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An overview of the competency movement

in Australian nursing and midwifery

Mary Chiarella Professor of Clinical Practice Development

and Policy Research Nursing and Midwifery Office, NSW Health

and Faculty of Nursing, Midwifery & Health, UTS

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1. Introduction Over the past twenty years in Australia there has been a significant and steady growth in the movement amongst professional groups, initially in nursing and more recently in midwifery, to develop sets of standards for practice known as competency standards (Percival 1995, ACMI 2002). The most significant early work was undertaken by the (then) Australian Nursing Council Inc., which developed the Australian National Competency Standards for the Registered Nurse. These were initially developed through a group known as the Australian Nurse Registering Authorities Advisory Council (ANRAC) in 1990, but with the incorporation of the Australian Nursing Council in 1992, these became the ANCI competencies and are now known as the Australian Nursing and Midwifery Council (ANMC) Competency Standards for the Registered Nurse (RN). ANMC has also developed competency standards for Enrolled Nurses (ENs), Midwives (MWs) and Nurse Practitioners (NPs). With the exception of the NP Standards, which will be discussed later, these standards are those that the RN, EN or MW is expected to demonstrate on entry to practice and are said to

“…provide the framework for assessing competence but also serve to communicate to consumers the standards they can expect….Universities use the standards in developing nursing curricula and to assess student performance” (Anon, 2006)

Further, ANMC points out that the MW Standards can be used by the States and Territories for a range of other activities:

“…to assess competence as part of the annual renewal of license process, to assess midwives educated overseas seeking to work in Australia, and to assess midwives returning to work after breaks in service. They are also used to assess midwives involved in professional conduct matters” (ANMC, 2006)

ANMC has also provided guidance as to how assessment of competence might occur and has identified six principles for the assessment of competency: accountability, performance-based assessment, contextual relevance, evidence-based assessment, validity and reliability in assessment and participation and collaboration (ANC, 2002). 2. Definitions ANMC provides a number of definitions in relation to competencies. Competency is defined as “an attribute of a person which results in effective performance” (ANC 2002). Although this definition is not included in the most recent ANMC Competency Standards for the Midwife (2006) the competencies set out below in Box 1 are consistent across the competency standards documents for ENs, RNs and MWs.

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Core Competency Standards: Essential competency standards for registration or licensure. Competence: The combination of skills, knowledge, attitudes, values and abilities that underpin effective and/or superior performance in a profession/occupational area. Competent: The person has competence across all the domains of competencies applicable to the (midwife), at a standard that is judged to be appropriate for the level of nurse being assessed. Competency Unit: Represents a major function/functional area in the total competencies of a Registered Nurse/Enrolled Nurse in a nursing context representing a stand-alone function which can be performed by the individual. Competency Element: Represents a sub-function of the competency unit. Competency Standards: Consists of competency units and competency elements. Box 1: ANMC definitions relating to competency standards (ANMC 2006)

3. Structure and content of the Competency Standards The competency standards for each professional group, RNs, ENs and MWs, are organised into a number of domains, each with a series of corresponding statements or descriptors. These descriptors or sub-headings are described in some (although not all) of the Competency Standards documents as elements, and each element has a corresponding number of cues by which it can be identified on observation or questioning. The names of the domains differ slightly for each group, as can be seen in Table 1 below.

Table 1. Competency Domains for RNs, ENs and MWs

Registered Nurse Domains

Enrolled Nurse Domains Midwifery Domains

Professional practice Professional and ethical practice

Legal and professional practice

Critical thinking and analysis

Critical thinking and analysis Midwifery knowledge and practice

Provision and coordination of care

Management of care Midwifery as primary health care

Collaborative and therapeutic practice

Enabling Reflective and ethical practice

The full content of the three sets of competency standards is set out in Appendix A of this document.

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4. Acceptance and use of the competency standards

Initially there was speculation both as to the impact of the competency standards on the liability and legal expectations for nurses (Chiarella 1995) and as to potential difficulties in identifying the minimum required level of performance in each competency (McMillan, Bujack & Little, 1995). It is true that the competencies have on occasions been used as a benchmark for determining the beginning level of professional conduct in disciplinary hearings (NSW NRB, 2001). Notwithstanding this regulatory requirement, overall nurses have accepted the Competency Standards as a positive development, one that gives them both professional standing and enables them to identify their areas of practice. A recent study of 831 Australian health professional including nurses demonstrated that all health professionals rated the ANCI competencies as important and that the respondent nurses identified nineteen out of the sixty-five competencies to be unique to the nursing profession (Wells, 2003). From a regulatory perspective, although the ANMC competency standards are already endorsed by all state and territory regulatory authorities, the National Review of Nursing Education (2002) initiated by the Department of Education, Science and Training, took a more formalised and national approach and recommended that nationally agreed principles should be developed to underpin State and Territory nursing legislation that should include requirements for:

“assessment against the ANCI competencies for initial regulation of registered and enrolled nurses”.(National Review of Nurse Education, 2002, p.120)

This work towards a formal and regulated national approach was noted with approval by the Report of the Australian Government Productivity Commission into Australia’s Health Workforce (2005). The Productivity Commission Report recommended that the Australian Health Ministers Advisory Council should establish a single national regulatory authority for all health professionals. However, such a process would be unlikely to impact upon the need for competency standards as the benchmark for beginning practice. Certainly the Commission Report strongly recommended the adoption of uniform national registration standards (at p. 140), thus the ANMC Competency Standards would appear to be highly topical and relevant to the current regulatory debate.

From an academic perspective, the competencies are used as the basis for all undergraduate programs and all nursing undergraduate curricula are required to demonstrate that graduates from the program will be able to meet the competency standards. However, recent concern has been expressed that the competencies may not be sufficiently culturally sensitive for contemporary Australian society. Chenoweth et al (2006) whilst on the one hand acknowledging the need for competencies, express concern that they are perhaps insufficiently nuanced about the complexity of nursing care in different cultural environments.

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“Through the process of tightening controls over knowledge acquisition, creation, development and application, key authorities, such as nurses' registration boards, define and legitimize particular nursing beliefs and values (Kanitsaki 2003). These competencies pursue both conformity in nursing standards and a particular way of practising nursing. Very few would argue against the pursuit of conformity to nursing standards; however, the authors take issue with the imposition of particular approaches to nursing that are applied uncritically and which are, at times, antithetical to the health care needs and expectations of some cultural health populations (Kanitsaki 2003).

The ANCI competency standards clearly define the principles to achieve culturally competent nursing care, and require nurses to respect the values, customs, spiritual beliefs and practices of all individuals and groups; however, they are not sufficiently explained or developed to guide nursing practice. What the standards need to make clear is that the constituents of competence are found not in the nurse alone, but in the relationship that exists between the nurse, their colleagues, patients, and families, and with the situation itself (McMurray 2004).”

From an industrial perspective, the Australian Nursing Federation (ANF) has recently reviewed and re-endorsed its policy statement relating to competency standards and nursing: this is reproduced in Box 2.ANF clearly supports the development of competency standards for entry to practice being developed through and for regulatory authorities, but is content to support the development of advanced or specialist competency standards by professional organisations and/or groups. The need for validation, evaluation and review is highlighted in the policy, and this will be discussed further in relation to advanced or specialist competencies.

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Box 2. ANF Policy on Competency Standards and Nursing

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Competency standards and nursing Where the term “nurse” is used it includes all licensed classifications including, but notlimited to: registered nurse, midwife, enrolled nurse, nurse practitioner. It is the policy of the Australian Nursing Federation that:

1. The interests of nursing and nurses must be represented in all forums wherecompetency standards relevant to nursing are being developed.

2. National competency standards developed for nursing work (no matter what the titleor classification of persons undertaking that work) and nursing classifications must: • Reflect the skills, knowledge and attributes required in the workplace; • reflect the relationship, and be conducive to articulation, between the different

levels of nursing; • form the basis for curriculum development; and • reflect the relationship between nursing work and work done by other workers in

the health sector. 3. Core competency standards should be prepared and used as the baseline by nurse

regulatory authorities assessing the competence of people licensed to practise asregistered nurses, enrolled nurses, midwives and nurse practitioners.

4. Other competency standards can be prepared and used by specialist professionalnursing organisations in a nursing practice framework for specialist nurses, e.g. nursesin critical care, or nurses working in a special context e.g. nurses in remote areas.

5. The process of development of competency standards relating to nursing work mustbe validated and have evaluation and review processes in place.

6. Mechanisms must be in place to monitor assessment processes, ensure adequateassessor preparation, develop inter-rater reliability and deal with appeals.

(ANF, 2005)

. The development of advanced or specialist competency standards

t is perhaps this ability to identify aspects of the competency standards that nurses erceive as unique to their work that has caused the proliferation of advanced and pecialist competency standards1. Some of the specialist nursing groups, specifically the ccupational health nurses, mental health nurses, critical care nurses and diabetes ducators’ groups2, had begun developing specialist competencies in the mid- 1990s, ossibly with a view to credentialing specialists nurses, although this was a topic of hot ebate (Robertson & Chiarella, 1995). ANF developed a generic set of competency tandards for the advanced nurse in 1997. These competency standards have been escribed as having three components:

Note that both the terms specialist and advanced are used throughout this paper as both terms are used in he different competency standard documents. It is recognised that not all diabetic educators are nurses, but they are included out of a wish to cknowledge their pioneering work.

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• The competency standard itself is a brief active statement of what the nurse does;

• Elements are also active statements, but are about how the nurse does what he/she does to demonstrate that particular competency; and

• Performance criteria are statements of the outcome of the nurse’s behaviour and actions. (Melbourne Sexual Health Centre, 2003)

and since then there has been an extraordinary proliferation of specialist and/or advanced competency standards. Barraclough (2002) provided a helpful list of documents currently available. Through a review of the Australian literature this has been updated but also amended to include only specialist or advanced competencies and is set out below in Table 2. Thirty sets of specialist or advanced competencies were found and it is acknowledged that this may not be exhaustive. What is remarkable is the amount of work represented in this table, most of it no doubt voluntary, that the development of these sets of competency standards would have entailed. Table 2 Existing Australian Competency Documents Available For Nursing Staff3

Name of Document

Target Group of Staff

Year Published

Available From

Competency Standards for Midwives

Midwives 1988 Revised 2002

Australian College Of Midwives

Standards of Practice for Mental Health Nursing in Australia

Mental Health Nurses

1995, revised 2003

Australian & New Zealand College Of Mental Health Nurses

Competency Standards for Child & Family Health Nurses

Child & Family Health Nurses

2000 Child & Family Health Nurses Association (NSW) Inc.

Competence Standards for Specialist Critical Care Nurses

Critical Care Nurses

1996 4th Ed 2002 (Currently Under Review)

Australian College Of Critical Care Nurses

Clinical Guidelines for Bone Marrow Transplantation & Advanced

Haematology & BM Transplant Nurses

2001 Cancer Nurses Society Australia

3 Developed by Frances Barraclough, Area Coordinator Nursing Services, New England Area Health Service, October 2002, Available on ANF website. Updated/ amended Mary Chiarella 2006 (updates/amendments in italics) NB: Non-specialist competencies have been removed for the purposes of this table. My thanks to Helen Robinson, Librarian, College of Nursing, for her assistance in this task.

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Cancer Nursing Practice Chemotherapy Clinical Practice Guidelines Outcome Standards for Australian Cancer Nursing Practice

Nurses Working in Chemotherapy Cancer Nurses

1996 Currently Under Review

Cancer Nurses Society Australia

Australian Standards for Specialist Cancer Nursing Education Programs

Cancer Nurses & Nurse Educators

1999 Cancer Nurses Society Australia

Competency Standards for the Advanced Nurse

All Advanced Practice Nurses

1997 Updated 2006

Australian Nursing Federation

Standards for the Emergency Nurse Specialist

Nurses Working in Emergency Departments

2003 Emergency Nurses Association

Competency Standards for Occupational Health Nurses

Occupational Health Nurses

1994 Australian College Occupational Health Nurses www.acohn.com.au

Competency Standards for Neuroscience Nurses

Neuroscience Nurses

2003 Australasian Neuroscience Nurses Association ANNAEXECUTIVE@Bigpond.com

National Core Competencies for Diabetes Educators

Diabetes Educators

1996Revised 2001

Australian Diabetes Educators Association adeasec@ozemail.com.au

Competencies for the Specialist Paediatric and Child Health Nurse

Paediatric & Child & Family Health Nurses

2000 www.acpchn.org.au/competencies

Competency Standards for the Community Health Nurse

Nurses Working in Community Health

1998 Revised 2001

Community Health Nurses, Health Department Of Western Australia

Competency Standards for the Advanced Gerontological Nurse

Gerontic Nurses 2000 Geriaction NSW,

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Competency Standards for Continence Nurse Advisors

Continence Nurse Advisors

2000 cfavic@continencevictoria.org

Nurse Educator Competencies

Nurse Educators 1998 Australian Nurse Teachers Society www.ants.org.au

Competency Standards for the Advanced Gastroenterology Nurse

Gastroenterology Nurses

2002 Gastroenterological Nurses College Of Australia (GENCA) admin@genca.org

Competencies for Perioperative Nurses

Perioperative Nurses

2006 Australian College Of Operating Room Nurses

Competencies for Remote Area Nurses

Remote Area Nurses

2001 CRANA Secretary, PMB 203, Alice Springs NT 0872 (Document And vdeo available)

Australian Advanced Practice Nephrology Nurse Competency Standards

Renal Nurses 1999 Renal Society of Australasia

Competency Standards for Nurse Audiometrists

Nurse Audiometrists

2000 Community Nurse Audiometrists Association Inc.

Competency Standards for Community Registered Nurses

Community Nurses

2002 Australian Council Of Community Nursing Services

Rehabilitation Nursing Competency Standards for Registered Nurses

Rehabilitation Nurses

2003 Australian Rehabilitation Nurses Association

Standards of Practice for Faith Community Nurses

Australian Faith Community Nurses

2001 Australian Faith Community Nurses Association Inc

Competency Standards for Women’s Health Nurses

Women’s Health Nurses

2005 Australian Women’s Health Nurse Association http://www.womenshealthnurses.asn.au

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Specialist Breast Nurse Competency Standards and Associated Educational Requirements

Breast Cancer Nurses

2005 National Breast Cancer Centre (Australia)

Competency Standards for Specialist Palliative Care Nursing Practice

Palliative Care Nurses

2005 Centre for Palliative Care Research and Education cprce@health.qld.gov.au

National Competency Standards for the Nurse Practitioner

Nurse Practitioners

2006 Australian Nursing & Midwifery Council

Advanced Competency Standards for Sexual and Reproductive Health Nursing

Sexual and Reproductive Health Nurses

2001 Australian Sexual Health Nurses Association

6. The ongoing debate about specialist or advanced competency standards

Although it is clear that specialist and professional nursing organizations have embraced the development of specialist or advanced competency standards with enthusiasm and energy, there is ongoing healthy debate as to their validity, utility, content and purpose. Royal College of Nursing, Australia (RCNA) in its recently reviewed policy statement on advanced practice nursing, recommends “the use of the ANF Competency standards for the advanced nurse (1997) for assessment of competence by advanced practice nurses” (RCNA, 2006) and makes no mention in the document of the myriad of specialist advanced competency standards listed above.

In terms of the purpose of specialist competencies, the question of whether to use them to recognise entry to specialist practice is an ongoing debate. The Australian College of Operating Room Nurses (ACORN) commissioned an analysis of the benefits or otherwise of introducing credentialing for perioperative nurses and concluded that “the utility, applicability and validity of credentialing cannot be clearly demonstrated. Indeed, there is no consensus on the meaning of the word itself” (Hamlin 2004).

In contrast, the credentialing process for specialist level critical care nurses has been under development since the publication of A proposed credentialing model for Australian critical care nurses (CACCN, 1997). The credentialing model was launched on 11 October 1998 in Adelaide. According to the Australian College of Critical Care Nurses’ website

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…the credential is awarded to the clinical critical care nurse who practices (sic) at or above the level of the Competency Standards for Specialist Critical Care Nurses (CACCN Inc. 1996). The applicant will be required to demonstrate that he/she meets the Standards by keeping a practice journal, reflecting upon clinical practice and drawing examples from the journal to demonstrate achievement of the competencies. (ACCCN 2006)

However, concerns about the construct validity of the Australian College of Critical Care Nurses (ACCCN) competency standards as a tool for assessing the clinical practice of specialist level critical care nurses were raised in a recent study undertaken by a group of critical care nurses (Fisher, Marshall & Kendrick, 2005). The study highlighted concerns about the validity of the ACCCN competency elements and standards as a tool with which to assess the practice of critical care nurses, in part because the elements did not fit uniquely to a single competency, but were multidimensional and loaded across several competencies. However, the study also reconfigured the current model into a four-factor competency model, which “demonstrated reasonable model fit”.

The Australian and New Zealand College of Mental Health Nurses Inc. has developed a set of Standards of Practice for Mental Health Nursing in Australia (1995) that contain within them an advanced practice level. In the introduction to the standards they make clear their purpose:

Standards for Professional Practice in Mental Health Nursing Entry-level standards for the profession of nursing are established by the relevant registering authority. They represent the level of competency expected of every registered nurse at the time of admission to the register. Standards for professional practice in mental health nursing represent the performance which may be expected from a registered nurse who has been working for a period equivalent to 12 months full-time in any mental health context. These standards complement and extend the standard for professional practice expected from all registered nurses. These standards for mental health nursing provide a foundation for public accountability as well as serving as a guide for the evaluation of mental health nursing practice. If standards of practice are to remain relevant as well as add to the continuing development of mental health nursing knowledge it is imperative that they be reviewed on a regular and consistent basis. (ANZCMHN 2003)

In addition, the ANZCMHN have been engaged in a Credential for Practice Program (CPP) since March 2003 in partnership with the Nursing Board of Tasmania (NBT) and the University of Tasmania. A registered nurse in Tasmania is able to apply to be credentialed for a period of three years. ANZCMHN reports that CPP has been developed

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through professional and workforce consultation, review of the literature, programs conducted by other professional bodies including nursing, medical and allied health, and recommendations from Self-Regulation and Credentialling in Mental Health Nursing: A Report to the Nursing Board of Tasmania, ANZCMHN and University of Tasmania

(Hazelton, Farrell & Biro, 1998). However, it was not possible to ascertain from either the ANZCMHN or NBT websites whether this project was ongoing or completed.

Recently, concern has been expressed about the general content of some of the specialist or advanced competencies. Chenoweth et al (2006) express disquiet that the specialist or advanced competencies also miss the contextual richness that is nursing practice.

…the generic list of attributes included in the document Competency standards for the advanced nurse (ANF 1997) is simply that: a list of attributes or standards to be met. Clearly from the cases presented by the respondents involved in preparation of the Competency standards for the advanced nurse (ANF 1997) … generalist and specialist nurses working at an advanced practice level do so in a wide range of practice contexts. They also have a vast array of clinical and personal experience from which to draw. Equally evident is that the central focus of their practice is nurturing or caring for their patients or clients.

They go on to suggest that all nurses working in Australia exhibit the roles of carer, educator, role model, researcher, consultant and leader at some time (Borbasi, 1999) and that such language “might provide a conceptual framework around which to build the Australian understanding of the advanced practice nurse” (Chenoweth et al, 2006).

There is also some discussion about whether to move into the management science language of capabilities (Campbell, 1999), rather than competencies. However, when the amount of work that has been undertaken in relation to competency standards is identified through an exercise such as this, it would seem to be swimming against an extraordinary tide of work to move in that direction. Perhaps a more beneficial exercise would be to undertake a mapping of the competency domains, elements and performance criteria to identify themes of similarity and difference. This would make an excellent research project and would be of great value for the development of post-graduate specialist curricula.

Conclusion

An immense amount of time and effort has already gone into the development of a wide and diverse range of competency standard documents, both at undergraduate and post-graduate level. This work is viewed by professional groups with great pride and a sense of considerable achievement. Such goodwill and commitment provides a valuable basis for further examination in relation to the validity and suitability of these documents in terms of the purposes for which they are designed. Mapping of the various specialty documents for comparability and difference would also provide valuable insight into the nature of both specialist and advanced practice nursing.

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Anonymous (2006) New Standards Australian Nursing Journal 13 (10), 14. Australian College of Midwives Inc (2002) ACMI Competency Standards for Midwives http://www.acmi.org.au/text/corporate_documents/competency.htm ANZCMHN. (1995). Standards of Practice for Mental Health Nurses in Australia, [www]. The Australian & New Zealand Collesge of Mental Health Nurses Inc. Available: www.anzcmhn.org [2003, 13 Dec]. Australian Nurse Registering Authorities Conference (ANRAC) (1990) Nursing Competencies Assessment Project Vol 1 – The Project Report, 1990 Vol.2, 1990 Vol.3. Assessment and Evaluation Research Unit, Education Department University of Queensland. Australian Nursing Council Incorporated (ANCI) (2001) Code of Professional Conduct for Nurses in Australia. Australian Nursing Council Incorporated, Canberra Australian Nursing Council (2002)Principles for the Assessment of National Competency Standards for Registered and Enrolled Nurses. ANMC: Canberra Australian Nursing and Midwifery Council (2006) National Competency standards for the Midwife ANMC: Canberra Australian Nursing and Midwifery Council (2005) National Competency standards for the Registered Nurse ANMC: Canberra http://www.anmc.org.au/docs/Competency_standards_RN.pdfAustralian Nursing and Midwifery Council (undated on website) National Competency standards for the Enrolled Nurse http://www.anmc.org.au/docs/CompetencystandardsfortheEnrolledNurse.pdfAustralian Nursing Federation (2005) Policy on competency standards and nursing ANF: Canberra Barraclough F (2002) Existing competency documents available for nursing staff NEAHS www.anf.org.au/nno/pdf/competencies.pdf Borbasi S (1999) Advanced practice/expert nurses: hospitals can't live without them. Australian Journal of Advanced Nursing. 16(3):21-29. Campbell G (1999) Cross-utilization of workers whose capabilities differ Management Science, 45 (5). 722-732 Chenoweth L, Jeon Y-H, Goff M & Burke C (2006) Cultural competency and nursing care: an Australian perspective. International Nursing Review 53, 34–40 Chiarella M, Regulatory mechanisms and standards: nurses’ friends or foes? in Gray G & Pratt R (Eds) (1995) Issues in Australian Nursing 4 Churchill Livingstone: Sydney, 61-74. Confederation of Australian Critical care Nurses (1996) Competence Standards for Specialist Critical Care Nurses CACCN: Melbourne Fisher M, Marshall A & Kendrick T (2005) Competency standards for critical care nurses: do they measure up? Australian Journal of Advanced Nursing 22 (4): 32-39. Hamlin L (2004) Determining the position of ACORN on credentialing perioperative nurses: a critical analysis. Journal of Advanced Perioperative Care. 2 (1): 5-10. Hazelton M, Farrell G, Biro P, (1998) Self-Regulation and Credentialing in Mental Health. Nursing: A Report to the Nursing Board of Tasmania. NBT: Hobart Kanitsaki, O. (2003) Foreword: transcultural nursing and challenging the status quo. Contemporary Nurse, 15 (3), v–x.

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McMillan M, Bujack E & Little P. Competence: learning through assessment and appraisal in Gray G & Pratt R (Eds) (1995) Issues in Australian Nursing 4 Churchill Livingstone: Sydney McMurray, A. (2004) Culturally sensitive evidence-based practice. Collegian, 11 (4), 14–19. Melbourne Sexual Health Centre (2003) Peer review record for sexual health nurses. MSHC: Melbourne Nurses Registration Board of NSW (2001) Chiarella EM & Keatinge D (co-investigators), Casebook of Disciplinary Decisions of the Nurses Tribunal and Professional Standards Committee NSW NRB: Sydney Percival E. Achieving national standards for the regulation of nursing in Gray G & Pratt R (Eds) (1995) Issues in Australian Nursing 4 Churchill Livingstone: Sydney, 11-28. Robertson S & Chiarella EM (1995) Credentialing debate & decisions! Australian Critical Care 8 (2) 4 Royal College of Nursing Australia (2006) Position statement: advanced practice nursing. RCNA: Canberra Wells E (2003) ANCI Competencies: an investigation of uniqueness and importance Unpublished PhD thesis: Griffith University: Queensland. NB: The competency documents from Table 2 (unless specifically discussed within the text) are not referenced here but most are available through Google. Where difficulty sourcing the documents has arisen, a contact has been included within the Table.

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