Wednesday, 25 February 2015

Commentary: Relevance of competence and competencies to nursing

Sally Lima1, Fiona Newall1, Sharon Kinney1, Helen Jordan2, Bridget Hamilton2
1Royal Children’s Hospital Melbourne, Australia
2University of Melbourne, Australia

Commentary on O’Connell J. Gardner, G. & Coyer F. (2014) Beyond competencies: using a capability framework in developing standards for advanced practice nursing. Journal of Advanced Nursing 70(12), 2728-2735


The debate about the relevance of competence and competencies to the nursing profession has been going on for decades. On one side are those who argue competencies have no place in the professions, relevant only for vocational training. On the other side are those who support a broader conceptualisation that can be applied to all levels of training, education and practice. The recent paper by O'Connell et al. (2014) has added another perspective suggesting that competencies, while relevant to undergraduate nursing education and beginning practice, are not appropriate for advanced practice nursing. Instead they recommend the use of a capability framework for the development of advanced nursing standards.

In beginning their discussion, O'Connell et al. (2014) describe competence as a nebulous concept, with varying definitions. Without question the literature is replete with discussion papers on the meaning of competence and its value to nursing. In his discussion of competence, Eraut (1998) states ‘those who like a tidy world will be disappointed’ (p. 127). Rather than avoid or complicate the issue, Eraut (1998) proposes the most worthwhile discussions about competence occur when there is clarity around why the word is being used, the issues that are being addressed and the assumptions that are being made.

O'Connell et al. (2014) are quite clear that their conceptualisation of competence relates primarily to the ability to perform clinical skills in a stable environment. Heywood et al. (1992) refer to this as a behaviourist approach to competence. In this context, competencies, in effect, are tasks in which there can be no disagreement as to what is required. O'Connell et al. (2014) argue that nurses in advanced practice roles do not function according to a prescribed list of tasks, but instead, incorporate cognition and recognition of context in complex environments to inform practice. O'Connell et al. (2014) claim there is a necessity to move beyond competencies to capabilities, particularly when developing standards in advance nursing practice. Heywood et al. (1992) refer to this as an attributes based approach to competence. From an attributes based perspective, competence represents one’s potential to perform (Watson et al. 2002), or what one is capable of (Eraut 1998).

The assumptions inherent in O'Connell et al. (2014) argument is that advanced practice nurses go beyond competent to capable; from a behaviourist approach to competence to an attributes-based approach. However, Heywood et al. (1992) propose a third approach to competence; one that has received little attention in the literature. From a holistic perspective, Heywood et al. (1992) propose that the behaviourist and attributes-based approaches are two sides of the same coin, and that while both approaches to competence attempt to gain evidence to determine the level of competence attained, each has inherent strengths and weaknesses. The application of a combination of both approaches, a holistic approach, is recommended. According to Chen and Watson (2011) the holistic approach to describing competence is accepted by researchers and regulatory bodies alike. At the same time Chen and Watson (2011) state the acceptance of a holistic approach has been at the level of gaining consensus as to what competence is, rather than operationalising the concept.

Instead of proposing a capability framework, it may be more beneficial to see how O'Connell et al. (2014) might operationalise the holistic approach to competence to advanced practice nursing. O'Connell et al. (2014) claim a key driver for the necessity to move beyond competencies to capabilities is the unpredictable and dynamic environments that advanced practice nurses work in. Yet, given the complexity of health care in the 21st Century, it is widely recognised that all nurses work in challenging, demanding, dynamic environments from the time of registration.

O'Connell et al. (2014) claim the focus in undergraduate studies places emphasis on development of psychomotor skills. Yet ask those responsible for developing the curricula, or the undergraduate nursing students completing their studies, and the response will be that the focus is on developing competent, qualified professionals who have the capacity to reflect, think critically, and act in dynamic, unpredictable environments. Supporting this argument, the Australian Qualifications Framework Council (2013) provide the specifications that guide accrediting authorities in both the education and training sectors in Australia. The Australian Qualifications Framework make explicit the expected knowledge, skills, and application of knowledge and skills from Level 1 training (a basic certificate in a vocational area of practice) to Level 10 education (a doctoral degree) (Australian Qualifications Framework Council, 2013). At Level 7 (a bachelor’s degree), it is stated the graduate will ‘analyse, generate and transmit solutions to unpredictable and sometimes complex problems’ (Australian Qualifications Framework Council, 2013, p. 47). Therefore, it is not capabilities that distinguish the advanced practice nurse. Rather, it is the extent to which those capabilities are applied along a continuum of competence.

In her seminal work, Benner applied the Dreyfus Model of Skill Acquisition to nursing, describing the five levels of development nurses pass through; novice, advanced beginner, competent, proficient, and expert (Benner, 2001). Notice that the competent level sits in the middle. It is important to recognise the Benner does not claim novices or advanced beginners as incompetent, and acknowledges that an expert might return to a novice or advanced beginner stage should the area of practice change. Perhaps, Dreyfus and Dreyfus (1980), did the professions and nursing no favours by placing the word competent in the middle of a model describing a continuum of competence (cited in Benner, 2001).

Heeding the words of Eraut (1998) that there should be clarity regarding terminology, the following definition of competence from a holistic perspective was proposed in a recently completed PhD thesis: ‘Competence is the application of abilities, knowledge, skills and attributes, for the benefit of the community being served. It is evolutionary, contextual and impermanent, requiring commitment to ongoing development’. Moving forward, the authors of this letter suggest re-focussing our priorities from discussing the division between advanced and non-advanced practice to better understanding and enabling the development of competence, as defined above, across the continuum of nursing practice.


Sally Lima, PhD, MN, Grad Dip, BN, RN
Royal Children’s Hospital Melbourne, Australia
e-mail: sally.lima@rch.org.au

Fiona Newall, PhD, MN, BSc (Nsg), RN
Royal Children’s Hospital Melbourne, Australia

Sharon Kinney, PhD,MN, BN, PICU Nursing Cert., Cardiothoracic Cert.
Royal Children’s Hospital Melbourne, Australia

Helen Jordan, PhD, DipEd, BSc(Hons)
University of Melbourne, Australia

Bridget Hamilton, PhD, BN (Hons), RN
University of Melbourne, Australia




References

Australian Qualifications Framework Council. (2013). Australian Qualifications Framework. 2nd edition. Retrieved February 13, 2015, from http://www.aqf.edu.au/wp-content/uploads/2013/05/AQF-2nd-Edition-January-2013.pdf

Benner, P. (2001). From novice to expert: excellence and power in clinical nursing practice (Commemorative ed.). Upper Saddle River, NJ: Prentice Hall.

Chen, Y., & Watson, R. (2011). A review of clinical competence assessment in nursing. Nurse Education Today, 31(8), 832-836.

Eraut, M. (1998). Concepts of competence. Journal of Interprofessional Care, 12(2), 127-139.

Heywood, L., Gonczi, A., & Hager, P. (1992). A guide to development of competency standards for professions. Canberra: Australian Government Publishing Service.

O'Connell, J., Gardner, G., & Coyer, F. (2014). Beyond competencies: using a capability framework in developing practice standards for advanced practice nursing. Journal of Advanced Nursing, 70(12), 2728-2735. doi: 10.1111/jan.12475

Watson, R., Stimpson, A., Topping, A., & Porock, D. (2002). Clinical competence assessment in nursing: a systematic review of the literature. Journal of Advanced Nursing, 39(5), 421-431.



Wednesday, 11 February 2015

Clarity Needed in Studies on Gender and Access to Cardiac Rehabilitation

Women are less likely than men to attend secondary prevention or cardiac rehabilitation services, but this problem may not be exclusively attributable to gender. Both women and men can benefit from secondary prevention and cardiac rehabilitation interventions, and there is a need to understand the barriers to uptake that exist for both genders.

A new review and synthesis of qualitative studies on the issue, published in JAN, found that despite the abundance of social theories of gender, few papers have specified a definition or theoretical position on gender.

Jan Angus, lead author of the paper, says: “Gender is frequently treated as a demographic variable or a property of an individual, not as the relational concept feminists intended it to be. Researchers then assume that men’s or women’s views are the result of gender, but overlook the social, material or institutional circumstances that contextualize and shape these meanings. Without conceptual clarity about the social origins of gender, we miss important analytic steps.”


Reference

Angus J.E., King-Shier K.M., Spaling M.A., Duncan A.S., Jaglal S.B., Stone J.A. & Clark A.M. (2015) A secondary meta-synthesis of qualitative studies of gender and access to cardiac rehabilitationJournal of Advanced Nursing. doi: 10.1111/jan.12620


Friday, 6 February 2015