Continuing competence and the regulation of nursing practice

Continuing competence and the regulation of nursing practice

ALAN PEARSON R N , O N C , D i p N E d , D A N S , M S c , P h D , F C N ( N S W ) , F I N A , F R C N A , F R C N1, MARY FITZGERALD R N , R N T ,

D i p N u r s ( L o n d o n ) , M N u r s ( W A L E S ) , P h D ( U N E ) ,2 KEN WALSH R P N , R G N , B N u r s , P h D ( A d e l a i d e )3 and SALLY BORBASI R N ,

B E d ( N u r s i n g ) , M A ( E d ) , P h D4

1Professor of Nursing, La Trobe University, Melbourne, Australia, 2Professor, University of Newcastle, Newcastle,Australia, 3Lecturer and 4Senior Lecturer in Nursing, The University of Adelaide, Adelaide, Australia

Introduction

A study to identify indicators of continuing competence

in nursing was commissioned by the Australian Nursing

Council in 1997 and carried out in 1997/1998. The

objectives of the study were to develop:

• a statement of indicators of continuing competence in

nursing;

• an explanation of the basis for each of the identified

indicators;

• a description of any boundaries, contexts, applica-

tions or qualifications which apply in respect of each

indicator; and

• recommendation for any further action or research.

This paper reports on the literature review of statu-

tory regulation of professions with particular reference

to regulation of the nursing profession carried out in

stage one of the study.

Competence and regulation in Australiannursing

A comprehensive review of the literature was under-

taken in two phases. The first phase of the literature

review built on the work of Johnson (1995), commis-

sioned by Australian Nursing Council Inc. (ANCI) to

review recency of practice as a competency indicator.

Later, more comprehensive review of the literature

revealed the complexity of the subject and covered

issues integral to the continuing competency debate.

The review presented here was developed as a back-

ground to the study and is an attempt to situate the

issue of continuing competence in nursing regulation

through exploring the concepts of professional and

continuing competence in Australia. The need for an

inquiry into continuing competence in nursing, to find

the most suitable means for Nursing’s statutory bodies

in Australia to discharge their duty to protect the public

Correspondence

Alan Pearson

Professor

School of Nursing and Midwifery

La Trobe University

Bundoora 3086

Melbourne

Australia

E-mail:

[email protected]

P E A R S O N A., F I T Z G E R A L D M., W A L S H K. & B O R B A S I S . (2002) Journal of Nursing Management

10, 357–364

Continuing competence and the regulation of nursing practice

A study commissioned by the Australian Nursing Council Inc. sought to develop an

approach to the maintenance of continuing competence in nursing that is broadlyacceptable to nurses in all States and Territories. The study involved a compre-

hensive review of the international literature and this paper provides an overview of

statutory regulation of professions with particular reference to regulation of thenursing profession. A definition of competence and competencies and a discussion

of beginning and continuing professional competence are presented, followed by a

review of current indicators of continuing professional competence used by a varietyof professions in Australia.

Keywords: continuing competence and professional licensing, nursing regulation

3Accepted for publication: 1 June 2000

Journal of Nursing Management, 2002, 10, 357–364

ª 2002 Blackwell Science Ltd 357

by ensuring continuing standards of practice, emerges

clearly from the literature.

The role of regulation in the professions

The British and European Guilds of the Middle Ages are

early examples of the regulation of occupational

groups. These Guilds tightly controlled entry to the

occupation they were associated with and thereby lim-

ited the practising of a trade, occupation or business to

an elite group. This regulation was sanctioned by the

Crown and governed locally by the Boroughs, operating

on authority delegated by the Crown. Although they

maintained high standards of craftsmanship, their aim

was unashamedly the protection of members’ livelihood

rather than the public good per se.

The hallmarks of a profession – although greatly em-

bellished by the sociologists of the 1960s and 1970s –

have their origins in these early Guilds and bear a strong

resemblance to these antecedent social institutions

today. Professions promote self-regulation through

membership in order to control practice. In most West-

ernized countries, many professions are regulated by the

State through specific legislation. Examples of profes-

sions frequently regulated in such a way are medicine,

nursing, architecture and dentistry. Such regulation is

generally associated with the professions that have the

potential to cause harm to individuals or communities.

Regulatory authorities established by legislation are

charged with responsibility for setting standards of

preparation for admission to the profession.

They are also expected to ensure that members of the

profession maintain competence to secure continued

licensing. The prime function of the regulatory bodies is

to ensure the safety of the public in its dealings with the

profession. As part of their social contract, profession-

als accept responsibility to maintain standards of service

to the public in return for status and remuneration.

While nursing boards and councils are set up and

supported by members they are often established by

parliament, but in some countries such as Canada, the

nurses association is the licensing authority. Social work

is an example of a profession which is not regulated by

the State (social workers do, however, make an attempt

to self-regulate through the operations of their profes-

sional association). Without a profession-specific stat-

utory body they have to rely on the general machinery

of the State and their employers to determine their

scope; matters of pay and conditions of service usually

override these concerns. This has traditionally been the

case in nursing although in Australia it has begun to

change in recent times.

Nursing and medicine were the first professions to

have entry regulated through legislation. In the case of

nursing, New Zealand passed a Nurses Registration Act

in 1901 (Nursing Council of New Zealand 1996). This

was followed by a number of States in the United States

of America, Britain, continental Europe and Australia.

However, there is still a great deal of diversity between

countries and indeed between States within countries

regarding the scope of practice, preparation for practice

and maintenance of competence.

Regulation is achieved through various Nursing Acts

that prescribe the responsibilities of the statutory bod-

ies. These responsibilities include but are not limited to,

inter alia, disciplinary procedures and powers; specific

requirements for licensure and relicensure; exemption

from licensure; grounds for removal from the register;

grounds for suspension of the licence and provision for

mutual recognition for nurses from other states or

countries (Leddy & Pepper 1998).

Within Australia each State and Territory has its own

legislation variously styled as the Nurses Act of the

Nursing Act depending upon the jurisdiction, regulating

nursing practice and standards. The variation between

them has been recognized as a problem and much work

has been carried out to establish minimum competency

standards for entry to the profession that are recognized

nationally (Anderson 1994). The point of entry to the

profession has been the most obvious focus for reg-

ulatory bodies and thus they have concentrated on

beginning competence4 . It is now some years since the

outcomes of this work were introduced and it is timely

for the nursing profession to look at the issue of con-

tinuing competence and its relationship to relicensure.

Entry level competence is different to the more

advanced levels of competence, already examined by an

Australian team (McMillan et al. 1997). Relicensure

relates to the minimum standards. Thus, any applica-

tion for licensing must be considered against the same

benchmarks irrespective of professional experience. It

has become important to regulatory bodies in all pro-

fessions to identify means of assuring minimum stan-

dards for all practising members of a profession who are

recurrently issued with a licence to practice.

Competence: what is it?

The background to competency-based training and

employment in Australia developed from the 1987

report, Australia Reconstructed. The resulting Finn

Report produced in 1991 set out a number of �key

competencies�. These key competencies were to

operate within a standard framework and, if applied

A. Pearson et al.

358 ª 2002 Blackwell Science Ltd, Journal of Nursing Management, 10, 357–364

consistently, they would ensure some consistency across

entry levels of training and education (Finn 1991).

Heywood et al. (1992, p. 15) list the general benefits for

an occupation when having competency entry require-

ments such as:

• consistent recognition across States and Territories;

• accreditation by all States and Territories for appli-

cants who meet the Standards (whether trained in

Australia or overseas);

• an open and equitable assessment of those with

overseas education and work experience against

agreed, public standards of performance;

• articulated training and progression within indus-

tries; and

• recognized articulations with related occupations.

Following discussions with industry, education and

the community, the Mayer Report produced a list of

seven key competencies and these competencies were

designed to reflect a focus for education and industry

notions of �best practice� (Mayer 1992). These key

competencies reflect the ability to:

• collect, analyse and organize information;

• communicate ideas and information;

• plan and organize activities;

• work with others in teams;

• use mathematical ideas and techniques;

• solve problems;

• use technology; and

• use cultural understandings (Gonczi et al. 1995, p. 3).

The most significant aspect of competence-based as-

sessment is the focus on outcome performance rather

than the means taken to acquire an ability. For example,

the length of training of the number of examinations is

less important than the ability to do something measured

against predetermined standards. This shift allows more

flexibility in the system allowing educational establish-

ments and individuals to choose from a range of learning

opportunities to achieve and take responsibility for the

required level of end performance (Anderson 1994).

Competence has been considered from the narrowest

of perspectives as lists of tasks able to be completed

through to the more complex abstract abilities to provide

an appropriate level of professional practice in a variety

of contexts. The latter competence involves abilities to

combine knowledge, attitudes and psychomotor skills

appropriate to professional service delivery (Girot 1993).

Writing and setting competencies that accommodate

the challenging and complex work of professionals is

contentious because the more accommodation that

is made for independent decision-making the less easy it

is to set specific criteria for the measurement of success.

It is easier to assess competencies that relate to specific

psychomotor skills and this is possibly why more pro-

gress has been made in vocational education. However,

Heywood et al. (1992, p. 16) claim that:

�Competency standards make no claim to exhaust

all facets of a profession, just as traditional

courses for professionals do not claim to be totally

comprehensive. What a good set of competency

standards does is to provide a clear statement of

what is considered to be important in competent

performance in that profession.�These authors (Heywood et al. 1992, p. 16) reiterate

that a competence is not directly observable but

describes a set of �… characteristics or attributes that

underlie and enable competent performance in an

occupation�. The ANRAC (1990) Nursing Competen-

cies Assessment Project undertook the original work on

competencies in Australian Nursing. They addressed the

issue of measurement and agreed that:

�The act of assessment for professionals compe-

tence is the making of an inference about the

candidates� knowledge, attitudes and practice. A

legal paradigm involving weighing evidence is

more appropriate that a scientific paradigm

entailing measurement.’ (ANRAC 1990, p. 39)

Competencies for beginning professionals also need

to take an account of the future needs of the workplace

where changes have occurred and will continue to occur

because of the introduction of new technologies and

new professional knowledge. Some tensions arise from

differing interpretations of the specific role of training

and more general approaches to education.

Education can be closely tied to a concept of �trans-

ferable skills�. In terms of higher education this again

favours the specific transfer of skills required by the

National Curriculum Council (UK) in relation to

�problem solving; communication; personal skills;

application of mathematics; information technology and

foreign language competence� (Milligan 1998, p. 276).

Within Australia, wider debates on competencies

occur within the framework of the National Training

Board, which sets national skill standards for occupa-

tions from entry to paraprofessional level. The use of

the term �competence� across a range of educational and

training fields has led to an increase rather than a

decrease in the variety of meanings and uses of the term.

The term �competence� became part of the education

debate in Australia in 1985. The Quality Education

Review Committee described competence as �the ability

to use knowledge and skills effectively to achieve a

purpose�. This general definition continues to have some

Regulation of nursing practice2

ª 2002 Blackwell Science Ltd, Journal of Nursing Management, 10, 357–364 359

relevance in areas of industry reform and postcompul-

sory schooling (Monash 1998, p. 1).

Beginning competence in nursing

Beginning competence is taken to mean entry-level

competence for professional practice. Beginning com-

petencies for Australian nurses were developed in the

early part of the decade. The ANCI competencies, as

they are known, originated from the ANRAC confer-

ence in 1986 as a response to concerns about variations

in requirements for nursing registration and enrolment

in each State and Territory.

In response, minimum competencies were designed to

provide a national registration base level. Competencies

were developed following agreement on a series of

competency standards, a philosophy of nursing and role

statements. These competencies were validated through

fieldwork carried out in workshops and with new

graduates. Nursing regulatory authorities adopted these

competencies in 1990 following a series of seminars,

issues paper and professional development workshops

(ANRAC 1990, ANCI 1995).

Continuing competence in Australian nursing

In Australia, continuing competence and recency of

practice are closely linked with the nursing legislation in

many of the States and Territories through the various

Nurses and Nursing Acts. In all Australian jurisdictions,

nursing registration authorities have been set up by

parliaments to establish and maintain acceptable stan-

dards of nursing care in the particular State or Territory

in which they function.

Table 1 outlines the current Acts for each State and

Territory of Australia. Johnson (1995) presents the

position in each State regarding those acts, which legis-

late conditions relating to recency of practice and those

that do not. In summary, the following legislatures

require proof of relevant practice within the previous

5 years prior to annual relicensing: Queensland, Aus-

tralian Capital Territory, Victoria, Western Australia

and South Australia. In the Northern Territory and

Tasmania there is no mention in the Act of recency of

practice.

However, the Northern Territory in a 1995 commu-

nication between the Registrars of the Australian

Nursing Registration Authorities and ANCI indicated

that persons not practising nursing in the previous

5 years would be considered to be unsafe to practice. In

the case of Tasmania, the Nursing Act 1995 establishes

the Nursing Board which required it ensure that nurses

maintain a high standard and to protect the public from

unsafe, incompetent and unethical nursing practices’

(Bates & Dewdney 1996). New South Wales is the only

exception.

There is no mention in the New South Wales Act of

the necessity to provide evidence of continuing compe-

tence prior to annual re-registration and the provisions

do not include recency of practice requirements for

continued registration. Further, according to a letter of

6 March 1995 from the Registrar, Nurses Registration

Board, to the Chief Executive Officer, ANCI, there are

no plans to change existing legislation.

Initial and continuing competence

None of the Acts specifically address the issue of

indicators of continuing competence beyond that of

recency of practice. The assumption is that, in applying

for renewal of licence, the nurse is per se asserting

his/her competence to practice: which should be granted

if there is no cause for removal from the register.

However, the Councils are clearly cognizant of other

issues. For example, Queensland Nursing Council, in

the (1997) Information paper no. 4 states that:

�Section 54 (2A) (of the Nursing Act 1992)

… requires Council to be satisfied that an appli-

cant for registration, and hence renewal of that

registration, is fit and competent to practice

nursing. In the absence of outcomes from the

projects being undertaken by the Australian

Nursing Council Incorporated and the Nurses

Board of Victoria. Council considers it would be

inappropriate to attempt to define such matters as

indicators of continuing competence and the

measurement of what is sufficient experience.�

Legal requirements

Whilst there is not one single definitive statement

relating to recency of practice, there is an assumption

Table 1Current Nurses Acts in Australia

State/Territory Current Act

South Australia Nurses Act 1984Victoria Nursing Act 1993Queensland Nursing Act 1992New South Wales Nurses Act 1991ACT Nurses Act 1988Western Australia Nurses Act 1992Tasmania Nursing Act 1995Northern Territory Nursing Act 1982

A. Pearson et al.


that nurses who have practiced in the last 5 years will

be safer and more competent in their practice. These

assumptions are based on a number of factors such as

the rapid changes that take place in the nursing envi-

ronment in terms of mediation and equipment and need

to keep abreast of changes in technology and nursing

practice, which includes:

�The introduction of new technologies, forms of

treatment, drugs and health information; chang-

ing demographics and population needs; and

increasing consumer awareness.� (Queensland

Nursing Council 1997)

The various Acts define the establishment and com-

position of the Nursing Boards and indicate the range of

procedures that are to be followed during the registra-

tion of nursing personnel in each State.

Figure 1 summarizes the different approaches taken by

Boards to relicensing. Disparities in the recency of prac-

tice legislature across States and Territories of Australia

indicate the difficulties faced by nursing authorities, and

the profession as a whole, in attempting to define, mon-

itor and regulate the continuing competence of nurses. A

review of current practices indicates the strong need to

work towards the development of common legislative

conditions relating to recency practice across Australia.

These disparities lead us to recognize that compe-

tency within a profession such as nursing is vastly

complex and difficult to operationalize into pragmatic

methods of regulation. Recency of practice is a simple

method of providing one indicator of competency.

However, this in itself does not recognize variations in

competency levels across nurses who have not practiced

for some time, and makes the assumption that nurses in

current practice, or who have not practiced for any

period up to 5 years, are indeed competent. Clearly,

other indicators of competency are required to monitor

re-registering nurses, alongside a growth in opportuni-

ties for nurses to undertake further professional devel-

opment. One potential direction is the use of a

competency assessment for nurses re-entering nursing

after a period away from the profession, and expanded

opportunities for nurses to undertake refresher or

re-entry training, based upon the outcomes of the assess-

ment and/or through personal choice for the training.

Figure 1Approaches to the relicensing of nurses by Australian States and Territories.



Alternative methods of regulating continuing com-

petence across a range of other professions are pre-

sented below, and are discussed in terms of the potential

for the nursing profession.

Continuing competence in other professionsin Australia

The means by which continuing competence is estab-

lished varies greatly across professions. Of the profes-

sions reviewed here (see Table 2) only physiotherapy

has an Act that addresses the recency of practice. Sim-

ilar to nursing, physiotherapists must have practiced in

a relevant field within the last 5 years to continue to

obtain registration.

However, across the professions, alternative criteria

for registration and/or assessment of competency have

been established (see Table 2). In the case of engineering,

prospective members must have worked in the field for

at least 3 years, and are required to complete a 4–500-

word competency-based report and examination to gain

membership. Continued competence is monitored

through the use of a work logbook, which is required to

maintain registration. These stringent requirements may

be more appropriate in this field, whereby the profes-

sion is self-regulating and membership to the national

body is voluntary. Therefore, those wishing to demon-

strate and maintain their professional competency are

able to do so via a voluntary system. However, this

system provides no assurance of competency amongst

those who do not register.

The most common form of competency assessment

and maintenance identified in the review is a points

system, whereby individuals must obtain a specific

number of points within a set time period, to obtain

or maintain registration. Points are obtained via

Table 2An overview of continuing competence across other professions in Australia

Profession Registration and recency requirements Alternative criteria for registration or competency assessment

Medicine Re-registration by fee only. No recencyof practice required

Specialist colleges such as The Royal Australian College of General Practitionershave their own criteria: members are required to accrue 130 points every 3 years,through continuing medical education, practice assessment orprofessional development

Law There are variations in registrationacross states, however, there are norecency requirements. In SouthAustralia, practitioners must applyevery year to obtain the practicingcertificate

In South Australia, responsibility for admitting a practitioner lies with the SupremeCourt. However, responsibility for the annual practicing certificate has beenpassed to the Law Society of South Australia

Engineering Engineering is a self-regulatingprofession, with voluntary member-ship through a national body: Instituteof Engineers. There are no recencyrequirements.

Prospective members may approach the institute to become a member after 3 yearsof practice. Prospective members must complete a 4000–5000-wordcompetence-based report and pass an examination to gain membership.Continuing competence is established through a log-book of work, required tomaintain membership

Social work There is no State or Federal legislationto regulate social work, and thereforeno recency requirements.

Social workers can register with a national professional body: the AustralianAssociation of Social Workers if they have completed an accredited course. Thereis a continuing professional education programme with a points system thatallows membership. This membership is frequently required by employers

Psychology Requirements to practice are regulatedby each State. There are norecency requirements

Individuals who have completed relevant accredited education and/or a period ofsupervised practice may apply to the Psychological Registration Board in theirstate. There are a number of professional bodies of psychologists throughoutAustralia that have requirements for specialist professional status in the field

Physiotherapy There are variations across States. InSouth Australia, the PhysiotherapistsAct contains a 5-year recency ofpractice clause. However, in Victoria,registration is by fee only

The Australian Physiotherapy Association has introduced a programme ofmandatory continuing professional development, whereby physiotherapistsobtain professional development points for a variety of professional activities,including speaking at conferences, lecturing and student supervision

Accountancy There is no legislation governing thepractice of accountants, exceptingthose practicing in the areas oftaxation, company audits andinsolvancy. There are no recencyrequirements

Broadly, accountants are regulated by professional bodies such as the Associationof certified Practicing Accountants and The Institute of Chartered Accountants.These bodies require members to undertake professional development and abideby a code of conduct. Certified Practicing Accountants are required to undertakea set number of professional development hours over 3 years, with randomaudits to ensure compliance with this requirement

All information was obtained from personal communications with the organizations named in the overview.

A. Pearson et al.


continuing education within the field, continued pro-

fessional development, practice assessments, lecturing,

speaking at conferences and student supervision. Simi-

larly, Certified Practicing Accountants are required to

undertake a set number of professional development

hours each 3 years, with random audits undertaken to

ensure individuals are meeting these requirements.

This form of competency regulation provides one

such direction for the nursing profession. The potential

exists for nursing authorities to establish a national

framework for competency regulation through contin-

ued professional development points system, whereby

nurses are required to undertake professional activities

such as attending inservices, workshops and/or confer-

ences, completing practice assessments and undertaking

supervision.

Conclusion: continuing competencein Australian nursing

There is extensive literature on the development and

adoption of various methods and systems for assessing

initial competence and monitoring continuing compe-

tence in the professions. However, besides anecdote

and local evaluation, there is little evidence to suggest

that any one method is better than another. No pro-

fession appears to have found a definitive answer to

the issue of continuing competence – one that is rea-

sonable to administer, reliable and acceptable to the

profession.

The review of other professions shows that there is

intensive interest and a great deal of activity directed at

monitoring the continuing competence amongst most

professions. The issue is clearly taken seriously by these

professions although none appear to have achieved

greater success than nursing in developing an effective

system.

Nursing has advanced rapidly in this area interna-

tionally, and has made more progress in the past

decade than many other professions both in Australia

and in the rest of the world. The challenges ahead are

to draw on the work that has been carried out to

date, canvass the views of experts and consumers, and

to develop and rigorously evaluate a system that is

acceptable to the profession and the community it

serves.

A number of recommendations are proposed here

for the future development of competency regula-

tion in nursing. The first is the need for a national

research programme to assess current professional

competency standards and regulation in nursing

practice, and draw upon key professionals in the field

to examine the development of clearer competency

standards in nursing. It is further recommended that

researchers, in collaboration with nursing authorities,

examine the potential to utilize systems drawn across

from other professions, such as a professional devel-

opment points system. Finally, this review of current

practices and literature indicates the strong need to

work towards the development of common legislative

conditions relating to recency practice, and indeed,

alternative methods of competency assessment and

regulation across all States and Territories in Austra-

lia. The disparities in competency standards across the

States and Territories provide a clear indication of the

uncertain terms with which we address continued

competency within the nursing profession, and the

need for well established and common standards

across Australia.

Acknowledgements

The authors wish to acknowledge the assistance of theAustralian Nursing Council Inc. and Dr Helen McCutcheonand Ms Catherine Andrews for their assistance in preparingthis paper.

References

ANCI (1995) Outline of the ANCI National Nursing

Competencies for Registered and Enrolled Nurses, ANCI,

Canberra.

Anderson M. (1994) National Nursing Competencies and

Assessment Framework Monograph. The University of New

England Press, Armidale.

ANRAC (1990) Nursing Competencies Assessment Project.

Report to the Australasian Nurse Registering Authorities

Conference, ANRAC, North Adelaide.

Bates P.W. & Dewdney J.C. (1996) Australian Health and

Medical Law Reporter. p. 9001. CCH Australia Ltd, Sydney.

Finn B. (1991) Young People’s Participation in Post-Compulsory

Education and Training, Commonwealth Government of

Australia, Canberra.

Girot E. (1993) Assessment of competence in clinical practice – a

review of the literature. Nurse Education Today 13, 83–90.

Gonczi A., Curtain R., Hager P., Hallard A. & Harrison J. (1995)

Key Competencies in On-the-Job Training: a Report. UTS/

Deet, Canberra.

Heywood L., Gonczi A. & Hager P. (1992) A Guide to Devel-

opment of Competency Standards for Professions, Research

Paper No. 7. Department of Employment Education and

Training, Canberra.

Johnson R. (1995) Recency of Practice as a Condition of Regis-

tration or Enrolment for Nurses, ANCI, Canberra.

Leddy S. & Pepper J. (1998) Conceptual Bases of Professional

Nursing, 4th edn. Lippincott, Philadelphia.

Mayer E.5 (1992) Employment-Related Key Competencies: a

Proposal for Consultation. AEC/MOVEET, Melbourne.



McMillan M., Keatinge D. & Little P. (1997) Competency

Standards for the Advanced Nurse. Australian Nursing Fed-

eration Federal Office, Melbourne.

Milligan F. (1998) Defining and assessing competence: the

distraction of outcomes and the importance of educational

process. Nurse Education Today 18, 273–280.

Monash (1998) The History and Development of Key Compe-

tencies, http://www.education.monash.edu.au/projects/kc/

bkgd.htm, Monash University, p. 3.

Nursing Council of New Zealand (1996) Discussion Paper: Per-

formance Based Practising Certificates: a Means to Ensure

Public Confidence in the Continuing Competence of Nurses

and Midwives, Nursing Canal of New Zealand, Wellington,

New Zealand.

Queensland Nursing Council (1997) Information Paper No. 4:

Annual Recency of Practice Requirements. pp. 1–4. Queens-

land Nursing Council, Queensland.

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Continuing competence and the regulation of nursing practice