It looks Good on Paper

Looks Good on Paper but what about Competence?Managing (In) Competency in the workplaceCathy GilmoreProfessional Nursing AdvisorNew Zealand Nurses Organisationcathyg@nzno.org.nz

Outline of this sessionHPCA Act 2003What is competencyNursing Councils roleInformation about competence issuesThe workplaceNatural JusticeSIPs & PIPsHealth Practitioners Competence Assurance Act 2003 (HPCA)To protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practise their professionsRegistration and practising certificates for health practitionersCompetence, fitness to practise and quality assuranceComplaints and discipline

What is nursing competencyMany literature reviews (NCNZ 2010, Vernon et al. 2011) show that confusion exists for nurses in relation to the meaning of competence, continuing competence, and performance

NCNZ implemented the continuing competence framework in 2004 following the enactment of the HPCAAct. It primary purpose was to provide mechanisms to ensure that nurses were competent and fit to practise their profession.How to determine competencyIts more than just NCNZ competencies!

The debate continues widely throughout the worldabout the conceptualisation of continuing competence

What is clear is that there is a need for flexibility given the multifaceted nature of nursing practice and the diversity of practice settings (Vernon et al. 2011).

The insight of individuals in relation to their expertise and limitations is critical.

There is a direct correlation between lack of insight and the potential or actual unsafe practice (Pearson etal. 2002a).The Nursing Council of New Zealand (NCNZ) is the regulatory authority for nurses in New Zealand.

Vernon et al. 2011, state The onus for demonstratingand maintaining competence is clearly the responsibilityof the individual nurse since the enactment of the HPCA Act, 2003.

NCNZ. 2009a, defines competence as the combinationof skills, knowledge, attitudes, values and abilities that underpin effective performance as a nurse.

However, managing competence in the workplace is the responsibility of all parties the nurse and the employer.Information about competence issuesThere are common patterns of issues occurring in nursing practice:

Some issues could be avoided by better selection and orientation

Some nurses are not suited to particular nursing environments

Some managers are not good at managing competence issues in the workplace

The environment does not induce growth and development or good practice

Competence review revelations

Some nurses have:

Poor insight into their practice and behaviours

Poor decision making skills

Limited critical reasoning

Inadequate nursing knowledge

Minimal assessment skills

Dont know their limitations

Some managers.....Have a poor understanding of practice needs and the contributory factors for the nurse who may be experiencing practice difficulties in the workplace

Are not fair and reasonable in their approach andprocesses when a competence issue arises

Are punitive and intimidating in their approach to resolve a nurses competence issuesOther managers....Bend over backwards to assist a nurse tomeet competence requirements in the workplace and keep them in practice.

Every nurse is vulnerablePersonal stressful circumstances affect nursingpractice and result in:MistakesOver-reaction or under-reaction to situationsExcessive monitoring and supervision causesnurses to:Make mistakesLose confidence and self esteemBecome stressed and anxious

Some indicators of continuing competenceThe nurse seeks out and does:

Post graduate education

professional development beyond what the employer provides

nurse initiated mentorship/support/ supervision to help them reflect on their practice

Identifies changes in nursing practice to keep up to date

Actively use evidenced based practice

Behaves professionally

Proactively seeks out knowledge and skills to improve their practice

The workplaceFactors that contribute to the growth of nurses competency:

Culture - open and innovative

Management style fair but firm, open and transparent

Staffing numbers adequate to meet the demand

Support clinical supervision

Communication open

Maslows Hierarchy of Needs

Usually used to understand patient behaviour but how does it apply to nurses:

Five levels of human needs from basic lower orderneeds to social and psychological needs of a higher order

People need to have lower order needs met first before they can focus on higher order needs i.e. patients who struggle with the ability to feed and house themselves may not be able to take in health educationFabre, (2005).

Maslows Hierarchy of NeedsConsider the following:

Nurses who transfer patients from their beds to their chairs, with too few staff.

This is frequently a cause of serious back injury, a violation of basic physical needs

Maslows Hierarchy of NeedsWhat about the registered nurse who arrives at work to find that she is on with 3 healthcare assistants instead of the usual five. She is told by management Well do what we can to help you.

The RN is scared and left angry! Scared that she will miss treatable complications or make a serious medical error. Angry because so many previous nurses have resigned due to multiple understaffing situations.

Management has violated this nurses basic need for safety and securityFabre, (2005).

Maslows Hierarchy of NeedsNurses thrive in Maslow-conscious environments because;

Physically: They are supported and consequently more productive. They have more energy and patience for the demanding work. Nurses support each other by working together.

Safety: Nurses flourish because they are supported by safety conscious organisations

Fabre, (2005).

Physical: the nurses on each unit work together so that each nurse will be able to take her breaks.Safety: Positive outcomes happen when reduced errors is an outcome for supporting patient safety.Social: Nurses in an area plan their time to get together to share lunch several times a week. Talking with their peers assists them to provide better patient care.Self-esteem: A patient needs extensive diabetic teaching. The nurse designs an individual plan that starts the patient along the road to recovery. The manager supports the nurse in her/his critical thinking and encourages her/him to find other ways to be innovative and improve patient care18Maslows Hierarchy of NeedsSocially: their organisation resonates with friendliness and warm support encouraging good rostering and the support of each other. Nurses feel appreciated.

Self-esteem: Nurses feel validated because their organisation views them as autonomous professionals

Self actualisation: these nurses innovate, outline improved work practises, and influence other staff membersto function at peak performance.

Fabre, (2005)An oncology nurse has developed several non-medication techniques to reduce pain and stress. She outlines her ideas and teaches the successful strategies to others by publishing her findings19Plans should......focus on supporting the nurse, not on disciplinary measures;

set fair, reasonable and achievable goals for the nurse that are clear and well-explained;

follow workplace policies;

ensure a reasonable and agreed timeframe for achieving improvements;

ensure training, mentoring and supervision is provided to the nurse;

be collaborative ensuring the nurse is involved in developing the performance plan

be fair and ensure impartial assessment ofthe nurses performance;

ensure performance criteria are objective, specific, measurable, agreed, realistic and time bound; and

ensure subjective performance criteria haveclear descriptions and examples of the typeof behaviour expected and can therefore be assessed fairly.

(Duncan, 2007; Boyte, 2006)21The Principles of Natural JusticeThis has a specific meaning in employment law and comprises two rules:The rule against bias andThe right to a fair hearing

Natural justice encompasses the following components:Prior notice of an issueFair opportunity to answer to any issues raised and The opportunity to present their case properlySmith & Partners

Employer & Organisation ObligationsTo fairly and transparently identify any competency issues

To follow a process of investigation and identification of any issues ensuring the process is fair and follows natural justice principles.

NB.( this will keep you out of trouble)

There is growing unease among managersabout the potential for a personal grievanceif the performance management process ispoorly managed

Process and documentation of the process is critically importantSIPs and PIPsMany workplaces have developed a framework to help them to identify competence issues or they use the NCNZ competence framework.

These frameworks are based on peer preceptor assessment and feedback on a daily basis on identified competency to practice issues.What's the Problem?RN J has been working in your area for the last 11 months. Other staff are beginning to voice their frustration when working with heron a shift or in the shift following. Some people look at the roster or daily allocation and sigh... when she is on!One RN has approached the Charge Nurse Managerwith her concerns. She describes the situation as noone wants to work with J. They think she is lazy and a bit useless! When asked for more information theRN says she (J) cant handle a normal workload and staff have started giving her less complex patients with a maximum of three patient workload. This hasbeen getting worse for the last 6 weeks and everyone has had enough!What does the CNM do about this?Option 1 Does nothing it will all blow overOption 2 Call in RN J and tell her to pull her socks upOption three investigate the allegations and try to define what the issues with RN J and assess are they accurateWhat step is missing here?Ask the RN to document her concerns then.....What tools/support does the CNM have?Nursing Council Competencies and guidelines

Nurse Director and/or Director of Nursing

Human Resource Advisors

NZNO Industrial and Professional Nursing AdvisorsWhat tools/support does RN J have?????What the CNM found...RN J was often late for shift so didnt get a full handover

She didn't take her breaks

Her patients missed care such as dressing changes, IV antibiotic doses, patient observationsnot done

Appears grumpy and moody at work particularly tostudents and the Health Care Assistants

Failed to do her daily bedside safety checksIs there a reason for RN Js poor performance?The CNM must explore this with RN J after she has identified to RN J there have been issues raised and she needs to talk to her about them. RN J should always have the opportunity to have a support person with her at any meeting with the CNM

Could be: Crisis at home, relationship issues, domesticviolence, problem with another family member etc....

Could be: a problem with alcohol, drug use or gambling.A good employer offers supportEAPAssistance to address competenceissues

Moves through a continuumSIPPIP

Agreed Timeframe

Stage One Supportive Improvement Plan (SIP)Based on supporting the nurse to reach a competent level of practise related to her currentlevel of practice

Is an informal process with no long term implications if the nurse returns to competence

Is time framed, supported and measured regularly

If no improvement within the timeframe then would move to a Performance Management Plan(more formal with potential employment outcomes and/or reporting to regulating body)ResearchAt times of increased job stress managers who showed supportive behaviours and staffthat received more positive recognition through the use of feedback increased thelikelihood of the nurses intention to stay at work Fabre, 2005

Positive reinforcement encourages participation Flannagan et al. 2000Research supports:Giving balanced feedback with both positivefeedback and an indication where improvements could be made is more beneficial

Verbal feedback is seen as powerful if immediate

Positive feedback is a potent motivator

Peer feedback is positive if given consistentlyWhy are nurses getting into trouble with competency one reoccurring scenarioYou the CNM, arrive at your office on Monday morning. Jackie, one of your most competent nurses, asks for a few moments of your time. She hands you a letter of resignation. She is the third RN to do so in the last 2 months.

Even as you think about how you are going to fill the roster youwonder why she is leaving. After all, the nurses have just received a substantial pay rise and they have the best conditionsin their contract.

However you must address what is becoming a vicious cycle of resignations and overtime for the remaining staff. You need to prevent more resignations and burnout.Jackie's point of ViewConsider one of her workdays:She arrives at work and discovers the unit will be short staffed

During her shift she encounters disrespectful behaviour from doctors, managers, or other nurses and wonders why she bothers. Patients are usually the prime source of support the nurse receives

She has had no break because of the heavy workload, causing her to be exhausted early and less effective as theday wears on

During a staff meeting she makes some suggestions that would improve care, but management table them, leavingher frustrated and angry

There are several patient admissions that afternoon, but thestaff have the attitude of every nurse for herself, each struggling to finish her work and unwilling to lend a hand where its needed

At the end of the day, certain tasks that would have made a big difference to patients remain undone, and Jackie leaves work feeling that the patients received poor care

Ongoing ManagementCompetence assessment of practising nurses is crucial to maintaining professional standards

Nurses should be assessed at the level of their continuing competence related to the complexitiesof nursing practice within the context in which it is occurring (Vernon et al. 2013)

Systems problems prevent nurses from performing at their full professional capacity

Organisations that provide environments where nurses can perform at their best attract and retain thebest peopleReferencesCook, Pauline (2011). Demystifying Supervision. Kai Tiaki Nursing New Zealand 16(11), 34.Fabre (2005). Smart NursingFlanagan, J., Baldwin, S. & Clarke, D. (2000) Work-based learning as a means of developing and assessing nursing competence. Journal of ClinicalNursing, 9, 360368.Health Practitioners Competence Assurance Act 2003Nursing Council of New Zealand. (2010). Evaluation of the Continuing Competence Framework. Report prepared for the Nursing Council of New Zealand. Downloaded 03/03/2014 file:///C:/Documents%20and%20Settings/cathyG/My%20Documents/Downloads/Evaluation%20Continuing%20Competence%20Framework%20(2).pdfPearson, A., FitzGerald, M. & Walsh, K. (2002a) Nurses views on competency indicators for Australian nursing. Collegian, 9 (1), 3640.Smith & Partners. Retrieved 03/03/2014. http://www.smithpartners.co.nz/library/articles/litigation/what-is-natural-justice/The competence review process. (2008) Nursing Council of New ZealandVernon, R.; Chiarella, M.; Papps, E. (2011). Confidence in competence: legislation and nursing in New Zealand. International Nursing Review. Mar2011, Vol. 58 Issue 1, p103-108. 6p.Vernon, R.; Chiarella, M.; Papps, E.; Dignam, D. (2013). New Zealand nurses' perceptions of the continuing competence framework. International Nursing Review. Mar2013, Vol. 60 Issue 1, p59-66. 8p.

Thank you