Nurses' views on competency indicators for Australian Nursing

Nurses' views on competency indicators for

AUSTRALIAN NURSING This paper reports on a project commissioned by the Australian Nursing Council Inc that sought to develop an approach to the maintenance of continuing competence in nursing broadly acceptable to nurses in all states and territories. This project involved extensive consultation with nurses, consumers and key stakeholders on appropriate competence indicators. Findings suggest that a majority of nurses support the development of competence indicators but most are confused about the nature of competence. By Alan Pearson, Mary FitzGerald and Ken Walsh. • Key words: nursing; regulation; continuing competence; professional licensing Introduction

describe a set ol "characteristics or attrib-

A project to identify indicators of contin-

utes that underlie and enable competent

uing competence in nursing was commis-

pcrlormance in an occupation" (Heywood

sioned by the Australian Nursing Council

et al 1992 pi6). The existence of compe-

Inc (ANC1) in 1997 and carried out in

tency indicators allows for a more readily

1997/1998 (Pearson et al 2000). T h e

available assessment of a person's skills

objectives of the study were to develop:

irrespective of the diilercnccs in training

• a statement of indicators of continuing

background with the focus being on the

competence in nursing,• an explanation of the basis for each ol the identified indicators,-

person's ability to complete tasks against p r e d e t e r m i n e d standards ( A n d e r s o n 1994). The benefits ol having a system of

• a description of any boundaries, con-

competency indicators for a given profes-

texts, applications or qualifications

sion range Irom consistent recognition

which apply in respect of each indica-

across states and territories,- a readily

tor,- and

available benchmark to compare skills of

• recommendations fo i a n y fu r t h e r action or research. Competence as with most terms has no singular definable meaning. A generally accepted belief is that competence is not a directly observable quality, but can

staff w i t h different educational backgrounds or skills acquired in other countries,- clearer training and progression w i t h i n an occupation,- and more ready comparison and progression with related occupations (Heywood et al 1992).

Alan Pearson RN ONC DipNEd DANS MSc PhD FCN(NSW) FINA FRCNA FRCN, Professor of Nursing, La Trobe University, Melbourne, Australia. E-mail: [email protected] Mary FitzGerald RN RNT DipNurs(London| MNurs(Wales) PhD (UNE|, Senior Lecturer, The University of Adelaide Ken Walsh RPN RGN BNurs PhD (Adelaide), Lecturer, The University of Adelaide

36

Collegian Vol 9 No I 2002

Il is important that the standards set

key stages:

ducted to ensure that nurses Irom rural

as competency indicators allow for cur-

Stage 1 - Detailed Project Planning

and regional areas had an opportunity to

rent needs, as well as recognise the future

and Identification of Appropriate Com-

participate in the consultation process. A

needs ol a profession w i t h respect to

petency Indicators

total of 75 rural nurses were involved in

changes in t e c h n o l o g y , professional knowledge and work culture. This allows lor a continually smooth accommodation of new technology and practices as they enter the industry allowing for the best outcome for the consumer.

Stage 1 - Data Analysis and Develop-

the consultancy from I 1 rural sites

ment of Pilot Instruments Stage 3 - Testing Indicators within the Australian Context, and

Consultations A total of 22 consultations were conduct-

Stage 4 - Development of an Options Booklet and a Survey of Nurses

ed in both urban and rural areas ol Aust r a l i a . D u r i n g the c o n s u l t a t i o n s the researchers particularly sought response to questions pertaining to: the type of evidence provided by nurses to show competence, how nurses identify lack ol competence in a colleague or how they k n o w a colleague is competent,- and ascertaining their preference lor a system to ensure continued competence. Finally they were asked to articulate where the responsibility for competence should lie. The consultation also focused on con-

To frame this in a nursing context, the

This paper reports on Stages 1 and 2

sumer requirements and questions per-

A N C I has developed a beginning compe-

of the project regarding nurses' views of

taining to consumer requirements were

tence, or entry level competence, lor pro-

appropriate indicators of continuing com-

asked.

fessional nursing practice. I hese arose

petence in nursing.

from a need to standardise nursing registration and enrolment across Australia

Methodology and approach

Fiach state and territory's respective nurs-

Data collection involved extensive con-

ing regulatory authority adopted these

sultation with key stakeholders in each of

competencies in 1990 following a process

the major capital cities. In each city, a

ol extensive consultation (ANRAC 1990,

researcher led an open forum; a meeting

A N C I 1995). This process is extended

with representatives from the Directors

legislatively in all states and territories,

ol Nursing Association and the Health

where nursing registration organisations

Department/Health Commission,- and a

have been initiated to establish and main-

meeting w i t h representatives from each

lain standards of nursing care in their

of the state nursing regulatory bodies.

Written submissions To generate further discussion, advertisements were placed in The Weekend Australian, The Sydney M o r n i n g Herald, The Melbourne Age and the Australian Telegraph calling for written submissions from professional nursing associations, individual nurses and the general public to the consultancy. Eleven submissions were received. Of these, five were from

respective region. While legislation has

individual nurses, two were from divi-

provided the framework lor the develop-

Participants and procedure

sions of the Australian Nursing Federa-

ment ol these bodies, none of the rele-

All levels of the profession were repre-

vant

Acts has addressed issues of

sented as participants in the consultation

continuing competence beyond recency

including clinicians, nursing educators,

of practice. Inherent in this interpretation

nursing managers, nursing academics and

of continuing competence is the assump-

officers of the major professional and

tion that nurses who have practised with-

industrial nursing organisations.

in the last five years will be safer and more competent in their practice w i t h respect to changes in technology, pharmaceutical i n t e r v e n t i o n s , t r e a t m e n t strategies, and patient demographics (Queensland Nursing Council 1997).

tion, one was from a university faculty of nursing, one from a hospital staff development unit and one from a division of the Western Australian Health Department. An interactive Internet web site was also set up to provide inlormation regard-

National

ing the project and that could accept

meetings

A total of 147 participants attended an

electronic written submissions to the pro-

open forum and 102 participants attended

ject.

the other meetings. In addition, a meeting

This component

of

the

project

was also held with representatives Irom

focused on the need to define a national approach to continuing competencies in

To determine factors that could com-

the New South Wales College of Nursing

plement current re-registration require-

and the principal investigator met with

nursing. As nurses have obvious difficul-

ments, and improve the assessment of

representatives from the Royal College of

ties with both the concept of competence

continuing competency amongst regis-

N u r s i n g , Australia and the Australian

and related issues, it was difficult to lind a

tered nurses, A N C I commissioned a pro-

Nursing Federation in Canberra.

common definition of the term. Concerns

ject to identify indicators of continuing competence in nursing The project design was based on lour

about the definition of competence have Video and tele-conference

meetings

Video and teleconferences were con-

been compounded by attempts to assess levels of it in the workplace. Collegian Vol '.) No I 2002

37

their peers. However, participants recog-

TABLE 1: THEMES IDENTIFIED AFFECTING DEFINITION OF COMPETENCE

nised the difficulty of using insight as an The nature of competence

assessable or measurable indicator.

The nature of incompetence Conflicts and confusion over the above definitions

The measurement

Instruments for the organisational monitoring of competence

The issue of measurement, and the inade-

of competence

quacy of indicators in current use, were

Data analysis

Results

recurrent themes through the transcripts-

The data resulting Irom the forums, con-

N o new ideas regarding what might con-

Participants fell that the measurement of

sultations and written submissions were

stitute an indicator of continuing compe-

competence involved more than the arbi-

analysed to elicit views on the nature of

tence

the

trary listing or determination of key areas

competence in nursing, and a number of

consultations. There were a number of

of concern. There was a feeling that indi-

indicators for measuring competence and

broad themes emanating from the analy-

cators relating to competence are not eas-

approaches for testing competency indi-

sis of the data and these arc f u r t h e r

ily defined and thai they relate to iorms

explored below.

of knowledge that remain beyond the

cators developed.

were

forthcoming

Irom

description of basic skills. Potential indi-

Issues of competence in nursing were Insight

cators identified arc displayed in Table 2.

analysed from two main perspectives:

The nature of competence:

viewing competence as a psychological

This theme was the most consistently

All of these indicators were seen by

construct to the performance of nursing

mentioned and agreed upon concept to

participants to have some potential in the

tasks and a contrary view that suggests

emerge from the consultations. When the

assessment of continuing competence,

competence may be viewed through an

nature of competence was discussed par-

but many of them were also seen to have

individual's performance (Runciman

ticipants referred frequently to the indi-

inherent limitations. Some arc worthy ol

1990, Girot 1993).

vidual's ability to be accurately aware of

brief discussion here.

F o l l o w i n g transcription, data were analysed using the N U D I S T qualitative research software package (non-numerical unstructured data indexing, searching and theorising) (Richards et al 1992) in order to determine key themes arising from the transcript records. In addition to the taped inputs, the preliminary literature review identified some analysis of

her/his own expertise or limitations,- this

Evidence oj recency oj practice

existing and future options and mecha-

was usually defined as "insight". I his

This commonly used indicator has the

nisms to assess and promote continuing

theme also ran strongly through the dis-

potential to infer currency ol knowledge

competence.

cussions on incompetence. It was often

and skills in the practice area but partici-

After reading and re-reading the tran-

l i n k e d to actual and p o t e n t i a l unsafe

pants suggested that it fails to provide

scriptions of the consultations, analysis

practice since nurses w i t h o u t "insight"

sufficient inference of competence or

proceeded using a computer-assisted

were seen to be unable to make adjust-

safety in practice.

manual thematic analysis procedure, and

ments necessary to update their knowl-

recurring themes and sub-themes were

edge and skills, participate actively in

Participation m appropriate

identified. These themes are displayed in

professional development,- and accurately

continuing education activities

Table I.

determine their own ability in relation to

This indicator, which dominates in overseas countries and in other health profes-

TABLE 2: POTENTIAL INDICATORS OF COMPETENCE IN THE NURSING INDUSTRY

sions in Australia, has the potential to

Evidence of recency of practice

Maintaining a professional journal of reflective self assessment that is used as a basis for regular critique by a peer or mentor

knowledge and psychomotor skills and to

Participation in relevant active professional organisations

and skills, participants noted that involve-

Participation/completion of accredited assessor nursing courses

a reliable inference of competence.

develop and improve reflective s k i l l , stimulate activity. While these factors ultimately promote currency of knowledge Participation in appropriate continuing education activities

Evidence of participation in research, health care committees and quality assurance programs

Credentialing of advanced practice within nursing specialties

Writing and publication in refereed health journals

Maintaining a professional portfolio

ment in educational activity alone was not

Evidence of participation in research, health care cotiunittees and quality assurance programs

These activities as indicators have potential, according to the participants, to infer

38

Collegian Vol 9 No 1 2002

currency and involvement in practice and the desire to develop professionally.

I lowever, it was noted that membership

in the negative, in the absence of positive

t i o n of e x i s t i n g ANC.I competencies

and participation does not directly inter

and competent qualities and has the same

should be evident w i t h i n any nursing

competence.

evasive characteristics.

practice setting across Australia.

W h e r e new trends in management

Within these areas of discussion there

Writing and publication in rejereed health journalsefficiency seek predominantly to measure

was a belief in the need for professional

Although participants saw this as an indi-

competence against cost, there was a con-

development, the need to be able to move

cator with some potential, most were of

cern that this may overlook some ot the

beyond beginning competence as experi-

the view that publication may only infer

more intuitive and rewarding aspects ol

ence increased or when employment roles

competence in a particular area of prac-

nursing.

and responsibilities changed over time.

tice rather' than the broad, continuing

A c o m m o n o b s e r v a t i o n was that

Participants tended to favour a focus

competence associated with the mainte-

incompetence may only apply to a very

on core competence. That is, the ability

nance ol registration.

small percentage of the nursing popula-

ol the nurse to follow certain fundamental

tion, and that this may require the dedica-

procedures and carry them out safely

Maintaining a professional portfolio

tion of an unreasonable amount of time

without hesitation and over a long period

The notion of maintaining an ongoing,

and energy in 'hunting down these people

ol time despite changes in roles and occu-

written accounl ol an individual's practice

to catch them out'. When talking about

pational status.

and of a broad range of activities that

competence and incompetence, there

could be related to a selection of indica-

appeared to'be some confusion amongst

Higher levels of competence

tors, was discussed by many participants.

participants on a number of issues, from

Specialties are seen to form part of more

There was some discussion about the time

the transcripts it became apparent that the

advanced training. Looking towards the

and clfort needed to develop a profes-

participants see differences between levels

future, the basic nature of nursing was seen

sional portfolio.

of competence and incompetence.

to be in a state of change with a continuing necessity to keep abreast of this change in

Generally, nurses consulted throughout Australia believed that no degree of valid

Confusion over levels of

competence

terms of technical and more specialist skills.

inference about continuing competence is

When talking about competence the nurs-

There was a feeling that competence at an

possible using a single indicator. Within a

es consulted olten started to talk about

advanced level should be assessed but be

framework bounded by reasonable costs

specialist and advanced practice. This

independent to re-registration.

and processes for Boards and nurses, par-

included the attributes and practices that

ticipants generally preferred an approach

they expected of good nurses with experi-

Influence of other professions

that seeks to determine a higher level of

ence who were able to accept responsibili-

In these times of uncertainly and change,

inference of competence through the use

ty. Interestingly, and in somewhat of a

nurses often asked what other professions

of a variety ol "evidence" streams. This

contradictory manner, they would then

did to monitor continuing competence.

view was reflected in the indicators tested

refer back to the beginning or core com-

Some nurses made comparisons between

in Stage 3 of this project.

petencies when talking about developing a

nursing and other professions in terms ol basic qualifications and the ongoing maintenance of professional status. Fart of these discussions related to the individual, but predominantly the ongoing responsibility for m o n i t o r i n g continuing competence was seen to relate to broader professional and organisational requirements.

Boundaries of

incompetence

basic measure for all nurses linked to re-

Regulation

By default, the participants' descriptions

registration. Context was often mentioned

The participants thought that the impor-

of competence were automatically con-

as something that had to be taken into

tance of determining continuing compe-

trasted with what it means to be 'incom-

account when measuring competence, but

tence related to both practice and safety

petent'. Incompetence has been regularly

when they began to talk ol nurses being

issues. In logistical terms, the monitoring

mentioned as a benchmark and as a wider-

able to nurse in areas they were not famil-

ol competence may be difficult to stan-

area of concern. Participants encountered

iar with, they again returned to the idea ol

dardise over a number of locations. Addi-

the same difficulty in reaching agreement

basic general competence.

tionally,

on incompetence as they did in defining

some

people

felt

thai

This basic approach to competence

mechanisms of determining continuing

was regarded as a 'starting p o i n t ' and

competence were already in place but

Just as d e f i n i t i o n s of c o m p e t e n c e

something to be i m p r o v e d upon w i t h

might need to be standardised across dif-

embrace less concrete and intuitive aspects

time. These basic or core attributes were

lerent areas. There were concerns that

of performance, incompetent work prac-

seen to be part of a broader level of com-

nursing is already heavily regulated and it

tices may also involve similar features that

petence and essential elements ol compe-

was observed that the concept of regula-

arc dillicult to measure such as attitude and

tence in nursing. At a broader level, many

tion by definition implies a form ol con-

insight. In effect, incompetence is assessed

participants believed that the demonstra-

striction and limitation.

competence.

C o l l e g i a n V o l 9 N o I 2(1(12

39

Responsibility for

competence

Summary and Conclusion

lenge of developing a coherent multifactor-

There was a strong belief that the employ-

T h e c o n s u l t a t i o n s c o v e r e d a r a n g e of

ial continuing competency assessment tool

er should have the interest and concern to

s t a k e h o l d e r s and s t i m u l a t e d

lengthy

will be beneficial to the nursing profession

ensure that stafl arc keeping up with their

debate. Nevertheless while issues such as

in Australia. W h a t has b e c o m e apparent

individual responsibilities. Others lelt that

self-regulation and the presence of 'insight'

following this period of consultation is that

there was a more general level of responsi-

came t h r o u g h s t r o n g l y in the data, n o

this tool will be difficult to develop il it is

bility to be shared across a n u m b e r of

definitive alternate indicators for continu-

to be applied across specialties and is to

bodies along with the individual nurse.

ing competence were forthcoming. Nurses

measure more than basic competence. To

At the same time professional c o n -

were able to identify evidence that would

gain the approval of nurses and respective

cerns w e r e seen lo p r o v i d e a g r o w i n g

indicate competence and incompetence in

nursing Boards across the country, the tool

inllucncc in debates over competence and

a nurse but there was confusion over how

will need to be simple to administer, allow

the monitoring of competency in nursing.

these subjective measures could be effec-

monitoring of standards ol c o m p e t e n c e ,

Some people tclt that professional issues

tively m o n i t o r e d while r e c o g n i s i n g the

and provide options/pathways to those not

were going to have some influence on

broad scope of nursing practice. Confusion

meeting c o m p e t e n c e requirements. T h e

how these credentials and work obliga-

over

echoed

concept of ongoing competency indicators

throughout the data with discussions alter-

appears lo have support among nurses, but

nating between basic and advanced prac-

care needs to be taken to ensure these indi-

tice. Levels of competence were frequently

cators can be applied across spcciallies and

tions were lulfilled. In terms of professional responsibilities a n d o b l i g a t i o n s , t h e p a r t i c i p a n t s raised a n u m b e r of q u e r i e s r e g a r d i n g whether these competency indicators will remain within the domain of the individ-

levels

of c o m p e t c n c e

described as being context bound and this

not be too invasive. I he assessment of

further clouded the issue. It was generally

ongoing competency in nursing will com-

agreed that maintaining continuing com-

plement ANC.I's current standards of begin-

p e t e n c e s h o u l d be shared b e t w e e n the

ning competence, and will allow for a more

ual or whether professional organisations

individual and professional organisations.

comprehensive indicator of nursing compe-

also have a role to play.

A range ol indicators was deemed prcler-

tence than is currently in place.

able to provide evidence of c o m p e t e n c e Consumer rights and

expectations

Issues of quality improvement and patient satisfaction were frequently cited as some of the more common issues within a whole range of concerns. W h i l e several nurses thought that consumers were not aware of levels of competence and were generally happy if their basic needs were fullilled such as a hot cup of tea, or Huffed pillow, or a smile - there is some indication that this perspective is changing.

rather than a solitary requirement such as recency of practice. Nurses also expressed an interest in the practices of other professions' professional

committee in the design and conduct of the study, and Dv H e l e n M c C u i c h e o n

there were already sufficient mechanisms

and Matthew Lewis for their assistance in

in place within nursing to monitor their

preparing this paper.

activities as a group. These include qualification requirements for specialty areas,

References

staff appraisal systems and a range of dis-

A N C I 1 9 9 5 Outline o) the ANCI national nitrsim) competencies for neutered and eniolled nurses A N C I , C a n berra

Nevertheless, the role of monitoring com-

there seemed to be some d i s a g r e e m e n t

p e t e n c e was seen to b e i m p o r t a n t to

over the practices involved in such an exer-

debate, particularly with changes in the

cise. Along with a general consensus that

health care environment, current trends in

consumers are going lo be more intensively

the nursing prolession and an increasing

involved in the activities of assessment and

sense of accountability to consumers and

information, there was some uncertainty

consumer awareness.

a m o n g t h e p a r t i c i p a n t s as to h o w this

It was generally agreed that while mini-

would take place and conflicts over con-

mum standards of practice may operate to

sumer expectations were apparent.

provide a baseline requirement for prac-

T h e nurses saw some areas of nursing

tice, for the regulation of continuing com-

as being more consumer driven than oth-

p e t e n c e in a rapidly c h a n g i n g n u r s i n g

ers. T h e solitary nature of i n d e p e n d e n t

e n v i r o n m e n t , t h e r e n e e d s to be s o m e

midwifery practice posed some problems

t h o u g h t given to future requirements of

in t e r m s of appraisal a n d p e r f o r m a n c e

the profession. While the responsibility for

indicators. Midwifery depends on 'word

maintaining competence may fall back on

of

a good

the individual, some structured guidelines

response from patients. At the same time

need to be developed. T h e s e guidelines

there was a concern that the professional

would provide a framework for determin-

status of such work should not be determined solely by public commentary. 40

Collegian Vol 9 No 1 3002

Nursing

organisations, and some strongly felt that

over measurement and quantification and

and

a s s i s t a n c e of t h e A u s t r a l i a n

C o u n c i l Inc, a n d t h e p r o j e c t s t e e r i n g

ciplinary procedures under various Acts.

advertising'

T h e a u t h o r s wish to a c k n o w l e d g e the

r e g u l a t o r y and c o n t i n u i n g e d u c a t i o n a l

Discussion returned to a central issue

mouth

Acknowledgements

ing competence into the next century I n c o r p o r a t i n g these views, the chal-

A n d e r s o n M 1 9 9 4 National nursinij competencies and assessment fiamework monograph T h e U n i v e r s i t y of N e w E n g l a n d Press, A r m i d a l e A N R A C 1 9 9 0 Nursiiu; competencies assessment projectrepovl to t/jf Australasian Nurse Registering Authorities Conference A N R A C , N o r t h A d e l a i d e O r a l E 1993 A s s e s s m e n t o( c o m p e t e n c e in clinical p r a c t i c e - a review ol t h e literature. Nurse Education Today 13:83-90 H e y w o o d L, C . o n c z i A, f l a y e r I1 1 9 9 2 Research papei = 7 A ijuide to development oj competency standards jo> professions. D e p a r t m e n t of E m p l o y m e n t . E d u c a t i o n a n d [raining, C a n b e r r a P e a r s o n A, F i t z g e r a l d M . B o r h a s i S. W a l s h K, P a r k c s R, l.azarevic L 2 0 0 0 A study lo identify the indicators of conUnuunJ competence w nursmt) -final n-pori. Australian N u r s i n g C o u n c i l I n c o r p o r a t e d , Canberra Q u e e n s l a n d N u r s i n g C o u n c i l 1997 A n n u a l r e c e n c y of p r a c t i c e r e q u i r e m e n t s . Oueensland Nutsuiif Louncil Infoinuition paper -, 4 1-4 R i c h a r d s T, R i c h a r d s L, M c C t l l a r d J, S h a r r o e k U 1 9 9 2 NIID.IST usei manual. R c p l e e P l y L t d , Uundoora R u n c i i n a n P 1990 Competency-based education and the assessment and accreditation of u'oik-based learning in the context of protect 3000 ptotfiammes of nurse education a hteiatuie review T h e N a t i o n a l Board for N u r s i n g , M i d w i l e r y dn<.\ I Icaltli V i s i t i n g (or S c o t l a n d .

Edinburgh