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How do expert clinicians assess student nurses competency during workplace experience? A modified nominal group approach to devising a guidance package

Published:February 06, 2016DOI:https://doi.org/10.1016/j.colegn.2016.01.004

      Summary

      This paper presents data regarding how experienced clinicians and academics said they assess the competency of nursing students progressing through eligibility to practice programmes in Australian universities. The development of competence during nursing education programmes is an essential part of university based nursing eligibility to practice courses and so facilitating consistent, reliable and valid assessment of the demonstration of those competencies is critical.
      A consensus methodology incorporating a modified nominal group technique was used to explore how clinicians assessed nursing students whilst on workplace experience. These assessment strategies were then analysed to develop guidance notes for assessors.
      Consensus was reached regarding strategies for assessing the competence of nursing students as they progress through their programme of study based on the views of experienced clinicians and academics.
      This work culminated in the production of guidance notes to assist assessors to feel confident that the student they were assessing was competent. The identification of strategies and activities, including the ‘work of the nurse’ could be observed within specific practice activities. Through using these ‘everyday activities’ the assessor would be able to observe, question and measure (within the student being assessed) all aspects of the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      Competencies of the Registered Nurse.

      Keywords

      1. Introduction

      This paper will present the findings from eleven groups of primarily clinicians and academics about how they assess the capabilities and competency of nursing students as practicing nurses using the National Competency Standards for the Registered Nurse (
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      ). The standards are presented in Table 1.
      Table 1National competency standards for the registered nurse, domains and competency statements (
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      ).
      DomainCompetence statement
      Professional practice

      This relates to the professional, legal and ethical responsibilities which require demonstration of a satisfactory knowledge base, accountability for practice, functioning in accordance with legislation affecting nursing and health care, and the protection of individual and group rights.
      1. Practises in accordance with legislation affecting nursing practice and health care.
      2. Practises within a professional and ethical nursing framework
      Critical thinking and analysis

      This relates to self-appraisal, professional development and the value of evidence and research for practice. Reflecting on practice, feelings and beliefs and the consequences of these for individuals/groups is an important professional benchmark.
      3. Practises within an evidence-based framework
      4. Participates in ongoing professional development of self and others
      Provision and coordination of care

      This domain relates to the coordination, organisation and provision of nursing care that includes the assessment of individuals/groups, planning, implementation and evaluation of care.
      5. Conducts a comprehensive and systematic nursing assessment
      6. Plans nursing care in consultation with individuals/groups, significant others and the interdisciplinary healthcare team
      7. Provides comprehensive, safe and effective evidence-based nursing care to achieve identified individual/group health outcomes
      8. Evaluates progress towards expected individual/group health outcomes in consultation with individuals/groups, significant others and interdisciplinary health care team
      Collaborative and therapeutic practice

      This relates to establishing, sustaining and concluding professional relationships with individuals/groups. This also contains those competencies that relate to nurses understanding their contribution
      9. Establishes, maintains and appropriately concludes therapeutic relationships
      10. Collaborates with the interdisciplinary health care team to provide comprehensive nursing care
      A modified nominal group technique utilised an iterative process to reach consensus within and then between the eleven groups (
      • Delbecq A.L.
      • Van de Ven A.H.
      • Gustafson D.H.
      Group techniques for program planning: A guide to nominal group and Delphi processes.
      ). The paper will draw on a documentary analysis which explored the competency assessment tools used in Australian universities, as well as the 30 skills areas outlined in the work of
      • Crookes P.A.
      • Brown R.A.
      The development of a pre-registration nursing competencies assessment tool for use across Australian universities.
      . Through combining and exploring these elements the rationale for the development of the eight employer competencies used in the Nursing Competency Assessment Schedule (NCAS) will be illustrated.
      An earlier documentary analysis of curriculum documents from Australian universities (n = 39) illustrated that there was no single approach to the assessment of student nurses competence; neither was there a single assessment tool or set of criteria that was consistently used (
      • Crookes P.A.
      • Brown R.A.
      The development of a pre-registration nursing competencies assessment tool for use across Australian universities.
      ). The documentary analysis however illustrated that 63% of universities utilised
      • Bondy K.N.
      Criterion-referenced definitions for rating scales in clinical evaluation.
      or some variation thereof. The remaining universities used a range of descriptors such as ‘competent’ vs ‘not yet competent’ or ‘satisfactory’ vs ‘unsatisfactory’. In addition to assessment of practice documents a significant number of universities (around one third) were using sections of the “Clinical Psychomotor Skills: Assessment for Nursing Students” the Tollefson text (
      • Tollefson J.
      Clinical psychomotor skills: Assessment tools for nursing students.
      since reprinted; the 5th edition was published in
      • Tollefson J.
      Clinical psychomotor skills: Assessment tools for nursing students.
      ) text. Each of these universities appeared to be utilising different aspects of the Tollefson text; in many cases the students were using it as an informal guide not as a formal summative assessment. These variations in assessment tools and assessment criteria (or the lack of them) led to this timely work which went on to create a structured developmental and competency assessment framework for use in nursing eligibility to practice programmes in Australia.

      1.1 Overview of the literature

      Literature in the area of student competency tends to be limited to opinion and theorising about how or where or why competency is assessed. There is no agreement about a clear definition of competency nor how ‘best’ to undertake competency assessment. Within Australia it is clearly mandated, as it is in other jurisdictions, that competency should be assessed against a national framework; in Australia the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      competencies are to be used (see Table 1). Definitions of competency are stated nationally; in Australia the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      ; the UK Nursing and Midwifery Council (
      • Nursing and Midwifery Council
      Standards for pre-registration nursing education.
      ) and the
      • American Nurses Association
      Position statement on professional role competence.
      utilise terms in their definitions of competency such as: knowledge’, ‘skills’, ‘attitudes’, ‘values’ ‘abilities’, ‘judgement’, ‘technical abilities’.
      These definitions, although not all embracing, capture important aspects of competency.
      • Eraut M.
      Developing professional knowledge and competence.
      ,
      • Eraut M.
      Concepts of competence.
      explored earlier definitions of competency which similarly identified such characteristics. Interestingly
      • Eraut M.
      Concepts of competence.
      identified ‘lay’ as well as ‘professional’ aspects of competency; he suggested (through reviewing
      • Pearson H.T.
      Competence: A normative analysis.
      work) that it may be viewed as a continuum with ‘knowing how to do something at one end and knowing how to do something very well at the other’ (
      • Pearson H.T.
      Competence: A normative analysis.
      :32).
      • Eraut M.
      Concepts of competence.
      goes on to consider a variety of differing national views in an attempt to illustrate the complexity of defining competency but by stressing that it is essential for the health professions to have a means of structuring competency as a means of describing a ‘minimum competence’ and then a ‘level’ that is about competency meaning excellence in the particular field. He used useful non-health professional examples to make these points; for example Eraut cites a ‘solicitor’ who is a specialist in family law would probably have a working knowledge of conveyancing but for more complex cases they would refer this work to a specialist. Parallels may be drawn here with clinical specialisms in nursing practice; critical care nursing has some overlapping skills with say coronary care practice and some but probably to a lesser degree with medical care on a general ward. Finally
      • Eraut M.
      Concepts of competence.
      relates the public's expectation of ‘an expected standard’ in terms of the nurses ‘ability to perform tasks and roles’
      • Eraut M.
      Concepts of competence.
      . The majority of the literature between 1986 and 2012 relates to the challenges of defining and assessing competency and appears to focus on the development of competency in registered nurses so is viewed from a postgraduate and not an undergraduate perspective (
      • Blažun H.
      • Kokol P.
      • Vošner J.
      Research literature production on nursing competences from 1981 till 2012: A bibliometric snapshot.
      ).

      2. Method

      The main aim of the study was to generate a series of guidance notes by asking experienced nurses to explain how they assessed the competency level of nursing students against the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      National Competency Standards for the Registered Nurse.
      A modified nominal group technique (NGT) was used in order to elicit expert opinion from the clinicians. The NGT was considered an appropriate approach as it is designed to facilitate collaborative and democratic decision making (
      • Delbecq A.L.
      • Van de Ven A.H.
      • Gustafson D.H.
      Group techniques for program planning: A guide to nominal group and Delphi processes.
      ) using a structured meeting format to generate information and opinions about a predetermined topic from a group of experts. Other benefits of the NGT (
      • Nelson J.S.
      • Jayanthi M.
      • Brittan C.S.
      • Epstein M.H.
      • Bursuck W.D.
      Using the nominal group technique for homework communication decisions: An exploratory study.
      ,
      • Waddell D.L.
      • Stephens S.
      Use of learning contracts in a RN-to-BSN leadership course.
      ) include:
      • balanced participation, which avoids issues caused by dominant individuals;
      • participants feeling less pressure to conform to a specific view;
      • the results are known at the end of the NGT meeting and
      • the approach is very flexible and can be used in a variety of situations.
      A sampling frame was used to structure and organise the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      competency standards to ensure that each standard was reviewed by at least three different nominal groups.
      The opportunistic population consisted of clinicians and academics invited from all states and territories of Australia. They represented a wide range of areas of practice as well as metropolitan, rural and remote locations. Groups were facilitated across 7 of the eight states and territories in Australia.

      2.1 Design of the study

      An inclusive, consensus methodology was employed to maximise contributions and ownership from the profession. The NGTs were conducted in each jurisdiction within Australia to reach a national consensus on relevant exemplars for the NMBA Competencies (2006) in a manner that allowed all participants to actively participate. The role of the modified nominal group was to identify clarify, evaluate, and prioritise each exemplar.
      Based on the process identified by
      • O’Neil M.J.
      • Jackson L.
      Nominal group technique: A process for initiating curriculum development in higher education.
      , this involved:
      • 1.
        Briefly reviewing the intended outcomes of the meeting and ensuring that the process was followed to achieve those outcomes.
      • 2.
        Participants generating a list of exemplar assessments for a number of the NMBA Competency Standards for the Registered Nurse (2006) as specified by the researcher.
      • 3.
        A strategy where each participant was asked to identify (by writing on post-it notes) their response for the first competency using the following;
        • a.
          Observations: what would you need to see in practice?
        • b.
          Questioning: what questions might you ask and what type of response would you expect?
        • c.
          Measurement: is there anything that you are able to measure and record?
        The respondent then placed their response onto butcher's paper; there was no discussion up to this point.
      • 4.
        After all the participants had an opportunity to document their ideas through this method, a discussion was facilitated for each competency that incorporated:
        • a.
          clarifying the comments
        • b.
          reaching consensus on whether the exemplar(s) did indeed assess the competency;
        • c.
          discussing each idea that was not considered to be assessing the competency to determine how it could be modified to do so.
      • 5.
        The results were organised thematically by the group with support from the facilitator, and the final outcome was discussed.
      Theming included an exploration of what participants termed ‘areas of practice’ or ‘the work of the nurse’; these were seen as those ‘common’ activities that are carried out in the majority of settings. They included, for example, the assessment of clients/patients; the administration or management of medications and the prioritising of care for a group of clients/patients.
      The approach of using modified NGT groups enabled a clear articulation of how assessors of nursing students assessed those students’ competencies in practice.
      Participants were also asked whether the observations, questions or measurements would be most appropriately assessed through simulation, practice or a combination of both – the data presented within this paper only deals with assessment during workplace experience. It was also suggested to participants that a ‘good’ exemplar should:
      • signpost a clear direction that is competency related;
      • be a clear statement of specific desired competence;
      • contain no potential confusion;
      • encourage different pathways to solutions;
      • provide clear criteria to judge value of achievement and
      • galvanise professional thinking/activity across the competencies.
      This strategy was repeated again in the remaining ten modified nominal groups – for a total of at least three iterations for each of the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      competencies. At the end of each of the nominal group sessions the findings from the previous nominal group to have undertaken the same exercise with that particular NMBA competency were shared so as to provide an opportunity to review and compare the findings of both that group and the earlier group.

      2.2 Data analysis

      During each modified nominal group activity the facilitator and research assistant recorded the interaction and the nature of the responses to the clarifying questions in order to explore this material both within the group and with later nominal groups as well as data analysis. During the theming of the exemplar statements, the groups were facilitated in verifying the themes, exemplars and observations, questions and measurements to ensure understanding and clarity.
      Ethical Considerations; a submission was made to the University of Wollongong's Human Research Ethics Committee (HREC (HE08/142)) in which all participant groups, research areas and methods were listed. The documents for all aspects of the work were submitted; this included the participant information sheets and consent forms to all stakeholders, this included Heads of schools, clinical academics, students and assessors/supervisors. Rigorous annual reporting was also maintained as a part of the HREC process.

      3. Results and discussion

      The results and discussion will explore the findings of the modified nominal groups beginning with an overview of the participant population and then explore, in some detail, one
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      competency and what exemplars were commonly suggested as enabling assessors to be assured that student nurses were competent at the expected level. The volume of material for all thirty four iterations of the modified nominal groups is too great to be explored in its entirety here however the key aspects will be explored using the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      competency 7 “Provides comprehensive, safe and effective evidence-based nursing care to achieve identified individual/group health outcomes.

      3.1 The participant population

      There were 87 participants who attended 11 nominal groups across 7 states and territories in Australia, see Table 2. All participants shared their experiences of assessing student nurses in practice; they often reported that they undertook the role of facilitator for more than one university and, for a small number of participants, across different states and territories. These groups were made up of thirty two academics (37%) of whom 34% were directly involved in clinical subject delivery and management; twenty one graduate nurses (24%); twenty seven ‘educators’ either clinical nurse educator, graduate programme coordinators or education managers (31%) whilst the remaining participants were made up of nurse unit managers and clinical nurse specialists. No detailed data was captured relating to the populations age, gender or amount of years as a nurse or in a specific clinical role; however there were mental health, community, aged and acute tertiary care nurses (e.g. medical surgical wards) in the nominal groups.
      Table 2Nominal group participant representation.
      Participant (main role)Number of participants%
      Academics3237%
      Clinical nurse educators2731%
      Graduate nurses2124%
      Nurse unit managers45%
      Clinical nurse specialists33%
      Total87100%

      3.2 The findings and analysis from the modified nominal groups who explored
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      competency 7: “Provides comprehensive, safe and effective evidence-based nursing care to achieve identified individual/group health outcomes”

      As mentioned earlier there are a great many responses so this number of the initial responses from individuals in the nominal groups seen in Table 3 were mentioned the greatest number of times (four or more) under each of the headings ‘observations’, ‘questions’ and ‘measurements’. These illustrate the types of exemplars that were individually cited by the NGT participants.
      Table 3Examples of responses by nominal group participants under the three headings.
      ‘Observations’‘Questions’‘Measurements’
      ‘Uses team nursing’‘To ensure capability and scope of team’‘Considers and records patient allocation’
      ‘Good time management’‘Prioritises care appropriately’‘Ability to complete work’
      ‘Recognises own and others scope and skill mix’‘Quality and safety’
      ‘Completes total care’‘Holistic approaches to care’‘Measures patient outcomes (e.g. discharge on time with paperwork and medication)’
      ‘Appropriately prioritises care’‘Urgency may be necessary’‘Acts, responds and record promptly’
      ‘Recognises (and deals with) deteriorating patient’‘Understands/appreciates EWS’‘Applies scoring appropriately’
      ‘Looks up procedure or guidelines’‘Need to be sure/confident so important to check’‘Explains relevance regarding quality and safety’
      ‘Uses care plans and other information appropriately’‘Able to explain why care plan followed and/or queried’‘Gathers relevant information’
      ‘Engages/relates to the client/patient’‘Values a therapeutic relationship and understands its purpose’‘Accurately records communication and client/patient interaction’
      ‘Uses effective communication within and between teams’‘Explore importance/how to manage difficult situations’‘Record keeping concerning such communications’
      ‘Uses effective teaching and education strategies’‘Illustrate different approaches and when to use them’
      The participants stated that they would relate questions to the observation and if possible utilise some form of measurement, this is reflected in the presentation in Table 3 for example respondents would observe ‘completes total care’; on questioning explored the value of ‘holistic approaches to care’; and finally highlighted that a competent student would ‘measure patient outcome’.
      This reflects
      • Tanner C.A.
      Thinking like a nurse: A research-based model of clinical judgement in nursing.
      work; she was reflecting on clinicians viewing patients however this is ‘mirrored’ in how assessors, themselves experienced clinicians, use their knowledge of patients as well as the student to form these judgements on a student's competency. This was explored usually, but not exclusively, by the participants identifying a nursing activity such as managing medication administration or wound care or admitting or assessing a client; again reinforcing
      • Tanner C.A.
      Thinking like a nurse: A research-based model of clinical judgement in nursing.
      ‘thinking like a nurse’ by connecting this to a nursing activity.
      Participants, also reported, particularly during theming of the responses that structured frameworks for care planning and carrying out nursing activities were used. A care planning framework such as: assessing, planning, implementing and evaluating the activities of living was said to be really useful. Respondents said that they used such frameworks, to explore the students understanding as well as the ‘process’ of ‘doing nursing’ (
      • Roper N.
      • Logan W.
      • Tierney A.
      The elements of nursing: A model for nursing based on a model of living.
      ). These approaches were viewed by respondents as an existing structure used in practice to organise and deliver care. Respondents valued exploring these whilst summarising the NGT activities to share their approaches to what worked well for them; in effect, their best practice(s) for assessing competency in nursing student. Virtually all respondents stated that they would expect students to clearly articulate what they believe needs to be undertaken with the patient/client and why; what factors might affect what is to be carried out and why. This is a strategy identified within the literature as being used by clinicians in which the student or neophyte clinician is expected to give clear explanation of what they are intending to do and why (
      • Aitken L.
      • Mardegan K.J.
      Thinking aloud: Data collection in the natural setting.
      ,
      • Benner P.
      • Stannard D.
      • Hooper P.L.
      A “thinking-in-action” approach to teaching clinical judgement. A classroom innovation for acute care advanced practice nurses.
      ,
      • Tanner C.A.
      Thinking like a nurse: A research-based model of clinical judgement in nursing.
      ). These ‘think out loud’ strategies are used by many assessors in practice but without adequate guidance notes for students to consider and for assessors to compare against ensuring consistency and reliability, they have been problematic. Table 4 reproduces the second level descriptors for Competency 7 of the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      National Competency Standards for the Registered Nurse.
      Table 4NMBA competency no. 7. “Provides comprehensive, safe and effective evidence-based nursing care to achieve identified individual/group health outcomes.”.
      7.1 – Effectively manages the nursing care of individuals/groups.7.4 – Responds effectively to unexpected or rapidly changing situations.7.7 – Educates individuals/groups to promote independence and control over their health.
      7.2 – Provides nursing care according to the documented care or treatment plan.7.5 – Delegates aspects of care to others according to their competence and scope of practice.7.8 – Uses health care resources effectively and efficiently to promote optimal nursing and health care.
      7.3 – Prioritises workload based on the individual's/group's needs, acuity and optimal time for intervention.7.6 – Provides effective and timely direction and supervision to ensure that delegated care is provided safely and accurately.
      Table 5 illustrates the guidance notes designed to assist assessors with respect to this specific
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      competency; the table is set out with the observations, questions and measurements developed for this competency.
      Table 5NMBA competency no. 7. “Guidance Notes to assist assessors and students to assess the competency of students in clinical practice.”.
      Observations:Questions:Measurements:
      Follows and evaluates care and/or treatment plan at the start of the period of duty and during a span of care; produces a plan to assist/guide the management of care; accepts the client/patient as partner rather than recipient of care; uses language and appropriate cultural approaches to meet the needs of the client/patient in terms of care and information; terminology is appropriate and abbreviations are avoided; constructively delegates/negotiates with others acknowledging scope of practice; deals with unexpected events; how much direction does the student need and do they seek guidance; reflection on outcomes; does the student manage the task in accordance with the scope of practice; identifies and uses resources (people and equipment); Timely and appropriate delivery of care; Team player including effective communication; liaises with MDT & AHP; consults clinical notes regularly; high standards of client/patient care; client/patient advocate and client/patient safety; see student client/patient teaching taking place effectively and appropriatelyDemonstrates effective skills that meet best practice guidelines and can articulate the rationale; Prioritises actions and acts in a timely manner if a client/patient is deteriorating and/or other variations; Can explain rationale for the appropriate delegation of care – what will you do to demonstrate safe/timely care in those circumstances?; can articulate processes clearly;Demonstrates that they can manage varying client/patient-RN ratios in a timely and appropriate manner; care is sensitive to ‘case’ and shows understanding of costings per case; presents clear evidence of progress (OR NOT) of client/patient; recalls information and when and how to use that information; minimal wastage/healthy clients/patients/satisfied client/patients/client/patient discharge home; aware of wider evidence and this is clear in how they use evidence in their practice;
      Scenarios offered/other: Provides care and rationale for client/patient care plan; creates and uses written care plan; ability to develop knowledge base to enable them to provide individuals with the right education – listening/communication rapport/recognises own lack of knowledge; Delegates appropriately; knows if care has been met or not; prioritises care of critical client/patient(s); Knows when care to be delivered is outside scope of practice. Leadership of client/patient care/team working & Education for all/recognises client/patient issues/effective time management/attends education sessions.
      The examples illustrated in Table 5 were gathered from experienced nurses involved in the assessment of nursing student. The guidance notes were transcribed under the headings with minimal modification (only the removal of abbreviations and acronyms) so as to reflect the expert nurses views. The ‘scenarios offered’ section was identified by respondents as strategies that might be used to enable the student to exhibit the competency during their time on work place experience. In this particular example they reflect the student's ability to explain the rationale or the analysis required within the competency statement; leadership and team working are highlighted for example.

      4. Conclusion

      Two main outcomes were achieved in this study. Firstly guidance notes for both the assessor and the student were developed. These guidance notes illustrate what was expected of the student in terms of demonstrating their competency; thus allowing the assessor to assess the student against the competency using specific guidance to support them. Secondly, a clearer articulation of the
      • Nursing Midwifery Board of Australia
      National competency standards for the registered nurse.
      competencies was reached, which assists assessors to identify that a student is achieving the level of competence expected for a student at that point within their programme of study. Importantly in the development of the guidance notes, assessors stressed that these would also provide a developmental, structured framework for dealing with students who are not achieving as expected/required within the programme.
      The guidance notes ‘package’ has since been developed into a booklet that is used by two thirds of universities in Australia. Evaluation and feedback is ongoing and will be developed for publication later.
      Interestingly the development of what
      • Allen D.
      What are the competencies required by Entry Level Nurses at Stanton Regional Hospital?.
      described as ‘employer competencies’ was also clearly identified; although this was not an intention this serendipitous outcome has been invaluable. This work was built on the development of both the guidance notes and the scenarios offered from the modified nominal groups. This information can be located within the project reports (
      • Crookes P.A.
      • Brown R.A.
      The development of a pre-registration nursing competencies assessment tool for use across Australian universities.
      ). These employer competencies are very important because they provide a basis for clearer articulation of the sorts of activities nursing students should be encouraged/facilitated to practice repeatedly whilst on practicum. They also represent something of statement regarding what employers might reasonably expect of a newly graduating nurse – an expectation more in keeping with reality than the typical expectation of ‘an experienced RN’.

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