Measuring Nursing & Midwifery Competence: Can it be measured and how should it be measured? Confidence in competence: Opening Pandora s Box Plenary Address 35 th Annual International Nursing & Midwifery Conference RCSI, Dublin, 3 March 2016 Associate Professor Rachael Vernon, RN, PhD Associate Head of School (Academic) School of Nursing and Midwifery University of South Australia Fulbright (NZ) Alumnae, CNA(NZ), STTI
Acknowledgement of Co-researchers Dr Elaine Papps RN PhD School of Nursing Eastern Institute of Technology New Zealand Professor Mary Chiarella RN LLB(Hons) PhD Sydney Nursing School The University of Sydney Australia Builds on three previous studies: Evaluation of the Continuing Competence Framework (Vernon, Chiarella, Papps & Dignam, 2010) International consensus model for the assessment of Continuing Competence (Vernon, 2012) Relationships between legislation, policy and continuing competence requirements for RNs in New Zealand (Vernon, 2012)
Confidence, competence and continuing professional development
Historical overview (NZ) Nurses Act 1977 and amendments previous legislation regulating nurses Stemmed from Nurses Act 1901 (NZ) concerned with public safety - Silent on competence (Papps, 2002; Burgess, 2008) Referred to fitness and properness infers suitability rather than capability Competence not defined in the Act judgement by the Nursing Council Health Practitioners Competence Assurance (HPCA) Act 2003 to protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practise their professions (HPCA Act, 2003, s1). Defines what constitutes competence, fitness to practise and quality assurance Requires Regulatory Authorities to stipulate processes to ensure continuing competence (HPCA Act, 2003, s26-29)
Historical overview (AU) National competency standards first adopted by ANMC in early 1990s ANMC worked in conjunction with national state and territory authorities (NMRAs) National legislation - Health Practitioner Regulation National Law 2009 (Qld), came into effect 1 July 2010 Health Practitioner Regulation National Law (South Australia) 2010 Australian Health Practitioner Regulation Agency (APHRA) - supports the national boards to implement the National Scheme NMBA (31/08/09) Responsible for regulation of nurses & midwives in Australia; ownership of the national competency standards ANMAC (24/11/10) Independent accrediting authority for nursing & midwifery professions under the National Scheme Continuing competence is a requirement stipulated in the National Law.
Health Practitioners Competence Assurance (HPCA) Act 2003 NZ Enacted 18 September 2004 Omnibus legislation covering fifteen health professional groups Repealed 11 separate statutes relating to 13 individual regulatory authorities Specified the legislative function of the regulatory authorities Established a multi-disciplinary professional conduct committee and Health Disciplinary Tribunal
The required standard of competence is defined as... the standard of competence reasonably to be expected of a health practitioner practising within that health practitioner s scope of practice (HPCA Act, 2003, s5(1)) Compliance of the individual nurse with the CCF requirements is mandatory NCNZ has the authority to decline to issue an APC if the applicant has failed to meet the required standard of competence failed to comply with condition failed to comply with conditions not held an APC (or practised) for three years preceding application (HPCA Act, 2003, s27(1a))
Continuing Competence Frameworks Principle function quality assurance mechanism Promotes consistency of competence standards and assessment processes Regulatory tool that facilitates the assessment and monitoring of the continuing competence of the profession, and as such they have a role in assuring and ensuring public safety Ensures consistency in the monitoring of continuing competence annual basis Demonstrates to public that the nursing profession is cognisant of / has mechanisms to assess the competence and continuing competence of the profession
NCNZ Continuing Competence Framework CCF regulatory tool that sets the standards for competence and competence assessment Ensures consistency in the monitoring of continuing competence annual basis Has a clear role in terms of public protection Combination of competence indicators Self assessment / self declaration Hours and recency of practice Hours of continuing professional development / education
Competence is defined as the combination of skills, knowledge attitudes, values and abilities that underpin effective and/or superior performance in a profession/occupational area and context of practice (Nursing & Midwifery Council, 2009). the combination of skills, knowledge attitudes, values and abilities that underpin effective performance as a nurse (Nursing Council of New Zealand, 2007).
Practice is defined as Using nursing knowledge in a direct relationship with clients or working in nursing management, nursing administration, nursing education, nursing research, nursing professional advice or nursing policy development roles, which impact on public safety (Nursing Council of New Zealand, 2010). Any role in which the individual uses their skills and knowledge as a nurse and/or midwife. For the purpose of the registration standard, practice is not restricted to providing direct clinical care. It also includes working in nonclinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession and/or use their professional skills (Nursing & Midwifery Board of Australia, 2014).
International comparison CC Frameworks (2012) Australia Nursing and Midwifery Board of Australia (National Legislation and National Framework) Canada Canadian Council of Registered Nurse Regulators (CCRNR 2011) (Incorporated Federated model - National principles - no National Framework) Revalidation of registration annually Maintain a professional portfolio Formal self-declaration of competence annually Practice must have practised in previous 5 years or completed return to practice programme statutory declaration from individual or employer indicating hours spent in practice Continuing Professional Development (CPD) minimum of 20 hours annually 2% Audited Annually National legislation, Health Practitioner Regulation National Law 2009 (Qld). Continuing competence is a regulatory requirement stipulated in the Act. Annual revalidation of registration Self-declaration including self-assessment Continuing education (CE) annual requirements o Report of CE activities and evaluation of learning needs o Development of a learning plan, report on previous plan o Peer feedback / review meetings Practice minimum of 1,125 hours in previous 5 years *Requirements vary between the legislative jurisdictions - General principles of the CNA implemented in each province *No Audit % stated Separate legislation by Province i.e. Health Professions Act 2009(BC). Continuing competence is a regulatory requirement stipulated in the Act.
New Zealand Nursing Council of New Zealand (NCNZ) (National Framework) United States of America National Council of State Boards of Nursing (NCSBN, Council of regulators - Incorporated Federal Model) (National Principles requirements vary across States /Territories United Kingdom Nursing and Midwifery Council (NMC) (National Framework) Annual recertification of practising certificate maintain a professional portfolio Self-declaration (self-assessment against practice standards, domains and competencies) o Practice - minimum of 450 hours (60 days) in previous 3 years o Professional Development minimum of 60 hours in previous 3 years o Physically and mentally able to perform in the role of a nurse *5% Nurses audited Annually National legislation, Health Practitioners Competence Assurance Act 2003 (NZ). Continuing competence is a regulatory requirement stipulated in the Act. Annual revalidation of registration models vary significantly between States. Indicators include Self-declaration, including self-assessment of competence Declaration of criminal convictions, physical, mental, and drug related issues that affect the ability to provide safe effective nursing care. Continuing Education credits Practice hours *Audit requirements exist in some States Risk based approach in some Separate legislative jurisdictions/regulatory Boards in each State/Territory. Mutual recognition agreements some States. Renewal of registration every 3 years (certification of practise). Annual fee Maintain professional portfolio Self-declaration complied with all Prep standards and signed notification of practice or intent to practice o Prep practice standard - minimum of 450 hours in previous 3 years or undertaken approved return to practice programme o Prep Continuing Professional Development (CPD) standard - in previous 3 years *No Audit % stated Risk based approach One regulatory council (NMC) National legislation, The Nursing and Midwifery Order, 2001 (UK), but separate legislative jurisdictions in each country i.e. Scotland, Northern Ireland, Wales, England, Guernsey, Jersey, Isle of Man, Gibraltar, Falkland Islands etc.
International Consensus The purpose of nursing regulation is protection of the public, in many countries it is a legislative mandate Public right to expect that RNs are competent Similarities in legislative requirements, role and purpose of Regulatory Authorities in Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America Education and practice standards for RNs are similar between the five countries Strong similarities in definitions of competence and continuing competence exist Similarities in models for assessment of continuing competence
Consistency between the indicators of competence, continuing competence and assurance of public safety Most common 'competence' indicator: Examination Most common 'continuing competence' indicators: CPD, Practice Hours, Self Declaration, Self/Peer Evaluation Issues of validity, reliability and efficacy within and between models, and indicators of continuing competence Competence is influenced by an individuals - behavioural and attitudinal traits Variation in distinction between core and higher levels of competence, and the impact of behaviours i.e. ethical comportment and insight
Consensus: Responsibilities RNs as registered health professionals are: responsible, accountable, ethical, competent and committed to lifelong learning and nursing practice Individual RNs are responsible and accountable for: ensuring their own continuing competence, relevant to the required practice standards, code of conduct, and practice setting Employers and employment settings have a responsibility and role in facilitating and ensuring that their registered nurse workforce is, and continues to be, competent and complies with regulatory requirements i.e. current validation / licensure / certification
Consensus : Best Practice Model Guiding Principles Common language Lexicon of terminology Best practice Continuing Competence Framework Mandatory assessment linked to: annual revalidation/ relicensure/recertification and indicators of CC Self-Assessment / Peer Assessment Mandatory Practice hours (specified number/timeframe) Mandatory Professional Development hours (specified number/timeframe) Annual audit of % of practising population CCF must be flexible, adaptable, administratively feasible, financially viable, and publically defensible
Common indicators of competence Continuing Professional Development (CPD) Hours of practice (recency of practice) Self-assessment against the competencies Three indicators are not a guarantee of competence Missing thread - competence awareness or insight
Framework for assessing competency standards Important measure to ensure initial and continuing competence of nurses and midwives Guides assessment of competence against NMBA national competency standards for ENs, RNs, NPs & MWs Assessment principles Accountability Performance based assessment Evidence based assessment Validity & reliability Participation & collaboration Critical issues Accountability / responsibility Includes - knowledge, skills & attributes Context Professional judgement, recognition of cues Impartiality, confidentiality, communication
Continuing Professional Development (CPD) Variation in understandings of what constitutes CPD Lack of understanding of how to articulate / demonstrate CPD Limited / lack of engagement in CPD Influenced by individuals' - behavioural and attitudinal traits, attitudes and beliefs Systems and operational influences Active engagement in CPD assures continuing competence to practise however does not ensure public safety
However It is difficult to ascertain how either CPD or indeed recency of practice can assure competence. For example, is there any link between a person who attends a lot of lectures and a person who is competent? Clearly there are people who complete their requisite CPD and practice requirements but are found to be unsafe to practise. Indeed it is difficult to be certain that continuing competence can be assured. For example, just because a health practitioner performs competently during one assessment of competence, will they perform competently the next time they undertake the same skill?
Relationship between CPD and Competence Competent Evidence of Sufficient CPD Sufficient CPD Competent NO PROBLEM No Evidence of Sufficient CPD No CPD NO PROBLEM they will be picked up but they are not dangerous Not Competent Sufficient CPD Not Competent PROBLEM Won t get picked up as they will meet renewal requirements but are not safe No CPD Not Competent POTENTIAL PROBLEM Should be picked up through lack of CPD (Chiarella and White, 2013)
Can competence be measured and how should it be measured? Perhaps the important aspect of competence assessment and CPD is not necessarily the assurance of competence, but rather an individuals heightened sense of self-awareness of risk and the ability to reflect on their own competence. Reviewing our practice against the competency standards or standards for practice cannot guarantee that we will always be competent. However nothing can. Perhaps it is more important that we are aware of our limitations and strengths and are able to measure these against the requirements of a given situation at a given time, and Perhaps it is more important that we are aware of our level of competence or indeed incompetence in any given situation.
Questions Comments?
References Adrian A & Chiarella M (2010) Professional Conduct: a casebook of disciplinary decisions relating to professional conduct matters (2nd Ed) Nurses and Midwives Board of New South Wales: Sydney. Australian Nursing and Midwifery Accreditation Council (2012)National accreditation guidelines [Online] Accessed on 13 th August 2012 at http://www.anmac.org.au/accreditation/nationalaccreditation-guidelines Chiarella, M., & White, J. (2013). Which tail wags which dog? Exploring the interface between professional regulation and professional education. Nurse Education Today, 1-5. doi: 10.1016/j.nedt.2013.02.002 Health Practitioner Regulation National Law 2009 (Qld) International Council of Nurses and World Health Organisation (2005). Nursing Regulation: A Futures Perspective, Geneva. Accessed 24 February 2009, http://www.icn.ch/ps_icn_who_regulation.pdf. NMBA (adopted 2010) National framework for the development of decision making tools for nursing and midwifery practice (original publication ANMC 2007) [Online] Accessed 13 th August 2012 at http://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/codes-gui.aspx Nursing Council of New Zealand. (2010). Nursing Council of New Zealand - Definition of Practising. Retrieved 9 March 2010, from http://nursingcouncil.org.nz/nurses/continuingcompetence
Nursing Council of New Zealand. (2010). Nursing Council of New Zealand - Definition of Competence. Retrieved 27 May 2012, from http://nursingcouncil.org.nz/nurses/continuingcompetence Vernon, R. (2014). Vernon, R. (2014). Competent or just confident? Nursing Review, series 2014, 18. Vernon, R., Chiarella, M., & Papps, E. (2013). Assessing the continuing competence of nurses in New Zealand. Journal of Nursing Regulation, 3(4), 19-24. Vernon, R. (2013). Relationships between legislation, policy and continuing competence requirements for Registered Nurses in New Zealand. Doctor of Philosophy Thesis, University of Sydney. Vernon, R., Chiarella, M., Papps, E., & Dignam, D. (2012). New Zealand nurses' perceptions of the continuing competence framework. International Nursing Review, 60(1), 59-66. Advance online publication, (2012), doi: 10.1111/inr.12001. Vernon, R., Doole, P., & Reed, C. (2011). Where is the international variation in the protection of the public? International Journal of Nursing Studies, 49(2), 243-245. Vernon R., Chiarella M. & Papps E. (2011) Confidence in competence: legislation and nursing in New Zealand. International Nursing Review, 58, 103 108. Vernon, R., Chiarella, M., Papps, E., & Dignam, D. (2010). Evaluation of the Continuing Competence Framework. Wellington, New Zealand: Nursing Council of New Zealand. ISBN 978-0-908662-34-0 http://nursingcouncil.org.nz/publications/reports