An overview of the competency movement in nursing and midwifery

Article Outline

• Summary
• Introduction
• Uses and definitions of competency standards
• Structure and content of the competency standards
• Acceptance and use of the competency standards
• The development of advanced or specialist competency standards
• The ongoing debate about specialist or advanced competency standards
  • Standards for professional practice in mental health nursing
• Suggestions for a research and development agenda
• Conclusion
• Acknowledgements
• References
• Copyright

Summary 

The aim of this paper is to examine the purpose and growth of the development of general, advanced and specialist competency standards in nursing and midwifery in Australia. The definitions, content, types, utility and acceptability of competencies are reviewed. This paper also reports the results of a recent survey of nurses and midwives about the uses of competency standards. Challenges in identifying and assessing the impact of competency standards on practice and professional development; reasons for their proliferation and associated shortcomings such as their lack of cultural sensitivity and inability to reflect the complexity of nursing care are also explored. The rationale for this paper is that charting these issues and identifying gaps in the field will assist the further development and refinement of competency frameworks for Australian nursing.

The paper concludes by recommending that future research in this area should focus on: (1) formal analysis of the validity and suitability of competency standards in relation to the purposes for which they are designed; (2) the mapping of competency domains, elements and performance criteria to identify similarities and differences in order to provide insight into the nature of both specialist and advanced practice nursing; and (3) a systematic review of the competency literature to ascertain the level of evidence that exists to support the use of competencies in terms of standard setting, safe practice and enhancement of patient outcomes.

Keywords: Competencies, Regulation, Credentialing, Specialist practice

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Introduction 

Over the past 20 years in Australia there has been a significant and steady growth in the movement amongst professional groups, initially in nursing and more recently in midwifery, to develop sets of standards for practice known as competency standards (ACMI, 2002, Percival, 1995). This reflects a general belief that effective professionals are those who not only possess technical skills and knowledge specific to their discipline but who also possess generic competencies (Hearn, Close, Smith, & Southey, 1996). An immense amount of time and effort has gone into the development of a wide and diverse range of nursing competency standard documents, both at undergraduate and post-graduate level. This work is viewed by professional groups with great pride and a sense of considerable achievement.

The first nursing competency standards were developed in 1990. It is therefore timely to identify challenges and gaps in this field of work and to suggest ways forward. Changes such as difficulties in identifying competencies, assessing their impact on practice and professional development; reasons for their proliferation and shortcomings such as lack of cultural sensitivity and inability to reflect the complexity of nursing care are currently worthy of exploration.

Accordingly, the aims of this paper are to

In undertaking this work, changes in approaches towards defining and assessing competencies throughout the years from ad hoc to more formalised and national approaches are charted with reference to an updated list of competency standards originally developed by Barraclough (2002). In addition, the paper also draws on the results of a recent survey of nurses and midwives about the uses of competency standards. It is hoped that this review will assist the further development and refinement of competency frameworks for Australian nursing and help to develop a research agenda in this field.

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Uses and definitions of competency standards 

The most significant early work in relation to nursing was undertaken by the (then) Australian Nursing Council (ANC) Inc., which developed the Australian National Competency Standards for the Registered Nurse. These were initially developed through a group known as the Australian Nurse Registering Authorities Advisory Council (ANRAC) in 1990, but with the incorporation of the Australian Nursing Council in 1992, these became the ANCI competencies and these standards are now known as the Australian Nursing and Midwifery Council (ANMC) Competency Standards for the Registered Nurse (RN). ANMC has also developed competency standards for Enrolled Nurses (ENs), Midwives (MWs) and Nurse Practitioners (NPs). With the exception of the NP Standards, these standards are those that the RN, EN or MW is expected to demonstrate on entry to practice and are said to ‘…provide the framework for assessing competence but also serve to communicate to consumers the standards they can expect…. Universities use the standards in developing nursing curricula and to assess student performance’ (Anonymous, 2006, p. 14).

Further, ANMC points out that the MW Standards can be used by the States and Territories for a range of other activities:

…to assess competence as part of the annual renewal of license process, to assess midwives educated overseas seeking to work in Australia, and to assess midwives returning to work after breaks in service. They are also used to assess midwives involved in professional conduct matters (ANMC, 2006, p. 1).

ANMC has provided guidance as to how assessment of competence might occur and has identified six principles for the assessment of competency: accountability, performance-based assessment, contextual relevance, evidence-based assessment, validity and reliability in assessment and participation and collaboration (ANC, 2002).

ANMC provides a number of definitions in relation to competencies. Competency is defined as “an attribute of a person which results in effective performance” (ANC, 2002). Although this definition is not included in the most recent ANMC Competency Standards for the Midwife (2006), the competency domains shown below in Box 1 demonstrate a general consistency across the competency standards documents for ENs, RNs and MWs (ANMC, undated, ANMC, 2005).

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Structure and content of the competency standards 

The ANMC competency standards for each professional group, RNs, ENs and MWs, are organised into a number of domains, each with a series of corresponding statements or descriptors. These descriptors or sub-headings are described in some (although not all) of the Competency Standards documents as elements, and each element has a corresponding number of cues by which it can be identified on observation or questioning. The names of the domains differ slightly for each professional group, as can be seen in Table 1.

Table 1. Competency domains for RNs, ENs and MWs

The full content of the three sets of competency standards including their domains, unit and elements are available via: http://www.anmc.org.au/professional_standards/index.php.

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Acceptance and use of the competency standards 

Acceptance of competency standards has grown over the years in parallel with an increasing awareness among individuals and organisations about their purpose and use. Initially, there was speculation both as to the impact of the competency standards on the liability and legal expectations for nurses (Chiarella, 1995) and as to potential difficulties in identifying the minimum required level of performance in each competency (McMillan, Bujack, & Little, 1995). It is true that the competencies have on occasions been used as a benchmark for determining the beginning level of professional conduct in disciplinary hearings (NRB of NSW, 2001). Notwithstanding this regulatory requirement, overall, nurses have accepted the Competency Standards as a positive development, one that gives them both professional standing and enables them to identify their areas of practice. A recent study of 831 Australian health professionals, including nurses, demonstrated that all health professionals rated the ANMC competencies as important and that the respondent nurses identified nineteen out of the 65 competencies to be unique to the nursing profession (Wells, 2003).

A survey of 136 participants attending a Nurses and Midwives Forum in NSW reported 25 sets of competency standards as being used as shown in Box 2. The competency standards most used were those produced by the ANMC. Others came from a variety of different sources and organisations and were used variably. At this forum, the view was strongly expressed that: (a) a professional portfolio across the board was a better accreditation process than specialist credentialing; (b) that competencies should focus on patient needs not nursing tasks; (c) that guidelines for the use of competencies would be helpful; and (d) that the competency debate should occur at a national level and involve both Chief Nursing Officers (CNOs) and National Nursing Organisations (NNOs).

Box 2. Competencies reported being used by participants at a Nurses & Midwives Forum (n=136)

ACCN (10)

ACORN (7)

ACPCHN (4)

ANF (advanced 13+RN 12)

ANMC (unspecified) (33)

ANMC (beginner) (6)

ANMC (RN) (4)

ANMC (EN) (4)

ANMC (NP) (3)

ANZCMHN (2)

APON (USA) (1)

Asthma education (1)

Audiometry (2)

CAFHNA (4)

Chemotherapy (1)

Child health (RN, EN) (1)

CNSA (3)

ANF (EN) (12)

GENCA (1)

RM (credentialing) (1)

RNSA (3)

School screening (2)

SGNSA (2)

TEN (2)

Women's health (1)

Competency standards were reported by these participants as being used for: registration/licensing (credentialing, benchmarking); education and training (curriculum development, teaching, re-education, new graduate training) and workplace management (performance appraisal, performance management, position description/job description, career progression). Respondents stated that competencies were most useful for: developing curricula and teaching including re-education and new graduate training; performance appraisal, credentialing (registration/licensing) and career progression; and highly useful for Re-Connect¹ as a means of describing nursing practice and expectations. They were least useful for position descriptions on the grounds that interpretation of each competency element is variable and inconsistent. This finding points to a need for standardisation of terms/domains and for debate about the transferability of specialist skills and the elements that can be transferred. There was also concern expressed regarding the use of the term ‘competency’ due to its association with the Vocational Educational and Training sector (VET).

The problems of standardization of terminology are illustrated by the following example. While the ANMC competency domains for RNs, ENs, and MWs (see Table 1) appear generally consistent at face value the units associated with each domain (see http://www.anmc.org.au/professional_standards/index.php) shows some inconsistencies in definitions and terminology. For example, for the domain ‘critical thinking and analysis’ the associated competency units for the RN are: practices in an evidence-based framework and participates in ongoing professional development of self and others. While for the EN, the competency unit for this domain is to demonstrate critical thinking in the conduct of EN practice. Yet for the RM, the equivalent domain has a different emphasis ‘midwifery knowledge and practice’ and it's three associated units is focused on the care of the client rather than on evidence-based or critical thinking as for the RN and EN. This raises a number of interesting questions including: why are the units defined differently; are such differences reflective of the nature of each profession; and should there be standardisation across common domains? This example illustrates that there is value in systematically mapping competency domains, elements and performance criteria to identify themes of similarity and difference; to assess the feasibility of standardisation and to see if these differences are attributable to the different technical skills and knowledge required or whether they are indicative of gaps in the competency standards that need to be addressed.

Competency standards also have a role in professional regulation. However, although the ANMC competency standards are already endorsed by all state and territory regulatory authorities, the National Review of Nursing Education (Commonwealth of Australia, 2002) initiated by the Department of Education, Science and Training, took a more formalised and national approach. This review recommended that nationally agreed principles should be developed to underpin State and Territory nursing legislation that should include requirements for: ‘assessment against the ANCI competencies for initial regulation of registered and enrolled nurses’ (Commonwealth of Australia, 2002, p. 120).

This work towards a formal and regulated national approach was noted with approval by the Report of the Australian Government Productivity Commission into Australia's Health Workforce (2005). The Productivity Commission Report (PCR) recommended that the Australian Health Ministers Advisory Council should establish a single national regulatory authority for all health professionals. However, such a process would be unlikely to impact upon the need for competency standards as the benchmark for beginning practice. Certainly the PCR strongly recommended the adoption of uniform national registration standards (p. 140), thus the ANMC Competency Standards would appear to be highly topical and relevant to the current regulatory debate.

From an academic perspective, the competencies are also used as the basis for all undergraduate programs. All nursing undergraduate curricula are required to demonstrate that graduates from the program will be able to meet the competency standards. However, concern has been expressed that the competencies may not be sufficiently culturally sensitive for contemporary Australian society. Chenoweth, Jeon, Goff, and Burke (2006), whilst on the one hand acknowledging the need for competencies, puts forward the view that they are perhaps insufficiently nuanced about the complexity of nursing care in different cultural environments:

The ANCI competency standards clearly define the principles to achieve culturally competent nursing care, and require nurses to respect the values, customs, spiritual beliefs and practices of all individuals and groups; however, they are not sufficiently explained or developed to guide nursing practice (Chenoweth et al., 2006).

From an industrial perspective, the Australian Nursing Federation (ANF) has recently reviewed and re-endorsed its policy statement relating to competency standards and nursing (at: http://www.anf.org.au/anf_pdf/P_Competency_Standards_Nursing.pdf). ANF clearly supports the development of competency standards for entry to practice being developed through and for regulatory authorities, but is content to expect that the development of advanced or specialist competency standards will be carried out by professional organisations and/or groups. The need for validation, evaluation and review is highlighted in the policy, and this will be discussed further in relation to advanced or specialist competencies in the next section.

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The development of advanced or specialist competency standards 

This paper now turns to the development and proliferation of advanced/specialist competency standards. It is perhaps the ability to identify aspects of the competency standards that nurses perceive as unique to their work, as emerged from the Nurses and Midwives Forum survey described above, that has caused the proliferation of advanced and specialist competency standards.² Some of the specialist nursing groups, specifically the occupational health nurses, mental health nurses, critical care nurses and diabetes educators’ groups,³ had begun developing specialist competencies in the mid-1990s, possibly with a view to credentialing specialist nurses, although this was a topic of hot debate (Robertson & Chiarella, 1995). The ANF subsequently developed a generic set of competency standards for the advanced nurse in 1997. These competency standards have three components:

Since then there has been an extraordinary proliferation of specialist and/or advanced competency standards. Barraclough (2002) provided a helpful list of documents currently available. A review of the Australian literature has been updated for this paper. The update was conducted by the professional search services offered by the librarian at the College of Nursing. The range of key terms mirrored those at the commencement of this article, with particular emphasis on the Australian context. The updated review has been amended to include only specialist or advanced competencies and is set out below in Table 2. Thirty sets of specialist or advanced competencies were found and this may not be exhaustive. What is remarkable is the amount of work represented in this table, most of it no doubt voluntary, that the development of these sets of competency standards would have entailed.

Table 2. Existing Australian Competency documents available for nursing staff^a

NB: The competency documents from this table (unless specifically discussed within the text) are not referenced here but most are available through Google. Where difficulty sourcing the documents has arisen, a contact has been included within the table.

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The ongoing debate about specialist or advanced competency standards 

Although it is clear from Table 2 that specialist and professional nursing organizations have embraced the development of specialist or advanced competency standards with enthusiasm and energy, there is ongoing healthy debate as to their validity, utility, content and purpose. Royal College of Nursing, Australia (RCNA) in its recently reviewed policy statement on advanced practice nursing, recommends “the use of the ANF Competency standards for the advanced nurse (1997) for assessment of competence by advanced practice nurses” (RCNA, 2006) and makes no mention in the document of the myriad of specialist advanced competency standards listed above.

In terms of the purpose of specialist competencies, the question of whether to use them to recognise entry to specialist practice is an ongoing debate. The Australian College of Operating Room Nurses (ACORN) commissioned an analysis of the benefits or otherwise of introducing credentialing for perioperative nurses and concluded that “the utility, applicability and validity of credentialing cannot be clearly demonstrated. Indeed, there is no consensus on the meaning of the word itself” (Hamlin, 2004).

In contrast, the credentialing process for specialist level critical care nurses has been under development since the publication of A proposed credentialing model for Australian critical care nurses (CACCN, 1997). The credentialing model was launched on 11 October 1998 in Adelaide. According to the Australian College of Critical Care Nurses’ (ACCCN) website:

…the credential is awarded to the clinical critical care nurse who practices (sic) at or above the level of the Competency Standards for Specialist Critical Care Nurses (CACCN, 1997). The applicant will be required to demonstrate that he/she meets the Standards by keeping a practice journal, reflecting upon clinical practice and drawing examples from the journal to demonstrate achievement of the competencies (ACCCN, 2006).

However, concerns about the construct validity of the Australian College of Critical Care Nurses competency standards as a tool for assessing the clinical practice of specialist level critical care nurses were raised in a recent study undertaken by a group of critical care nurses (Fisher, Marshall, & Kendrick, 2005). The study highlighted concerns about the validity of the ACCCN competency elements and standards as a tool with which to assess the practice of critical care nurses, in part because the elements did not fit uniquely to a single competency, but were multidimensional and loaded across several competencies. However, the study also reconfigured the current model into a four-factor competency model, which “demonstrated reasonable model fit”.

The Australian and New Zealand College of Mental Health Nurses Inc. has developed a set of Standards of Practice for Mental Health Nursing in Australia (1995) that contain within them an advanced practice level. In the introduction to the standards they make clear their purpose.

Standards for professional practice in mental health nursing 

In addition, the ANZCMHN have been engaged in a Credential for Practice Program (CPP) since March 2003 in partnership with the Nursing Board of Tasmania (NBT) and the University of Tasmania. A registered nurse in Tasmania is able to apply to be credentialed for a period of three years. ANZCMHN reports that CPP has been developed through professional and workforce consultation, review of the literature, programs conducted by other professional bodies including nursing, medical and allied health, and recommendations from Self-Regulation and Credentialling in Mental Health Nursing: A Report to the Nursing Board of Tasmania, ANZCMHN and University of Tasmania (Hazelton, Farrell, & Biro, 1998). However, it was not possible to ascertain from either the ANZCMHN or NBT websites whether this project was ongoing or completed.

Recently, concern has been raised about the general content of some of the specialist or advanced competencies. The RCNA (2001) have expressed disquiet that the specialist or advanced competencies miss the contextual richness that is nursing practice.

…the generic list of attributes included in the document Competency standards for the advanced nurse (ANF, 1997) is simply that: a list of attributes or standards to be met. Clearly from the cases presented by the respondents involved in preparation of the Competency standards for the advanced nurse (ANF, 1997) … generalist and specialist nurses working at an advanced practice level do so in a wide range of practice contexts. They also have a vast array of clinical and personal experience from which to draw. Equally evident is that the central focus of their practice is nurturing or caring for their patients or clients (RCNA, 2001, p. 19).

They go on to suggest that all nurses working in Australia exhibit the roles of carer, educator, role model, researcher, consultant and leader at some time (Borbasi, 1999), and that such language “might provide a conceptual framework around which to build the Australian understanding of the advanced practice nurse” (RCNA, 2001, p. 19).

There is also some discussion about whether to move into the management science language of capabilities (Campbell, 1999), rather than competencies. ‘Capabilities’ goes beyond the acquisition of knowledge or skills, referring to a broader attribute of which competence is a part. However, when the amount of work that has been undertaken in relation to competency standards is identified through a review such as this, it would seem to be swimming against an extraordinary tide of work to move in that direction.

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Suggestions for a research and development agenda 

On the basis of this review, several areas have been highlighted as requiring further development or the commissioning of research and development activities to further advance and refine competency standards and their use. Firstly, it would appear to be of benefit to undertake a mapping of competency domains, elements and performance criteria across the various competency standards to identify themes of similarity and differences in order to assess the feasibility of standardisation of some domains; to ascertain if these differences are attributable to the different technical skills and knowledge required or whether they are gaps that need to be addressed. This would also provide valuable insight into the nature of both general, specialist and advanced practice nursing and would make an excellent research project that would be of great value for the development of post-graduate specialist curricula.

Other informative work could include examination of the construct validity and suitability of competency documents in terms of the purposes for which they are designed. This would include the assessment of competency standards for assessment for fitness to practice; cultural sensitivity and ability to reflect the complexity and multidimensional nature of nursing care. Finally, as recommended at the Nurses and Midwives Forum, a systematic review of the competency literature would also be valuable to ascertain how much and what level of evidence there is to support the use of competencies in terms of standard setting, safe practice and enhancement of patient outcomes.

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Conclusion 

This paper has reviewed some of the issues associated with the development and use of competency standards with reference to debates concerning the purpose, growth and definitions of general and advanced competencies in Australia. It has shown how over the years competencies have shifted from ad hoc to more formal approaches increasing the professional standing of nurses and midwives, developing curricula and underpinning regulatory frameworks. It has also shown that competency standards do assist with providing standards for professional education and licensing.

However, although, competencies are accepted as a positive development, this review has shown that there are some issues associated with their use and development. These include identifying the minimum required level of performance in each competency; defining cultural competence; their ability to reflect the complex nature of general and advanced practice in addition to technical aspects of patient management; the validity and interpretation of competency domains and their constituent parts; their use as criteria for entry to specialist practice; and the proliferation of competency standards with varying definitions of domains and elements. This review and the reported research indicate that there is considerable scope for advancing the utility of these standards through further refinement and research and development.

The survey and other research cited have also highlighted preferences among practitioners for client focused rather than task focused criteria and standardisation of terms to ensure that there is consistency across the major domains while recognising that there needs to be some differences to adequately reflect the nature of general or advanced and specialized care. Other initiatives which are suggested, are the need for guidelines to assist practitioners with understanding terminology used and how to operationalise competency standards and the establishment of a national, co-ordinated approach involving both CNOs and NNOs to meet the challenges of developing and implementing national competency standards.

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Acknowledgements 

This work was initially undertaken by Professor Mary Chiarella in her role as sponsored Professor to the Nursing and Midwifery Office at the request of A/Professor Debra Thoms, (then) Chief Nursing Officer⁴ (CNO), NSW Health. The original work was presented at a Nursing and Midwifery Office Peak Nursing and Midwifery Forum funded by the CNO to stimulate professional debate and discussion about key topics. The workshop session was facilitated by Professor Chiarella and A/Professor Thoms and data were collected from the workshop participants in relation to their use of and views about competencies. These data were collated by Dr Cecilia Lau as part of her role as Senior Policy Analyst for the Nursing and Midwifery Office. Ms Liz McInnes has been instrumental in bringing the final piece of work together.

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• 1 Re-Connect is a scheme developed by the Nursing & Midwifery Office in NSW Health assist nurses to return to practice.
• 2 Note that both the terms specialist and advanced are used throughout this paper as both terms are used in the different competency standard documents.
• 3 It is recognised that not all diabetic educators are nurses, but they are included out of a wish to acknowledge their pioneering work.
• 4 A/Prof Thoms is now the Chief Nursing and Midwifery Officer.