Nu~~~durakm T&y (1994) 14,3@?-393 0 Longman Group Lrd 1994

Australian nursing - moving forward? Competencies and the nursing profession

Fran A Sutton and Paul A Arbon

The introduction of national competencies for registration as a nurse in Australia has been met with great enthusiasm. While this development clearly brings some positive benefits the authors believe that competencies and competency development must be carefully monitored if Australian nurses are to avoid some of the pitfalls associated with this approach.

INTRODUCTION

Australia has, in recent years, suffered under the

weight of economic recession. Economic rational-

ism has significantly affected government policy

at all levels and influenced the lives of most

Australians. Burgeoning unemployment rates and

declining demand for goods and services have

encouraged the rationalists and limited initiatives

in several areas. Environmental reforms, social

services, living standards and the health care

industry have all been constrained by government

policy aimed at reducing the impact of economic

recession.

Micro-economic reform has been viewed as an

important means to limit the decline in economic

activity. It has included restructuring of employ-

ment awards, the development of productivity

agreements between employers and employees in

exchange for improved salaries or conditions,

Fran A Sutton RN RPN DipT BEd MEdAdmin, Associate Professor and Paul A Arbon RN BSc GDip HEd MEdStudies Senior Lecturer, Faculty of Nursing, The University of South Australia, Holbrooks Road, Underdale, South Australia, 5032.

(Requests for offprints to PA) Manuscript accepted 16 February 1994

and the introduction of competency-based stan-

dards in industry and the professions (Bartlett

1991).

COMPETENCY DEVELOPMENT

Competency development is generally viewed as

achieving two ends. The first intended outcome is

the recognition of qualifications obtained in

other countries, states or territories. Competen-

ties applicable across the industry and the nation

facilitate the exchange of skilled workers and the

establishment of common standards which can be

used for quality control and the development of

national industrial awards.

The second goal of competency development is

a change in the focus of education from process

to outcome. A focus on educational outcomes

rather than learning processes enables students to

progress at varying rates through material and to

receive appropriate acknowledgement for previ-

ous experience and learning. The focus is on the

achievement of desired competencies (out-

comes) rather than the means by which they have

been acquired (process). Contemporary educa-

tional planners believe that this change in

approach to education will result in more effi-

388

cient use of educational resources. This resource

efficiency derives from students completing any

programme, or part thereof, when they are able

to demonstrate the desired competencies,

although minimum time requirements may be

set. Additionally, programmes can be designed in

specific ways or for specific groups. As they are

outcome oriented little time is lost during the

programmes on exposing students to content

unrelated to achieving the desired competencies.

This allows students to progress at their own rate

through learning experiences. This changing

emphasis has influenced staff development activi-

ties as well as award based courses offered from

the educational sector.

In Australia, considerable pressure has been

applied by the national government to encourage

industry and the professions to adopt a

competency-based approach to education, staff

development and performance appraisal. This

impetus continues despite recognition that the

competency-based standards model is not sup

ported by research evidence (Tuxworth 1989).

The extent of government interest in this area

is indicated by the establishment of a national

coordinating body (The National Training

Board) which reports directly to government and

aims to provide for:

A consistent national framework for develop

ing competency standards.

Acceptance by all governments and training

authorities of competency standards ratified by

the Board as the benchmarks for vocational

education, curriculum development, industry

training and recognition and the delivery and

accreditation of training.

Competency standards endorsed by the Board

to be the benchmarks for recognition of skills

and qualifications of those trained overseas

(National Training Board, 1991).

A second government body, the National Office

of Overseas Skills Recognition (NOOSR) has

been established specifically to encourage the

development of strategies which will allow for

ready recognition of overseas qualifications with-

in Australia. This group has focused its attention

on the development of competencies for the pro-

fessions.

NURSE EDUCATION TODAY 389

In addition to this significant impetus from gov-

ernment, various professional groups have recog-

nised the potential value in adopting competen-

ties as a means of describing their practice.

Competencies provide consumers and profession-

als with some common notion of the standards

and expectations of professionals and thereby

enable all parties to relate and function more con-

sistently and successfully.

In nursing, competencies have been used not

only to describe practice but also delineate

between roles and fields of practice. This has led

to the development of level-specific competencies

(to be discussed later) and the establishment of

discrete sets of competencies for Registered and

Enrolled nurses.

THE AUSTRALIAN NURSING CONTEXT

Over the past decade, the nursing profession has

undergone several significant changes primarily

arising from changes in the health care system.

These changes are associated with a number of

factors including the desire to restrain burgeon-

ing health care costs, increasing specialism in

nursing and changing demographic factors with-

in the Australian community. In turn they have

led to the need to develop innovative nursing

strategies which are more cost-effective and broad-

er in scope. Early discharge and day surgery,

growth in community-based nursing services and

the introduction of new technology and associat-

ed nursing skills, are examples of the changing

face of Australian nursing.

Changes have also been generated from within

nursing with the introduction of a new career

structure for Registered Nurses (1988)) establish-

ment of Standards of Nursing Practice (1986),

transfer of nurse education to the tertiary educa-

tion sector (19851993), and more recently the

acceptance of minimum competencies for regis-

tered nurses by the Australian Nurse Registering

Authorities Conference (ANRAC) (1990).

The career structure, while varying in detail

from State to State, has as its common theme the recognition of clinical expertise in a way not pre-

390 NURSE EDUCATION TODAY

viously possible. Clinicians are no longer required

to accept positions in management or education

to establish a viable career pathway, although

these options are still available.

The nursing standards of practice embody a

definitive role statement that indicates registered

nursing practice involves a wide range of activi-

ties. These include being able to provide care

appropriate to the needs and problems of the

client through assessment and planning, culmi-

nating in evaluation of care activities. These stan-

dards also focus on acceptance of responsiblity

and accountability in the provision of nursing

care. In enacting the nursing role practitioners

are expected to communicate effectively, func-

tion independently, participate in research and

engage in ongoing educational activities.

The Australian nurse’s role is a changing one.

As a result, the nursing profession has, sought to

change the manner in which nurses were pre-

pared. Their successful negotations, although

lengthy, resulted in the progressive transfer of

nursing education from its traditional hospital

base into the Australian higher education sector.

The transfer of nurse education, which occurred

between 1985 and 1993, allowed changes to be

made to the emphasis and focus of Registered

Nurse preparatory programmes. As a conse-

quence generalist or comprehensive pre-registra-

tion nursing education programmes were devel-

oped. These contrasted with the preexisting

hospital-based programmes which traditionally

focused on acute inpatient nursing. Generalist

pre-registration nursing programmes aimed to

prepare students of nursing for the broad range

of possible roles which they might full4 on gradu-

ation.

Thus students of nursing were exposed to com-

munity, psychiatric, acute medical and surgical,

rural and non-traditional nursing settings in a

manner not previously attempted. Graduates of

these programmes were arguably less well pre-

pared to nurse in acute medical and surgical hos-

pitals but possessed substantially increased nurs-

ing knowledge and breadth of experience. Two

outcomes appear to have arisen from these devel- opments. Firstly, new graduates seem to be more

adaptable and effective in their nursing care fol-

lowing a short period of orientation to the work-

ing environment. And secondly, employers in the

acute care sector have recognised the need to

develop orientation and staff development pro-

grammes which are specifically directed at this

new kind of graduate nurse (Sutton & Rudge

1993).

During the 1980s Australian nursing estab-

lished professional and educational structures

considered foundational to a developing profes-

sion and emerging discipline. The career struc-

tures, practice standards and tertiary level educa-

tion were an integral part of this development.

Nurses began to view their role as autonomous

and valuable, and this in turn affected their place

in a multi-disciplinary health care team. The tradi-

tional focus on providing support for medical and

other health care professions was gradually

replaced by one of providing complementary

functions as nurses increasingly valued their own

contribution and knowledge. By 1990, Australian

nurses were routinely involved in multidisci-

plinary professional forums, research, strategic

planning in health services and conference

participation. Activities which a decade previously

would have been considered unusual were in

1990 the norm.

THE INTRODUCTION OF NURSING COMPETENCIES

The Australasian Nurse Registering Authorities

Conference (ANRAC) began in 1986 to develop

competencies for the registration and enrolment

of nurses. This initiative resulted in the specifica-

tion and acceptance of National Competencies

for Registration and Enrolment of Nurses in

Australia and New Zealand (ANRAC 1990).

These statements paved the way for recognition of

nursing qualifications across all States and

Territories and moved Australian nursing closer

to establishing a national registration system. In

addition, they have facilitated the recognition of

overseas nurse’s qualifications and experience. As

we have stated earlier, these developments have

arisen from federal government pressure for all

industries and professions to develop competen-

ties.

NURSE EDUCATION TODAY 391

However, the primary motivation to develop

nursing competencies appears to have arisen

from within nursing. Australian nurses have

accepted the responsibility of the profession to

monitor and maintain its own standards.

Competency development is viewed as one means

by which the profession can self-evaluate and

enhance its accountability to the public.

This early recognition of the potential value of

competency development has resulted in nursing

moving quickly with respect to this matter and

leading the way for other professions.

The application of a competency-based model

of professional education appears to mirror the

experience of the UK and USA and, as in these

countries, nurses have taken the lead in this devel-

opment (ANKAC, 1990). While other profession-

al groups are engaged in competency develop

ment (Pharmacy, Education Medicine, Law,

Engineering), the nursing profession is at the

forefront of this activity (Gonczi 1990).

The key components of a competency based

approach to professional education are:

l A list of competencies which specify the profes-

sional expectations associated with the role.

l The establishment of specified standards for

each competency.

l Appropriate educational programmes to facili-

tate the development of competencies.

l Assesment methods for each competency or

sets of competencies.

l Guidelines for the application of competencies

in staff development and performance appraisal.

THE IMPLICATIONS FOR THE NURSING PROFESSION

The development of a competency-based model

of professional education in nursing has raised a

number of interesting questions and concerns.

Nurses are only beginning to realise the ramifica-

tions of this development for practice and their

profession. While economic restraints have limit-

ed nurses in their abilitv to extend further the

quality of care provided and develop new initia-

tives, competencies have the potential to shape

Australian nursing and its future.

The degree to which competencies can be used

to describe professional practice is questionable.

Competency statements purport to describe the

attributes, including knowledge and skills, neces-

sary for effective and/or superior performance

(Butler et al 1991). The practice of health care

professionals, including that of nurses, is undeni-

ably complex and there is little doubt that compe-

tency-based standards provide only a limited view

of this practice. They must, by their very nature,

provide a reductive analysis of practice. For exam-

ple, it is difficult to incorporate notions such as

intuition (Benner 1982) or somology (Lawler

1991) into a competency-based standard.

It may seem self-evident that competencies will

establish only minimal standards and cannot be

used to truly reflect the complexity of practice.

However, as nursing authorities and employers

seek to establish competencies as the basis for role (job) descriptions, performance appraisal and

quality assurance, the possibility of nurses contin-

uing to work in adaptive and innovative ways is

put at risk.

The recognition that competencies cannot

address the complexity of nursing practice is

important. It leads to a number of related conclu-

sions. Nurses must be supported and encouraged

to practice in new or different ways as their prac-

tice evolves. To restrict practice within the bounds

of established competencies will lead to stagna-

tion and a gradual decline in the relevance of

nursing care. All competency statements, and par-

ticularly those associated with highly skilled work,

must continue to evolve and follow developments

in practice. For this to occur competencies must

be written and reviewed by practitioners.

Practitioners rather than governments, employers

or a limited group of ‘experts’ must ultimately

control the development of competencies to

ensure they keep pace with the world of practice.

The evolution of practice is in part related to

the continual rub which occurs at professional

boundaries. In health care it is not uncommon

for patient care procedures, investigations and

the like to move from the domain of one profes-

sion to another. This continual ‘movement of the

392 NURSE EDUCATION TODAY

border’ is a common feature of evolving work

relationships and tends to ensure that patient

care needs are met in an efficient and appropriate

manner. It is generally viewed as a form of healthy

give and take between closely related professions

although often associated with a degree of angst

at the time. Rigid adherence to competency state-

ments or restrictive interpretation of competen-

ties will of course limit the possibility that this sort

of activity will occur. Thus, instead of competen-

ties contributing to efftciency within the industry,

as intended, they may lead to a loss of efficiency

and effectiveness as professions become less able

to respond to the need for change. This is particu-

larly a concern for nurses who work within a pro-

fessional culture which appears more accepting of

structure and bureaucracy than other health care

professions (Sutton 1993).

In Australia, nursing career structures have

been established which acknowledge clinical,

managerial and educational career pathways.

Consequently, various groups have now em-

barked on the development of level and/or field

specific competencies in nursing. Level specific

competencies are associated with different

appointment levels within the established career

structures. These accommodate the view that

senior nurses responsible for activities such as for-

ward planning or management of clinical units

will be required to possess a different range of

competencies from those held by novice practi-

tioners who work predominantly with clients.

Some professions have established a single set of competency statements and developed the notion

that novices are different from experts (Benner

1982) by virtue of the standard achieved in rela-

tion to each competency. Therefore all practition-

ers, within this model, have the same set of com-

petencies but those more experienced will be

expected to perform the competency at a higher

level. In Australian nursing however, level specific

competencies imply that each level of appoint-

ment brings with it qualitatively different roles

and requires the development of somewhat differ-

ent competencies. This approach acknowledges

the need for adequate succession planning and

associated staffdevelopment programmes to facil-

itate staffmovement between levels.

Field specific competencies are also being

developed. That is, for example, competencies

specific to midwifery or psychiatric nursing.

Again, the assumption is that the roles vary sufh-

ciently to require different competencies and that

generic nursing competencies will not suffice.

These developments have opened a Pandora’s

box for the nursing profession and a number of

issues now need to be addressed. The profession

must consider the way in which it delineates

between nursing specialities and the extent to

which generic competencies can be used to

describe nursing practice within them. There is

also an issue related to the way that we describe

our practice in that we refer to fields derived from

medicine, for example, surgical nurse, critical

care nurse, psychiatric nurse. The competencies

provide us with an opportunity to describe nurs-

ing practice without resorting to terminology

derived from medicine. A further issue is related

to the development of level and field specific

competencies that may lead to fragmentation

within the profession. This latter issue is of partic-

ular importance given the recent statements by

the International Council of Nurses with respect

to Specialization in Nursing (1992). Finally, we

need to consider the issues related to the develop

ment and implementation of competencies.

Discussion and clarification of these issues will

identify who is perceived as appropriate to devel-

op and monitor competencies. These issues will

assist the profession to clarify or identify the risks

and potential opportunities associated with compe-

tency development.

COMPETENCY DEVELOPMENT TECHNIQUES

Associated with the idea that competencies can-

not describe adequately the intricacies of nursing

practice is the question of competency develop

ment. Various approaches have been used to facilitate

the development of competencies for nurses.

Each technique will describe the knowledge, abili-

ties, skills and attitudes (attributes) which com-

NURSE EDUCATION TODAY 3%

prise competence more or less well. The choice of technique will determine the extent to which competencies become focused on one or other component of competence, for example, skills rather than other attributes (Gonczi et al 1990).

The tendency to seek skill based competencies is understandable and natural. Particularly, if one does subscribe to the view that competencies should be developed by practitioners themselves. Skill based competency statements provide readi- ly measurable criteria which are easily observed and assessed. Practitioners, given the practical and applied nature of their work may be attracted to skill based statements. When confronted with competency statements which relate to other attributes of the nurse (knowledge, abilities and attitudes) no less essential than skills, practition- ers may experience some difficulty in developing assessment of competence. For example, a compe- tency relating to advocacy may require that the assessor infer that the standard has been met from the nurse’s comments or behaviour. It may not be possible to directly observe the nurse act- ing as advocate. Assessment of these types of com- petencies requires experience and sensitivity on the part of the assessor.

The nursing profession will need to monitor carefully its development of competencies with a view to avoiding a drift away from important attributes toward equally important but directly measurable statements related to skill.

References

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Benner P 1982 From novice to expert. American Journal of Nursing (March): 402407

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