Developing a competency framework for preoperative assessment Hilary Walsgrove

Chapter 20 Developing a competency framework for preoperative assessment


Hilary Walsgrove


SUMMARY


This chapter will cover:


the background to developing competencies for preoperative assessment


standards of practice and levels of practice


a competency-based framework for education, training and assessment


the competency portfolio as a learning and assessment tool


assessment of competence


educational courses.


Background


Preoperative assessment has developed as a service provided by a variety of members of the healthcare team, such as doctors, nurses and allied health professionals.1 However, preoperative assessment services have tended to evolve within the United Kingdom in a rather ad hoc and haphazard fashion, often without clear structure, adequate finances and invariably as an ‘addon’ to other surgical services. This has led to a lack of clarity around what constitutes best practice in preoperative assessment, a dearth of information relating to any minimum standards of practice for preoperative assessment and limited education and training packages for staff providing this vital service.


Against this general background, two key points emerge that need careful consideration if well-planned, effective and efficient services are to be developed that meet the needs of patients, as well as being in line with the organisation providing the services. First, the development of clear, good practice guidelines for preoperative assessment is necessary, such as those produced through work carried out by the NHS Modernisation Agency (NHSMA), which were published by the Department of Health.2,3 Secondly, a robust, comprehensive education and training programme needs to be developed for staff involved in preoperative assessment, if best practice is to be established and maintained.


The purpose of preoperative assessment


Preoperative assessment is not only about determining the medical fitness of patients for surgery.4 It should also involve a two-way consultation between patient and preoperative assessor whereby the patient is assessed for physical, psychological and social suitability to have surgery performed.5 This provides the healthcare team with relevant information about the patient prior to admission. Also, it should be an opportunity for the patient to gather information about pending surgery and its implications. Some main aims for preoperative assessment, which feature in current literature, are as follows:


to minimise patient risk2,3,6,7


to identify patient suitability/fitness for surgery/anaesthetic2,3,6,7


to provide information for informed choices1,6,8


to facilitate better utilisation of theatre/ward resources2,3,6


to reduce fears and anxieties for patient2,3,6,7,8


to improve surgical patients’ hospital experience.2,3,9


Standards of practice for preoperative assessment


Standards of practice for preoperative assessment are likely to vary according to local requirements and the specific specialist areas involved.8 However, the standards are likely to fall into the following broad categories:


management of clinics/patient appointments


patient assessment for surgery and anaesthesia


information-giving and consent for surgery and anaesthesia


patient admission and discharge planning.


If these categories are looked at in more detail, the sort of aspects that emerge might be as follows.


Minimum standards of practice within the category of ‘Management of clinics/patient appointments’ would include aspects such as:


ensuring that patients are seen promptly, within 10 minutes of their allocated appointment time


making sure the appointment runs to time and patients aren’t kept waiting to see other members of staff


making sure that communication channels between all relevant departments are good, enabling the patient’s journey to run smoothly


ensuring patients have all necessary details relating to their admission, contact details for enquiries and so on


making sure patients are preoperatively assessed at least seven days prior to their admission for surgery


ensuring patients are treated with dignity and respect and offered appropriate reassurance and support by the preoperative assessor.


Within the category of ‘Patient assessment for surgery and anaesthesia’, minimum standards of practice should include elements such as:


checking the patient’s current health and social status, in relation to suitability for surgery within the allocated environment (e.g. day surgery, inpatient facility)


checking patient’s suitability for planned surgery


carrying out a relevant patient assessment including medical, surgical, anaesthetic, nursing, social and psychological issues


carrying out all relevant vital signs and preoperative investigations and checking and appropriately actioning the results of these tests


carrying out physical examination relevant to the impending surgery and anaesthetic


documenting in full all of the above points, making appropriate referrals based on the information gathered and acting on the results of the assessment carried out


dealing with any problems identified during patient assessment appropriately and in a timely and efficient manner.


Within the category of ‘Information-giving/Consent for surgery and anaesthesia’, minimum standards that apply should include:


provision of verbal and written information to the patient and/or carer pertaining to their admission to hospital, anaesthetic, surgical procedure, pre- and postoperative care and discharge arrangements required


providing patients with adequate information and checking their understanding in relation to being able to give their fully informed consent for both anaesthetic and surgery10,11


giving patients the opportunity to ask questions and voice concerns about their pending admission for surgery.


Once standards of practice for preoperative assessment have been formulated and agreed within the local area, which are also in line with national guidance,12 they can provide a baseline for acceptable performance for staff working within preoperative assessment13 and can act as a benchmark for best practice.14 From the perspective of the organisation, standards of practice help protect patient safety as well as safeguarding the organisation’s liability.15


In order to meet the aims of preoperative assessment and to run a preoperative assessment service that is characterised by acceptable and agreed standards of practice, a relevant programme of education, training and assessment should be developed for all staff involved in the preoperative assessment of patients. Currently there is no national educational programme for preoperative assessment across the United Kingdom and therefore different areas have set up their own programmes, depending on local requirements.4,7,16 Such programmes range from short, in-house training involving mainly observation of others’ practice and sometimes some theoretical sessions up to first degree and Masters programmes for advanced nursing practice, which include historytaking and physical examination skills.4,17 There are also courses provided by commercial companies as well, such as MandK, whose course provides an introduction to preoperative assessment and assists in offering evidence-based care to improve patient outcomes.18


Levels of practice for preoperative assessment


Before a framework of education can be formulated, it is important to review what staff are actually doing at present. This will highlight that individuals work at different levels of practice within different preoperative assessment structures. Staff working at different levels of practice can all make a valuable contribution to patient care and this should be inherent within any programme that is set up to support learning. What is important is that individuals are working safely and effectively within their own level of competence and not beyond their limitations.19 There must be a clear and transparent outline of the roles and responsibilities of the different members of the preoperative assessment team. This will enable an educational programme to be developed based on the knowledge and skills required for safe and effective practice. This should then meet the varied individuals’ needs within the context of the preoperative assessment team and meet the requirements of the organisation they work for.


Due to wide-ranging variation across the United Kingdom in relation to the structure of preoperative assessment services, there is no single particular model to use as a template for the ‘ideal preoperative assessment service’. However, where a service is provided by an integrated team of individual healthcare workers, the level at which these individuals work is likely to range through healthcare assistant, registered nurse or allied health professional, registered nurse or allied health professional with advanced knowledge and skills, such as advanced nurse practitioner or surgical care practitioner, junior doctor, junior and consultant anaesthetist.


Benner’s (1984)20 levels of skills acquisition model is one model that can be used as a structured framework for identifying levels of practice for healthcare professionals working in preoperative assessment. This model has been used extensively within nursing21,22,23,24 and, as many staff involved with preoperative assessment are nurses, this tool is ideal to use within this area.


Benner’s ‘Novice to Expert’ model20 was used as a basis for a competency framework for preoperative assessment that was developed within an acute hospital trust in the South of England. It fitted well with the development of skills and knowledge for the preoperative assessment nurses involved. Benner’s levels of practice as applied to this particular organisation are outlined in Box 20.1. These levels of practice suited this particular hospital Trust but may not be appropriate in other organisations with preoperative assessment services that are structured differently, but they could be adapted to suit individual requirements. The model provides standard level descriptors that are used for the education programme that has subsequently been devised. The level descriptors are the definition of achievement against the identified standard: ‘novice’, ‘advanced beginner’, ‘competent’, ‘proficient’ and ‘expert’. Within this particular Trust, levels 1 to 3, which loosely equate to Benner’s ‘novice’, ‘advanced beginner’ and ‘competent’, relate to the expected knowledge and skills of the Band 525 preoperative assessment nurses, depending on what level they are at within their own personal career structure. They can move along the continuum as they progress through their personal and professional development. Level 4 preoperative nurses tend to be Band 5 or 6 nurses25 with advanced nursing skills, such as physical examination and history taking and student advanced nurse practitioners. Level 5 nurses are usually qualified advanced nurse practitioners, usually working at Band 7.25. The level 4 and 5 nurses would loosely equate to Benner’s ‘proficient’ and ‘expert’ levels.



Box 20.1 Levels of practice for preoperative assessment



There are five levels of practice for registered nurses working within preoperative assessment (POA), which are based on Benner’s (1984) ‘Novice to Expert’ model.



Level 1: Novice


A registered nurse who has been qualified for one year or less and has been working within a surgical environment or a registered nurse who has been working within a different specialist area and has minimal or no surgical experience.



Level 2: Advanced Beginner


A registered nurse who has completed the preoperative assessment competency portfolio and has been assessed as competent. Once competent, the nurse can see a patient in an unsupervised capacity, within a joint nurse/junior doctor clinic.



Level 3: Competent


As for level 2. In addition, the nurse will have successfully completed the preoperative and planning unit of learning. The nurse also takes on some additional responsibilities within own speciality area.



Level 4: Proficient


As for levels 2 and 3. In addition, the nurse will have successfully completed physical examination and health assessment unit of learning. This nurse will conduct nurse-led POA clinics without doctor involvement.



Level 5: Expert


As for levels 2 to 4. In addition this nurse will be a qualified nurse practitioner who has completed an RCN-accredited nurse practitioner programme.


Although these levels were identified within the framework, it is important to point out that these are considered to be flexible descriptors. The preoperative assessment nurses are able to move between levels interchangeably depending on their practice at the time and this ensures that the framework takes into account individuals involved at different levels of training and education. As the nurses progress in terms of professional development and confidence and competence in practice for preoperative assessment, they can move through the competencies at increasingly higher levels of achievement within the framework (from levels 1 to 5).


With standards of practice for preoperative assessment and the levels of practice established that staff are either working at or working towards, it is possible to devise a suitable education, training and assessment programme. In the case of nurses, who tend to make up the majority of preoperative assessors, there is a general perception that they should be ‘experienced’, but this is not clearly elaborated upon within current available literature. As it is likely that preoperative assessment constitutes adjustments to the nurse’s scope of practice,19 if the role is to be undertaken effectively, they should have sound knowledge of anaesthesia and the surgical speciality involved, as well as well-developed assessment skills.1 Alongside this, competencies can be identified that meet with the standards of best practice within that specific preoperative assessment service.


Competence for preoperative assessment


Competence attracts different definitions depending on the context within which it is used.26 Competence may be defined within a professional context and is the broad ability with which a professional person is able to practise to required standards in a range of situations. Competencies are the various aspects performed to the predetermined standard, which combine to create professional competence in a defined role.27 For the purpose of a preoperative assessment competency framework, Eraut’s (1994)26 notion of competence and competency would be an appropriate approach to adopt. Competence is a generic notion that refers to a person’s overall capacity, while competency refers to a specific capability. Competencies consist of knowledge and skills combined with attitudes and values required in a particular context to perform to a prescribed standard,28 which in this case is preoperative assessment. Trust, caring, communication skills, knowledge and adaptability are identifiable attributes of competence, together with emotions and values.28,29,30 The competency approach to training, job selection, appraisal and development is advocated as a strategy for helping to deliver quality, cost-effective healthcare.31,32 It is important from an organisational perspective for competence of healthcare staff to be continuously identified, monitored and assessed if safe and effective practice is to be maintained.28


With the above issues in mind, it is possible to see that overall competence is dependent on the level of every specified competency. This fits well with the idea of staff working at different levels of practice, which has been discussed earlier in this chapter. A holistic approach to competence, incorporating specified work tasks and roles as well as the concepts of knowledge and understanding drawing on Benner’s20 levels of skills acquisition, is an appropriate starting point for considering the development of a competency framework for preoperative assessment that is based on identified standards of care.31,33,34


Developing a competency framework


The development of a competency-based approach to training, education and assessment for preoperative assessment can help to safeguard the interests of patients, the practitioner and the organisation. It promotes the identification of best practice from a sound evidence base and allows practice to be advanced in a safe and supportive manner. It promotes professional and personal development, enabling practitioners to demonstrate advancing practice from novice to expert, and increasing personal awareness to recognise competence as well as limitations of practice. It also encourages self-reflection and peer review and contributes towards professional profiling. It has been suggested that a practitioner’s self-recognition of their own level of competence is essential in maintaining high standards of care.28


A competency-based framework for education, training and assessment for preoperative assessment


This section will provide an overview of the competency-based framework of education, training and assessment that was developed within a particular hospital Trust. It is likely that numerous different models exist that would be equally appropriate to other organisations. However, this particular framework has been introduced and is now an established and well-evaluated local initiative within preoperative assessment that meets the requirements of this hospital Trust. The two main components of the programme are an in-house competency portfolio and a number of educational courses offered by the local university for post-registration healthcare professionals. It seems reasonable that other preoperative assessment services could draw on the experiences of this particular Trust in order to provide a robust and effective process for their own staff. In fact, this has proved to be the case, as publicity around the framework generated interest from other preoperative assessment services, which have used the package as a basis for their own areas.


Standards and levels of practice


Prior to devising the preoperative assessment programme at the Trust, a number of standards of practice were identified as a baseline, through work undertaken by the preoperative assessment group, led by the Trust’s preoperative assessment lead nurse and comprising representatives from all surgical inpatient wards, day case and short-stay unit, all preoperative assessment clinics and main and day theatres. Once this baseline of standards had been devised, an audit of current practice across the Trust was carried out using these standards. The standards focused on a number of key areas, namely management of clinics, patient assessment, information-giving and staff education. Data from the audit demonstrated that improvements could be made in all of these key areas and it was agreed that the formulation of a relevant preoperative assessment education, training and assessment programme would be a tool to enable improvements to be made, in order to develop and maintain high standards of practice and promote high-quality patient care. The audit was also instrumental in highlighting the different levels of practice that staff were working at and helped to highlight and shape the levels of practice that form an inherent part of the programme.


Preoperative assessment competency portfolio


The competencies within the preoperative assessment portfolio were compiled in line with the National Heath Service Modernisation Agency’s guidance for preoperative assessment,2,3,12 local and regional guidelines and standards and evidence gained from current literature relating to preoperative assessment practice. They give the preoperative assessment nurses, their employers and education providers with standards to work towards in order to achieve quality care and consistency within preoperative assessment. Although this is currently a local initiative, it is being rolled out across the region and is being used as the gold standard for preoperative assessment education, training and assessment within other local Trusts, thus increasing consistency and parity of practice at a wider level.


In addition, an analysis of the nurse’s role in preoperative assessment identified a number of components, which closely match those that are inherent within the portfolio outlined here. These components were: administrative function, physical assessment (medical and nursing history), psychological and social assessment, decision making, interventions (referral, counselling, ordering and performing tests and investigations).35 An analysis such as this has helped to strengthen the evidence base for development of both standards of practice as well as the competencies required to meet those standards, within the Trust identified here.


Currently the portfolio is available for registered nurses working within preoperative assessment, as it is nurses who predominantly make up the workforce within preoperative assessment at this particular Trust. However, the competencies could easily be adapted to meet the requirements of other healthcare professionals undertaking preoperative assessment.


A set of competencies for each level of practice are categorised into a number of sections that make up the competency portfolio (see Table 20.1). The competency sections are not presented in any particular order of priority, as each section should be considered equally important in terms of providing a service that adequately meets patient and organisational need. Each individual section starts with a broad competency statement, followed by a set of specific competencies designed to enable the nurse to achieve the overall competence. The competency statements identify the knowledge, skills and attitudes needed to perform within different elements of preoperative assessment.36



Table 20.1 The competency portfolio



















































Section number Title of section Level of practice
1 Knowledge and skills for patient appointments/clinic management 1 to 5
2 Interpersonal skills 1 to 5
3 Patient consultation and information-giving skills 1 to 5
4 Teaching and assessing skills 3 to 5
5 Maintenance of standards of practice 3 to 5
6 History taking 4 and 5
7 Physical examination 4 and 5
8 Informed consent (written) 4 and 5
9 Lead POA role for Trust 5
10 POA service delivery 5
11 Advanced practice 5

The competencies within the portfolio


Section 1: Knowledge and skills for patient appointments/clinic management


The competency statement for this section of the portfolio is that: ‘The nurse is able to work without supervision, maintaining a smooth running, systematic and well-organised clinic that meets the needs of the patient, staff and the service, in line with the guidelines and standards for practice for preoperative assessment’.


This section involves the preoperative assessor using a systematic approach to preoperative assessment appointments and ensuring that all aspects of the process are carried out and lead to a satisfactory outcome for both patient and assessor. The assessor requires good knowledge and understanding of the patient’s surgical journey and who and what is involved in the various stages of that journey. They need to be able to work effectively as a team member who is fully aware of their own role responsibilities and the responsibilities of other members of the team and be able to access the right individuals to liaise with in relation to communicating information about individual patients. This is likely to include admissions staff, the admitting ward/department, anaesthetic department and anyone that the assessor may need to refer the patient to. In addition to ensuring that appointments run smoothly, the assessor needs to be aware of time management issues, such as keeping to appointment times and being mindful of keeping patients waiting for long periods of time.


Section 2: Interpersonal skills


The competency statement reads: ‘The nurse has good interpersonal skills during interactions with patients/carers in the preoperative assessment appointment.’


The importance of good communication skills for preoperative assessment cannot be overlooked as it is key to building a therapeutic relationship with the patient, which will help them to travel along their surgical journey. Qualities such as empathy and caring should be evident. The preoperative assessor needs to convey to the patient a level of self-assurance that demonstrates confidence in their role, not showing any undue hesitation, confusion or embarrassment. The assessor should encourage the patient to be an active participant in the preoperative assessment process, to encourage interaction with patient and carer, encouraging them to express their feelings and thoughts, helping the patient to articulate fears and anxieties, to voice any concerns or queries about their pending admission and to ask appropriate questions. The assessor needs to be able to convey information to the patient so that they have a good understanding of what is going to be happening to them and to use language that the patient will understand.


Section 3: Patient consultation and information-giving skills


The competency statement for this section reads: ‘The preoperative assessment nurse confidently and competently conducts a patient consultation within a framework that includes the following elements: opening the consultation, patient assessment, information giving, closing the consultation, and team work.’


This section of the portfolio involves the content of the preoperative assessment appointment undertaken by the preoperative assessor, considering each individual appointment as a whole patient consultation. Opening the consultation is important, as it sets the scene for how the rest of the appointment will run and is the starting point for building a good relationship and partnership with the patient in a short space of time. Included within this section is assessment of the patient from a physical, psychological and social perspective, building up a picture of the patient that will help in planning their care and treatment during admission for surgery and planning for their discharge home and recovery following surgery. As part of the patient’s preoperative assessment appointment, the preoperative assessor will provide the patient with information about their pending admission and what to expect following surgery, helping them to make informed choices about the surgery, as well as the anaesthetic. Good closure of the consultation is also key to the process, ensuring that the patient is fully aware of what to expect and that preoperative assessor and patient both have all the information required to enable the best possible outcome. The preoperative assessor does not work in isolation but as part of a team, and therefore team-work is an essential element of the process.


Section 4: Teaching and assessing skills


The competency statement reads: ‘The level 3 nurse assumes a teaching and assessing role within preoperative assessment and acts as a mentor, providing support, guidance and advice to level 1 and 2 nurses.’


Once the preoperative assessor has gained experience within their role and is competent and confident in their abilities as a preoperative assessor, they need to be able to help maintain high standards of practice and high-quality patient care. This can be partly realised through teaching and assessing junior members of staff using the competency portfolio as guidance. The preoperative assessor needs to develop good teaching skills, to be able to act as an effective mentor and to be able to assess competence of junior staff.


Section 5: Maintenance of standards of practice


The competency statement reads: ‘The nurse will be responsible for ensuring that standards of practice for preoperative assessment are maintained.’


The preoperative assessor needs to be fully aware of the standards of practice for the POA service and must ensure that high standards are maintained at all times. They should ensure that they have good knowledge and understanding of up-to-date research and developments relating to preoperative assessment generally and within their specialist area of practice.


Level 4 preoperative assessors are expected to meet the competencies numbered from 1 to 5 and in addition will meet further competencies, which are detailed within Sections 6 to 8 of the portfolio.


Section 6: History taking


The competency statement reads: ‘The nurse confidently and competently obtains a comprehensive and accurate health history from the patient and/or carer.’


The preoperative assessor should be able to obtain an accurate account of the patient’s health history, distinguishing between relevant and irrelevant information and use this information to guide the physical examination of the patient. They should be able to identify the reason for patient admission, their presenting problem/s and the planned course of action. Accurate and comprehensive documentation of both the patient’s health history and physical examination is an essential aspect of the preoperative assessor’s role.


Section 7: Physical examination skills


The competency statement reads: ‘The nurse will be able to confidently and competently physically examine a patient in relation to assessing their fitness for surgery and anaesthetic.’


The preoperative assessor needs to be able to carry out an appropriate physical examination of the patient, in order to ascertain their fitness for surgery and anaesthetic. The preoperative assessor should be able to demonstrate an ability to distinguish between significant and nonsignificant findings, in relation to the examination. They must have good knowledge of the protocols regarding preoperative testing and their ordering and be able to act on results. They will be able to request and/or perform relevant investigations, based on patient assessment and examination, in accordance with guidelines.


Section 8: Informed consent (written)


The competency statement reads: ‘The nurse will obtain the patient’s informed consent for operation in writing and document this accurately on the consent form.’


If the preoperative assessor is to take on responsibility for obtaining written consent for surgery and/or anaesthetic, they need to have a good working knowledge of relevant anaesthetic and surgical procedures, risks and benefits, contra-indications and what actions need to take place. They have to be able to provide adequate, accurate information for patients to be able to make informed decisions about their operation and anaesthetic. Documentation of the information given to the patient and use of the appropriate forms is essential, in relation to obtaining written consent.


At level 5, the preoperative assessor is likely to have met all the competencies from all the previous sections and, in addition, will assume a leadership role within preoperative assessment.


Section 9: Lead preoperative assessment role for the Trust


The competency statement reads: ‘To act as a lead nurse for the Trust.’


At this level, the preoperative assessor assumes a wider remit with regard to preoperative assessment. They will actively participate in local and regional activities and act in a leadership role for preoperative assessment within the organisation.


Section 10: Preoperative assessment service developments


The competency statement reads: ‘The nurse is able to act as a key player in initiating, taking forward and promoting preoperative assessment service developments at local and regional levels.’


At this level, the preoperative assessor will be proactive in identifying and taking forward developments in preoperative assessment. This will include areas such as audit, research and development, and key aspects of any change processes.


Section 11: Advanced practice


The competency statement reads: ‘The nurse works at an advanced level of practice and is involved at a strategic level with clinical, managerial, education, research and practice development aspects of preoperative assessment.’


This will involve areas such as autonomy and accountability at an advanced level of practice and consideration of legal, ethical and professional issues relating to the advancement of practitioners’ roles. They are able to work as an autonomous practitioner within preoperative assessment but are also part of the multi-disciplinary team.


Each section contains activities that are required in order to enable the nurse to achieve the competencies identified and the evidence that they need to gather in order to demonstrate that the competencies have been successfully achieved. All preoperative assessment nurses are expected to meet all the competencies outlined within sections 1 to 3 of the portfolio. As the nurse progresses in relation to their level of practice, they are able to build on these initial competencies, depending on which level they have reached or is progressing towards. As the nurse moves from levels 1 to 5, they are expected to meet more competencies, in accordance with that particular level of practice.


The portfolio as a learning tool and an assessment tool


Due to the progressive nature of the preoperative assessment portfolio, it is used as both a learning tool and as an assessment tool. As a learning tool, it is used to help guide staffwho are new to preoperative assessment. It enables them to identify the knowledge and skills required to practise within preoperative assessment and provides them with a structured plan for working towards the development of their knowledge and skills. Once they have worked through the portfolio, through self-directed learning, supervised practice and observed practice, they can be assessed as competent to practise at whichever level of practice they fit.


For more experienced preoperative assessment staff, the portfolio can be used as a tool to reflect on their current practice and to guide them in advancing their practice within preoperative assessment. As it is likely that this group of staff will be supervising and teaching more junior members of the team, they can use the portfolio to help with teaching and assessing junior staff. The portfolio is also useful in terms of identifying personal and professional development opportunities and achievements from a career planning and appraisal viewpoint.


Assessment of the competencies


Once the portfolio has been completed and reviewed by the preoperative assessment lead nurse or another senior member of preoperative assessment staff, the nurse is ready to be assessed in practice by one of these senior members of staff. Prior to completion of the final practicebased assessment, the nurse is encouraged to use the portfolio in a reflective manner, and to consider their own skills and knowledge and the extent to which they feel they are able to meet the specifiled competencies and at what level (levels 1 to 5), thus using the portfolio as a form of self-assessment.37 Having assessed their performance against the specified competencies, it is possible to establish a ‘strengths versus opportunities’ ratio that can be used to highlight competence or identify opportunities for further development.38


The final assessment involves the nurse being observed in practice by a senior member of preoperative assessment staff, who has previously undergone assessment through this portfolio process. An assessment form is used, which enables the assessor to check whether the nurse has achieved each of the specified competencies required within a particular level of practice. This element of peer review strengthens the initial self-assessment process and facilitates the provision of constructive feedback to the nurse.39 Constructive feedback is considered to be an essential step in developing skills and in improving practice.40 Although not currently incorporated within the framework outlined here, it would be useful to consider patient feedback as part of the competency assessment for preoperative assessors.41 The interaction between the assessor and the patient and/or carer is so vital to the patient’s overall experience of their surgical journey and should not be overlooked.


Other competency frameworks have been developed across the United Kingdom, which are designed to meet the needs of the organisations they serve and have been developed very much as locally based initiatives. One example is of a competency package for all new preoperative assessment nurses, that covers assessment of competencies for anaesthetic assessment forms, electrocardiograph recording and reading, lung function testing, blood pressure monitoring and referrals. Another framework describes three essential components for the preparation of preoperative assessment nurses, using a medically orientated approach, namely undertaking masters-level modules in anatomy, physical examination and test ordering, having a senior doctor as a clinical mentor and being required to maintain a learning log book as evidence of developing skills.35


Other competency frameworks have been developed from a much wider perspective involving the Department of Health and various professional organisations and are designed to fit with nationally based education and training programmes. A training guide published by the Royal College of Anaesthetists42 outlines the training and assessment required for different levels of anaesthetic trainees, which leads them to a certificate of completion of training in anaesthesia. This is a competency-based training and assessment tool used as part of the anaesthetist’s overall anaesthetic training programme, which includes competencies for preoperative assessment.


The Surgical Care Practitioner programme was developed as part of a national initiative by the Department of Health, in conjunction with professional bodies, including the Royal College of Surgeons of England and Association of Operating Department Practitioners.43 It is aimed at nurses and other healthcare professionals who are working at or towards senior/specialist and/or advanced practitioner levels 6 and 7 of the Agenda for Change banding scale.25 It requires the trainee surgical care practitioner to demonstrate competence in both core and speciality elements, including elements inherent within preoperative assessment. Two levels of competence are utilised within this programme, and the trainee practitioner maintains a portfolio of evidence which provides a record of progress that informs the assessment process and its outcome.


The Department of Health and NHS Modernisation Agency worked with a number of professional bodies, including the Royal College of Anaesthetists, in the production of the Anaesthetic Practitioner Curriculum Framework.44 This is a programme delivered at postgraduate diploma level. Within this framework, communication, practical procedural and clinical examination skills are identified to meet the requirements of the programme. This includes a framework of competencies that the Royal College of Anaesthetists use for the clinical teaching of the anaesthetic practitioner student. Amongst these competencies are a number of core competencies that relate to preoperative assessment. A selection of these competencies can be found in Box 20.2.



Box 20.2 Anaesthetic practittoner curriculum farmework



(Selection of competencies within programme)



1. The anaesthetic practitioner shows an understanding of the principles underlying the preparation of the patient for surgery:



Knows the ASA classification and other scoring systems such as Glasgow Coma Scale


Explains the implications for anaesthesia of common operations


Explains the implications for anaesthesia of common medical conditions


Explains the importance of the patient’s anaesthetic history


Describes the relevant protocols and guidelines relating to preparation of patients for anaesthesia and surgery

Mar 21, 2017 | Posted by in ANESTHESIA | Comments Off on Developing a competency framework for preoperative assessment Hilary Walsgrove
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