- Email: [email protected]
The role of performance feedback in the self-assessment of competence: A research study with nursing clinicians
The role of performance feedback in the self-assessment of competence: A research study with nursing clinicians Dr Jennifer Fereday, University of South Australia Associate Professor Eimear Muir-Cochrane
Introduction Performance feedback has the potential to contribute to a nurse’s self-awareness and, in turn, their ability to self-assess their level of competence. Because a declaration of self-assessment of competence is a current requirement for continuing nursing registration within South Australia, Queensland and Tasmania, the search to identify sources and processes that may assist nurses to self-assess their performance is potentially of benefit to the profession. This paper is based on one aspect of a PhD study exploring the utility of performance feedback primarily from a nursing clinicians’ perspective. Focus group interviews were conducted with hospital-based nursing clinicians and the data were analysed using a process of thematic analysis. Findings highlighted that nursing clinicians frequently engaged in a process of performance self-monitoring that was a balance between feeling competent and feeling uncertain in relation to their own level of clinical competence. On a daily basis, nursing clinicians held an assumption of competence to practise that was based on their ability to act in a situation, receiving positive feedback from others and in the absence of evidence to the contrary. At times feelings of doubt or uncertainty intervened especially in situations that were unfamiliar or challenging or when receiving feedback from others that questioned their own perceptions of competence. The findings of the study provide support for the types of self-monitoring processes that serve to enhance both the relevance of feedback for nurses and the quality of evaluative data regarding ongoing competence. Keywords: Feedback, competence, self-assessment, professional practice
Dr Jennifer Fereday RGN, RM, Dip.App.Sci(Nsg) BN Med(Mgt) PhD, Children, Youth & Women’s Health Service, Adelaide. Email: [email protected] Associate Professor Eimear Muir-Cochrane BSc (Hons), RN, RMN, Grad Dip Adult Ed, MNS, PhD
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License to practise as a nurse and/or midwife requires registration with the designated nurses’ board or council within the states and territories of Australia (Scheiwe 1998). Nursing regulatory and professional organisations have commissioned studies to explore the indicators for continuing competence in nursing (Pearson et al 2000; FitzGerald et al 2001). These reports indicate that competency to practise nursing can not be adequately measured by a single process of assessment. A systematic review by FitzGerald et al (2001) indicates that self-assessment by nurses is often the most favoured approach, and a key finding of a study by Pearson et al (2000) supports a self-declaration of competence for continuing registration. The Nurses Board of South Australia (NBSA 2000) recommends that self-assessment procedures include the use of reflection by nurses to review feedback from patients/clients, together with performance appraisals to confirm the nurse’s own competence to practise. This paper draws on the study findings involving the nursing clinicians’ perceptions of the utility of performance feedback and suggests strategies to enhance the impact of performance feedback within the clinical setting.
Methodology The philosophical framework for the research was the social phenomenology of Alfred Schutz (1967). He believed a deeper understanding of society was achieved by uncovering the ‘takenfor-granted’ meanings and seeing how social reality structures itself in a person’s immediate consciousness, and their experience of it. By applying Schutz’s (1967) concept of verstehen or interpretive understanding the study was placed in the context of human beings acting and interacting with emphasis on the individual’s motivations and meanings. The subjective experiences, as described by individuals, form the first order constructs (Schutz 1967). The researcher is able to construct a second order of understanding by describing ‘ideal types’ (Schutz 1967) that interpret and describe the phenomenon under investigation, in this case performance feedback. Focus groups were chosen as an appropriate data collection method to stimulate discussion and ascertain the nursing clinician’s perspective of the utility of performance feedback. The group technique was chosen to encourage both individual and shared
The role of performance feedback in the self-assessment of competence: A research study with nursing clinicians
accounts of ‘reality’, which were more likely to be discussed in greater depth when explored in a group interview format (Frey & Fontana 1993). Purposeful sampling of information-rich cases was adopted to select participants for the focus groups (Rice & Ezzy 1999). Participants within the groups were from the same work area to allow for participant comfort and maximum, uninhibited discussion (Krueger & Casey 2000). Nursing clinicians participating in the study fulfilled the criteria of nurses working in clinical areas of a hospital who did not have a role as an identified manager. All participants in the study were Registered Nurses and/or Midwives Level 1 / Division 1. For the study they are referred collectively as nursing clinicians. Two private and one public hospital were selected to participate in the study. Ethics approval was obtained from the University Human Ethics Committee and from each hospital individually. Participation was voluntary, without financial reimbursement, and discussions were audio-taped with the informed consent of each participant. For this part of the study a total of seven nursing clinician focus groups were held between the hospitals totalling 26 participants over a period of five months. A short questionnaire was completed by each participant to collect demographic data. For nursing clinicians, the demographics collected included area of nursing work and years of nursing experience. Three nursing clinical groups were represented; midwifery, general surgical and general medical (including palliative care). Several of the nurses worked in all three areas, and two were employed on a casual basis. The participants’ level of nursing experience varied. For the purpose of analysis a less experienced nursing clinician was one with less than 4.5 years post-graduate experience as the next grouping of nurses (more experienced nurses) was from 11-35 years of postgraduate experience. Structured, open-ended questions explored the following issues: • sources of feedback identified by participants; • rating of these sources according to usefulness for the nurse’s own performance evaluation; and • the impact and changes in performance that resulted from feedback. At the conclusion of the session, the researcher summarised the discussion for verification by the group and provided the opportunity for correction. Only one interview was conducted with each group as participants expressed this was the level of participation they were willing to commit. Data analysis involved the group discussions being transcribed verbatim (excluding identifiable data of any person). The data were then thematically coded by incorporating the inductive method of data-driven codes (Boyatzis 1998), and the application of a template of codes, as outlined in the deductive approach of Crabtree and Miller (1999). The template of codes was derived from the work of Schutz (1967).
Performance feedback The term ‘feedback’ in the literature is applied over a broad spectrum of intended meanings. The term is based on the broad concept that describes the adjustment of a process following information about the effects produced (Yalom 1995). The application of the
concept of feedback to studies in human relations is generally attributed to the work of Kurt Lewin in the 1940s (Schein & Bennis 1965; Torbert 1972; Yalom 1995). Learning processes may be activated when feedback highlights a discrepancy between the standard of performance required and actual performance (Kluger & DeNisi 1996). Performance feedback as a staff development mechanism has the potential to motivate behaviour, contribute to self-awareness, provide a path for career development, and improve both work relationships and the overall quality of work performance for employees (Kramar et al 1997; London 1997; Hulett 2002). In the nursing literature, feedback on performance is commonly equated with the formalised processes of performance appraisals, reviews or management systems (Huber 2000; MarrinerTomey 2000; Yoder-Wise 2003). In contrast to these formalised written processes, informal discussions and sharing of experiences with colleagues during day-to-day activities may provide feedback to individuals or groups on their work performance. The common denominator for both formal and informal processes of performance feedback involves the measurement of performance against expectations. These can be in the form of a nurse’s personal expectations or expectations set by others. Performance can also be guided by a set of standards, either professionally based, for example, Australian Nursing Council competencies (ANC 2002), or specified by the organisation, for example, a position description. Performance feedback involves an evaluation process of gathering information regarding a person’s performance, making a judgment about the person’s ability and then delivering this judgment to the person concerned. Performance feedback explored in this study is defined as information provided to employees about how well they are performing in their work role. This may be a formal and/or informal feedback process but the focus of this paper is on feedback in relation to continuing competence and is not linked to an ongoing disciplinary procedure.
Self-assessment of competence The self-assessment of competence is often one step in the formal process of an annual appraisal within nursing (Huber 2000, Marriner-Tomey 2000, Yoder-Wise 2003). This step involves the individual rating their own performance against set criteria which is then reviewed by another person as part of the appraisal process (commonly the manager of the area). However, competence is a complex term and has remained equivocal in the nursing literature over the past decade (Girot 1993; While 1994; Bradshaw 1997; Bradshaw 1998; FitzGerald et al 2001; Meretoja, Eriksson & LeinoKilpi 2002; Watson et al 2002). Inevitably, difficulties can arise when one is required to assess a nebulous concept, and no single method is recommended to assess continuing competence within nursing. Rather, a multi-method approach is often recommended (Pearson et al 2000; FitzGerald et al 2001; Redfern et al 2002). Competence is succinctly defined by NBSA (2000 p 8) as ‘the ability to do something well and effectively’. Competence is also defined within the nursing profession as a ‘combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/occupational area’ Collegian Vol 13 No 1 2006
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(ANC 2000 p1). Competence within nursing in Australia is defined in terms of outcome standards. Minimum competency standards include those specified for registered nurses and enrolled nurses (ANC 2002), although professional nursing organisations have adapted them for their particular scope of practice. The term ‘continuing competence’ is the ability of nurses to demonstrate that they have maintained their level of competence within their scope of practice (NBSA 2000). This study has adopted the description of self-assessment of competence outlined in the Australian Nursing Council policy on continuing competence (ANC 2000), that is, an ongoing process whereby nurses examine their practice against national competency standards accepted by the nurse regulatory authorities for registration. It is the outcome of the ongoing process of self-assessment that is called upon as evidence by nursing regulatory authorities and organisations employing nurses. The process may include formal and/or informal performance feedback, which nurses may use to evaluate their practice to ensure competence is maintained and ideally to improve upon their practice.
Findings of the study Themes generated from the coded transcripts of the focus group discussions identified that nursing clinicians evaluated their own level of competence through a process of self-assessment often relative to the immediate requirements of the situation. The following themes support the concept that competence or an ability to act safely in a situation was ‘assumed’ by nursing clinicians on a daily basis. When they encountered a situation that raised ‘doubt’ or uncertainty in their level of competency, this triggered the active process of seeking external feedback generally for assistance. These key findings, that underpin the utility of feedback from the nursing clinicians’ perspective, are illustrated in the following coded themes.
Theme 1: Performance feedback is needed for positive reinforcement and affirmation Nursing clinicians, not surprisingly, expressed their preference for receiving positive feedback to reinforce feelings of competence. Feedback comments and actions were sometimes delivered indirectly, for example, being asked to assist someone else: They’re trusting you with a problem and therefore saying that you are competent in that field. (Focus group 3)
For casual staff their level of competence was implied by being asked to work in areas requiring specialised skills: They’re ringing me up asking me to do the work, they must realise I’m capable of doing the work because I’m going to areas like labour ward, neonates and ICU. If my performance wasn’t up to scratch I wouldn’t be receiving the phone calls. (Focus group 5)
However, nursing clinicians also expressed a need for direct, positive comments to increase feelings of satisfaction and provide a motivational force: It would be good if you could have some sort of feedback all the time, you know ‘thanks for a great job’ ... ‘thanks for doing that, that was great I know you had a terrible day’ … you just don’t get that. (Focus group 2) 12
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You would like to have feedback from your peers or your manager telling you ‘you did a good job’ because that sort of gives you the boost to sort of keep on a positive note for the rest of the week. (Focus group 1)
Positive feedback was often referred to as receiving recognition for a job ‘well done’. As two nurses explained: Because as human beings we all like that sort of positiveness (sic). (Focus group 3) She (the clinical manager) is quite affirming ... if it’s been a difficult situation she’ll put a note in the communication book thanking us all. (Focus group 2)
The idea of feedback providing a moral boost once again implied that competence is assumed and feedback provided positive reinforcement. Feedback from peers was especially noted as useful by participants: Often you will hear another RN say ‘that was really well done’. (Focus group 7) But if I was to get a warm fuzzy from (name of peer) like ‘Oh you handled that well’ or something that would mean the world to me. (Focus group 4) I think you can appraise yourself from comments from your coworkers. (Focus group 3)
Positive comments from medical staff were rare and thought of as a ‘bonus’ by nursing clinicians. Feedback from patients was important to nursing clinicians and was described as a ‘warm fuzzy’. Once again, feedback from patients generally affirmed the competence of nursing staff: You know you’re doing a good job as a nurse when the patient will make a comment. (Focus group 1)
Feedback was sometimes in the form of a gift or card, but mostly it was implied by patients’ comments to the nurse: When are you on again? (Focus group 7) Are you going to be back tonight? (Focus group 4)
Competence was often assumed until a nurse received feedback to the contrary. In a situation where a nurse was assessed as not performing at the level of competence expected, and was not personally aware of this, then delaying or omitting to provide any feedback was significant in terms of perpetuating potentially unsafe practice.
Theme 2: Performance feedback that is lacking or delayed leads the receiver to assume competence Lack of feedback was an issue of concern that was raised in the focus groups. No feedback supported the notion of assumed competence, as indicated in the following comments: We assume that we are doing okay unless something to the contrary is brought up. (Focus group 4) You only get feedback if you do something wrong. (Focus group 6) I haven’t heard any complaints so far so I only assume it is all good. (Focus group 7) RN1: They (managers) are too busy to let you know. RN2: Perhaps they just think you know that you’re good. (Focus group 6)
A lack of feedback became problematic for nursing clinicians if an issue was raised at a later date and the nurse felt feedback should have been provided closer to the time of the incident or when a problem was noticed. This delay in feedback was a source
The role of performance feedback in the self-assessment of competence: A research study with nursing clinicians
of grievance, expressed most clearly by less experienced nurses and became an issue of an individual’s right to receive feedback on poor performance. How have they got the right to complain if they’re not telling you what is wrong. (Focus group 7) If something was wrong I’d need to be picked up before now. (Focus group 4) I mean you expect that if something goes astray your managers will say something. (Focus group 3)
Nursing clinicians expressed an expectation that any problem arising in relation to their performance should be fed back to them without delay. Furthermore they believed it was unacceptable for this type of feedback to be postponed for the annual appraisal. Problems also arose when an appraisal or performance feedback had been provided but there was no follow-up. The entire process was thus undermined and, once again, the nursing clinician assumed they were performing at a satisfactory level.
Theme 3: Nursing clinicians perceived the formal performance review system as an imposition Nursing clinicians strongly viewed the performance appraisal system as a management-driven organisational requirement. They understood the necessity of completing an annual appraisal as a condition of their employment and that the consequences of not participating would result in a violation of their employment contract possibly leading to disciplinary action, even dismissal. In the focus group discussions the nursing clinicians described the formal performance appraisal process in terms of an imposition. The need to complete an annual appraisal form was viewed by many as ‘going through the motions’ as evidenced by the following comments: Annual appraisal is like a little animal that raises its head once a year, you’ve got to put the rubbish down on paper to make it look good so you can send it off. (Focus group 4) The ones we do here we all go ‘oh God not again’. (Focus group 1)
Clearly such complacency has inherent risks in utilising a performance appraisal as an indicator of nursing competence. The following comments indicate the questionable value of a process of self-assessment required as part of a traditional performance appraisal: This is what they want to hear, this is what they want to know, just pop it in, they’ll sign it off and it’s done…………… it’s not showing them at all what I’ve learnt. (Focus group 7) The worst part is you have to put an objective for the next year and you sort of think I’ve been putting to do a palliative care course for fifteen years. (Focus group 1)
These comments are also indicative of the nursing clinicians’ perception that undertaking a process to ensure competency was irrelevant when they already believed themselves to be competent. The following theme highlights situations when nurses were more receptive to receiving feedback on their performance.
Theme 4: The need for feedback is greater if a person’s ability is doubted At times nursing clinicians themselves, or other people, raised doubts or feelings of uncertainty in the nursing clinician’s ability
to reach a level of competence that was deemed acceptable. Doubts were most often raised when nursing clinicians faced unfamiliar situations. Participants described situations where they felt more confident to actively seek feedback from more experienced peers working within the clinical setting. Learning or validating a new procedure commonly facilitated a request for support and feedback: If I was feeling that uncertain I would want another RN there whom I knew had the experience and the skills to get me through that. (Focus group 1) We have been here for so many years you sort of know, you’re familiar with all the different scenarios that happen in labour ward and whatever and if there is something that’s just a bit different, well you ask and you question and you query. (Focus group 3) ... some sense of where I feel incompetent or a little bit less confident you can actually go and ask somebody, a peer or the manager. (Focus group 2)
When a situation of doubt did arise, nursing clinicians often sought feedback to allay their concerns and/or to rectify a problem. On these occasions feedback was felt to be relevant and therefore was often actively sought. Most nursing clinicians indicated they didn’t seek feedback unless they felt unsure about a situation and required some advice or the expertise of another nurse: At particular times you do, on the whole most people are fairly comfortable but we have had some situations where we have sought to find out if we did okay. (Focus group 2) If you find yourself having to do a new procedure or something you haven’t done very often, you would get somebody that you worked with to assess you. (Focus group 1)
Feedback was most often required ‘to get the job done’ and the perceived relevance or utility of the feedback was relative to the context of the situation. The following section discusses the utility of feedback when the individual did not perceive an immediate need for seeking assistance. Feedback, in this situation, potentially provided a stimulus for self-reflection.
Theme 5: Listening to the experiences of others triggers a process of self-reflection Opportunities for peer discussions motivated nurses to reflect on their own performance. This situation was evident during a discussion about the value of shift handover as a feedback session: People discussing things in that perhaps you sort of reflect on it and think oh gee did I do it that way. (Focus group 7) I’ll reflect on, say perhaps over handover or something that has been said, and I think I didn’t see that or I didn’t do that. (Focus group 2) It (handover) sort of gives you a bit of a prompt to think oh well that is a good idea, maybe I should think more about doing it better in that area myself. (Focus group 7)
Debriefing an incident as a group also had benefits, by triggering a process of reflection, as described by one participant: It might not be anything that is pertinent to you at the moment but later on you go away and think about it and think it could have been me. (Focus group 3)
When discussing an emergency situation that had occurred recently, a nursing clinician stated that no opportunity to debrief was a disadvantage: I needed to know if I did okay in that [emergency situation], I’m in absolute limbo now and I still think about it now and think what could have I done. (Focus group 7) Collegian Vol 13 No 1 2006
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Other group members supported her comments and expressed debriefing was necessary ‘especially with something you haven’t experienced before’. Not having opportunities for discussion and debriefing often resulted in nurses leaving work thinking ‘could I have done things better’, and in this situation, doubt could become a destructive emotion as opposed to a catalyst for seeking feedback.
Discussion Themes generated from the focus group discussions support the premise that nursing clinicians in this study constantly engaged in a process of self-monitoring their own performance. This process is similar to that of self-regulated learning (Butler & Winne 1995; Winne 1995a; Winne 1995b) when the individual engages in a process of self-monitoring using internal and external feedback paths. The principles of self-regulated learning are applicable to this study, as nursing clinicians were able to detect variance in their own performance through a process of self-monitoring. For many nurses, especially those with more situational experience in a clinical area, this process became automated and involved being able to recognise the need for additional knowledge and skills based on a self-assessment. Feedback in this context is viewed as a personal resource that individuals actively monitored and then selected when relevant to the situation. The pragmatic motive for seeking or receiving feedback is a concept that accords with Schutz’s belief that people in everyday life are oriented to achieve practical outcomes (Schutz 1967). From the findings of this study, the general attitude within the working world of nursing clinicians was to assume a level of competence to fulfill their role of patient care which formed the baseline of their assessment of continuing competence. This assumed level of competence was affirmed by positive feedback, both formal and informal, and by the absence of feedback to the contrary. A positive assessment of self-competence, in turn, increases feelings of self-efficacy and self-esteem (Bandura 1997). When experiencing high levels of confidence in their ability, overall nursing clinicians were less receptive to feedback that was contrary to their self-assessment. However, a level of competence that is taken for granted has the potential and capability to be questioned. Situations were described by participants when doubts were raised and nursing clinicians either questioned their own level of competence or others raised their concerns. Feedback messages have the potential to raise the level of awareness, often expressed as feelings of uncertainty, in relation to performance. At this time the nursing clinician was most receptive to feedback from others, an important implication for those providing feedback. From these findings the key recommendation from the study is the need to stimulate self-awareness through providing opportunities for feedback and professional reflection at work. This recommendation was initially founded on the dynamics of the focus group discussions. At the commencement of the focus group discussions the nursing clinicians had a generalised, rather narrow, view of what feedback they were currently receiving in the clinical environment. All responded with ‘performance appraisals’ as the most significant source of feedback they received on their 14
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performance; a method of assessment also heavily criticised by many participants. It was evident during the focus groups that the process utilised by nursing clinicians to measure their own competence to practise, and the sources of feedback that assisted this process, were not issues they had considered in detail. The open-ended questions asked during the focus groups triggered a process of self-reflection. Evolving discussion amongst group members demonstrated their increasing level of insight into the role other sources played (patients, peers, task-related feedback) and the important role of their own self-assessment. The researcher believes the process of conducting the focus group discussions was similar to the process that underpins facilitated or guided reflection groups as a method of professional development (Donaghy & Morss 2000; Johns 2002; Yearly 2003). Involvement in guided reflection groups is considered a legitimate continuing professional development activity in the United Kingdom (Yearly 2003). The nursing clinicians in this study highlighted the benefits of informal feedback that occurred during work discussions with peers and clinical managers. Both shift handover and debriefing sessions provided opportunities for vicarious learning from the actions of others who shared similar experiences within the clinical environment. This comparative method of feedback was felt to be non-threatening, and provided a stimulus for reflection on work practices. This type of professional networking allowed nurses to actively seek feedback or to be passive recipients of feedback provided to others. Sharing the experiences of patient care was seen as an opportunity for nurses to validate their current practice or question their practice. This latter reflection introduced a level of doubt that encouraged further receptiveness to feedback from others. In conclusion, findings demonstrate that opportunities for professional reflection were either diminishing or no longer offered in hospitals. One group of nursing clinicians reported feeling despondent that critical clinical situations on the ward were no longer followed up by debriefing sessions. The use of taped handovers and staggered shift times also reduced the opportunity for face-to-face interaction at a time of shift handover. These situations are notable deficits in the current hospital system, especially in view of this study’s findings that highlight the importance of strengthening all opportunities for individuals to receive and reflect on feedback to inform their ongoing self-assessment of competence. The challenge now is for organisations to provide opportunities for facilitated reflection to stimulate the process of self-assessment and professional interaction and to incorporate this process into the design of performance review systems. References Australian Nursing Council 2000 Position statement: Continuing competence in nursing. Retrieved 14 April 2004 from World Wide Web: http://www.anc.org.au/02standards/_docs/Positions/Contin_comp.pdf ANC (Australian Nursing Council) 2002 National competency standards for the registered nurse and the enrolled nurse, 3rd edn. Australian Nursing Council, Canberra Bandura A 1997 Self-efficacy – The exercise of control. W H Freeman, New York Boyatzis R 1998 Transforming qualitative information – Thematic analysis and code development. Sage Publications, California Bradshaw A 1997 Defining ‘competency’ in nursing (part 1): a policy review. Journal of Clinical Nursing 6: 347-354
The role of performance feedback in the self-assessment of competence: A research study with nursing clinicians
Bradshaw A 1998 Defining ‘competency’ in nursing (part II): an analytical review. Journal of Clinical Nursing 7: 103-111 Butler D, Winne P 1995 Feedback and self-regulated earning: a theoretical synthesis. Review of Educational Research 65(3): 245-281 Crabtree B, Miller W 1999 A template approach to text analysis: developing and using codebooks. In: Crabtree B & Miller W (eds) Doing qualitative research. Sage, Newbury Park Donaghy M, Morss K 2000 Guided reflection: a framework to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice 16: 3-14 FitzGerald M, Walsh K, McCutcheon H 2001 An integrative systematic review of indicators of competence for practice and protocol for validation of indicators of competence. Commissioned by Queensland Nursing Council Frey J, Fontana A 1993 The group interview in social research. In: Morgan D (ed) Successful focus groups – advancing the state of the art. Sage Publications, California Girot E 1993 Assessment of competence in clinical practice: a review of the literature. Nurse Education Today 13: 83-90 Huber D 2000 Leadership and nursing care management. W.B. Saunders, Philadelphia Hulett K 2002 An honest evaluation. Advisor Today March: 86 Johns C 2002 Guided reflection: advancing practice. Blackwell Publishing, Oxford. Kluger A, DeNisi A 1996 The effects of feedback interventions on performance: a historical review, a meta-analysis, and a preliminary feedback intervention theory. Psychological Bulletin 119(2): 254-284 Kramar R, McGraw P, Schuler R 1997 Human resource management in Australia, 3rd edn. Longman, Melbourne Krueger R, Casey M 2000 Focus groups – a practical guide for applied research, 3rd edn. Sage Publications, California London M 1997 Job feedback: giving, seeking, and using feedback for performance improvement. Lawrence Erlbaum, New Jersey Marriner-Tomey A 2000 Guide to nursing management and leadership 6th edn. Mosby, St Louis Meretoja R, Eriksson, Leino-Kilpi H 2002 Indicators for competent nursing practice. Journal of Nursing Management 10: 95-102
NBSA (Nurses Board Of South Australia) 2000 Your Practice, Continuing Competence and Self-Regulation. Nurses Board of South Australia, Adelaide Pearson A, FitzGerald M, Borbasi S, Walsh K, Parkes R, Lazarrevic, L 2000 A study to identify the indicators of continuing competence in nursing: final report January 1999. Commissioned by Australian Nursing Council Inc Redfern S, Norman I, Calman L , Watson R, Murrells T 2002 Assessing competence to practise in nursing: a review of the literature. Research Papers in Education 17(1): 51-77 Rice P, Ezzy D 1999 Qualitative research methods – a health focus. Oxford University Press, Melbourne Schein E, Bennis W 1965 Personal and organizational change through group methods: the laboratory approach. Wiley, New York Scheiwe D 1998 The Australian nursing profession. In: Clinton M, Scheiwe D (eds) Management in the Australian health care industry. Longman, Australia Schutz A 1967 The phenomenology of the social world, G. Walsh and F. Lehnert, trans. North Western University Press, Illinois Translation of Der sinnhafte Aufbau der sozialen Welt 1932 Torbert W 1972 Learning from experience – toward consciousness. Columbia University Press, New York Watson R, Stimpson A, Topping A, Porock D 2002b Clinical competence assessment in nursing: a systematic review of the literature. Journal of Advanced Nursing 39(5): 421-431 While A 1994 Competence versus performance: which is more important? Journal of Advanced Nursing 20: 525-531 Winne P 1995a Inherent details in self-regulated learning. Educational Psychologist 30(4): 173-187 Winne P 1995b Self-regulation is ubiquitous but its forms vary with knowledge. Educational Psychologist 30(4): 223-228 Yalom I 1995 The theory and practice of group psychotherapy 4th edn. Basic Books, New York Yearly C 2003 Guided reflection as a tool for CPD. British Journal of Midwifery 11(4): 223-226 Yoder-Wise P 2003 Leading and managing in nursing 3rd edn. Mosby, St Louis
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Introduction Performance feedback has the potential to contribute to a nurse’s self-awareness and, in turn, their ability to self-assess their level of competence. Because a declaration of self-assessment of competence is a current requirement for continuing nursing registration within South Australia, Queensland and Tasmania, the search to identify sources and processes that may assist nurses to self-assess their performance is potentially of benefit to the profession. This paper is based on one aspect of a PhD study exploring the utility of performance feedback primarily from a nursing clinicians’ perspective. Focus group interviews were conducted with hospital-based nursing clinicians and the data were analysed using a process of thematic analysis. Findings highlighted that nursing clinicians frequently engaged in a process of performance self-monitoring that was a balance between feeling competent and feeling uncertain in relation to their own level of clinical competence. On a daily basis, nursing clinicians held an assumption of competence to practise that was based on their ability to act in a situation, receiving positive feedback from others and in the absence of evidence to the contrary. At times feelings of doubt or uncertainty intervened especially in situations that were unfamiliar or challenging or when receiving feedback from others that questioned their own perceptions of competence. The findings of the study provide support for the types of self-monitoring processes that serve to enhance both the relevance of feedback for nurses and the quality of evaluative data regarding ongoing competence. Keywords: Feedback, competence, self-assessment, professional practice
Dr Jennifer Fereday RGN, RM, Dip.App.Sci(Nsg) BN Med(Mgt) PhD, Children, Youth & Women’s Health Service, Adelaide. Email: [email protected] Associate Professor Eimear Muir-Cochrane BSc (Hons), RN, RMN, Grad Dip Adult Ed, MNS, PhD
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License to practise as a nurse and/or midwife requires registration with the designated nurses’ board or council within the states and territories of Australia (Scheiwe 1998). Nursing regulatory and professional organisations have commissioned studies to explore the indicators for continuing competence in nursing (Pearson et al 2000; FitzGerald et al 2001). These reports indicate that competency to practise nursing can not be adequately measured by a single process of assessment. A systematic review by FitzGerald et al (2001) indicates that self-assessment by nurses is often the most favoured approach, and a key finding of a study by Pearson et al (2000) supports a self-declaration of competence for continuing registration. The Nurses Board of South Australia (NBSA 2000) recommends that self-assessment procedures include the use of reflection by nurses to review feedback from patients/clients, together with performance appraisals to confirm the nurse’s own competence to practise. This paper draws on the study findings involving the nursing clinicians’ perceptions of the utility of performance feedback and suggests strategies to enhance the impact of performance feedback within the clinical setting.
Methodology The philosophical framework for the research was the social phenomenology of Alfred Schutz (1967). He believed a deeper understanding of society was achieved by uncovering the ‘takenfor-granted’ meanings and seeing how social reality structures itself in a person’s immediate consciousness, and their experience of it. By applying Schutz’s (1967) concept of verstehen or interpretive understanding the study was placed in the context of human beings acting and interacting with emphasis on the individual’s motivations and meanings. The subjective experiences, as described by individuals, form the first order constructs (Schutz 1967). The researcher is able to construct a second order of understanding by describing ‘ideal types’ (Schutz 1967) that interpret and describe the phenomenon under investigation, in this case performance feedback. Focus groups were chosen as an appropriate data collection method to stimulate discussion and ascertain the nursing clinician’s perspective of the utility of performance feedback. The group technique was chosen to encourage both individual and shared
The role of performance feedback in the self-assessment of competence: A research study with nursing clinicians
accounts of ‘reality’, which were more likely to be discussed in greater depth when explored in a group interview format (Frey & Fontana 1993). Purposeful sampling of information-rich cases was adopted to select participants for the focus groups (Rice & Ezzy 1999). Participants within the groups were from the same work area to allow for participant comfort and maximum, uninhibited discussion (Krueger & Casey 2000). Nursing clinicians participating in the study fulfilled the criteria of nurses working in clinical areas of a hospital who did not have a role as an identified manager. All participants in the study were Registered Nurses and/or Midwives Level 1 / Division 1. For the study they are referred collectively as nursing clinicians. Two private and one public hospital were selected to participate in the study. Ethics approval was obtained from the University Human Ethics Committee and from each hospital individually. Participation was voluntary, without financial reimbursement, and discussions were audio-taped with the informed consent of each participant. For this part of the study a total of seven nursing clinician focus groups were held between the hospitals totalling 26 participants over a period of five months. A short questionnaire was completed by each participant to collect demographic data. For nursing clinicians, the demographics collected included area of nursing work and years of nursing experience. Three nursing clinical groups were represented; midwifery, general surgical and general medical (including palliative care). Several of the nurses worked in all three areas, and two were employed on a casual basis. The participants’ level of nursing experience varied. For the purpose of analysis a less experienced nursing clinician was one with less than 4.5 years post-graduate experience as the next grouping of nurses (more experienced nurses) was from 11-35 years of postgraduate experience. Structured, open-ended questions explored the following issues: • sources of feedback identified by participants; • rating of these sources according to usefulness for the nurse’s own performance evaluation; and • the impact and changes in performance that resulted from feedback. At the conclusion of the session, the researcher summarised the discussion for verification by the group and provided the opportunity for correction. Only one interview was conducted with each group as participants expressed this was the level of participation they were willing to commit. Data analysis involved the group discussions being transcribed verbatim (excluding identifiable data of any person). The data were then thematically coded by incorporating the inductive method of data-driven codes (Boyatzis 1998), and the application of a template of codes, as outlined in the deductive approach of Crabtree and Miller (1999). The template of codes was derived from the work of Schutz (1967).
Performance feedback The term ‘feedback’ in the literature is applied over a broad spectrum of intended meanings. The term is based on the broad concept that describes the adjustment of a process following information about the effects produced (Yalom 1995). The application of the
concept of feedback to studies in human relations is generally attributed to the work of Kurt Lewin in the 1940s (Schein & Bennis 1965; Torbert 1972; Yalom 1995). Learning processes may be activated when feedback highlights a discrepancy between the standard of performance required and actual performance (Kluger & DeNisi 1996). Performance feedback as a staff development mechanism has the potential to motivate behaviour, contribute to self-awareness, provide a path for career development, and improve both work relationships and the overall quality of work performance for employees (Kramar et al 1997; London 1997; Hulett 2002). In the nursing literature, feedback on performance is commonly equated with the formalised processes of performance appraisals, reviews or management systems (Huber 2000; MarrinerTomey 2000; Yoder-Wise 2003). In contrast to these formalised written processes, informal discussions and sharing of experiences with colleagues during day-to-day activities may provide feedback to individuals or groups on their work performance. The common denominator for both formal and informal processes of performance feedback involves the measurement of performance against expectations. These can be in the form of a nurse’s personal expectations or expectations set by others. Performance can also be guided by a set of standards, either professionally based, for example, Australian Nursing Council competencies (ANC 2002), or specified by the organisation, for example, a position description. Performance feedback involves an evaluation process of gathering information regarding a person’s performance, making a judgment about the person’s ability and then delivering this judgment to the person concerned. Performance feedback explored in this study is defined as information provided to employees about how well they are performing in their work role. This may be a formal and/or informal feedback process but the focus of this paper is on feedback in relation to continuing competence and is not linked to an ongoing disciplinary procedure.
Self-assessment of competence The self-assessment of competence is often one step in the formal process of an annual appraisal within nursing (Huber 2000, Marriner-Tomey 2000, Yoder-Wise 2003). This step involves the individual rating their own performance against set criteria which is then reviewed by another person as part of the appraisal process (commonly the manager of the area). However, competence is a complex term and has remained equivocal in the nursing literature over the past decade (Girot 1993; While 1994; Bradshaw 1997; Bradshaw 1998; FitzGerald et al 2001; Meretoja, Eriksson & LeinoKilpi 2002; Watson et al 2002). Inevitably, difficulties can arise when one is required to assess a nebulous concept, and no single method is recommended to assess continuing competence within nursing. Rather, a multi-method approach is often recommended (Pearson et al 2000; FitzGerald et al 2001; Redfern et al 2002). Competence is succinctly defined by NBSA (2000 p 8) as ‘the ability to do something well and effectively’. Competence is also defined within the nursing profession as a ‘combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/occupational area’ Collegian Vol 13 No 1 2006
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(ANC 2000 p1). Competence within nursing in Australia is defined in terms of outcome standards. Minimum competency standards include those specified for registered nurses and enrolled nurses (ANC 2002), although professional nursing organisations have adapted them for their particular scope of practice. The term ‘continuing competence’ is the ability of nurses to demonstrate that they have maintained their level of competence within their scope of practice (NBSA 2000). This study has adopted the description of self-assessment of competence outlined in the Australian Nursing Council policy on continuing competence (ANC 2000), that is, an ongoing process whereby nurses examine their practice against national competency standards accepted by the nurse regulatory authorities for registration. It is the outcome of the ongoing process of self-assessment that is called upon as evidence by nursing regulatory authorities and organisations employing nurses. The process may include formal and/or informal performance feedback, which nurses may use to evaluate their practice to ensure competence is maintained and ideally to improve upon their practice.
Findings of the study Themes generated from the coded transcripts of the focus group discussions identified that nursing clinicians evaluated their own level of competence through a process of self-assessment often relative to the immediate requirements of the situation. The following themes support the concept that competence or an ability to act safely in a situation was ‘assumed’ by nursing clinicians on a daily basis. When they encountered a situation that raised ‘doubt’ or uncertainty in their level of competency, this triggered the active process of seeking external feedback generally for assistance. These key findings, that underpin the utility of feedback from the nursing clinicians’ perspective, are illustrated in the following coded themes.
Theme 1: Performance feedback is needed for positive reinforcement and affirmation Nursing clinicians, not surprisingly, expressed their preference for receiving positive feedback to reinforce feelings of competence. Feedback comments and actions were sometimes delivered indirectly, for example, being asked to assist someone else: They’re trusting you with a problem and therefore saying that you are competent in that field. (Focus group 3)
For casual staff their level of competence was implied by being asked to work in areas requiring specialised skills: They’re ringing me up asking me to do the work, they must realise I’m capable of doing the work because I’m going to areas like labour ward, neonates and ICU. If my performance wasn’t up to scratch I wouldn’t be receiving the phone calls. (Focus group 5)
However, nursing clinicians also expressed a need for direct, positive comments to increase feelings of satisfaction and provide a motivational force: It would be good if you could have some sort of feedback all the time, you know ‘thanks for a great job’ ... ‘thanks for doing that, that was great I know you had a terrible day’ … you just don’t get that. (Focus group 2) 12
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You would like to have feedback from your peers or your manager telling you ‘you did a good job’ because that sort of gives you the boost to sort of keep on a positive note for the rest of the week. (Focus group 1)
Positive feedback was often referred to as receiving recognition for a job ‘well done’. As two nurses explained: Because as human beings we all like that sort of positiveness (sic). (Focus group 3) She (the clinical manager) is quite affirming ... if it’s been a difficult situation she’ll put a note in the communication book thanking us all. (Focus group 2)
The idea of feedback providing a moral boost once again implied that competence is assumed and feedback provided positive reinforcement. Feedback from peers was especially noted as useful by participants: Often you will hear another RN say ‘that was really well done’. (Focus group 7) But if I was to get a warm fuzzy from (name of peer) like ‘Oh you handled that well’ or something that would mean the world to me. (Focus group 4) I think you can appraise yourself from comments from your coworkers. (Focus group 3)
Positive comments from medical staff were rare and thought of as a ‘bonus’ by nursing clinicians. Feedback from patients was important to nursing clinicians and was described as a ‘warm fuzzy’. Once again, feedback from patients generally affirmed the competence of nursing staff: You know you’re doing a good job as a nurse when the patient will make a comment. (Focus group 1)
Feedback was sometimes in the form of a gift or card, but mostly it was implied by patients’ comments to the nurse: When are you on again? (Focus group 7) Are you going to be back tonight? (Focus group 4)
Competence was often assumed until a nurse received feedback to the contrary. In a situation where a nurse was assessed as not performing at the level of competence expected, and was not personally aware of this, then delaying or omitting to provide any feedback was significant in terms of perpetuating potentially unsafe practice.
Theme 2: Performance feedback that is lacking or delayed leads the receiver to assume competence Lack of feedback was an issue of concern that was raised in the focus groups. No feedback supported the notion of assumed competence, as indicated in the following comments: We assume that we are doing okay unless something to the contrary is brought up. (Focus group 4) You only get feedback if you do something wrong. (Focus group 6) I haven’t heard any complaints so far so I only assume it is all good. (Focus group 7) RN1: They (managers) are too busy to let you know. RN2: Perhaps they just think you know that you’re good. (Focus group 6)
A lack of feedback became problematic for nursing clinicians if an issue was raised at a later date and the nurse felt feedback should have been provided closer to the time of the incident or when a problem was noticed. This delay in feedback was a source
The role of performance feedback in the self-assessment of competence: A research study with nursing clinicians
of grievance, expressed most clearly by less experienced nurses and became an issue of an individual’s right to receive feedback on poor performance. How have they got the right to complain if they’re not telling you what is wrong. (Focus group 7) If something was wrong I’d need to be picked up before now. (Focus group 4) I mean you expect that if something goes astray your managers will say something. (Focus group 3)
Nursing clinicians expressed an expectation that any problem arising in relation to their performance should be fed back to them without delay. Furthermore they believed it was unacceptable for this type of feedback to be postponed for the annual appraisal. Problems also arose when an appraisal or performance feedback had been provided but there was no follow-up. The entire process was thus undermined and, once again, the nursing clinician assumed they were performing at a satisfactory level.
Theme 3: Nursing clinicians perceived the formal performance review system as an imposition Nursing clinicians strongly viewed the performance appraisal system as a management-driven organisational requirement. They understood the necessity of completing an annual appraisal as a condition of their employment and that the consequences of not participating would result in a violation of their employment contract possibly leading to disciplinary action, even dismissal. In the focus group discussions the nursing clinicians described the formal performance appraisal process in terms of an imposition. The need to complete an annual appraisal form was viewed by many as ‘going through the motions’ as evidenced by the following comments: Annual appraisal is like a little animal that raises its head once a year, you’ve got to put the rubbish down on paper to make it look good so you can send it off. (Focus group 4) The ones we do here we all go ‘oh God not again’. (Focus group 1)
Clearly such complacency has inherent risks in utilising a performance appraisal as an indicator of nursing competence. The following comments indicate the questionable value of a process of self-assessment required as part of a traditional performance appraisal: This is what they want to hear, this is what they want to know, just pop it in, they’ll sign it off and it’s done…………… it’s not showing them at all what I’ve learnt. (Focus group 7) The worst part is you have to put an objective for the next year and you sort of think I’ve been putting to do a palliative care course for fifteen years. (Focus group 1)
These comments are also indicative of the nursing clinicians’ perception that undertaking a process to ensure competency was irrelevant when they already believed themselves to be competent. The following theme highlights situations when nurses were more receptive to receiving feedback on their performance.
Theme 4: The need for feedback is greater if a person’s ability is doubted At times nursing clinicians themselves, or other people, raised doubts or feelings of uncertainty in the nursing clinician’s ability
to reach a level of competence that was deemed acceptable. Doubts were most often raised when nursing clinicians faced unfamiliar situations. Participants described situations where they felt more confident to actively seek feedback from more experienced peers working within the clinical setting. Learning or validating a new procedure commonly facilitated a request for support and feedback: If I was feeling that uncertain I would want another RN there whom I knew had the experience and the skills to get me through that. (Focus group 1) We have been here for so many years you sort of know, you’re familiar with all the different scenarios that happen in labour ward and whatever and if there is something that’s just a bit different, well you ask and you question and you query. (Focus group 3) ... some sense of where I feel incompetent or a little bit less confident you can actually go and ask somebody, a peer or the manager. (Focus group 2)
When a situation of doubt did arise, nursing clinicians often sought feedback to allay their concerns and/or to rectify a problem. On these occasions feedback was felt to be relevant and therefore was often actively sought. Most nursing clinicians indicated they didn’t seek feedback unless they felt unsure about a situation and required some advice or the expertise of another nurse: At particular times you do, on the whole most people are fairly comfortable but we have had some situations where we have sought to find out if we did okay. (Focus group 2) If you find yourself having to do a new procedure or something you haven’t done very often, you would get somebody that you worked with to assess you. (Focus group 1)
Feedback was most often required ‘to get the job done’ and the perceived relevance or utility of the feedback was relative to the context of the situation. The following section discusses the utility of feedback when the individual did not perceive an immediate need for seeking assistance. Feedback, in this situation, potentially provided a stimulus for self-reflection.
Theme 5: Listening to the experiences of others triggers a process of self-reflection Opportunities for peer discussions motivated nurses to reflect on their own performance. This situation was evident during a discussion about the value of shift handover as a feedback session: People discussing things in that perhaps you sort of reflect on it and think oh gee did I do it that way. (Focus group 7) I’ll reflect on, say perhaps over handover or something that has been said, and I think I didn’t see that or I didn’t do that. (Focus group 2) It (handover) sort of gives you a bit of a prompt to think oh well that is a good idea, maybe I should think more about doing it better in that area myself. (Focus group 7)
Debriefing an incident as a group also had benefits, by triggering a process of reflection, as described by one participant: It might not be anything that is pertinent to you at the moment but later on you go away and think about it and think it could have been me. (Focus group 3)
When discussing an emergency situation that had occurred recently, a nursing clinician stated that no opportunity to debrief was a disadvantage: I needed to know if I did okay in that [emergency situation], I’m in absolute limbo now and I still think about it now and think what could have I done. (Focus group 7) Collegian Vol 13 No 1 2006
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Other group members supported her comments and expressed debriefing was necessary ‘especially with something you haven’t experienced before’. Not having opportunities for discussion and debriefing often resulted in nurses leaving work thinking ‘could I have done things better’, and in this situation, doubt could become a destructive emotion as opposed to a catalyst for seeking feedback.
Discussion Themes generated from the focus group discussions support the premise that nursing clinicians in this study constantly engaged in a process of self-monitoring their own performance. This process is similar to that of self-regulated learning (Butler & Winne 1995; Winne 1995a; Winne 1995b) when the individual engages in a process of self-monitoring using internal and external feedback paths. The principles of self-regulated learning are applicable to this study, as nursing clinicians were able to detect variance in their own performance through a process of self-monitoring. For many nurses, especially those with more situational experience in a clinical area, this process became automated and involved being able to recognise the need for additional knowledge and skills based on a self-assessment. Feedback in this context is viewed as a personal resource that individuals actively monitored and then selected when relevant to the situation. The pragmatic motive for seeking or receiving feedback is a concept that accords with Schutz’s belief that people in everyday life are oriented to achieve practical outcomes (Schutz 1967). From the findings of this study, the general attitude within the working world of nursing clinicians was to assume a level of competence to fulfill their role of patient care which formed the baseline of their assessment of continuing competence. This assumed level of competence was affirmed by positive feedback, both formal and informal, and by the absence of feedback to the contrary. A positive assessment of self-competence, in turn, increases feelings of self-efficacy and self-esteem (Bandura 1997). When experiencing high levels of confidence in their ability, overall nursing clinicians were less receptive to feedback that was contrary to their self-assessment. However, a level of competence that is taken for granted has the potential and capability to be questioned. Situations were described by participants when doubts were raised and nursing clinicians either questioned their own level of competence or others raised their concerns. Feedback messages have the potential to raise the level of awareness, often expressed as feelings of uncertainty, in relation to performance. At this time the nursing clinician was most receptive to feedback from others, an important implication for those providing feedback. From these findings the key recommendation from the study is the need to stimulate self-awareness through providing opportunities for feedback and professional reflection at work. This recommendation was initially founded on the dynamics of the focus group discussions. At the commencement of the focus group discussions the nursing clinicians had a generalised, rather narrow, view of what feedback they were currently receiving in the clinical environment. All responded with ‘performance appraisals’ as the most significant source of feedback they received on their 14
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performance; a method of assessment also heavily criticised by many participants. It was evident during the focus groups that the process utilised by nursing clinicians to measure their own competence to practise, and the sources of feedback that assisted this process, were not issues they had considered in detail. The open-ended questions asked during the focus groups triggered a process of self-reflection. Evolving discussion amongst group members demonstrated their increasing level of insight into the role other sources played (patients, peers, task-related feedback) and the important role of their own self-assessment. The researcher believes the process of conducting the focus group discussions was similar to the process that underpins facilitated or guided reflection groups as a method of professional development (Donaghy & Morss 2000; Johns 2002; Yearly 2003). Involvement in guided reflection groups is considered a legitimate continuing professional development activity in the United Kingdom (Yearly 2003). The nursing clinicians in this study highlighted the benefits of informal feedback that occurred during work discussions with peers and clinical managers. Both shift handover and debriefing sessions provided opportunities for vicarious learning from the actions of others who shared similar experiences within the clinical environment. This comparative method of feedback was felt to be non-threatening, and provided a stimulus for reflection on work practices. This type of professional networking allowed nurses to actively seek feedback or to be passive recipients of feedback provided to others. Sharing the experiences of patient care was seen as an opportunity for nurses to validate their current practice or question their practice. This latter reflection introduced a level of doubt that encouraged further receptiveness to feedback from others. In conclusion, findings demonstrate that opportunities for professional reflection were either diminishing or no longer offered in hospitals. One group of nursing clinicians reported feeling despondent that critical clinical situations on the ward were no longer followed up by debriefing sessions. The use of taped handovers and staggered shift times also reduced the opportunity for face-to-face interaction at a time of shift handover. These situations are notable deficits in the current hospital system, especially in view of this study’s findings that highlight the importance of strengthening all opportunities for individuals to receive and reflect on feedback to inform their ongoing self-assessment of competence. The challenge now is for organisations to provide opportunities for facilitated reflection to stimulate the process of self-assessment and professional interaction and to incorporate this process into the design of performance review systems. References Australian Nursing Council 2000 Position statement: Continuing competence in nursing. Retrieved 14 April 2004 from World Wide Web: http://www.anc.org.au/02standards/_docs/Positions/Contin_comp.pdf ANC (Australian Nursing Council) 2002 National competency standards for the registered nurse and the enrolled nurse, 3rd edn. Australian Nursing Council, Canberra Bandura A 1997 Self-efficacy – The exercise of control. W H Freeman, New York Boyatzis R 1998 Transforming qualitative information – Thematic analysis and code development. Sage Publications, California Bradshaw A 1997 Defining ‘competency’ in nursing (part 1): a policy review. Journal of Clinical Nursing 6: 347-354
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Bradshaw A 1998 Defining ‘competency’ in nursing (part II): an analytical review. Journal of Clinical Nursing 7: 103-111 Butler D, Winne P 1995 Feedback and self-regulated earning: a theoretical synthesis. Review of Educational Research 65(3): 245-281 Crabtree B, Miller W 1999 A template approach to text analysis: developing and using codebooks. In: Crabtree B & Miller W (eds) Doing qualitative research. Sage, Newbury Park Donaghy M, Morss K 2000 Guided reflection: a framework to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice 16: 3-14 FitzGerald M, Walsh K, McCutcheon H 2001 An integrative systematic review of indicators of competence for practice and protocol for validation of indicators of competence. Commissioned by Queensland Nursing Council Frey J, Fontana A 1993 The group interview in social research. In: Morgan D (ed) Successful focus groups – advancing the state of the art. Sage Publications, California Girot E 1993 Assessment of competence in clinical practice: a review of the literature. Nurse Education Today 13: 83-90 Huber D 2000 Leadership and nursing care management. W.B. Saunders, Philadelphia Hulett K 2002 An honest evaluation. Advisor Today March: 86 Johns C 2002 Guided reflection: advancing practice. Blackwell Publishing, Oxford. Kluger A, DeNisi A 1996 The effects of feedback interventions on performance: a historical review, a meta-analysis, and a preliminary feedback intervention theory. Psychological Bulletin 119(2): 254-284 Kramar R, McGraw P, Schuler R 1997 Human resource management in Australia, 3rd edn. Longman, Melbourne Krueger R, Casey M 2000 Focus groups – a practical guide for applied research, 3rd edn. Sage Publications, California London M 1997 Job feedback: giving, seeking, and using feedback for performance improvement. Lawrence Erlbaum, New Jersey Marriner-Tomey A 2000 Guide to nursing management and leadership 6th edn. Mosby, St Louis Meretoja R, Eriksson, Leino-Kilpi H 2002 Indicators for competent nursing practice. Journal of Nursing Management 10: 95-102
NBSA (Nurses Board Of South Australia) 2000 Your Practice, Continuing Competence and Self-Regulation. Nurses Board of South Australia, Adelaide Pearson A, FitzGerald M, Borbasi S, Walsh K, Parkes R, Lazarrevic, L 2000 A study to identify the indicators of continuing competence in nursing: final report January 1999. Commissioned by Australian Nursing Council Inc Redfern S, Norman I, Calman L , Watson R, Murrells T 2002 Assessing competence to practise in nursing: a review of the literature. Research Papers in Education 17(1): 51-77 Rice P, Ezzy D 1999 Qualitative research methods – a health focus. Oxford University Press, Melbourne Schein E, Bennis W 1965 Personal and organizational change through group methods: the laboratory approach. Wiley, New York Scheiwe D 1998 The Australian nursing profession. In: Clinton M, Scheiwe D (eds) Management in the Australian health care industry. Longman, Australia Schutz A 1967 The phenomenology of the social world, G. Walsh and F. Lehnert, trans. North Western University Press, Illinois Translation of Der sinnhafte Aufbau der sozialen Welt 1932 Torbert W 1972 Learning from experience – toward consciousness. Columbia University Press, New York Watson R, Stimpson A, Topping A, Porock D 2002b Clinical competence assessment in nursing: a systematic review of the literature. Journal of Advanced Nursing 39(5): 421-431 While A 1994 Competence versus performance: which is more important? Journal of Advanced Nursing 20: 525-531 Winne P 1995a Inherent details in self-regulated learning. Educational Psychologist 30(4): 173-187 Winne P 1995b Self-regulation is ubiquitous but its forms vary with knowledge. Educational Psychologist 30(4): 223-228 Yalom I 1995 The theory and practice of group psychotherapy 4th edn. Basic Books, New York Yearly C 2003 Guided reflection as a tool for CPD. British Journal of Midwifery 11(4): 223-226 Yoder-Wise P 2003 Leading and managing in nursing 3rd edn. Mosby, St Louis
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