of health and allied health disciplines. Conclusion Distinct educator competency domains were identified in this analysis, applicable across a range of healthcare disciplines. Along with the description of design elements, these provide a guide for the development and evaluation of educator competency frameworks.


Introduction
Acceptable healthcare delivery requires educators in medicine, nursing, and the health sciences to train healthcare practitioners at all stages of their professional development. Societal expectations are for clinical practitioners to be trained to a specified level of competence, as reflected in standards set by accreditation and registration bodies. Less often emphasized are competency standards for educators, which serve to specify the level of skills, knowledge, attitudes, and behaviours required to function in that role. A 'competency' is the synthesis of several component parts (knowledge, skills, attitudes, and behaviours) used in combination, that is context-dependent and influenced by a common set of values (Child and Shaw 2020). Explicit educator competencies are important for demonstrating accountability, defining roles and responsibilities, selfassessment, and continuing professional development guidance (Steinert 2009). Competency frameworks may be used to structure both formal (e.g. courses or workshops) and informal (e.g. peer-coaching or mentoring) activities for educator training and development, define standards, facilitate quality assurance of educational programmes, evaluate educators, review performance, shape career development or promotion, and promote the professionalisation of teaching (Steinert 2009). Recognising this, some have proposed domains of competency for educators Srinivasan et al. 2011;Tucker 2017) and institutions of varying roles and backgrounds have produced detailed competency frameworks for affiliated educators (WHO 2013; Academy of Medical Educators 2014; Royal Australasian College of Physicians 2018). Some frameworks are generic in nature whilst others are designed for specific educator roles.
We believe a gap exists in our understanding of educator competency domains and frameworks. For example: How many competency frameworks are in use? Do they share similar design elements? What are the related clinical disciplines, if any? Are they generic or catered to specific learner levels? Whilst published frameworks list different domains of competence for educators in medicine, nursing, and health sciences, do common underlying themes exist across disciplines? To our knowledge, there has not been a comprehensive review of educator competency domains or their frameworks.
The objectives of this review were to: 1. Conduct a systematic search to identify and describe educator competency domains in medical, nursing, and health sciences education 2. Generate an inclusive structure for educator competency domains through a thematic analysis of competency domains in medical, nursing, and health sciences education

Methods
We adopted a constructivist research paradigm in carrying out this review. The constructivist paradigm contains aspects of both postpositivist and interpretive paradigmsan ontological critical realism weaved within epistemological subjectivism (Levers 2013). In this paradigm, our observations are shaped by what we are observing as well as societal influences, with new knowledge constructed rather than discovered (Levers 2013). This means that our interpretation of the data is influenced by our own understanding of competency domains and the societal context in which we operate, and we are unable to claim to be discovering 'truth' in describing an inclusive structure for competency domains. We selected an integrative methodology due to the heterogenous nature of published frameworks in the literature and the scope to perform a thematic analysis to generate a new theory, based on published guides (Whittemore and Knafl 2005;da Silva et al. 2020). Our review was comprised of five phases: (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis, and (5) presentation/results.

Problem identification
Multiple competency frameworks for educators have been produced or published in recent years. However, they vary widely in design, context, and domain labels and numbers. In addition, educator competency domains have been proposed without being nested in a specific framework. A thematic analysis of educator competency domains and a review of the formal design in which they were often presented (i.e. competency frameworks) was proposed as an effective method to identify convergence and determine an inclusive structure for competency domains. A set of definitions were formulated and applied to clarify the research question and aid the study design (Table 1).

Literature search
We included documents from a variety of sourcesbooks, theses, grey literature, position papers, institutional documents, and peer-reviewed publications including review papers and commentaries. We identified relevant records using a three-stage search strategy to balance feasibility with breadth and comprehensiveness. An initial limited search of Ovid Medline V R was performed on 2 June 2019 followed by a title and abstract screening to identify

Practice points
This integrative review of educator competencies identified six distinct domains of competence: Teaching and facilitating learning; Designing and planning to learn; Assessment of learning; Educational research and scholarship; Educational leadership and management; Educational environment, quality, and safety. These domains of educator competence were consistent across and applicable to a range of healthcare disciplines. This review provides an evidence base for the development and evaluation of educator competency frameworks in medical, nursing, and health sciences education. A single inclusive framework may be designed for any educator role by incorporating a developmental continuum, mapping roles to appropriate levels of expertise in each domain, and assigning progression indicators. Competency frameworks with a binary design contain progression indicators at a single level of expertise, implying a binary distinction -'competent' or 'not yet competent' (Child and Shaw 2020). Frameworks designed in a continuum contain progression indicators at multiple levels of expertise for a domain or sub-domain, implying a continuum or progression of learning keywords and terms used to refer to or associated with the review topic. The search terms were tested on different databases and refined with multiple test searches. The second stage, a search of multiple databases, was performed on 15 January 2020 with the keywords: 'educator' AND 'competencies.' Identical search terms were applied in the Google Scholar, CINAHL Plus, ERIC, and Scopus databases. In addition, we performed a Google search to identify institutional documents as these were less likely to be stored in a literature database. The terms 'medical' and 'healthcare' were added to Google and Google Scholar search queries to filter out non-medical and non-healthcare documents. For the final stage, we concurrently performed an initial abstract review, a bibliographic review (backward referencing), and a Google Scholar search of citing articles for all articles included after full-text review (forward referencing) using the 'cited by' feature. Forward referencing took place over an extended period, from 3 November 2020 to 23 February 2021. With Google and Google Scholar searches, except for the review of citing articles, an a priori decision was made to halt screening once no relevant citations were found in the previous two pages (20 citations), after the first 100 citations rated by relevance were screened. The search strategy is described further in Figure 1.
We included records that listed or described educator competency domains in medical, nursing and health sciences education. We included documents published from the year 2000 onwards as the competency-based movement began in the early 1990s, focusing on learners, with the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) agreeing on competencies for the certification of doctors in 1999 (Albanese et al. 2008). Whilst descriptions of ideal traits or characteristics of educators may have been published prior to 2000, these were unlikely to have been framed as competencies. Furthermore, an editorial on educator competencies did not reference papers prior to 2000 when discussing previous research (Steinert 2009). Our limited initial literature search also identified an adequate data sample within our selected timeframe for an integrative review. We included all record types, including institutional documents that were not peer-reviewed. Documents that listed or described competency domains were included, regardless of whether they were presented as a framework or if they contained individual progression indicators. We excluded records that described 'ideal traits' or 'characteristics of good teachers/educators,' unless these met the definition of competencies (Table 1). We excluded documents where competencies were presented as a component of a larger curricular framework (e.g. teaching competencies required of residents in specialty training) as these were not focused on educators as a primary role and unlikely to be captured by our search strategy. We included records where competencies were referenced in programme or course curricula but excluded curricular descriptions of medical or health science education courses. We excluded teaching assessment tool content unless they were based on a competency framework. We excluded records not in the English language for practical reasons.

Data evaluation
Pilot screening to test the search strategy was performed by NS, NC, KA, MH, MW, and JT. Initial screening comprised of citation title and abstract, performed independently by NS, CJ, and KG. Relevant citations, along with those identified from bibliographic review and targeted searches, underwent subsequent full-text review. NS performed the initial full-text review followed by the further independent review of all documents by KA and NC. Disagreements were resolved by consensus discussion. Trial reviews were performed at the first stage of the search strategy to establish consistency among authors.

Data analysis
Data were collected and coded using a Microsoft Excel spreadsheet. We performed a quantitative (frequency) analysis on various descriptive aspects of included documents and frameworks. We then undertook an inductive thematic analysis of domains found in each document or framework to identify educator competency domains. In an inductive thematic analysis, data is coded without trying to fit into a pre-existing coding frame or our analytic preconceptions, whilst acknowledging the epistemological framework in which the research is being undertaken (Braun and Clarke 2006). Conforming to the constructivist paradigm, we sought to theorise the socio-cultural contexts (competency domains) that best describe the content of the included documents. We expected to find many different terms for competency domains with overlapping meanings and coded these according to how they were described in each document where that information was available. In keeping with subjectivist epistemological elements, themes and sub-themes evolved as we performed the analysis and grew our understanding of the findings. Although competency domain prevalence was measured, it was not considered crucial to the thematic analysis. NS undertook the initial analysis followed by KA and NC performing independent reviews.

Search results
The search of multiple databases produced 2942 individual records after the removal of duplicates (Figure 1). Initial screening of titles and abstracts yielded 125 records for full-text review. Backward referencing and records identified based on our collective knowledge yielded a further 96 records. Forward referencing was able to be performed Medicalspecific role Harris et al. 2007;Ross and Stenfors-Hayes 2008;Heflin et al. 2009  in 55 records, with a median of 20 citations per record (inter-quartile range ¼ 3.5-49), resulting in 80 records identified for full-text review (see Supplementary Material). A total of 301 records were reviewed in detail per eligibility criteria, with 67 identified as describing educator competency domains eligible for analysis. Specific reasons for exclusion are listed in Figure 1, including 11 records that listed educator competencies without related domains. There was a 94.4% initial agreement level for the full-text review, with disagreements resolved through consensus discussion.

Educator competency domains
Included documents each listed or described a median of six domains (inter-quartile range ¼ 5-7, range ¼ 2-13). Eighteen documents (26.9%) included further levels of aggregation or sub-domains. Ten documents (14.9%) described overarching elements across their domains, with a median of 1.5 elements (inter-quartile range ¼ 1-4). The most common overarching elements related to professionalism and role-modelling (seven documents) and clinical skills/patient care (five documents). Almost half the documents described competency domains in a medical context with nursing accounting for approximately a quarter of all documents. Some professional groups, such as veterinarians (Academy of Medical Educators 2014) and allied health as a whole  were represented in multidisciplinary frameworks. Further description of the professional context and other aspects of included documents are included in Tables 2 and 3.

Design of competency frameworks
Fifty documents (74.6%) contained both competency domains and progression indicators, meeting our definition of educator competency frameworks. Competency frameworks also contained a median of six domains (inter-quartile range ¼ 5-7, range ¼ 2-13). Sixteen frameworks (32.0%) included sub-domains. In 36 frameworks (72.0%), the progression indicators for competency domains were written as statements of activity. Fifteen frameworks (30.0%) were designed in a continuum for different levels of expertise, with a median of three levels (range ¼ 2-4). Overarching elements were present in seven frameworks (14.0%).

Thematic analysis of competency domains
The initial coding of educator competency domains within these documents identified 12 broad categories. A review of the relationships between these initial categories, looking for coherent patterns and convergence, resulted in consolidation into an inclusive structure for domains of educator competence, comprising six themes. 'Teaching and facilitating learning' describes the promotion of learning using appropriate methods and resources, including assessment for learning. 'Designing and planning learning' is the pathway of creating a structure to teaching, from basic lesson plans to entire programme curricula, from needs assessment to delivery, assessment, and evaluation. 'Assessment of learning' is the knowledge and practice of conferring judgement on competence using appropriate tools and resources, and delivering feedback based on that judgement. 'Educational research and scholarship' is the systematic inquiry into educational theory and learning, to advance the science and practice of clinical education. 'Educational leadership and management' describes the governance of and support for individuals and teams of educators, including collaboration, professionalism, recruitment, role-modelling, coaching, and mentoring. 'Educational environment, quality, and safety' describes the provision of effective and safe learning environments, incorporating learner-centred approaches and patient safety, to achieve cultural change in education and improved clinical outcomes. The consolidated items were retained as specific sub-themes, as illustrated in Figure 2.  Table 4 shows the frequency of source documents mapping to themes and sub-themes, and examples of competency domains from the source literature. A small number of domains mapped to more than one theme. Included documents used a variety of terms to convey a similar intent when labeling educator domains of competence (Table 4), with the complete list of terms visible in the Supplementary Material.

Discussion
We set out to conduct an integrative review of educator competency domains in medical, nursing, and health sciences education, analysing 67 documents with a median of six competency domains each. Approximately one-quarter contained further levels of aggregation (sub-domains). Fifty documents met our definition of being a competency framework, with almost one-third designed for use in a continuum of expertise. Inductive thematic analysis of included documents identified an inclusive structure comprised of six distinct domains of educator competence (Figure 2). This review has a number of implications for practice. Institutions may use our findings when formulating competency frameworks for medical, nursing, and health sciences educators, or evaluating existing frameworks for completeness. The utility of incorporating design aspects such as sub-domains, overarching elements, or a continuum of expertise can be evaluated based on the examples found in the literature. This review identified an inclusive structure that provides information on both the scope of educator competency domains as well as a formal outline for presentation. All educator competency domains identified in the literature review are encompassed in the six domains (and sub-domains) generated by the thematic analysis.
The responsibility for developing competencies in educators is laid onto educational institutions via accreditation requirements (Australian Medical Council 2012;General Medical Council 2015). Institutions are required to be accountable to regulators, the public, and learners in ensuring that educators are competent in their roles. Tacit recognition of educators as learners themselves is essential to developing educator competencies. In some cases, expert and accomplished clinicians may function as novice educators. Appropriately designed competency frameworks allow for a clearer articulation of expected competencies of educators in various roles, essential for educator training, as well as goals for continuing educator professional development. Such frameworks assist institutions in ensuring they meet appropriate accreditation and registration standards, and may help with job sizing, role clarity, appointment criteria, and promotion.
We chose to review a wide range of healthcare disciplines at all levels of training. Despite documents and frameworks often referring to different professional groups or for a specific context, educator competency domains were able to be mapped to an inclusive structure. This shows that educator competencies in medicine, nursing and health sciences are universal and applicable across all disciplines, even if different roles place particular emphasis on specific domains. We believe this supports the concept of educator competence being independent of clinical competence, requiring its own specific training and faculty development activities to achieve and maintain appropriate standards.
Only two domains are expanded as these were based on the 12 broad items identified in the initial coding. Though sub-domains may be generated from other domains, these were not clearly evident in our coding process. The most obvious possibilities included expanding 'Assessment of learning' into 'assessment ' and 'feedback,' or 'Educational research and scholarship' into 'research' and 'scholarship.' In either case, it was felt that further expansion of the domains was unnecessary for the purposes of this review. If the domains identified in this review were to be used as a basis for generating a competency framework, new work could be undertaken to generate possible subdomains. Competency frameworks generated by different institutions may vary in emphasis and relevance depending on the context, even with identical domains and sub-domains.
Almost 15% of documents incorporated overarching elementsitems or broad areas applied across competency domains. These items were not unique in themselves. Most were related to professionalism, role-modelling, safe patient care, and faculty developmentitems that other frameworks included as individual domains or sub-domains. The intention of incorporating an overarching element may be to place additional importance on an item or to make it distinct from domains requiring different levels of expertise. In our opinion, competency frameworks can be designed satisfactorily with or without the use of overarching elements. Of paramount importance is the inclusion and characterisation of all items relevant to the educator role the framework is intended for; the item's placement as an overarching element, domain, or sub-domain is influenced by the educator role itself, emphasis on specific competencies, and underlying institutional values. For example, frameworks may incorporate 'professionalism' as an over-arching element, a competence domain, or a sub-domain under 'educational leadership and management,' articulating clearly how it applies to different educator roles.
Whilst competencies and entrustable professional activities (EPAs) both feature prominently in competency-based education, it is important to understand how they differ. An EPA is a unit of professional practice that can be fully entrusted to a learner, as soon as they have demonstrated the necessary competence to execute this activity unsupervised (ten Cate et al. 2015). Competencies describe the qualities of professionals, providing generalised descriptions to guide learners, their supervisors, and institutions in teaching and assessment (ten Cate 2013). EPAs were conceived to facilitate the translation of competency frameworks into actual practice, addressing the concern that these frameworks would otherwise be overly theoretical to have any utility in workplace-based training and assessment (ten Cate 2013). Within a competency framework, progression indicators that are written as statements of activity (see Table 1 for definitions) are more readily translatable into EPAs À 72% of frameworks in this review.
Whilst our search strategy designated educators as a homogenous group, expertise varies with individual roles and responsibilities. It is unsurprising therefore that many documents and frameworks refer to a particular educator role. Despite this, role-specific competency domains in our review were able to be mapped to an inclusive structure, though individual progression indicators within these domains were clearly aligned to the intended roles. In our opinion, the framework we describe (Figure 2) may be used for any educator role by incorporating a continuum of expertise, mapping specific roles to the appropriate expected level of expertise in each domain, and assigning relevant progression indicators. For example, a senior doctor designing and delivering oral examinations for a specialty medical college might map on a higher tier in the 'assessment of learning' domain but at the base tier for most other domains.
Frameworks designed in a continuum allow recognition of different expertise levels, for both generic and specific roles, reflecting both minimum baseline requirements in a domain and the need for the educator's continued development and learning. The Dreyfus & Dreyfus developmental model, a construct of a continuum of skill acquisition and arguably the most widely known model of its kind consists of five levels of expertise (Dreyfus and Dreyfus 1980). In contrast, competency frameworks in our review that used a continuum of expertise had a maximum of four levels and a median of three. As each level requires progression items to be described for every domain of competency, significant effort is required to formulate frameworks with more developmental levels. Furthermore, the Dreyfus & Dreyfus model relates to skill acquisition, which is only one aspect of competence, and there is no consensus on the ideal number of developmental levels for educator (or learner) competence.

Limitations
It is possible that some documents or frameworks were not identified by our search strategy, in particular those not published in peer-reviewed literature or only available as institutional documents. A small number of documents contained overarching elements that others had utilised as singular domains and these were not included in the thematic analysis of competency domains. Documents may have placed some areas of competence within another or conversely broken down others into multiple elements; these were not represented in the thematic analysis unless explicitly identified as a singular competence domain. Both these limitations would have changed the outcomes on prevalence but not have influenced the thematic analysis as additional items would have been coded into the existing structure on further interrogation. As explained in the methods section, domain prevalence was not considered crucial to the thematic analysis.

Conclusions
The educator domains identified in this integrative review are representative of documents and frameworks from a range of healthcare disciplines and contextual applications. Our findings could be a resource for institutions seeking to meet accreditation obligations, for programmes describing requirements for faculty, and for individuals striving for career progression. This review provides guidance for the development of future frameworks, and evaluation of existing frameworks against the domains and sub-domains identified.