Competence, Nursing Practice, and Safe Patient Care

Chapter 4 Competence, Nursing Practice, and Safe Patient Care



Linda Brazen, MSN, BSN, RN, CNOR


Competent, competence, competences, competency, competencies—all describe, but in no way define, the complex of knowledge, skill, and ability that is the hallmark of successful practice in any profession, including the nursing profession. Attempts to define competence as a concept, to create a model of competence, or to measure it have been made for almost 20 years in the nursing education, staff development, and practice literature.


Yet, although competence is relevant to all health care disciplines, consumers of health care, academic and clinical educators, student nurses, employers, and administrators, there is not even a common understanding or consensus of what competence is or is not (Tilley, 2008). Implicitly though, competence is essential.



THE COMPETENCE CONTINUUM


Nursing faculty struggle to create curricula that provide content and teaching strategies to best prepare students with entry-level competencies. Health care facilities with registered nurse (RN) employees struggle with entry-level competence. Nursing administrators and directors struggle with obtaining the finances to support competence development, especially as it relates to safe patient care issues. Unit-based managers struggle to keep staff competent in light of constantly increasing technologies. Clinical educators and staff-development specialists struggle to assess, validate, and maintain all the points along the continuum of competence: from the entry-level competences of graduate nurses, to the initial- competence of new hires, to the new- and ongoing-competence needs of staff. Distinguishing the intent and purpose of competence provides a consensus about the requisite knowledge, skill, and ability inherent in professional clinical nursing practice.


Academic nursing education curriculum is designed to provide students with a baseline of knowledge and a real-time skill base that ensures that they are generically “safe” clinicians upon graduation. Because of this intention, student nurses are prepared for success in earning a professional nursing license. There are issues in licensure that are beyond the scope of this chapter. Specific to competence, however, it may be argued that the licensure examination is a static test of knowledge for a dynamic practice; it does not and cannot provide an indication of accuracy in future performance. A more common idea is that an RN license provides a measurable criterion for schools and colleges of nursing and employers. The license is intended to ensure that graduates from various types of nursing education programs will be equally successful.


In the workplace, employers use the RN license as a baseline indicator of an ability to do a job, competence notwithstanding. However, nurses starting their career or those hired into a care setting that they have no experience in are not always prepared to do the job. Employers who recognize this liability but use the recruit-to-retain strategy to hire candidates who value competence as a process that continues after their licensure, rather than an end product, are most successful. The quality, not the quantity, of new hires should be considered because what RNs do with their basic education has become the indicator of success in this quantum age of nursing practice (Porter-O’Grady, 2008).


The gap between knowledge gained through nursing education and its application to nursing practice is a conundrum when considering competence. Similarly, the gap between knowledge gained in the work setting and its implementation in practice is another challenge. Patients, as the recipients of nursing care, need competent RNs, and RNs need career competence. Competence is absolutely necessary, but is still without definition.



Continuing Competence


Competence is an issue in nursing education, for employers of nurses, and for nursing itself. There are regulatory agencies, professional organizations, accrediting bodies, and, in the clinical practice arena, a certification process that creates challenges and opportunities for attaining and measuring RN competence. All of these entities consider and influence issues of competence. Because nursing is primarily a clinical, practice-based profession, the influence of these organizations reaches far into health care settings, traditionally the largest employers of RNs. The Joint Commission (TJC), the accrediting organization for health care facilities, requires employers to have programs in place that assess, maintain, and provide their employees with an ongoing process to maintain and gain competence.


Performance evaluation is a separate requirement and process of The Joint Commission; it relates to issues of competence at the organizational and individual employee level. The Joint Commission added National Patient Safety Goals (NPSGs) to its standards that measure, in part, the organization’s and its employees’ competence and performance. The Joint Commission does not prescribe how to improve or to measure an organization’s or an employee’s performance. The expectation is that catastrophic errors and near-miss patient incidents in health care settings will never occur. The Joint Commission added a never event list to the NPSGs in 2006. It continues to review organizational performance, and update and create new standards as needed, to attain the goal of eliminating never events in patient care (Catalano, 2008).


The standards of practice set by specialty nursing organizations are used by health care facilities and RN employees to develop competencies. Most specialty nursing organizations publish evidence-based guidelines for practice and support evidence in ongoing research. The results are then shared in professional journals. An additional set of guidelines and recommended practices, published with the standards of practice, are available from the organizations. These are used to develop workplace policies that support RN patient care competence. The Association of periOperative Registered Nurses (2008) has published guidelines that support the NPSGs.


Other groups that also contribute to professional competence issues, literature, and practice settings are the credentialing bodies for each specialty practice. Research is lacking to demonstrate a link between certification examinations and improved patient outcomes (Wittaker, 2008). However, a number of credentialing organizations are exploring how to validate competence so that portability and reciprocity are options for certified RNs who change employers or move to another state. Continuing career competence, through certification by examination and by participation in competence and skills-based activities, would be profiled and transferable throughout the RN’s career and from employer to employer.



Organizational Competence


The goal of accreditation for the performance of a health care facility is to decrease the competition to be all things to all consumers and to increase the ability to do what the organization does best. Historically the word competent was used in accreditation manuals to indicate the quality of the organization by employing quantitative measurements such as fewer undesirable patient outcomes compared with a neighboring organization. A patient could use these measurements to determine the safety of the health care organization. A health care organization was considered competent if fewer patient risks were associated with it. In addition, it was implied that employees of a competent organization were themselves competent. In the scheme of accreditation, the mechanistic term capacity was often associated with a quantitative organizational measure and a perception of quality employees. Competent and accredited facilities demonstrated two performance measures: successful patient outcomes and the capacity to employ staff to provide such outcomes. Relative to the concept of competence, entry-level knowledge and skill combined with the RN license were considered equivalent to the knowledge and skill of the career-level competent RN in assigning roles and responsibilities. A large amount of health care, nursing education, and nursing practice literature was published in this era about competency as it related to entry-into-practice issues, including the comprehensive work of Patricia Benner (2008).


In 1991 the word competent in The Joint Commission manual was changed to competence. This was a deliberate move on the part of The Joint Commission Agenda for Change. The administrative and accreditation changes were designed to be less prescriptive and more process oriented. In turn, health care facilities were expected to be more process oriented and to use competence as a criterion of performance. Instead of organizations attempting to provide all care to all consumers, each organization identified its competence according to what it did best; for example, organ transplant surgery, a birthing center, or a specialization such as oncology. Because employee competence was a critical component of an organization’s competence, the design of competence programs for employees was an indication of organizational performance. Employee competence programs included organizational expectations and identification of observable and measurable actions indicating individual performance. An employee who successfully demonstrated the combined performance of knowledge and skill had achieved competence. Implicit in the achievement was the expectation of continuing competence, which will be addressed in a later section of this chapter.


The terms competent, competence, and competency are often used interchangeably. Relative to accreditation standards, it may important to note that in addition to changing the word, the competence standard was moved from its original place in the nursing care standards section (1987–1991) to the staff education standards, where it remained until 1994. Then it was moved into the human resources article, where it remains as of this writing.



NATIONAL PATIENT SAFETY GOALS


Accreditation has evolved over the years, but what has remained constant is that it is a process, not a standardized or terminal point, along a continuum of patient care. Regardless of changes in the process of accreditation, The Joint Commission sets the primary benchmark for the safety and quality of care provided to future and current consumers of health care. Patients, as the consummate consumers of services provided by health care organizations, have become actively engaged in determining the nature and quality of their own care and services. Through the years, The Joint Commission has fostered and nurtured progressive and prospective process improvement initiatives in accredited health care organizations. This has been supported by consumers declaring that catastrophic errors and near-miss patient safety incidents are not acceptable. A representative group was invited to work with The Joint Commission to explore and prioritize the elimination of untoward patient incidents. They reviewed current goals, suggested new goals, and recommended requirements, based on evidence and best practices, designed to prevent such incidents from occurring. These goals are presented in the NPSG section of the accreditation manual. Any organization, accredited or seeking accreditation, that offers health care, treatments, and services relevant to the NPSGs is responsible for implementing the applicable requirements or effective alternatives. A term used in reference to The Joint Commission Safe Patient Care Initiative is the safety trilogy. Components of the safety trilogy are (1) trends in sentinel events, (2) preventive patient safety programs related to near-miss incidents, catastrophic errors, and never events, and (3) the NPSGs.

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Aug 5, 2016 | Posted by in ANESTHESIA | Comments Off on Competence, Nursing Practice, and Safe Patient Care

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