In this evermore litigious society, there is a real fear that success may for some, come to mean an unblemished career without claims of negligence, abuse or liability through ommision. Worse still, it may mean simply reaching retirement without too much brutalisation or work stress or PTSD !
Perhaps though, we ought to take a more wholesome and altruistic analysis of successful nursing, as a career filled with reward through 'skillful care' and acknowledged 'competency'. It is important therefore to develop a clear perspective on these terms if we are to be successfully recognised and valued within our workplace.
There can be a degree of confusion surrounding the terms and purpose of measuring competence. A trawl trough literature even from just the past decade poses a multitude of complex issues. Manley & Garbutt (2000) question the purpose of assessment pointing out that, in the UK for example, competence frameworks are reflected in the human resource strategy. Competency in this respect can therefore be aligned with career progression targets and performance related pay. Some would suggest that competence can only be assessed through outcomes. It is difficult to assess the way in which a nurse utilises insight and experience to produce a tangible outcome or practice. What is easier to assess, is the actual practical outcome. In assessing competency, we can therefore only reliably analyse the product of a worker's expertise in a given area. The 'intelligent skill knowledge' (Pearson 1984) that underpins outcomes is implicit through competence but not reliably assessed, therefore competency can only be a measure of minimum standards.
Ramritu & Barnard (2001) formulate differing concepts of competence from their interviews with new graduate nurses. It was possible for them to relate these various conceptions logically as suggested by Marton (1986) and Bruce (1997) and construct a hierarchal approach to competence development over three levels ranging from safe practice to evolving competence. Perhaps this is more qualitatively described by Benner (1984) as a developmental continuum from Novice to Expert.
Tyrer & Oyebode (2004) point out that tests of clinical competence require assessment of knowledge, comprehension of the subject matter, analysis of all aspects of the topic, evaluation of the problem or clinical scenario, synthesis of the issues, and application of these elements in the management of clients.
My favoured view is that competence is the demonstrable achievement of set standards related to a specific skill. Furthermore, the attainment of these standards should demonstrate both 'validity' and 'reliability' Wass et al (2001) proven in a set number of contexts, thus providing evidence of intelligent and robust action in different situations (Elliot 1991).
Assessment of a person's capabilities alone does not accurately predict that they will apply their knowledge in practice. Various other factors come into play here, including motivation, reward, ethical values and attitude.
There are similarities with Kolb's Learning model (1984) in understanding the development of knowledge, skills and attitude as a continuum of development from knowledge, through competence to performance.
We cannot guarantee the performance and therefore indeed the success of any individual. What is unquestionably required is continued supervision and an application of competency into everyday practice. A process of support, self analysis and assessment that is multidimensional and spreads across different domains of practice is needed to ensure that a worker has capacity to practice safely, happily and according to best practice. With this in mind it is important to recognise the importance a nurse's own judgement is, in assessing their own success. One thing is clear; whatever the standard of performance at the end of training, Pietroni, M. (1993) points out that the expectation must be for continuing improvement thereafter. This depends on a clinician's attitude towards quality improvement and lifelong learning. Whether clinical or more broadly professional, judgement, performance and credibility takes time to acquire and its development cannot be guaranteed by good training. The acquisition of these traits, I believe has a direct and lasting effect on the global success of nurses, by whatever measures they choose.
References:
Benner P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice . Addison-Wesley California.
Bruce C. (1997) The seven faces of information literacy. Auslib Press, Adelaide.
Elliot J. (1991) Competency based training and the education of the professions: is a happy marriage possible? Action Research for educational change. Open University. Milton Keynes (118-134)
Kolb D.A (1984) Experiential Learning. Prentice Hall, New Jersey.
Manley K. & Garbutt R. (2000) Paying Peter and Paul: Reconciling concepts of expertise with competency for a clinical career structure. Journal of Clinical Nursing, 9, 347-359
Marton F. (1986) Phenomenography - A Research Approach to Investigating Different Understandings of Reality. Journal of Thought, 21(3), 28-49
Pearson H.T (1984) Competence: An historical analysis. In Competence Inquiries into it's meaning and acquisition in educational settings (short E.C) University Press of America Lanham, New York & London.
Ramritu P.L & Barnard A (2001) New Nurse Graduates understanding of Competence. International Council of Nurses, International Nursing Review. 48, 47-57
Pietroni M. (1993). Guidelines and standards in surgical training. Annals of the Royal College of Surgeons of England, 75(5):305-307.
Rethans J. Norcini J. Baron Moldonado M. Blackmore D. Jolly B.C. LaDuca et al (2002) The relationship between competence and performance: Implications for assessing practice performance. Medical Education, 36(10) 901-909
Roe R. A (2002) What makes a competent psycholgist? European Psycholgist, 7(3) 192-202.
Tyrer S. & Oyebode F. (2004) Why does the MRCPsych examination need to change? British Journal of Psychiatry, 184, 197 -199
UKCC (1999) Fitness for Practice - report of the UKCC Commision for Nursing and Midwifery education. UKCC, London. (now NMC)
Ward, P (1997) 360 Degree Feedback, Institute of Personnel and Development, London.
Wass V. Jones R. & Van der Vleuten C. (2001) Standardised or real patients to test clinical competence? The long case revisited. Medical Education, 35, 321 -325