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Competence in relation to assessment of competence to practice nursing

Discuss about the Perception of Continuing Competence Framework.

It has been long since nursing has characterized competence. Since then there had been various debated regarding the competence standard in nursing. The profession of nursing has change dramatically and has become a technological enriched profession. Today the practice of nursing is engrossed in lifelong learning, including the application of the evidence based research, making a patient centered care possible (Pijl-Zieber et al., 2013). All these changes require a high quality of professional standards in nursing. This paper will critically discuss about the competence in nursing in relation to the scope of a registered nurse working in a long term care facility. The concept of competence with also be discussed in relation to reliability, feasibility and validity.

Competence in relation to assessment of competence to practice nursing.

In order to understand the levels of the competence the experiences of Ms. X has been considered, who has been a registered nurse in a long term facility.

The primary role of the registered nurse in a long term care facility is the delegation of the tasks to the licensed practical nurses and the vocational nurses, supervising the performances, evaluating the performances of the delegated nurses and the reassessing or adjusting the care plan. Ms. X was in charge of a palliative care cancer patient that is also supported by a palliative care team. The patient belongs to a culturally diverse Maori background. On understanding the hesitation of the patient to approach a female, Ms. X appointed a male clinical staff to take care of the toiletries of the patient. While the insertion of the intravenous catheter the RN made it sure to take the consent of the patient and on refusal the RN emphasized and educated the patient about the need of the patient.  Since most of the patients are geriatric hence require most complex client care approach. Health promotion, disease prevention, supportive, curative, palliative and rehabilitative nursing services has been provided by Ms. X. She remained mindful about the emotional burden of the patient and tried to provide mental and spiritual support to the patient by motivating him or improving his quality of life for the last few days. Ms. X also showed evidence based practice by practicing infection control measures and also notified her juniors and peers about the importance.

Due to the drastic deterioration that takes place in cancer, the registered nurses have to be very careful regarding the task delegation and the accountability of the scope of practice (Lejonqvist, Eriksson and Meretoja, 2012). Ms. X has to be careful in the client documentation or the utilization of the assessment instruments. She has to remain careful about the continence care, pressure ulcer prevention, dementia care, slips and falls and wound care. 

Importance of competence in nursing

With the increasing complexities in health care, the competence in nursing has become a compulsory phenomenon to deliver a safe and quality care (Vernon et al., 2013). Competence in nursing has become a matter of concern and thus the hospitals are long been trying to combat the issue by the incorporation of transition to practice programs, mentorships, competency assessment and preceptorship (Corazzini et al., 2010). Competence in the practicing nurses is also become an important factor in the accreditation of the nursing standards by accreditation bodies (Smith, 2012).

Some of the common defining attributes of competence is the understanding of the key concepts, sound decision making skills, situational application of the skills, positive interpersonal relationships and mastery over the discipline specific skills (Van Mechelen et al., 2013). As stated by Smith, (2012) quality of care occurs as a result of the competence and are supported by the consequences of the improved outcomes, safe practices and higher care of standards. According to Smith (2012), the evaluation of the competence in nursing is generally a two tired issue, the first tier that focuses on the entry into the practice and the secondary tier focuses on the continuing nurse competence. According to (Benner), nurses may begin their career as a novice but gradually develop competence by continuous practice. According to the author nurse require at least 2-3 years for gaining experience for achieving the competence. Lejonqvist, Eriksson and Meretoja (2012), has reflected that competence lacks clarity and skill acquisition. This is important for the understanding that the nurse competence lacks the clarity. Pijl-Zieber et al., (2013) have argued that a competent individual may be trustworthy but not to the degree of the expert. Van Mechelen et al., (2013), have supported the fact that in order to understand and evaluate the competence of the nurses there should be a framework. The Competency Outcomes and Performance Assessment (COPA) Model is a tool that can be used to measure the competency standard of nursing. As per this model there are eight core factors that are required to determine the competence and these are the assessment and the intervention skills, the critical thinking skills, communication skills, human caring and the relationship skills (Smith, 2012).

The scope of practice of the registered nurse as per the nursing council of New Zealand is that they practice independently and in collaboration with the health care professionals, perform general  nursing functions and delegate enrolled nurses and responsibilities (Corazzini et al., 2013).

Defining attributes of competence in nursing

In order to assess the competence in nursing three types of assessments are normally done- The seniors nurse assessment, the self-assessment and the peer assessment. The assessment is normally made on the basis of the observation of the clinical procedures. This paper compares the nursing competence exhibited by the concerned nurse with the competency skills of the nursing council ("Competence assessment / Continuing competence / Nurses / Nursing Council of New Zealand", 2018). 

As per the nursing council there are four domains of competence, one is the professional responsibility that encompasses ethical and legal responsibilities to the nurses along with cultural safety. According to Grace and DRN (2017), professional responsibility involves the demonstration of the knowledge and judgment and to be accountable to his/ her own responsibility while providing health care delivery to the people. In the case study we can find that Ms. X is being professionally accountable for delegating competent nurse workforce for serious geriatric patient. He was also mindful while supervising his juniors handling the palliative care patients. It has to be noted that if any adverse incident takes place by the hand of the RNs then the RNs will be equally accountable. Accountability in nursing involves being able to give an account of the midwifery judgments, omissions. The nurses should be able to able to justify their standpoint in context of the legislation.  According to Grace and DRN (2017), nurses and the midwives holds positions of responsibility that is the obligation to perform their duties using sound professional judgment and being answerable to the decisions made in doing this. They has to be accountable for all the decisions they make and the consequences of those decisions.  It should be remembered that the scope of practice of the nurses depends upon the designation of the nurses. As stated by Donald et al., (2013) accountability can only be achieved if the nurses have the scopes of autonomy to practice. Professional autonomy refers to the use of various kinds of knowledge in a critical manner, offering safe care to the patient.

Another element that can be used to determine the core competence of the nurses are the management of the nursing care, that involved catering to the health care needs of the clients supported by the evidence based research (Stevens, 2013). It is evident from the case study that Mr. X applied evidence based practice while dealing with the palliative care patients, such as educating the peer nurses about pressure ulcers and keeping extra care of the patients who are difficult to immobilize (Cramer et al., 2012). Thus incorporating a patient-centered approach.  Ms. X had ben mindful in applying the intravenous medication to the palliative care patient in a competent and a safe way. One of the essential elements of competent care is the application of a holistic care of approach to the patient. It has to be remembered that the patient was terminally ill and might be suffering from the last few days of his life, hence was in need of immense mental support from both the family as well as the care giver (Morton et al., 2013). As a successful caregiver she has been able to collaborate with the family members to improve the condition of the last days of his life and helping him out to die a dignified death (Morton et al., 2013).

Competencies defined by NCNZ

Another aspect to define the core competency is the interpersonal relationships developed between the nurse and the patient. This interpersonal communication is also required to communicate between the peer nurses (Vernon et al., 2013). As stated by Arnold and Boggs (2015), It is the good communication skills that helps to make the difference in the nursing care throughout the spectrum of health, healing, illness and recovery. The underlying reason behind the nurse patient relationship is always the same regardless of the point of contact (Finkelman & Finkelman, 2012). It should be stated that Ms. X being a registered nurse have to take charge of multiple patients and hence might get less chance to spend time with the patients (Vernon et al., 2013). The underlying principle of the therapeutic relationship remains the same regardless of the length of the contact: respect, genuineness, empathy, trust, active, listening and confidentiality. Cramer et al., (2012), have stated that a therapeutic relationship is different that of the social relationship. It is more patient centered and has got a defined boundary. It is evident from the experiences shared by the concerned RN, that she had practiced nursing in a negotiated partnership with the health care consumers (Riley, 2015). It is essential to recognize and support the personal resourcefulness of the patient with physical or mental illness (Arnold & Boggs 2015).  Communication is the cornerstone of the nurse-patient relationship.  It is evidenced from the above stated experience that Ms. X tries to encourage communication with the patients by taking patient feedbacks or by taking hourly rounds seeking for any grievances expressed by the patients. As stated by Riley (2015), the time of the communication is also essential as teaching about aerobic exercise or low cholesterol diet to a patient who had just suffered from myocardial infarction is not appropriate, as the patient would not be able to absorb this information. Furthermore as per the competency skill 3.3, an RN would be able to use a number of effective communication techniques and employs a user friendly language with the patient (Competencies for registered nurses, 2018) . In this case the RN is in charge of a Maori patient and was estimated to have a very low health literacy. The RN tried its level best to communicate verbally or non-verbally without the use of any medical jargon. In case of consumers with linguistically different background, an interpreter can be assessed (Harding, 2013).


An important thing that has to be kept in mind while dealing with patients is the preservation of the cultural safety. As per the competency 1.5 of the NCNZ, an RN should be able to recognize the impact of the culture of nursing on the endeavors of the clients for protecting the wellbeing of the health care consumers (Competencies for registered nurses, 2018). Ms. X was found to be displaying a culturally safe practice by allowing a male nurse to take care of the man with Maori origin when he felt hesitated in front of the RN. An RN should be able to liaise or advocate for the patients belonging from a diverse cultural background and should be able to practice in a way that respects the identity and the rights of the health care consumers (Finkelman & Finkelman, 2012). An RN should be refrain from imposing prejudices and provide advocacy when the prejudice is apparent. The nursing assessment should be taken up in an accurate and a comprehensive way. Relevant nursing research have to be taken up for underpinning of the nursing assessment (Harding, 2013). Nursing assessment involves the suitable collection of patient feedback for evaluating the health care service delivery to the patients, which is compliance with the competency 2.2 of NCNZ (Competencies for registered nurses, 2018).

Privacy and confidentiality is another core competency of the nursing skills. Adherence to the confidentiality rules require correct documentation and safe preservation of the patient’s medical records (Stevens, 2013). Any kind of medical discussions should be held in public should be restricted to the clinical settings, learning situations and relevant members of the multidisciplinary team (Latour & Albarran, 2012). An RN should be updated by the privacy laws like HIPAA and the FRPA rules and should be able to disseminate the same to her peers and het junior nurses. Nurses would be able to demonstrate literacy and the computer skills required record, enter, store and retrieve the organized data required for the health care delivery (Stevens, 2013).. Involving the patient and the families in the decision making process is an essential step in nursing practice as it is the initial step of the self-management of the disease (Bradshaw et al., 2012). As per the competency standards 2.4. Appropriate information should be provided to the health consumers for protecting their rights and allow informed decision making (Competencies for registered nurses, 2018). As stated by Franklin and Melville (2015), autonomy by the health care professionals may act as paternalistic to the patient and the family, hence it is important to involve the patients in the multidisciplinary to adopt a collaborative care approach (Lejonqvist et al., 2013). A registered nurse should be able to assess the readiness of the health care consumers for participating in the health education that would ultimately assist the health care consumers to get access to appropriate therapies (Lejonqvist et al., 2013). As per the nursing codes of ethics it is necessary to take the preferences of the consumer’s in to consideration while the provision of care (Donald et al., 2013). As per the domain four of the nursing standard, an RN should be able to promote inter-professional activities within the health care teams and should provide continuous guidance to those who have just entered the profession of nursing and should be able to collaborate with the health care consumers to provide a person centered care, developing a proper discharge plan and a follow up care in consultation with the health care consumers and other members of the health care team, arrange appropriate referrals to the other members of the health care sectors and the team members who require consultation (Corazzini et al., 2013). According to Morton et al., (2013) an RN should be able to contribute to the coordination of care for maximizing the health outcomes of the health care consumers. Apart from practicing a Person centered nursing it is essential to evaluate and assess the quality of the health care facilities in a clinical setting. Hence, as per the competency 4.3 of nursing, it is important to remain updated regarding the policy procedures and also to educate the other members about the new policies and the procedures (Competencies for registered nurses, 2018). Updating would obviously help the RN to identify the researchable practice issues and refer them to the responsible people. This would ultimately lead to the quality improvement of the clinical setting and would also enhance the professional standard of the nurse. It can be seen that the aforesaid competencies are efficient in evaluating the competency of Ms. X.

The competency assessment tools are challenged to demonstrate the validity in the clinical environment. The trustworthiness of the tool for assessing competence, is how exact or precise the tool is. A lot of challenges can be posed by the competence assessment tools (Franklin & Melville, 2015). For example- if a nurse is evaluated for competency in the management of the central venous access device. The question can be raised would the assessor mark the same nurse competent a week later or would the same caregiver be marked competent by a different accessor. This fact is supported by Randolph et al., (2013), where it has been identified that clinical competence is actually both subjective and relative. Carney and Bistline (2008), have described how assessment for competence can be subjective instead of an objective process and the assertion that the validity and the reliability of the competency assessment tool can be at  risk when the assessment for competence are separated from the real life clinical settings. The competency assessment tool should be able to reflect a real life clinical practice but should also be able to demonstrate the content validity. While the competency assessment tool aims to assess the ability of the nurses to plan, assess, execute, calculate and communicate patient care via four chief constituents (like performance, outcome, competence criteria, and a rating scale) (Franklin & Melville, 2015). Many of the competence assessment tool focus on the psychomotor skills of the nurses and on the tasks instead of focusing on the attitudes and the behaviors. Again why how a nurse should deal with the patient depends upon the clinical situation. For example application of a venous catheter might be painful but is important for the patient and taking into consideration the perseverance of the condition, nurse has to converse with the patient in a different way (Franklin & Melville, 2015). Without the understanding of the contextual situation it is truly not possible to assess the nurse’s behavior.

Assessment for competency in nursing will always remain difficult and there are very few studies that could actually demonstrate the reliability and the validity of the competency assessment and which method is appropriate in measuring the clinical competency (Garside & Nhemachena, 2013). Assessing the clinical competency should be done over a continuous period of time to increase the validity of the search.

Conclusion

There is a range of complexities in relation to the competency assessment tools in the clinical environment. One of the ways of assessing the competency in a valid and a reliable manner is to determine the competency by the nurses over a ‘continuum of time’ rather in just a snapshot-in –time. The competency assessment tools shall be based on the real life clinical setting involving more pedagogical approaches. Furthermore using the competency standards of the New Zealand nursing council, the competence assessment of the Ms. X has been conducted. The real life clinical competency aspects makes it possible to evaluate the competency of the concerned nurse.  The core competencies of the New Zealand nursing standard is valid and reliable and generally focuses on “continuum of time “. Moreover although there are no clear solution to the competency debate, a multifaceted or a holistic approach can be taken for the competency assessment.

References

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