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Rebecca Molloy Abstract: What makes a good nurse? Over the years there have been many theories: this article traces the route that led to the development of the Trust's competency framework. 12 References (12) and bibliography (7). Return to Nursing Progress contents list Contents: Historically, competence was related to the nature of the nurse's role as a practical bedside nurse. This system of competence presumed a clearly defined purpose, the production of the bedside nurse, whose primary function was to care for the sick person. 'Hints for Hospital Nurses', published in 1877, begins by entreating women, not to enter nursing for love of notoriety, false sentiment, or even just as a means of earning a living. Nursing had to be an 'in-born love' of the work, which was sadly only given to a few. (1) Elsewhere, however, textbooks of the time suggested that a nurse was not born, but made and required six qualities of character: presence of mind, gentleness of heart and thereby touch, accuracy, memory, observation and forethought. (2) The nurses' character was seen as the mainstay of competence for nearly a century. These are just two of the many attempts in the nineteenth and twentieth centuries to define what is required of nurses in order for them to carry out their jobs effectively. Inevitably, the variety in definitions led to wide variations in theories about appropriate training including whether the qualities of nurses were such that they could even be taught at all. By the second half of the twentieth century, the practical nursing care of patients was linked to and synthesised with a theoretical knowledge base, linking underlying theory to the clinical practice of patient care. However, it was heavily reliant on the ward sister/charge nurse, who was expected to know and understand each individual student nurse and to provide close monitoring of each of them to ensure they developed appropriate nursing skills within an appropriate nursing ethos. Training up until 1977 relied on a standardised, explicit, defined syllabus. After the Nurses, Midwives and Health Visitors Act of 1979, the objective of nursing became less clear. From the 1980s onwards, there was a shift in nurse training, that moved the focus away from the clinical environment and more into the classroom. Professional boundaries and the competence needed for new roles had become far less distinct than they were in the past. From 1983, the UKCC defined preparation for competence in very general terms, with broad competency umbrellas such as the ability to assess, plan, implement and evaluate care. Other definitions of competence in the 1 990s also tended to be quite broad. For example, Beaumont: (3) "Competency is the ability to apply knowledge, understanding and skills in performing to the standards required in employment, including solving problems and meeting changing demands." (4) Or Bass (5): "Displayed behaviours or attitudes which have been identified as key to the success of the client/patient care, and are shared by everyone at every level. They are a reflection of knowledge, skills and personal qualities." (Taken from CELEC Nursing Core Competency Pilot Project NELWDC 2001) Confusion in the variety of definitions of competence may have contributed to the current difficulties of modern nursing in defining competency standards and indeed to questions about whether nurses are being prepared to be 'fit for practice' in the many different areas of nursing today. These questions have contributed to a growing recognition across the profession of the need for greater precision about the purpose of nursing practice and what it constitutes at different levels. Other factors that have driven the development of competency frameworks include Government/Department of Health initiatives such as the NHS Plan, Clinical Governance, Essence of Care programme and Agenda for Chance. The trend for increased demand on services and government drive to reduce waiting lists and times along with greater informed and empowered patients/clients through media interest drives the need for a highly competent workforce. The health service is dependent on its staff who are working at full capacity, they are encouraged to work "Smarter not harder" (DOH 2000)
The change of emphasis from outcomes to clinical competencies was recognised through Fitness for Practice (12) recommendations based around the concept of competence in clinical practice expected at the point of registration. The UKCC/NMC have also made significant changes to education programmes leading to the point of professional registration. For example, at City University a skills schedule was developed for student nurses, defining the competencies they need in order to qualify and practice as nurses, across a range of knowledge, skills and attitudes. The development of a competency framework at Barts and The London was born out of a training needs analysis undertaken by the Education Nursing Team in 1999. With the assistance of an outside consultant, the group came up with the idea of a competency-based framework for D grade nurses, which would map out the competencies they need to develop in order to practice safely and effectively. The competency-based framework they developed has six sections, five of which are generic for all clinical areas and taken from the D grade job description.
One additional section to be tailored to each individual ward area reflecting specific needs The framework was deliberately based on the City University skills schedule, as it was felt that a familiar system would make it easier for the D grade nurses using it. It would also be familiar to the mentors in clinical areas using it to assess their staff. It was piloted on Devonshire Ward at The Royal London for six months, prior to being validated by the Nursing Policy Board in April 2002 for roll-out across the Trust. The work of the Education Nursing Team was just the starting point for competency development in the Trust, leading to the creation of the new role of Senior Nurse, Competency Development. This role, is designed to lead on the development and implementation of a Trust-wide competency development programme. The aims of this programme include:
All D grades who have started in the Trust since January receive a copy of the competency framework during their initial generic orientation week. This is the theory turning into practice, and a very exciting step forward. Since my appointment, I have also been benchmarking what has been achieved so far within the Trust against other NHS trusts, both locally and nationally. It has emerged from this that other organisations are at very different stages of development. The Trust's own competency programme is being spearheaded by the Competency Development Steering Group, which was set up in January. The role of this group is to further develop a competency development programme; to gather and co-ordinate information within the Trust; to promote the profile of competency development to a wider audience; to share information and good practice both internally and externally; and to become a validation group within the Trust for competency.
In conclusion a Competency is the written statement that refers to a combination of knowledge, skills and attitudes of a person who performs at a predefined level and considers the wider implications of their practice and its affect on the patient. The competence of a person is their ability to perform consistently in different situations using their knowledge, skills and attitudes to achieve optimum outcomes. With careful development of Competency Frameworks and behaviour statements this could increase the reliability in meaning. A nurse's competence is dependent on his/her knowledge, skill and attitude. Effective behaviour is essential to successful performance. It is important to recognise that staff and competencies are independent of each other. Competency Frameworks themselves do not guarantee effective performance by nurses. Effective outcomes and quality care are also dependent on the motivation and commitment of staff to perform best practice. By increasing personal awareness and recognising areas of competency and further development, staff can address their limitations and practice and work towards working 'smarter not harder', thus becoming more efficient in the provision of quality care. Reflection and empowerment by the practitioner are the greatest supporting aspect of effective assessment, selfprofiling and competency development. Here the nurses can identify their strengths and areas for development, learn from mistakes and propose alternative approaches and strategies if faced with the same or similar situation again. Another of the benefits of an effective competency development programme is in the development of a common language applied across academic and practice contexts to support on-going personal and professional development, which will play a crucial part in supporting life-long learning and, thereby, continuously maintaining and improving standards of nursing care. Feedback from both staff nurses and their ward managers involved in the pilot of the D grade competency framework indicate its effectiveness, particularly as a means for identifying training needs. 'It has been helpful in establishing areas of development, which may not have been addressed as soon aids memory, a prompt." "The document has enabled me to identity areas that I need to work on for my professional development. As a result I know my training needs." "It could help to facilitate the mentorship process if staff were using it from the start of employment." "I find it hard to identity specific needs and I found the document acted as a trigger." "I am now more focused on my training needs and I feel more able to discuss my training needs at my IPR." "Helps to identify both over and under achievers" 1. Williams R, Fisher A. Hints for Hospital Nurses. MacLachlan, Stewart, Edinburgh 1877. 2. Bradshaw A. Competence and British Nursing: a view from history. Journal of Clinical Nursing 2000; 9: 321-29. 3. Beaumont G. Definition of Competence in Smosko S, Cook C. Applying APL principles in flexible assessment: a practical guide. Kogan Page, London 1996. 4. Barker M. How to competency frameworks impact on Professional Nursing. BSc (Unpublished);4. 5. Bass plc. Staff Development and Appraisal System. Bass plc. London (Unpublished) 1998. 6. Department of Health. A First Class Service: Quality In the new NHS.1990. 7. Department of Health. The NHS Plan 2000. 8. Department of Health. Making a Difference. 1999. 9. Department of Health. New NHS Modern and Dependable. 1997. 10. Department of Health. Working Together - Learning Together. 2001. 11. Department of Health Continuing Professional Development, Quality in the New NHS. 1999. 12. UKCC. Fitness for Practice. UKCC, London.1999. Bradshaw A. Defining 'competency' in nursing (part 1); a policy review. Journal of Clinical Nursing 1997; 6.5;347-54. Bradshaw A. Defining competency' in nursing (part 2): an analytical review. Journal of Clinical Nursing 1998; 7.2 :103-11. Del Bueno D. Why can't new grads think like nurses? Nurse Educator 1994; 19.4: 9-11. Diede N, et al. Performance expectations of the associate degree nurse graduate within first six months. Journal of Nursing Education 2000; 39.7:302-7. General Nursing Council. Syllabus of lectures and demonstrations for education and training in General Nursing. General Nursing Council of England and Wales; London 1923a. Lückes ECE. Lectures on General Nursing. 4th Edition, Kegan Paul, Trench, Trubuer, Ltd. London.1899. O'Dea D et al. New ways for new staff. Nursing Management 1997; 4.5; 20-21. Stewart l, Cuff, HE. Practical Nursing; Ist Edition, William Blackwood and Sons, London 1899. Cited in Bradshaw A. 2000. Training Agency. Definition of Competence 1988. Cited in Fletcher S. NVQs Standards and Competence. Kagan Page, London 1991: 32. Progress in Practice: September 2003. Copyright: Progress in Practice 2003, Back to Progress in Practice issue 14 index Return to Nursing Progress contents index Page last updated by DEB on 23/10/03 |
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