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RELATIONSHIPS BETWEEN LEGISLATION, POLICY AND CONTINUING COMPETENCE REQUIREMENTS FOR
REGISTERED NURSES IN NEW ZEALAND
A thesis presented in fulfilment of the requirements for the degree of
Doctor of Philosophy
in
Nursing
The University of Sydney
Rachael Anne Vernon
2013
i
ABSTRACT
The regulatory requirements in the jurisdictions of most countries contain an expectation that
nurses will be competent to practise nursing on registration, and that they will maintain their
competence to practise throughout their nursing careers (Chiarella, Thoms, Lau, & McInnes,
2008). However, whilst nursing regulatory authorities internationally agree that monitoring
the continuing competence of the profession is necessary to protect the public, there is limited
research-based evidence to support a particular approach to the monitoring and assessment
of continuing competence.
The purpose of this research was to explore the relationships between legislation, policy
drivers and the continuing competence requirements for nurses in New Zealand, in association
with determining international best practice for the assessment of continuing competence.
The research was completed in two stages. Stage One focused on the relationship between
legislation, policy and continuing competence requirements for nurses in New Zealand since
the enactment of the Health Practitioners Competence Assurance (HPCA) Act 2003 (NZ), and
the subsequent implementation of the Nursing Council of New Zealand Continuing
Competence Framework in 2004. A mixed method evaluation of the efficacy of the Nursing
Council of New Zealand Continuing Framework was completed in 2010 and significantly
contributed to development of the second stage of the research. Stage Two was completed in
2012, using a Delphi technique to determine the international consensus views of regulatory
experts from six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and
the United States of America), with regard to the development of a best practice international
consensus model for the assessment of continuing competence.
Overall this research has analysed the relationships between legislation, policy and continuing
competence requirements for nurses in New Zealand and concluded that the Nursing Council
of New Zealand Continuing Competence Framework is a well-accepted and recognised
regulatory tool for the assessment and monitoring of continuing competence, providing an
acknowledged level of functionality in terms of assuring the safety to practise of nurses and
ensuring public safety. In addition, the consensus views of international nurse regulatory
experts, with regard to the concept of continuing competence and the development of a best
practice consensus model for the assessment of continuing competence, have been
determined, collated and are presented in association with the recommendations for further
development of the international best practice model for the assessment of continuing
competence.
ii
ACKNOWLEDGEMENTS
This thesis signifies the culmination of an important chapter of my life in terms of my personal,
professional and academic goals. During this research journey I have been privileged to work
with some truly exceptional people to whom I will always be grateful.
Firstly I wish to thank my husband Malcolm, who has unreservedly supported and encouraged
me throughout my research journey and my professional career.
To my research supervisors Professor Mary Chiarella (Professor of Nursing and Research Chair,
University of Sydney) and Dr Elaine Papps (Senior Lecturer, Eastern Institute of Technology), I
thank you for your unfailing encouragement, knowledge, expertise, mentorship and above all
your friendship. You are truly exceptional professional women and I am indeed privileged to
have worked so closely with you.
Professor Denise Dignam, thank you for your colleagueship and input during the evaluation of
the Nursing Council of New Zealand Continuing Competence Framework.
I am grateful for the financial support I have received from the University of Sydney and the
Eastern Institute of Technology during my candidature that has allowed me to participate in
international forums and present my work at a number of international conferences.
I would like to acknowledge my employer the Eastern Institute of Technology for allowing me
leave to undertake the Nursing Council of New Zealand Evaluation and my Fulbright Senior
Scholar Award. In particular I would like to acknowledge and thank Dr Susan Jacobs and the
team within the School of Nursing to whom, during my absence, much of the day-today work
fell.
Last but not least, I would particularly like to acknowledge and thank the research participants
and the many other people who have contributed to this research, without whom completion
of this thesis would not have been possible.
Undertaking this work has afforded me with many professional and personal challenges,
opportunities and experiences. I have learned an immeasurable amount, not only in terms of
the research I have undertaken, but also about myself. Whilst, tortuous at times I have
enjoyed this experience. I now look forward to what the next chapter will bring. As Alexander
Graham Bell said “When one door closes, another opens” (Alexander Graham Bell, n.d.).
iii
TABLE OF CONTENTS
ABSTRACT .................................................................................................................................................................. i
ACKNOWLEDGEMENTS ..................................................................................................................................... ii
LIST OF FIGURES ................................................................................................................................................. vii
LIST OF TABLES .................................................................................................................................................... ix
LIST OF AUTHORITIES ...................................................................................................................................... xi
LIST OF ABBREVIATIONS ............................................................................................................................... xii
LIST OF PUBLICATIONS AND CONFERENCE PRESENTATIONS ................................................. xiii
STATEMENT OF AUTHORSHIP AND ORIGINALITY .......................................................................... xvi
SECTION ONE INTRODUCTION AND POSITIONING OF THE THESIS ..................... 1
CHAPTER ONE - INTRODUCTION AND BACKGROUND ...................................................................... 2
1.1 Introduction ...................................................................................................... 2
1.2 Positioning of the thesis .................................................................................... 2
1.3 Structure of the thesis ....................................................................................... 5
1.4 Background ....................................................................................................... 7
1.5 The purpose of professional regulation ............................................................. 8
1.6 Health Practitioners Competence Assurance Act 2003 (NZ) .............................. 9
1.7 Legislation and the Nursing Council of New Zealand ...................................... 11
1.8 Continuing competence in New Zealand ......................................................... 13
1.9 Professional development and recognition programmes (PDRP) .................... 15
1.10 Continuing competence in the international context ...................................... 16
1.11 The impact of undertaking this work on my professional career .................... 17
1.12 Section and Chapter Descriptions ................................................................... 18
1.13 Concluding remarks ........................................................................................ 20
CHAPTER TWO - LITERATURE REVIEW ................................................................................................. 21
2.1 Introduction .................................................................................................... 21
2.2 Search strategy ............................................................................................... 21
2.3 Background – national and international regulatory context ......................... 22
2.4 Competence and continuing competence ....................................................... 37
iv
2.5 Competence frameworks ................................................................................ 39
2.6 Professional Standards and competence assessment ..................................... 41
2.7 Continuing competence indicators .................................................................. 43
2.8 Summary of findings from the literature ......................................................... 45
2.9 Concluding remarks ........................................................................................ 49
CHAPTER THREE - RESEARCH DESIGN AND METHOD ................................................................... 51
3.1 Introduction .................................................................................................... 51
3.2 Selection of the Research Approach ................................................................ 52
3.3 Research Design and Methods ........................................................................ 54
3.4 Management of researcher bias ..................................................................... 74
3.5 Ethical approval .............................................................................................. 74
3.6 Limitations of the research ............................................................................. 75
3.7 Concluding remarks ........................................................................................ 77
SECTION TWO STAGE ONE: EVALUATION OF THE NURSING COUNCIL OF NEW ZEALAND CONTINUING COMPETENCE FRAMEWORK .................................. 78
CHAPTER FOUR - PHASE ONE FINDINGS: DOCUMENT REVIEW AND POLICY ANALYSIS ................................................................................................................................................................. 79
4.1 Introduction .................................................................................................... 79
4.2 Framework for the document review and analysis ......................................... 80
4.3 The evolution of nursing regulation in New Zealand ....................................... 80
4.4 Review of Nursing Council of New Zealand documents .................................. 92
4.5 Analysis of Continuing Competence Framework and Recertification policies . 95
4.6 Nursing Council of New Zealand statistics ...................................................... 98
4.7 Summary of findings from the document review and policy analysis ........... 100
4.8 Concluding remarks ...................................................................................... 101
CHAPTER FIVE - PHASE TWO FINDINGS: INTERVIEW DATA .................................................. 103
5.1 Introduction .................................................................................................. 103
5.2 Competence .................................................................................................. 105
5.3 The role of the Nursing Council of New Zealand ........................................... 111
v
5.4 Recertification audit process ......................................................................... 113
5.5 Summary of findings from the interviews ..................................................... 119
5.6 Concluding remarks ...................................................................................... 121
CHAPTER SIX - PHASE THREE FINDINGS: E-SURVEY DATA ..................................................... 122
6.1 Introduction .................................................................................................. 122
6.2 Demographic data ........................................................................................ 122
6.3 Competence and fitness to practise .............................................................. 129
6.4 Recertification audit...................................................................................... 134
6.5 Professional development and recognition programmes .............................. 139
6.6 Summary of findings from the e-survey ........................................................ 141
6.7 Concluding remarks ...................................................................................... 143
CHAPTER SEVEN - DISCUSSION, CONCLUSION AND RECOMMENDATIONS ...................... 144
7.1 Introduction .................................................................................................. 144
7.2 Data triangulation and discussion ................................................................ 144
7.3 Key research findings .................................................................................... 157
7.4 Concluding remarks ...................................................................................... 160
SECTION THREE STAGE TWO: THE INTERNATIONAL CONSENSUS MODEL FOR THE ASSESSMENT OF CONTINUING COMPETENCE ...................................... 163
CHAPTER EIGHT - STAGE TWO: FINDINGS OF THE DELPHI STUDY .................................... 164
8.1 Introduction .................................................................................................. 164
8.2 Delphi Round One - Interviews ...................................................................... 165
8.3 Delphi Round Two – E-survey ........................................................................ 181
8.4 Delphi Round Three – E-survey...................................................................... 189
8.5 Summary of findings from the Delphi rounds (one – three) .......................... 204
8.6 Key principles and core components underpinning the development of an international consensus model ..................................................................... 206
8.7 Concluding remarks ...................................................................................... 208
vi
CHAPTER NINE – THE CONSENSUS VIEW; DISCUSSION, CONCLUSION AND RECOMMENDATIONS ................................................................................................................ 209
9.1 Introduction .................................................................................................. 209
9.2 Delphi Round Four – The consensus view ...................................................... 210
9.3 What is the consensus view of regulatory experts? ...................................... 216
9.4 The best-practice international consensus model for the assessment of Continuing Competence ................................................................................ 226
9.5 Changes required to align international regulatory requirements with best practice for the assessment of continuing competence ................................ 230
9.6 Recommendations for further development of the international consensus model ............................................................................................................ 231
9.7 Concluding remarks ...................................................................................... 232
SECTION FOUR CONTINUING COMPETENCE AND PUBLIC SAFETY A RELATIONSHIP BETWEEN LEGISLATION, POLICY AND PRACTICE .................. 233
CHAPTER TEN - DISCUSSION, CONCLUSION AND RECOMMENDATIONS ........................... 234
10.1 Introduction .................................................................................................. 234
10.2 Relationships between legislation, policy drivers and statutory requirements to ensure registered nurses are competent and fit to practise...................... 235
10.3 Is it competence that is being assessed / measured, or safety to practise? .. 240
10.4 The consensus view of regulatory experts in relation to best practice for nurses to demonstrate continuing competence; and best practice for regulatory authorities to assess continuing competence .............................. 242
10.5 Contribution to the national and international research environment ......... 244
10.6 Recommendations for future research .......................................................... 245
10.7 Conclusion ..................................................................................................... 246
REFERENCES...................................................................................................................... 248
APPENDICES ...................................................................................................................... 261
vii
LIST OF FIGURES
Figure 1 Structure of the Thesis ............................................................................................... 6
Figure 2 Evaluation Research Process .................................................................................... 55
Figure 3 Practising Certificates issued .................................................................................... 98
Figure 4 Recertification audit trends and competence notifications ..................................... 99
Figure 5 Representation of questionnaire participants ........................................................ 123
Figure 6 Highest qualification - Overall group response ...................................................... 124
Figure 7 Current employment setting - overall group response .......................................... 125
Figure 8 Current nursing practice area – overall participant group ..................................... 127
Figure 9 Indicators that provide the best evidence of competence to practise ................... 129
Figure 10 Indicators that provide the best evidence of continuing professional development ............................................................................................................................... 130
Figure 11 A mechanism to ensure nurses are competent and fit to practise ......................... 131
Figure 12 Responsibility for maintaining continuing competence to practise ....................... 131
Figure 13 Peer Assessor ......................................................................................................... 135
Figure 14 Recertification audit distribution of participants by audit year .............................. 135
Figure 15 Should Professional Development and Recognition Programmes be Compulsory? ............................................................................................................................... 140
Figure 16 Professional Development and Recognition Programmes ..................................... 141
Figure 17 Possible to develop a consensus model for the demonstration and assessment of continuing competence .......................................................................................... 188
Figure 18 Definition of nursing practice ................................................................................. 192
Figure 19 Individual nurses are responsible for their own continuing competence .............. 194
Figure 20 Responsibility and accountability ........................................................................... 196
Figure 21 Assessment of continuing competence .................................................................. 198
Figure 22 Indicators of continuing competence ..................................................................... 199
Figure 23 Outlying competence indicators ............................................................................ 200
viii
Figure 24 Barriers and enablers ............................................................................................. 201
Figure 25 Consensus model ................................................................................................... 203
Figure 26 Healthcare Environment (New Zealand) ................................................................ 238
ix
LIST OF TABLES
Table 1 Nursing Council of New Zealand evaluation objectives ................................................ 3
Table 2 Summary of Research Questions .................................................................................. 5
Table 3 Continuing competence requirements for nurses across six countries ...................... 35
Table 4 Stage One research questions and the Nursing Council of New Zealand objectives ... 56
Table 5 Analysis of key Nursing Council of New Zealand policy documents ............................ 97
Table 6 Thematic categories and sub-themes ....................................................................... 104
Table 7 Participation rates and sample size .......................................................................... 123
Table 8 Cross tabulation highest qualification by scope of practice ...................................... 124
Table 9 Cross tabulation of current employment settings by scope of practice .................... 126
Table 10 Cross tabulation current area of nursing practice by scope of practice .................... 128
Table 11 Responsibility for maintaining continuing competence to practise .......................... 132
Table 12 Nursing Council of New Zealand recertification application questions ..................... 133
Table 13 Participation as a Peer Assessor ............................................................................... 134
Table 14 Recertification audit information.............................................................................. 136
Table 15 Recertification audit information – comparison by audit year ................................. 137
Table 16 Understanding of evidence required for the Recertification Audit ........................... 137
Table 17 Submission of audit documentation ......................................................................... 138
Table 18 Satisfaction with audit documentation, communication and processes .................. 139
Table 19 Cross-tabulation of Employment setting by “Should PDRPs be compulsory?” ......... 140
Table 20 Summary of recommendations made to the Nursing Council of New Zealand ........ 161
Table 21 Thematic categories and sub-themes - Delphi Round One ....................................... 167
Table 22 Knowledge and / or experience of Continuing Competence Frameworks? .............. 182
Table 23 The ways it is possible and appropriate to demonstrate continuing competence.... 184
Table 24 How should continuing competence be assessed..................................................... 185
Table 25 Barriers and enablers to implementing a model for assessment of continuing competence .............................................................................................................. 187
x
Table 26 Participation rate and sample size ............................................................................ 190
Table 27 Definitions of competence and continuing competence .......................................... 191
Table 28 As a registered health professional individual nurses are responsible for ................ 193
Table 29 Continuing competence of registered nurses – who is responsible? ........................ 195
Table 30 Continuing competence consensus model requirements ......................................... 197
Table 31 Assessment of continuing competence .................................................................... 198
Table 32 Competence indicators ............................................................................................. 200
Table 33 Barriers and enablers ................................................................................................ 202
Table 34 Continuing competence consensus model requirements ......................................... 203
Table 35 Participation rate and sample size ............................................................................ 211
Table 36 Key principles underpinning the best practice consensus model ............................. 211
Table 37 Core components of the best practice consensus model ......................................... 215
Table 38 Essential components for tool box of continuing competence indicators ................ 215
Table 39 Optional components for tool box of continuing competence indicators ................ 216
Table 40 Components of the best practice international consensus model ............................ 228
xi
LIST OF AUTHORITIES
STATUTES
Health Practitioners Competence Assurance (HPCA) Act 2003 (NZ)
Health Practitioners Competency Assurance Bill 2002 (NZ)
Nurses Amendment Act 1990 (NZ)
Nurses Act 1977 (NZ)
Nurses Act 1971 (NZ)
Nurses Regulations, 1986 (NZ)
Nurses Registration Act 1901 (NZ)
Tohunga Suppression Act (NZ) (1907)
The Health Act 1956 (NZ)
New Zealand Public Health and Disability Act 2000 (NZ)
Health and Disability Commissioner Act 2004 (NZ)
Crown Entities Act 2004 (NZ).
Nurses Act 1950 (Ireland)
Nurses Act 1985 (Ireland)
Nurses and Midwives Act 2011 (Ireland)
Nurses, Midwives and Health Visitors Act 1997 (UK)
Health Practitioner Regulation National Law Act 2009 (Qld)
CASES
Condon, NMT230206JHC in NSW NMB (2010) Professional Conduct casebook 2nd edition NSW
NMB: Sydney
Health Care Complaints Commission v Bruce Litchfield, (1997, 41 NSWLR 630)
xii
LIST OF ABBREVIATIONS
APC Annual Practising Certificate
CCF Continuing Competence Framework
CNA Canadian Nurses Association
CPD Continuing Professional Development
DHB District Health Board
EN Enrolled Nurse
HPCA Health Practitioners Competence Assurance Act
ICN International Council of Nurses
MECA Multi-Employer Contract Agreement
NA Nurse Assistant
NCNZ Nursing Council of New Zealand
NCSBN National Council of State Boards of Nursing
NCQAC Nursing Care Quality Assurance Commission
NMC Nursing and Midwifery Council (UK)
NP Nurse Practitioner
NZ New Zealand
NZNO New Zealand Nurses Organisation
PDRP Professional Development and Recognition Programme
RN Registered Nurse
UK United Kingdom
UKCC United Kingdom Central Council for Nursing, Midwifery and Health Visiting
USA United States of America
xiii
LIST OF PUBLICATIONS AND CONFERENCE PRESENTATIONS
International Journal publications:
Vernon, R., Chiarella, M., & Papps, E. (2013). Assessing the continuing competence of nurses
in New Zealand. Journal of Nursing Regulation, 3(4), 19-24.
Vernon, R., Chiarella, M., Papps, E., & Dignam, D. (2012). New Zealand nurses' perceptions of
the continuing competence framework. International Nursing Review. Advance online
publication, doi: 10.1111/inr.12001.
Vernon, R., Doole, P., & Reed, C. (2011). Where is the international variation in the protection of the public? International Journal of Nursing Studies, 49(2), 243-245.
Vernon R., Chiarella M. & Papps E. (2011) Confidence in competence: legislation and nursing in
New Zealand. International Nursing Review, 58, 103–108.
Book Chapter:
Vernon, R., Papps, E., & Dignam, D. (2012). Continuing competence: preparing for professional
practice. In Chang, E. M. L., & Daly, J. Transitions in Nursing: Preparing for professional
practice 3e. Sydney: Elsevier Australia.
Reports:
Vernon, R., Chiarella, M., Papps, E., & Dignam, D. (2010, March). Evaluation of the Nursing Council of New Zealand Continuing Competence Framework. Confidential Report. Napier, Author. ISBN 978-0-908662-33-3
Vernon, R., Chiarella, M., Papps, E., & Dignam, D. (2010, October). Evaluation of the Continuing Competence Framework. Wellington, New Zealand: Nursing Council of New Zealand. ISBN 978-0-908662-34-0
International Conference Presentations:
Vernon, R. (2012, September). Continuing competence: consensus or not? National Council of
State Board of Nursing 2012 Scientific Symposium: From Research to Policy. Alexandria,
Virginia, United States of America.
xiv
Vernon, R., Chiarella, M. & Papps, E. (2011, November). Confidence in competence: Developing
a conceptual model for the demonstration and assessment of continuing competence.
Keynote Speaker. Paper presented at the International Council of Nurses (ICN)
Credentialing and Regulators Forum, Taipei, Taiwan.
Vernon, R., Chiarella, M. & Papps, E. (2011, July). Public safety: Confidence in competence.
Paper presented at the 22nd STTI International Nursing Research Congress, Cancun,
Mexico.
Vernon, R. (2010, April). Burden of proof or an issue of public safety. NEP/NET 2010. 3rd
International Nurse Education Conference. Nursing Education in a global community:
collaboration and networking for the future. Sydney, Australia.
Vernon, R. & Doole, P. (2010, October). Confidence in Competence - Nursing Council of New
Zealand Continuing Competence Framework. Western Pacific and South East Asian
Regulators (WP/SEAR) Meeting. Singapore.
Vernon, R. (2008, September). Legislation and policy drivers in competence requirements for
registered nurses in New Zealand. Nurse education Tomorrow, Cambridge University,
United Kingdom.
Invited Presentations:
Vernon, R. (2011, May). Legislation, policy and competence requirements for registered nurses
in New Zealand. Presentation to Washington State Department of Health – Nursing Care
Quality Assurance Commission (NCQAC) Special Meeting, Tumwater, WA, United States
of America.
Vernon, R. (2011, June). Public safety, competence and nursing in New Zealand. Presentation
to Faculty and Students, School of Nursing, University of Washington, Seattle, WA,
United States of America.
Vernon, R. (2011, July). Nursing in New Zealand. Presentation to North Carolina Board of
Nursing and invited University and Community College Nursing Programmes, Raleigh,
NC, United States of America.
xv
Vernon, R. (2010, June). Evaluation of the Nursing Council of New Zealand Continuing
Competence Framework. Presentation at Nursing Council of New Zealand – Learning
Curve Programme. Wellington, New Zealand.
Vernon, R. (2010, July). Evaluation of the Nursing Council of New Zealand Continuing
Competence Framework. Presentation to Nursing Council of New Zealand. Wellington,
New Zealand.
Vernon, R. (2009, August). Competence to Practise? Innovations in Nursing Forum, Nursing
Council of New Zealand and Ministry of Health (NZ).
Conference Poster Presentations:
Vernon, R. & Reed, C. (2012). Public safety, confidence and competence, Poster Presentation
at the National Council of State Board of Nursing, 2012 Scientific Symposium: From
Research to Policy. September 2012, Alexandria, Virginia, United States of America.
Awards:
Fulbright (NZ) Senior Scholar Award – (2011). University of Washington, Seattle, WA, United
States of America. Research title: Development of an international consensus model for
the assessment of continuing competence.
Scholarships:
The University of Sydney, Postgraduate Research Support Scheme (PRSS) Scholarship - 2009,
2011, & 2012.
Eastern Institute of Technology (NZ) Performance Based Research Funding (PBRF) - Research
Scholarship – 2008.
xvi
STATEMENT OF AUTHORSHIP AND ORIGINALITY
I certify that the work presented in this thesis has not previously been submitted for a degree nor has it been submitted as part of the requirements for a degree except as fully acknowledged within the text.
I also certify that this thesis has been written by me and any assistance that I have received while undertaking this research and in the preparation of the thesis itself is acknowledged. In addition, I certify that all information sources and literature used in this thesis are acknowledged and referenced.
Signature: Rachael Anne Vernon
Date: 10 May 2013
1
SECTION ONE INTRODUCTION AND POSITIONING OF THE THESIS
Section One of this thesis provides an overview of the purpose and structure of the research
undertaken and is comprised of three chapters.
Chapter One provides the introduction and the contextual background in which this research is
situated. An overview of the structure of the thesis is provided.
Chapter Two presents a review of national and international literature relating to the
development, implementation and assessment of continuing competence models and
frameworks. It also provides a brief summary of the current regulatory practices relating to
the continuing competence of requirements for nurses, in the six countries identified as
participants in this research, Australia, Canada, Ireland, New Zealand, the United Kingdom, and
the United States of America. The conceptualisation of competence, continuing competence,
competence assessment and the validity and reliability of competence indicators, in as much
as these relate to public safety, is examined and key findings are presented. The literature will
also be used to inform the key research outcomes in Chapters Seven, Nine and Ten.
Chapter Three sets out the overarching theoretical framework, research perspective, and
method used to undertake this research, including the rationale for the research design and
the ethical considerations. Detail of the data collection processes, analysis and findings of the
research undertaken are presented sequentially in Section Two – Evaluation of the Nursing
Council of New Zealand Continuing Competence Framework and in Section Three – Consensus
Model for the Assessment of Continuing Competence.
2
CHAPTER ONE - INTRODUCTION AND BACKGROUND
1.1 Introduction
Chapter One provides an introduction to the research that has been undertaken and provides
an overview of the contextual background in which this thesis is situated. The structure of the
thesis is described and chapter descriptions are provided.
1.2 Positioning of the thesis
This research grew from my interest in the relationship between legislation, policy drivers and
competence requirements for nurses in New Zealand, particularly in relation to the way in
which the legislative requirements related to competence in the Health Practitioners
Competence Assurance Act 2003 (NZ), were translated into practice. The primary purpose of
my research was to evaluate the current regulatory mechanism implemented in New Zealand
to ensure that nurses are competent and fit to practise their profession. In order to situate the
New Zealand findings within the wider international context of nursing regulation, it is
important to understand also the views of international nursing experts. The overarching
questions posed are:
1. What are the relationships between current legislation, policy drivers and the statutory
requirements to ensure registered nurses are competent and fit to practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the international consensus view of regulatory experts in relation to:
a) best practice for nurses to demonstrate continuing competence; and
b) best practice for regulatory authorities to assess continuing competence?
The issues of safety to practise and the monitoring and assessment of continuing competence
in the health professions, including nursing are gathering momentum. The demonstration of
both competence and continuing competence for nurses, have become increasingly important
nationally and internationally. Internationally many nursing regulatory jurisdictions have
developed and implemented Continuing Competence Frameworks in response to national
legislative mandates that require registered health professionals to maintain and demonstrate
their continuing competence throughout their career. The overall purpose of these
3
frameworks is to ensure on-going safe, competent and ethical practice by registered nurses
and in turn protect the public (Australian Nursing and Midwifery Council, 2009; Canadian
Nurses Association, 2000; National Council of State Boards of Nursing, 2009a; Nursing Council
of New Zealand, 2006b).
In September 2008, soon after commencing this doctoral research, the Nursing Council of New
Zealand (the regulatory authority for nursing in New Zealand) put out a public ‘Request for
Proposals’ to examine the efficacy of the Continuing Competence Framework (CCF) for nurses
that had been implemented as a requirement of the Health Practitioners Competence
Assurance Act 2003 (NZ). Recognising the significant similarities between my research, which I
had already commenced for my thesis, and the requirements of the Nursing Council of New
Zealand request for proposals, my doctoral supervisors and I responded to the request for
proposals. Subsequently we were awarded the contract to undertake the evaluation of the
Nursing Council of New Zealand Continuing Competence Framework.
The overarching purpose of this commissioned research was to evaluate the efficacy of the
Nursing Council of New Zealand Continuing Competence Framework in relation to its success
in assuring nurses’ competence in terms of the requirements of the Health Practitioners
Competence Assurance Act 2003 (NZ), and to seek to determine the understanding and
attitudes of New Zealand nurses to these requirements. The five objectives listed below in
Table 1 were those identified by the Nursing Council of New Zealand at the commencement of
this work.
Table 1 Nursing Council of New Zealand evaluation objectives
• Explore the validity of the stipulated hours of professional development and days/hours of practice over a three-year period, as indicators of competence.
• Provide information on the efficacy of undertaking a random audit of five percent of the nursing workforce to meet recertification requirements.
• Document and track the different forms of written evidence that are currently acceptable to the Nursing Council of New Zealand to demonstrate competence.
• Identify issues related to peer assessment of competence.
• Develop a framework to enable the Nursing Council of New Zealand to complete a further evaluation in five years’ time (Nursing Council of New Zealand, 2008).
The Evaluation of the Nursing Council of New Zealand Continuing Competence Framework
contributes significantly to Stage One of my thesis. By undertaking this contracted work my
4
doctoral supervisors and I were fortunate to be provided with access to a wide range of data,
personnel and resources to which, as a doctoral student, I would not normally have been privy.
The contracted component of this work was completed in March 2010 and published by the
Nursing Council of New Zealand in October 2010 (Vernon, Chiarella, Papps, & Dignam, 2010).
Agreement was made at the outset with the Nursing Council of New Zealand to allow me to
use aspects of this contracted work for the purposes of my doctoral thesis, and for the
associated conference presentations and publications listed on pages xiii-xv. In addition my
doctoral supervisors took great care to enable me to lead and undertake large sections of this
contracted work completely independently, thus enabling its substantial contribution to my
final thesis. A matrix demonstrating the contributions of my doctoral supervisors as co-
researchers for the evaluation of the Nursing Council of New Zealand Continuing Competence
Framework is included as Appendix I. Care has been taken throughout this thesis to maintain
the confidentially of the research participants, and to adhere to the agreements made with the
Nursing Council of New Zealand in relation to intellectual property.
To date, little research has been undertaken internationally in the area of nursing regulation
overall and even less in relation to the efficacy of Continuing Competence Frameworks.
International interest from nursing regulatory authorities with regard to the work that was
being undertaken in New Zealand, Stage One – Evaluation of the Nursing Council of New
Zealand Continuing Competence Framework; led me to expand my thesis and develop a
second stage of research, Stage Two – Consensus model for the assessment of continuing
competence.
The findings from Stage One - the evaluation of the Nursing Council of New Zealand Continuing
Competence Framework, contributed to the development of Stage Two - the international
consensus model for the assessment of continuing competence, and assisted in positioning the
New Zealand findings in terms of their international relevance. Stage One also provided the
platform from which to investigate if there were a consensus view amongst regulatory nurse
experts in the following six countries: Australia, Canada, Ireland, New Zealand, the United
Kingdom, and the United States of America.
Table 2 presents a summary of the overarching research questions that were initially posed
and the associated research questions that relate specifically to Stage One and Stage Two of
this research.
5
Table 2 Summary of Research Questions
Overarching Research Questions 1. What are the relationships between current legislation, policy drivers and the statutory
requirements to ensure registered nurses are competent and fit to practise? 2. Is it competence that is being assessed / measured, or safety to practise? 3. What is the international consensus view of regulatory experts in relation to:
a) best practice for nurses to demonstrate continuing competence; and b) best practice regulatory authorities to assess continuing competence?
Research questions - Stage One Evaluation of the Nursing Council of New Zealand Continuing Competence Framework
Research questions – Stage Two Consensus model for the assessment of continuing competence
1. What are the relationships between current legislation, policy drivers and statutory requirements to ensure registered nurses in New Zealand are competent and fit to practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the efficacy of the current Continuing Competence Framework for nurses in New Zealand and does it reflect efficacious best practice?
1. What is the international consensus view of regulatory experts in relation to: a) best practice for nurses to demonstrate
continuing competence; and b) best practice for regulatory authorities to
assess continuing competence? 2. What, if any, differences are present between
the current regulatory requirements for the demonstration and assessment of continuing competence in six identified countries?
3. What changes, if any, would be required to policy and regulation in these six countries to align their regulatory framework with best practice for demonstration and assessment of continuing competence?
1.3 Structure of the thesis
This thesis is presented in four Sections; each Section presenting the chapters pertaining to a
particular aspect of the research process. Figure 1 (p. 6) represents a diagrammatic map of the
overall thesis structure. A summary of each Section and associated Chapter Descriptions is
provided in 1.12 (pp. 18-20).
6
Figure 1 Structure of the Thesis
The following section (1.4) provides a background overview of the national and international
regulatory scene in which this research is situated.
7
1.4 Background
This section will introduce and provide a background to the concept of continuing competence
and its relationship to public safety, in New Zealand and internationally. Continuing
competence has been a regulatory focus of many jurisdictions for over a decade and, in many
cases, is associated with the notion of public protection. The registration requirements in
most resource rich countries contain an expectation that nurses will not only be competent to
practise nursing on registration, but will maintain that competence in respect of their chosen
field or scope of practice, as they develop in their careers and renew their registration
(Chiarella, et al., 2008). However, internationally, the development and implementation of
credible frameworks for the demonstration and assessment of continuing competence is still
acknowledged as being a complex issue (Vandewater, 2004; Vernon, et al., 2010). A key factor
in the successful implementation of such frameworks appears to be related to the ‘legislative
authority’ of the regulatory body (International Council of Nurses, 2009; Vernon, Doole, &
Reed, 2011), in particular the powers that are bestowed to the regulatory authority by
legislation in the jurisdiction in which they function. In addition the conceptualisation of what
constitutes competence, competence assessment, and continuing competence has been
extensively debated (Bryant, 2005; Chiarella, 2006; Chiarella, et al., 2008; Cowan, Norman, &
Coopamah, 2005; Hendry, Lauder, & Roxburgh, 2007; Pearson, Fitzgerald, Walsh, & Borbasi,
2002). Recurring themes include the lack of consensus, the need for flexibility, and the
subjective nature of assessment processes (Vernon, Chiarella, & Papps, 2011; Vernon, et al.,
2010).
New Zealand is no different in this regard and, whilst the nursing profession has been
regulated for over 100 years, the enactment of the Health Practitioners Competence Assurance
Act 2003 (NZ) heralded a significant change in the regulation of all health practitioners,
including nurses (Vernon, Chiarella, et al., 2011). This new legislation brought fifteen health
professional groups under one Act and repealed previous separate statutes relating to
individual regulatory bodies. The principal purpose of the Health Practitioners Competence
Assurance Act 2003 (NZ) is stated as being
to protect the health and safety of members of the public by providing for
mechanisms to ensure that health practitioners are competent and fit to
practise their professions (Health Practitioners Competence Assurance Act
(NZ), 2003, s3).
8
The Health Practitioners Competence Act 2003 (NZ) delegates particular responsibilities to the
named regulatory authorities whose statutory role it is to regulate its practitioners. The
Nursing Council of New Zealand is the regulatory authority established to administer the
legislation in relation to nurses in New Zealand, and among other responsibilities, it establishes
and maintains the standards of education and practice, including continuing competence.
During the first years following implementation of the Health Practitioners Competence Act
2003 (NZ), there was vigorous public debate from some health professional groups with regard
to a perceived loss of their professional regulatory autonomy, and a perceived increase in
political and external government control (Briscoe, 2004). However the purpose of statutory
professional regulation is “to protect the public from harm – physical, mental or financial”
(Ministry of Economic Development (NZ), 2005a, 2005b), and, as such, it is the role of the
regulatory authority to implement and administer mechanisms to ensure the public are safe.
1.5 The purpose of professional regulation
Nurses and indeed other health professionals often misunderstand that the role of the
professional regulatory legislation is protective (Chiarella, 2002; Swankin, 1995). The
legislation, and therefore the institutions, roles and committees created by it, all exist to
protect the public from the risk of harm, rather than to protect the interests of the professions
so regulated (Adrian & Chiarella, 2010). The functions and powers of a regulatory authority
are defined in legislation and establish a form of regulatory regime known as a ‘protective
jurisdiction’ (Staunton & Chiarella, 2008, pp. 213-214). This form of professional regulation
provides:
• a barrier to entry to the professions by untrained persons;
• a mechanism for standards of education and practice to be established and enforced;
• an avenue for consumers to have complaints against practitioners addressed (National
Nursing and Nursing Education Taskforce, 2006).
This need for professional regulation is always a balancing act between public safety and the
risk of exclusionary practices or elitism. In New Zealand the Health Practitioners Competence
Assurance Act 2003 (NZ) was passed by Parliament on 11 September 2003 and received the
Royal Assent on 18 September 2003. The Act came fully into force one year later, on 18
September 2004. In doing so, the Act repealed eleven occupational statutes governing
9
thirteen health professions. The Health Practitioners Competence Assurance Act 2003 (NZ)
specifies the regulatory authorities that are responsible for the registration and oversight of
practitioners in the named health professions. These regulatory authorities are bodies
corporate, legislated for by the Health Practitioners Competence Assurance Act 2003 (NZ).
They have their own staff and premises and are funded by a levy on their professions. There
are now sixteen health professional groups regulated under this Act.
As previously noted, the purpose of the Health Practitioners Competence Assurance Act 2003
(NZ) is to protect the health and safety of the public; the responsible authorities1 fulfil this
purpose by ensuring that all health practitioners registered in that profession, are competent
in the practice of their profession. While in New Zealand the Minister of Health appoints the
members of all the regulatory authorities, there is a power in the Health Practitioners
Competence Assurance Act 2003 (NZ) for the Minister to make regulations so that a proportion
of the health professional members of an authority may be appointed according to elections
held among the profession. These provisions relating to elections have been enacted in New
Zealand with respect to two regulatory authorities; the Nursing Council and the Medical
Council.
1.6 Health Practitioners Competence Assurance Act 2003 (NZ)
The Health Practitioners Competence Assurance Act 2003 (NZ) names the regulatory
authorities, stipulates their legislative functions and related requirements, and affords them
individual discretion in relation to setting standards of professional competence, fitness to
practise and quality assurance (Vernon, Chiarella, et al., 2011). As previously noted, the
purpose of professional regulation in statute is “to protect the public from harm – physical,
mental or financial” (Ministry of Economic Development (NZ), 2005a), as such the Health
Practitioners Competence Assurance Act 2003 (NZ) affords regulatory authorities significant
power in relation to professional competence and requires them “to set standards of clinical
competence, cultural competence, and ethical conduct to be observed by health practitioners
of the profession” (Health Practitioners Competence Assurance Act (NZ), 2003, s118). These
1 The authority appointed in respect of the profession, the regulatory authority.
10
three standards are translated into the cornerstones of health professional education and are
afforded equal significance under the Act.
The Health Practitioners Competence Assurance Act 2003 (NZ) also stipulates that the
regulatory authority is responsible for the on-going assessment and monitoring of competence
throughout the professional’s career in practice. This does not remove the onus of
responsibility from the individual nurse to ensure they are, and continue to be, safe and
competent practitioners. However, at the time of its inception, it did provide the Nursing
Council of New Zealand, the regulatory authority for nurses in New Zealand since 1971, with
the opportunity to implement a mandatory process for the monitoring, assessment and
demonstration of continuing competence (Vernon, et al., 2010).
An additional provision of the Health Practitioners Competence Assurance Act 2003 (NZ) Part 1
s3 is that any health practitioner who is concerned about another health practitioner’s practice
and who considers the standard of practice “may pose a risk of harm to the public” is
mandated to notify the Registrar of the relevant authority (Health Practitioners Competence
Assurance Act (NZ), 2003, s34). On receipt of any complaint an investigation must be
completed. There are also mandatory provisions for both the public and specified health
providers to notify the Registrar about health concerns that may affect a health practitioner’s
ability to practise (Health Practitioners Competence Assurance Act (NZ), 2003, s45). However,
primarily it remains the responsibility of each individual health professional to ensure they are,
and continue to be, a safe practitioner.
Part 2 of the Health Practitioners Competence Assurance Act 2003 (NZ) is specific in terms of
setting out the conditions that a health practitioner is required to meet in order to practise. To
a large extent these conditions relate to the competence, and continuing competence, of
health practitioners and include, but are not limited to, having the qualifications prescribed by
the responsible regulatory authority; being competent to practise within the gazetted scope of
practice; and being ‘fit for registration’, which includes the ability to communicate effectively
for the purpose of practising within the specified scope of practice (Health Practitioners
Competence Assurance Act (NZ), 2003).
Part 3 of the Act provides the mechanisms for “improving the competence of health
practitioners and for protecting the public from health practitioners who practise below the
required standard of competence” (Health Practitioners Competence Assurance Act (NZ),
2003, s4). These mechanisms include provision for competence programmes, competence
11
reviews, recertification programmes, medical examinations and protected quality assurance
activities. This section of the Act contains provisions that allow health practitioners to notify
the regulatory authority if they have reason to believe another health practitioner may “pose a
risk of harm to the public by practising below the required standard of competence” (Health
Practitioners Competence Assurance Act (NZ), 2003, s34). It also enables the regulatory
authority to take any actions that they deem appropriate, to prevent a practitioner, who is
believed to pose a risk of serious “harm to the public by performing below the required
standard of competence” (Health Practitioners Competence Assurance Act (NZ), 2003, s34),
from practising. Part 3 of the Act also mandates the establishment of a single interdisciplinary
tribunal, the Health Practitioners Disciplinary Tribunal. The role of the Health Practitioners
Disciplinary Tribunal is to “hear and determine charges brought against health practitioners by
the Director of Proceedings or by a professional conduct committee” (Health Practitioners
Competence Assurance Act (NZ), 2003, s4). Part 4 of the Act provides for the establishment of
professional conduct committees to investigate offences (including those relating to
competence) made by health practitioners and to investigate complaints referred by the
Health and Disability Commissioner2.
1.7 Legislation and the Nursing Council of New Zealand
The legislation previously regulating the registration of nurses in New Zealand, the Nurses Act
1977 (NZ) and its subsequent amendments, was the last iteration of separate professional
legislation regulating nurses, and had its origins in the Nurses Registration Act 1901 (NZ).
Between 1901 and 1977, there were various changes to this legislation that quite specifically
addressed issues of public safety, but made no reference to competence. Instead, other terms
such as ‘fitness’ and ‘properness’ were used (Burgess, 2008; Papps & Kilpatrick, 2002). These
terms are arguably more associated with the notion of suitability to practise rather than
capability or ability to practise, which is more the focus of competence. Furthermore the
terms “fitness” and “properness” were not clearly defined under the Nurses Act 1977 (NZ), as
they were considered matters for judgment by the Nursing Council of New Zealand (Nurses
Regulations (NZ), 1986, R19(3)). Additionally, on payment of an annual fee, a practising
certificate was issued to each nurse on the register. There was no regulated requirement to
2 The Health and Disability Commissioner is appointed under the Health and Disability Commissioner Act 1994 (NZ).
12
demonstrate continuing competence for the practising certificate to be issued. It was assumed
that, on the basis of being registered, the practitioner was competent to practise.
The Health Practitioners Competence Assurance Act 2003 (NZ) clearly specifies the legislative
functions of the sixteen regulatory authorities, including the Nursing Council of New Zealand.
The statute does not provide a definition of competence, as this is a legislative function
delegated to the regulatory authority. However, as previously noted it does specify the
behaviour, accountability and responsibility required of health practitioners who are deemed
competent by the regulatory authority. The Nursing Council of New Zealand has defined
competence as “the combination of skills, knowledge, attitudes, values and abilities that
underpin effective performance as a nurse” (Nursing Council of New Zealand, 2010b).
Additionally the Health Practitioners Competence Assurance Act 2003 (NZ) s12 requires that
each regulatory authority appointed in respect of a health profession must, “by notice
published in the Gazette, describe the contents of that profession in terms of one or more
scopes of practice” (s12). “Scope of practice” means any health service that forms part of a
health profession described under section 11 of the Act and in relation to a “health
practitioner of that profession” means
One or more of such health services that the practitioner is, under an
authorisation granted under section 21, permitted to perform, subject to any
considerations for the time being imposed by the responsible authority (Health
Practitioners Competence Assurance Act (NZ), 2003, s5).
A scope of practice may be described in any way the regulatory authority sees fit and may be
by reference to a name or words commonly understood by persons who work in the health
sector (Health Practitioners Competence Assurance Act (NZ), 2003, s11). The regulatory
authority is also responsible for setting the standards for each scope of practice and, in doing
so, sets the boundaries in which a practitioner may practise, prescribes the necessary
qualifications and programmes of education required, is responsible for registering and
maintaining the register of practitioners, issues annual practising certificates, and monitors the
continuing competence of registered practitioners. The regulatory authorities have autonomy
in making such decisions as setting scopes of practice or fees. The instruments that give effect
to those decisions are known as ‘regulations’ and are subordinate legislation under the Act.
13
In 2004 the Nursing Council of New Zealand specified and gazetted four scopes of practice,
each with registration and competence requirements - Nurse Assistant, Enrolled Nurse,
Registered Nurse and Nurse Practitioner. In 2010 the Nurse Assistant scope of practice was
incorporated into the Enrolled Nurse scope of practice, thus there are now three registered
scopes of practice for nurses in New Zealand: Enrolled Nurse, Registered Nurse and Nurse
Practitioner. Each scope of practice has its own specified standards, domains and
competencies, which are required to be met on an on-going basis by all nurses registered
under the scope of practice.
The ‘profession specific’ registration authorities have the legal responsibility for monitoring the
educational institutions accredited and approved to provide programmes leading to
registration in a particular scope of practice. All Nurse Assistant, Enrolled Nurse, Bachelor of
Nursing, Master of Nursing (for preparation of Nurse Practitioners), and Competence
Assessment Programmes (CAP) are under the scrutiny of the Nursing Council of New Zealand,
which approves, monitors, and audits all nursing programmes for preparation for entry to the
register of nurses. Currently the Nursing Council of New Zealand also approves and monitors
some nursing programmes at graduate and postgraduate level, which do not lead to
registration in a scope of practice, for example, the Nurse Entry to Practice (NETP)
programmes, and some postgraduate programmes that contribute to the development of
Nurse Practitioner and advanced practice roles.
1.8 Continuing competence in New Zealand
In 2004, following the enactment of the Health Practitioners Competence Assurance Act 2003
(NZ), the Nursing Council of New Zealand established and implemented a Continuing
Competence Framework (Nursing Council of New Zealand, 2004a). Its primary purpose was to
provide mechanisms to ensure that nurses are “competent and fit to practise their profession”
as stipulated in s1 Health Practitioners Competence Assurance Act 2003 (NZ).
This new requirement introduced a significant change to the process for on-going nurse
registration that was neither possible nor necessary prior to the implementation of the new
legislation. Before the introduction of the Health Practitioners Competence Assurance Act
2003 (NZ), the only requirement for a nurse upon renewal of their certification of registration
was that they paid an annual fee and signed the renewal form. There was no requirement to
14
declare competence or to provide evidence of being competent (Papps, 1997; Vernon, et al.,
2010).
The changes following the introduction of the Health Practitioners Competence Assurance Act
2003 (NZ) were significant. The process for the on-going monitoring of the ‘continuing
competence’ of nurses, once registered and in practice is now the responsibility of the Nursing
Council of New Zealand. The Nursing Council of New Zealand now has the authority to decline
to issue an annual practising certificate (APC) if the applicant has, at any time, failed to meet
the required standard of competence, failed to comply with conditions, not completed an
ordered competence programme, or if they have not held an annual practising certificate or
practised for three years preceding application (Health Practitioners Competence Assurance
Act (NZ), 2003). The “required standard of competence” is identified under the Health
Practitioners Competence Assurance Act 2003 (NZ) as “the standard of competence reasonably
to be expected of a health practitioner practising within that health practitioner’s scope of
practice” (s5(1)).
The Nursing Council of New Zealand initially signalled the introduction of competence-based
practising certificates in 1994 with the publication of the ‘Strategic Plan 1st April 1994 to 31st
March 1997’. This, and further review of the historical progress of competence-based practice
in New Zealand, will be discussed in Chapter Four. However, it should be noted that the
original concept of the Nursing Council of New Zealand in 1994 varied from the Continuing
Competence Framework actually implemented by the Nursing Council of New Zealand in 2004
(Nursing Council of New Zealand, 2004a), which specified three indicators of continuing
competence. The original framework also specified the requirement for nurses to maintain a
personal professional profile and make a self-declaration of competence annually on
application for recertification.
The three current Nursing Council of New Zealand requirements for the Continuing
Competence Framework are:
A Evidence of on-going professional practice,
• Nursing practice is using nursing knowledge in a direct relationship with clients or
working in nursing management nursing administration, nursing education, nursing
research, nursing professional advice or nursing policy development roles, which
impact on public safety (minimum of 60 days or 450 hours within the last three
years).
15
B Evidence of on-going professional development,
• On-going education (minimum of 60 hours in the last three years, relevant to work
environment and practice as a nurse).
C Evidence of meeting the Council’s competencies for the “nurse” scope of practice,
• Self-declaration that states the individual meets the Council's competencies for
their scope of practice i.e. Registered Nurse, applied to the area or context in which
you practise (Nursing Council of New Zealand, 2006a).
The Nursing Council of New Zealand annually calls to audit, a random selection of 5% of the
nurses identified as ‘practice active’ on the register. In addition the Nursing Council of New
Zealand may call to audit any nurse who may be indicated as not meeting the continuing
competence requirements.
1.9 Professional development and recognition programmes (PDRP)
A point of confusion amongst nurses in the outcomes of Stage One of this research has been
the relationship of the Continuing Competence Framework, developed by the Nursing Council
of New Zealand, to the Framework for Professional Development and Recognition
Programmes, developed by the National Nursing Organisation (NNO)3 group. For this reason it
is included here in the background to the scheme, as it is an affiliated, although not an integral
system, to the Continuing Competence Framework.
Nationally the Professional Development and Recognition Programmes are offered by health
provider organisations to their nursing staff. These programmes have been approved and
audited by the Nursing Council of New Zealand, thus meeting a minimum set of continuing
competence standards. These programmes, whilst not leading to entry to the register, are
approved by the Nursing Council of New Zealand because they are a means of monitoring the
continuing competence of nurses within the approved health provider organisation. Following
the implementation of the Continuing Competence Framework (Nursing Council of New
Zealand, 2004a) the Nursing Council of New Zealand implemented guidelines for the approval
3 The National Nursing Organisation (NNO) group includes the Chief Nurse (MOH), Nurse Executives of New Zealand, New Zealand Nurses Organisation, Nurse Educators in the Tertiary Sector, college of Nurses (Aotearoa), Council of Maori Nurses, Nursing Council of New Zealand, Samoan Nurses’ Association, Australian and New Zealand College of mental Health Nurses and the College of Midwives.
16
of Professional Development and Recognition Programmes (PDRP) (Nursing Council of New
Zealand, 2004b). The National Framework for Nursing Professional Development and
Recognition Programmes and Designated Role Titles (2004) is the template for the
development of Professional Development and Recognition Programmes in New Zealand and
was developed by the National Nursing Organisation group as a tool that enables career
development of nurses.
Nurses that are identified as participating in a Professional Development and Recognition
Programme that has been approved by the Nursing Council of New Zealand, are then exempt
from the Nursing Council of New Zealand continuing competence audit process (Gunn et al.,
2009; Nursing Council of New Zealand, 2004b). It is not mandatory for employers to participate
in or administer a Professional Development and Recognition Programme. Nor is it a
requirement, in many employment situations, that nurses participate in a Professional
Development and Recognition Programme (Brinkman 2007). However, in addition to the tool
being used to monitor the continuing competence of nurses in some organisations, it has been
attached to salary increments, and is a component of Multi-Employer Collective Agreements
(MECAs)4.
1.10 Continuing competence in the international context
Continuing competence and public safety have been a focus of the International Council of
Nurses (ICN) and many regulatory jurisdictions internationally for over a decade. Regulatory
authorities in a number of countries make reference to “their duty to protect the public”
(Cutcliffe, 2010, p. 1343) and the relationship between continuing competence and safety to
practise (Bryant, 2005; International Council of Nurses, 2009). Implementation of credible
frameworks for the demonstration and assessment of continuing competence is acknowledged
as being a complex issue. It is also acknowledged that Continuing Competence Frameworks
are quality improvement tools that have a role in assisting regulators to guide and monitor the
continuing competence of the profession (Bryant, 2005; Canadian Nurses Association, 2000;
National Council of State Boards of Nursing, 2009a; Nursing and Midwifery Council (UK), 2011;
Nursing Council of New Zealand, 2006b).
4 Employment contracts between District Health Boards in New Zealand and the New Zealand Nurses Organisation (professional organisation and union representing the nurses).
17
Internationally a number of nursing regulatory jurisdictions have implemented continuing
competence models. However, over the past decade extensive debate has continued to occur
with regard to the efficacy of Continuing Competence Frameworks and, in particular the
purpose they have in terms of ensuring the safety to practise of health professionals. Issues
such as the validity and reliability of the competence indicators, and the financial viability and
administrative feasibility of these frameworks continue to be raised. To date no consensus
had been reached with regard to the most appropriate and efficacious model for regulatory
authorities to implement, in order to assess and monitor appropriately, the continuing
competence of the profession.
1.11 The impact of undertaking this work on my professional career
In the political climate where the health workforce is a matter of major concern, the regulation
of health professionals, in this case nurses, has become the subject of intense political scrutiny
and fast moving intervention. This has meant that my supervisors and I have had to move
quickly and be able to capitalise on opportunities made available to us in this political
environment. As a result, the design of my thesis has adapted according to the opportunities
and changing political context, and has therefore taken some paths that were not envisaged at
the commencement of the thesis. I believe that these opportunities have had a positive
impact on my final thesis. In fact, it would be fair to say that this work has had a beneficial
impact on my career, my personal and professional development.
I have held a variety of clinical leadership and management positions in the New Zealand
health sector and in nursing education during the past twenty years, and throughout this
journey I have become increasingly interested in the standards required for nursing education
and practice and the associated regulatory mechanisms required to protect the public. It was
primarily my interest in the latter that led me to undertake my doctoral studies.
Throughout my studies I have continued to develop my research platform with a particular
focus on nursing regulation and continuing competence. During this time I am privileged to
have been awarded a Fulbright Scholarship, and to have had the opportunity to work closely
with some inspirational nurse leaders, including my doctoral supervisors. I have presented my
research at a number of national and international conferences and have co-published with my
doctoral supervisors. A list of these research outcomes is provided (pp. xiii-xv).
18
1.12 Section and Chapter Descriptions
1.12.1 Section One introduces and positions the thesis and is divided into three chapters.
Chapter One has provided the introduction and the contextual background in
which the study is situated and presented the thesis structure and chapter
descriptions.
Chapter Two presents a review of national and international literature relating
to the development, implementation and assessment of continuing competence
models and frameworks. A brief summary of the current regulatory practices
relating to the continuing competence of requirements for nurses, in the six
countries identified as participants in this research (Australia, Canada, Ireland,
New Zealand, the United Kingdom, and the United States of America) is
provided. The conceptualisation of competence, continuing competence,
competence assessment and the validity and reliability of competence
indicators, in as much as these relate to public safety, is examined and key
findings are presented. The literature will also be used to inform the key
research outcomes in Chapters Seven, Nine and Ten.
Chapter Three sets out the overarching theoretical framework, research
perspective, and method used to undertake this research including a
justification for the research design, methods and the ethical considerations
taken. The detailed methods associated with the data collection and analyses,
for each of the two Stages of this research are presented sequentially in Section
Two and Section Three of the thesis.
1.12.2 Section Two presents Stage One of the research; the Evaluation of the Nursing Council
of New Zealand Continuing Competence Framework which was completed in three phases as
depicted in Figure 2 (p. 55). As previously noted, aspects of this thesis were completed under
contract to the Nursing Council of New Zealand to evaluate the efficacy of the Continuing
Competence Framework, which was implemented by the Nursing Council of New Zealand in
2004 following enactment of the Health Practitioners Competence Assurance Act 2003 (NZ).
Chapter Four presents the findings of Phase One of the evaluations of the
Nursing Council of New Zealand Continuing Competence Framework and
19
provides an overview of the legislative history governing the regulation of the
nursing profession in New Zealand. The collated findings derived from the
document review and policy analysis of Nursing Council of New Zealand
documents leading up to and following implementation of the Health
Practitioners Competence Assurance Act (NZ) 2003 are presented.
Chapter Five presents the findings of Phase Two of the evaluation, the
interviews with key nurse stakeholders.
Chapter Six presents the findings of Phase Three, the e-survey of New Zealand
nurses active on the Nursing Council of New Zealand register.
Chapter Seven provides a triangulation of the cumulative data from Phase One,
Two and Three addressing the project outcomes identified by the Nursing
Council of New Zealand and providing a summary of key research findings to
inform the second Stage of this research.
1.12.3 Section Three presents Stage Two; The consensus model for the assessment of
continuing competence. The international component of this thesis draws on the findings of
Stage One, and in particular the evaluation of the Nursing Council of New Zealand Continuing
Competence Framework. Findings from Stage One assisted to position the research in terms
of its international relevance and transferability, providing a platform from which to evaluate
the possibility of developing an international consensus model for the assessment of
continuing competence.
Chapter Eight provides an overview of the Delphi processes that were
undertaken and presents the analysis of the findings that emerged from the first
three Delphi rounds. A summary of the consensus views and the key principles
derived from the Delphi rounds (one-three) are presented.
Chapter Nine presents and discusses the analysis of the Delphi Round Four
participant responses and provides a summary of the overall consensus views in
relation to the three research questions, and in association with the
contemporary literature. Recommendations for the development of a best
practice international consensus model for the assessment of continuing
competence are proposed.
20
1.12.4 Section Four focuses on positioning the thesis in terms of the New Zealand and
international nursing regulatory environment.
Chapter Ten presents the triangulation of the cumulative findings from Stages
One and Two of the research in relation to the three overarching research
questions:
1. What are the relationships between current legislation, policy drivers and the
statutory requirements to ensure registered nurses are competent and fit to
practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the international consensus view of regulatory experts in relation to:
a) best practice for nurses to demonstrate continuing competence; and
b) best practice for regulatory authorities to assess continuing competence?
A discussion of the findings and the limitations of this thesis are presented,
including recommendations for future development of the best practice
consensus model for the assessment of continuing competence, the associated
implications for key stakeholders, and recommendations for policy change.
1.13 Concluding remarks
This chapter has provided an introduction and background to the thesis. The thesis structure
has been described and presented in association with the Section and Chapter descriptions.
Chapter Two will provide a summary of the contemporary literature in relation to the concept
of continuing competence, understandings of competence frameworks, validity and reliability
of assessment processes, and the relationship of legislation, regulatory authorities, and public
safety, to models of continuing competence.
21
CHAPTER TWO - LITERATURE REVIEW
2.1 Introduction
This chapter reviews and summarises national and international literature relating to the
development and implementation of Continuing Competence Frameworks. A brief summary
of the current regulatory practices relating to the continuing competence of requirements for
nurses, in the six countries identified as participants in this research (Australia, Canada,
Ireland, New Zealand, the United Kingdom, and the United States of America is provided). The
conceptualisation of competence, continuing competence, competence assessment and the
validity and reliability of competence indicators, in as much as these relate to public safety, will
be examined. Key findings are summarised and presented at the conclusion of this chapter.
2.2 Search strategy
An extensive search of national and international literature relating to nursing, and health
professional disciplines was completed using the following search engines and data bases –
CINAHL, Google, ProQuest, and Ovid. In addition, the websites of nursing regulatory
authorities in New Zealand, Australia, Canada, Ireland, the United Kingdom and the United
States of America were searched. The International Council of Nurses and nursing regulatory
authorities and / or professional organisations in Australia, Canada, Ireland, the United
Kingdom, the United States of America and New Zealand were contacted directly by email,
telephone and/or face-to-face to ascertain and discuss the ‘continuing competence models’
currently being used in each jurisdiction.
The key search terms were – nursing regulation, competence, nurse competence,
continuing[ed]5 competence, competence frameworks, competence indicators, continuing[ed]
professional development, continuing[ed] nursing education, competence indicators, and
recency of practice. These words and terms were searched for in combination and
individually. Publication in the English language was an additional search criterion.
Of particular note to this literature review were eight important international reviews related
to nursing regulation and continuing competence in nursing completed between, 2000 and
5 The terms ‘continuing competence’ and ‘continued competence’ appear to be synonymous, and are frequently used interchangeably in the literature. For the purpose of this research the term continuing competence will be used.
22
2012 (Australian Nursing and Midwifery Council, 2007; Bryant, 2005; Canadian Nurses
Association, 2000; Chiarella, et al., 2008; EdCaN, 2008; Fitzgerald, Walsh, & McCutcheon, 2001;
International Council of Nurses, 2009; National Council of State Boards of Nursing, 2009a;
Vandewater, 2004).
2.3 Background – national and international regulatory context
Nationally and internationally the understandings of competence, and continuing competence
have been extensively debated (Bryant, 2005; Chiarella, 2006; Chiarella, et al., 2008; Cowan, et
al., 2005; EdCaN, 2008; Hendry, et al., 2007; Pearson, Fitzgerald, Walsh, et al., 2002; Vernon, et
al., 2010). This is particularly evident when reviewing the international literature published in
the period from 1995 to 2010. During this time, work was undertaken worldwide by the
various groups including the International Council of Nurses, nursing regulatory authorities and
professional nursing organisations in an attempt to define and understand the concept of
continuing competence, how it can be measured, and its relationship to public protection
(Australian Nursing and Midwifery Council, 2007; Brunke, 1997; Bryant, 2005; Campbell &
MacKay, 2001; Canadian Nurses Association, 2000; Nursing and Midwifery Council (UK), 2011;
Nursing Council of New Zealand, 1999; Pearson et al., 1999; Swankin, 1995).
Traditionally the system for regulating health professionals, once qualified and deemed fit to
practise, was that the relevant regulatory authority placed their name on the professional
register, where it remained for the period of their life unless a serious reason for removal was
proven. Members of the profession and public trusted that registrants continued to be fit to
practise throughout their careers (Secretary of State for Health (UK), 2007). Swankin (1995)
reports that in 1995 the Citizen Advocacy Centre (USA) asked the question “Can the public be
confident that health care professionals who demonstrated minimum levels of competence
when they earned their licenses continue to be competent years and decades after they have
been in practice?” (Swankin, Arnold LeBuhn, & Morrison, 2006, p. 3). Whilst there is general
agreement that the “purpose of assuring the continuing competence of nurses, is the
protection of the public” (International Council of Nurses, 2006, p. 1) and this is the reason
regulatory authorities exist, the ultimate responsibility and accountability to continue to be
competent lies with the individual health professional (Canadian Nurses Association &
Canadian Association of Schools of Nursing, 2004; National Council of State Boards of Nursing,
2005; Nursing Council of New Zealand, 2006b). However, assuring the continued competence
of health professionals is still an item of debate that continues to receive attention as
23
consumers of health care have greater access to information, and are more questioning of the
services that they receive (International Council of Nurses, 2006). Health professionals no
longer work in an environment where trust alone is proof of continuing competence. The
public expectation is that any trust that is bestowed is underpinned by objective assurance
(Secretary of State for Health (UK), 2007). How to assure the continuing competence of health
professionals is at the core of this international debate.
As previously noted, the regulatory requirements in the jurisdictions of most countries contain
an expectation that nurses will be competent to practise nursing on registration, and that they
will maintain their competence to practise throughout their nursing careers (Chiarella, et al.,
2008). In addition the regulatory authorities within many of these countries also have a legal
mandate to ensure professional competence (Vandewater, 2004) and assure public safety.
An international comparative study was undertaken in 2009 by the International Council of
Nurses (International Council of Nurses, 2009) focusing on the role and identity of the
regulator. An aspect of this study examined the legislation and continuing competence
requirements of the 172 participant nursing jurisdictions. The study reported that 59% of the
jurisdictions specified requirements for ongoing registration and relicensure including
demonstrated hours of practice, continuing education and /or continuing competence. The
report noted that the requirement to provide evidence of hours of practice for ongoing
relicensure was significantly higher within the United States of America (65%) and Canada
(78%) than in other participant countries. Continuing professional development (hours and
education credits) were also requirements within these two regions and also in African
countries. Continuing competence requirements were identified in the African, Australian
[New Zealand was included in this grouping] and Canadian jurisdictions (International Council
of Nurses, 2009).
In 46% (n = 49) of the nursing jurisdictions, continuing professional development was required
by legislation. Practice hours were required by legislation in 38% (n = 41) of jurisdictions and
continuing competence was required by legislation in 47% (n = 50) of jurisdictions. Audit of a
registrant’s compliance with the continuing competence requirements was identified as being
required in only 18% (n = 19) jurisdictions. Frequency of recertification / relicensure / renewal
processes ranged from annually to every six years (International Council of Nurses, 2009, p.
19). Of note is that ongoing relicensure and/or continuing competence requirements were
more evident in the legislation in jurisdictions in the United States of America, Canada, and
Australia where legal challenges are far more prevalent. In other jurisdictions, such as the
24
United Kingdom, the primary legislation is silent; however provision for continuing
competence is located in subordinate legislation (International Council of Nurses, 2009).
It is acknowledged that the nursing profession is a mobile workforce, nationally and
internationally. The literature indicates that globalisation, rapid technological advances,
changes in the provision of health services and health workforce requirements, have gone
hand-in-hand with nursing workforce challenges including nursing shortages in some
jurisdictions (Cutcliffe, 2010; International Council of Nurses, 2009; Vandewater, 2004). These
factors have increased the need to provide timely, consistent and streamlined regulatory
processes to facilitate the movement of nurses (Cutcliffe, 2010). A number of countries and/or
states or provinces within countries have instituted mutual recognition agreements. An
example of a mutual recognition agreement is the Trans-Tasman Mutual Recognition
Agreement (TTMRA) between Australia and New Zealand (Council of Australian Governments
Committee on Regulatory Reform, 1998), that exists to provide a mechanism for “reducing or
eliminating regulatory impediments to trade in goods and in the movement of skilled
practitioners between Australia and New Zealand” (Council of Australian Governments
Committee on Regulatory Reform, 1998, p. 10). The Nurse Licensure Compact (USA) (National
Council of State Boards of Nursing, 2013c), which was enacted in 2000 to expand the mobility
of nurses within the United States requires them to have one multistate license, with the
ability to practice in their home state and other party states. These agreements provide
reciprocity of equivalent qualifications and are based on the premise that the standards of
education and practice, including competence requirements, are of an equivalent standard
between the regulatory jurisdictions who are party to the agreement. The challenge now
being faced by regulators, is how to equate continuing competence requirements without
producing undue barriers (Cutcliffe, 2010; International Council of Nurses, 2009).
2.3.1 New Zealand
Competency standards have been developed in New Zealand and internationally as a way of
differentiating and standardising the variations in scopes and levels of practice within the
nursing profession (Chiarella, et al., 2008; EdCaN, 2008; International Council of Nurses, 2007;
Vernon, et al., 2010). In New Zealand the implementation of the Health Practitioners
Competence Assurance Act 2003 (NZ) brought with it a major shift in emphasis, and mandated
a greater focus on health practitioners’ competence and continuing[ed] competence (Health
Practitioners Competence Assurance Act (NZ), 2003). With this change in legislation has come
an increased consumer awareness and a focus on public safety (Health and Disability
25
Commissioner Act (NZ), 1994; Vernon, Chiarella, et al., 2011). Prior to this, the system for
regulating health professionals in New Zealand once they had qualified in their respective
discipline, and demonstrated that they were fit to practise, was registration for life. For nurses,
practising certificates were renewed annually on application to the Nursing Council of New
Zealand and by paying a fee (Vernon, Chiarella, et al., 2011; Vernon, et al., 2010), and was not
unlike many of the other regulatory jurisdictions of the time.
As previously noted the Health Practitioners Competence Assurance Act 2003 (NZ) requires the
Nursing Council of New Zealand (the regulatory authority) to set the requirements for
programmes that lead to entry to the register of nurses and also the requirements for, and
monitoring of, the continuing competence of nurses once registered. The Nursing Council of
New Zealand is the product of a protective jurisdiction6 and its Continuing Competence
Framework is a mechanism of recertification that allows nurses to demonstrate annually that
they remain competent and fit to practise. These changes have been the subject of
considerable debate in New Zealand following the introduction of the Continuing Competence
Framework (2004), but the prevailing view of government is that trust alone is insufficient to
guarantee individuals are “competent and fit to practise in their profession”(Health
Practitioners Competence Assurance Act (NZ), 2003, s3). For the large majority of New Zealand
nurses, this mechanism of recertification provides reassurance and reinforcement of their
continued competence and performance. However, for a small minority, it is a mechanism for
identifying noncompliance with the recertification requirements and in some instances
continuing competence issues (Vernon, et al., 2010).
In 2010 the Nursing Council of New Zealand requested the Council for Healthcare Regulatory
Excellence (UK) to undertake a review of the effectiveness of the Nursing Council of New
Zealand governance arrangements, and the conduct, competence and health functions. The
review was carried out in 2012. The review considered that overall the Nursing Council of New
Zealand
has satisfactory governance arrangements and that it generally has effective
processes for handling cases under the conduct, health and competence
procedures, researches appropriate decisions that protect the public and
6 The legislation, and therefore the institutions, roles and committees created by it, all exist to protect the public from the risk of harm, rather than to protect the interests of the professions so regulated (Staunton & Chiarella, 2008).
26
provides a good level of service to those who are involved (Council for
Healthcare Regulatory Excellence, 2012a, p. 3).
The review determined that the Nursing Council of New Zealand has effective processes for
handling conduct, competence and health related cases and thereby fulfils its role of
protecting the public by ensuring that the individual health professionals they regulate are fit
to practise (Council for Healthcare Regulatory Excellence, 2012a).
2.3.2 Australia
During the past decade the Australian Nursing and Midwifery Council (ANMC), the peak
regulatory body in Australia until 2010, undertook a considerable amount of work related to
continuing competence and the assessment of continuing competence (Australian Nursing and
Midwifery Council, 2007, 2009; Chiarella, 2006; Chiarella, et al., 2008). In 2009 the Australian
Nursing and Midwifery Council presented a Continuing Competence Framework (2009) for
nurses that is similar to, and references the Nursing Council of New Zealand Continuing
Competence Framework (Australian Nursing and Midwifery Council, 2009). In October of 2009
the Nursing and Midwifery Board of Australia (the newly formed national regulatory authority
for nurses in Australia) consulted on six mandatory registration standards relating to
registration, continuing competence and licensure.
The Health Practitioner Regulation National Law Act 2009 (Qld) was enacted on the 1 July 2010
and with it, the National Registration and Accreditation Scheme (NRAS) came into force. The
National Scheme amalgamated “eight state and territory jurisdictional registration and
accreditation schemes into one national scheme for fourteen separate health professions”
(Chiarella & White, 2013, p. 3). The introduction of the National Registration and
Accreditation Scheme involved a shift of separate 65 pieces of legislation into one National
Law (Chiarella & White, 2013), the Health Practitioner Regulation National Law Act 2009 (Qld).
National registration of nurses in Australia is now a legislated requirement. The
implementation of the mandatory Continuing Competence Registration Standards (Health
Practitioner Regulation National Law Act (Qld), 2009) took effect at the same time. These
Standards incorporate similar indicators of competence to those found in the Nursing Council
of New Zealand Continuing Competence Framework: self-assessment; practice hours; and
continuing professional development (CPD). However, they provide more comprehensive
detail in terms of their specific requirements, definitions and terminology and are situated in
the primary legislation.
27
2.3.3 Canada
Throughout the Canadian regulatory jurisdictions continuing competence assessment
programs exist and are instituted with either voluntary or mandatory requirements. The
continuing competence programs instituted by Canadian regulatory bodies draw heavily on
the work completed by the Canadian Nurses Association in 2000 – Development of a national
framework for continuing competence programmes for registered nurses (Canadian Nurses
Association, 2000). This document provides an in depth overview of the concept of continuing
competence in nursing, including the advantages, limitations and regulatory considerations, of
nine tools currently in use by nursing regulatory bodies within Canada.
In 2011 the Canadian Council of Registered Nurse Regulators (CCRNR) Incorporated, a national
organisation of registered nurse regulators in Canada, was formed bringing together
representation from all twelve nursing regulatory bodies in Canada:
• College of Registered Nurses of British Columbia
• College and Association of Registered Nurses of Alberta
• Saskatchewan Registered Nurses’ Association
• College of Registered Nurses of Manitoba
• College of Nurses of Ontario
• Ordre des infirmières et infirmiers du Québec
• Nurses Association of New Brunswick
• College of Registered Nurses of Nova Scotia
• Association of Registered Nurses of Newfoundland and Labrador
• Association of Registered Nurses of Prince Edward Island
• Registered Nurses Association of the Northwest Territories and Nunavut
• Yukon Registered Nurses Association (Canadian Council of Registered Nurse Regulators, 2011).
Prior to 2011, the individual Regulatory Boards in each Canadian province and territory, except
for Quebec, belonged to the Canadian Nurses Association (CNA). Introduction of this
incorporated federated model has provided the ability to institute national regulatory
principles, however to date there is not a national Continuing Competence Framework.
The central premise of the continuing competence programmes instituted in Canada is that
the individual nurse has the primary responsibility for demonstrating continued competence
and each Regulatory Board has a legal mandate, through its province’s legislation to ensure
28
professional competence (Canadian Nurses Association & Canadian Association of Schools of
Nursing, 2004; Vandewater, 2004). The regulatory jurisdictions in Australia and New Zealand
also consider that the individual nurse is responsible and accountable for their own continuing
competence. However, in New Zealand the Government, through the legislation (Health
Practitioners Competence Assurance Act (NZ), 2003), also holds the organisations that employ
nurses responsible for enabling competent practice (New Zealand Public Health and Disability
Act (NZ), 2000).
2.3.4 The United States of America
The United States of America and its territories has a federated system of government,
containing the largest number of regulatory bodies and the largest number of nurses
registered / licensed to practice in the world (International Council of Nurses, 2009). The
National Council of State Boards of Nursing (NCSBN) is defined as a
not-for-profit organization whose purpose is to provide an organization through
which Boards of nursing act and counsel together on matters of common
interest and concern affecting the public health, safety and welfare, including
the development of licensing examinations in nursing (National Council of State
Boards of Nursing, 2013a, p. 1).
The National Council of State Boards of Nursing has an important role in: promoting uniformity
of the regulation of nursing practice; collaboratively setting national standards and policy
direction lobbying Federal Government; monitoring trends in public policy, nursing practice
and education; and conducting research on nursing practice issues (National Council of State
Boards of Nursing, 2013a). Although having no authority in terms of specific regulatory
functions, the National Council of State Boards of Nursing has 60 Member Boards. The
member boards are comprised of the Regulatory Boards of nursing in the following
jurisdictions:
• Fifty U.S. states;
• District of Columbia;
• Four United State territories-American Samoa, Guam, Northern Mariana Islands,
and the Virgin Islands;
29
• Four states have two Boards of nursing, one for registered nurses (RNs) and one
for licensed practical/vocational nurses (LPN/VNs): California, Georgia, Louisiana
and West Virginia;
• One state, Nebraska, has both the Board of nursing and the Board for Advanced
Practice Nurses (APRNs) represented (National Council of State Boards of
Nursing, 2013b).
The National Council of State Boards of Nursing has long acknowledged that continued
competence is a critical regulatory issue and has undertaken a substantial amount of work
attempting to establish an economically feasible, valid and reliable tool. In addition nursing
Licensing Boards within the United States jurisdictions are increasingly being challenged to
provide assurance to the public that licensees (nurses) continue to be competent throughout
their careers (National Council of State Boards of Nursing, 2005, 2009a). However, nationally
across the states and territories “there is no agreement on who should be responsible for
continuing competence” (National Council of State Boards of Nursing, 2005, p. 1), nor has
there been consistent implementation of Continuing Competence Frameworks or
requirements for evaluating and ensuring continuing competence (National Council of State
Boards of Nursing, 2009c). A number of individual nursing Regulatory Boards have developed
and implemented comprehensive continuing competence requirements and associated
frameworks, for example the North Carolina Board of Nursing, the Texas Board of Nursing, and
the Washington State Nursing Care Quality Assurance Commission. However, at the other end
of the continuum there are Boards of nursing that still do not require any demonstration of
continuing competence in order for their nurses to gain relicensure.
In the United States of America as early as 1991 the National Council of State Boards of
Nursing was considering the measurement of competence from an empirical and standard
setting perspective. The NCSBN Conceptual Framework for Continued Competence was
published in 1991 (National Council of State Boards of Nursing, 1991). This paper stressed the
importance of the assessment of learning needs and strategies to promote continued
competence. In 1995 the Pew Health Professions Commission7 Task Force on Health Care
Workforce Regulation report Reforming healthcare workforce regulation: Policy consideration
for the 21st century (Taskforce on Health Care Workforce Regulation, 1995) was published.
7 The Pew Health Professions Commission (USA) is a leader in health force policy in the United States of America.
30
This (1995) report advocates the periodic demonstration of competence by health
professionals throughout their careers, and has become a landmark document in the ongoing
‘continuing competence’ debate. The report made ten recommendations, two of which relate
specifically to the continued competence of health professionals in the United States.
Recommendation (3) - States should base their practice acts on demonstrated
initial and continued competence…
Recommendation (7) - States should require each Regulatory Board to develop,
implement and evaluate continuing competency requirements to assure the
continuing competence of regulated health professions (Taskforce on Health
Care Workforce Regulation, 1995, p. ix).
In 1996, in response to the recommendations of the Pew Report (1995) the National Council of
State Boards of Nursing issued the position paper Assuring Competence: A Regulatory
Responsibility. This paper included the following definition of competence “the application of
knowledge and the interpersonal, decision-making, and psychomotor skills expected for the
Nurse’s practice role, within the context of public health, safety and welfare” (National Council
of State Boards of Nursing, 1996). This definition remains current today (National Council of
State Boards of Nursing, 2011, p. 12) and reflects the importance of nurses being able to apply
knowledge, interpersonal skills and decision making within a practice context rather than
purely retaining factual information (National Council of State Boards of Nursing, 2005).
The American Nurses Association Expert Panel (1999) developed and published a summary of
key assumptions relating to continuing competence. These key assumptions are of particular
relevance to the research being undertaken for this thesis:
• Continuing competence is for the protection of the public and advancement of
the profession.
• It is the public’s right to expect competence.
• Competency assurance must be shaped by the profession.
• Assurance of continued competence is a shared responsibility of the profession,
regulatory bodies, employers, and individual nurses.
• Nurses are individually responsible for maintaining competence.
• It is the employers’ responsibility to provide an environment conducive to
competent practice.
31
• Competence is considered in the context of level of expertise, responsibility, and
domains of practice (Whittaker, Carson, & Smolenski, 2000).
An important research project Evaluating the Efficacy of Continuing Education Mandates
(Smith, 2003) was completed for the National Council of State Boards of Nursing in 2003. This
research explored the link between mandatory continuing education for relicensure and the
development of professional competence. A survey was sent to 4000 randomly selected
nurses from the following groups: 2000 licensed practical or vocational nurses, and 2000
registered nurses. This statistically significant study identified that nurses perceived that work
experience, their basic professional education, and mentors / preceptors were stronger
contributors to their professional development than continuing education (Smith, 2003). This
research contributed to the development of the NCSBN Model of Nursing Practice Act and
Model Nursing Administrative Rules adopted by the National Council of State Boards of
Nursing Delegate Assembly8 in 2004, that requires 900 practice hours over the preceding three
year period, rather than specified continuing education (National Council of State Boards of
Nursing, 2005) for relicensure.
2.3.5 Ireland
The Nursing and Midwifery Board of Ireland (Bord Altranais agus Cnáimhseachais na
hÉireann), the Regulatory Board for the nursing profession in Ireland was established by the
Nurses Act 1950 (Ireland). In 1985 the Board was re-constituted and had its functions re-
defined and expanded to operate under the provisions of the Nurses Act 1985 (Ireland). The
Nurses and Midwives Act 2011 (Ireland) was signed into legislation on 21 December 2011,
however to date only Sections 1 and 2 and Part 12 have been enacted. At the present time
the Nursing and Midwifery Board continues to operate under the provisions of the old Nurses
Act, 1985 pending commencement of the various provisions of the new national legislation.
The Nurses Act 1985 (Ireland) is silent on the issue of continuing competence and instead
refers to fitness to practice. Currently the Nursing and Midwifery Board of Ireland do not
require nurses to demonstrate continuing competence. Annual payment of a ‘retention’ fee is
all that is required for nurses and midwives to remain active on the register. However nurses
and midwives are encouraged by the Nursing and Midwifery Board to engage in approved
8 NCSBN Delegate Assembly has representation from all the United States and Territories Regulatory Boards.
32
continuing education programmes. Continuing competence is a regulatory requirement
stipulated in the Nurses and Midwives Act 2011 (Ireland). Development of a Continuing
Competence Framework is a project currently being undertaken by the Planning and
Development Department of the Nursing and Midwifery Board of Ireland and is being trialled
with Nurse Practitioners.
2.3.6 The United Kingdom
Improved regulation has been a theme of government action in the United Kingdom (UK) since
the establishment of the Better Regulation Task Force9 in 1997, whose task it was to advise the
Government on action to reduce unnecessary regulatory and administrative burdens, and
ensure that regulation and its enforcement are proportionate, accountable, consistent,
transparent and targeted” (Better Regulation Task Force, 1997). The Task Force identified five
core principles as a test of whether regulation is fit for purpose:
Proportionality: Regulators should intervene only when necessary. Remedies
should be appropriate to the risk posed, and costs identified and minimised.
Accountability: Regulators should be able to justify decisions and be subject to
public scrutiny.
Consistency: Government rules and standards must be joined up and
implemented fairly.
Transparency: Regulators should be open, and keep regulations simple and
user-friendly.
Targeting: Regulation should be focused on the problem and minimise side
effects (Better Regulation Task Force (UK), 2005, pp. 26-27).
The concept of ‘right-touch’ regulation emerged from the European financial crisis and the
application of the UK Principles of better regulation (Better Regulation Task Force (UK), 2005,
pp. 26-27). It has since been applied to the regulation of health professions, with the addition
in 2009, of a sixth core principle “agile and adaptive” (The House of Commons Regulatory
Reform Committee (UK), 2009, p. 3). It is described as regulation that exists to protect people,
but does not unduly control how they live their lives. It occurs through “laws, regulations and
standards that restrain those who intend ill, those who are careless of the wellbeing of others
9 A quasi-autonomous public body who worked under the oversight of the Department for Business, Enterprise and Regulatory Reform (UK).
33
and those whose greed or incompetence causes harm” (Council for Healthcare Regulatory
Excellence, 2010, p. 4). It is defined as “the minimum regulatory force required to achieve the
desired result” (Council for Healthcare Regulatory Excellence, 2010, p. 4).
A landmark document Trust, Assurance and Safety – The Regulation of Health Professionals in
the 21st Century (Secretary of State for Health (UK), 2007), commonly known as The White
Paper, was presented to the parliament of the United Kingdom by the Secretary of State for
Health in 2007. This document outlines a programme of reform for the regulation of health
professionals in the United Kingdom and draws on the findings of two previous reviews of
professional regulation Good doctors, safer patients (Chief Medical Officer of Health (UK),
2006) and The regulation of the non-medical healthcare professions (Department of Health
(UK), 2006). The report presents a proposed programme of reform for the regulation of health
professionals in the United Kingdom. An important aspect of this paper is the proposal to
ensure that all statutorily regulated health professions have as part of their revalidation, a
requirement to demonstrate their continued fitness to practise, and for employees of an
approved body, for example nurses working in a National Health Service organisation,
evidence to support revalidation will be provided by the employer to the regulatory Council
(Secretary of State for Health (UK), 2007). The report proposes that for the majority of health
professionals, revalidation provides reassurance and reinforcement of performance and
encourages improvement. However for a minority of health professionals revalidation
provides a way of identifying problems and an opportunity to address them (Secretary of State
for Health (UK), 2007).
As previously noted the legislation that governs nurses and midwives in the United Kingdom,
the Nurses, Midwives and Health Visitors Act 1997 (UK) is silent with regard to continuing
competence requirements. However, The Nursing and Midwifery Order 2001 (UK) Part V s21
clearly stipulates the Nursing and Midwifery Council’s functions in respect of “fitness to
practise, ethics and other matters” (The Nursing and Midwifery Order 2001 (UK) 2001, p. 13).
For over 20 years the Nursing and Midwifery Council (NMC) has had in place the Post-
registration Education and Practice (Prep) model. This model is designed to assist nurses and
midwives to provide a high standard of practice and care and is comprised of the Nursing and
Midwifery Council standards and guidelines (Nursing and Midwifery Council (UK), 2011) in
association with The code: Standards of conduct, performance and ethics for nurses and
midwives (Nursing and Midwifery Council (UK), 2008). Aspects of the Prep model contributed
34
to the development of the Continuing Competence Frameworks in Canada (Canadian Nurses
Association, 2000) and New Zealand (Nursing Council of New Zealand, 1999) in the late 1990s.
The Prep Handbook - A post-registration ongoing education and practice resource for nurses,
midwives and specialist community public health nurses (Nursing and Midwifery Council (UK),
2011) specifies the “professional standards” (Nursing and Midwifery Council (UK), 2011, p. 4)
required of nurses who are applying to renew their registration. The Prep Practice Standard
requires that nurses complete a minimum of 450 hours of nursing or midwifery practice; and
the Prep Continuing Professional Development Standard requires completion of a minimum of
35 hours of learning activity (relevant to practice) in the three years prior to renewal of
registration, or the successful completion of a return to practice course (Nursing and
Midwifery Council (UK), 2011). In addition, a nurse or midwife must keep a record of all
continuing professional development undertaken in the three years prior to renewal of
registration and comply with any request from the Nursing and Midwifery Council to audit
these requirements (Nursing and Midwifery Council (UK), 2011). Whilst an annual registration
fee is paid, renewal of registration is only required every three years. Since April 2000 nurses
have been required to declare on the ‘notification of practice (NoP) form’ that they have met
these standards.
Despite the recommendations of the White Paper (2007), the Nursing and Midwifery Council
Prep requirements, and the previous United Kingdom Central Council for Nursing, Midwifery
and Health Visiting (UKCC) Fitness for Practice Review (1999), concerns continued to be raised
about skill deficits and lack of national approaches to competence assessment (National
Nursing Research Unit, 2009). In 2012 the Council for Healthcare Regulatory Excellence was
commissioned by the government of the United Kingdom (UK) to undertake a strategic review
of the Nursing and Midwifery Council (UK) following criticisms about its performance, including
a failure to deal with a longstanding backlog of fitness to practise cases (Council for Healthcare
Regulatory Excellence, 2012b). The report findings stated
A regulator is charged with two key responsibilities: to protect the public and to
uphold public confidence. In the NMC’s [Nursing and Midwifery Council] case, this
means to uphold confidence in the practice of nurses and midwives. The NMC has
continued to carry out its public protection duties, although not as well as it
should but, as its stakeholders make clear, it is not inspiring confidence in the
professions or in professional regulation (Council for Healthcare Regulatory
Excellence, 2012b, p. 3).
35
In response to the findings of the Strategic review of the Nursing and Midwifery Council
(Council for Healthcare Regulatory Excellence, 2012b) and building on the recommendations of
The White Paper (2007), the Nursing and Midwifery Council is currently undertaking a
substantial review of their continuing competence requirements and systems for revalidation
of nurses and midwives. The Nursing and Midwifery Council states that the aim of this review
is to “deliver a proportionate, risk-based and affordable system that will provide greater public
confidence in the professionals regulated by the NMC” (Nursing and Midwifery Council (UK),
2012, p. 1). This work is not anticipated to be completed before 2015.
A summary of the current continuing competence requirements for nurses across the six
countries that are identified as the primary focus of this research (Australia, Canada, Ireland,
New Zealand, the United Kingdom, and the United States of America) are presented in Table 3.
Table 3 Continuing competence requirements for nurses across six countries
Australia Nursing and Midwifery Board of Australia (National Legislation, and National Framework)
Revalidation of registration annually • Maintain a professional portfolio • Formal self-declaration of competence annually • Practice – must have practised in previous 5 years or completed
return to practice programme – statutory declaration from individual or employer indicating hours spent in practice
• Continuing Professional Development (CPD) minimum of 20 hours annually
*Percentage of nurses to be audited annually – pilot to be commenced in 2013 National legislation, Health Practitioner Regulation National Law Act 2009 (Qld). Continuing competence is a regulatory requirement stipulated in the Act.
Canada Canadian Council of Registered Nurse Regulators (CCRNR 2011) Incorporated organisation. (Incorporated Federated model - National principles - no National Framework) Prior to CCRNR individual Regulatory Boards in each province and territory except for Quebec belonged to the Canadian Nurses Association (CNA)
Annual revalidation of registration • Self-declaration including self-assessment • Continuing education (CE) – annual requirements
o Report of CE activities and evaluation of learning needs o Development of a learning plan, report on previous plan o Peer feedback / review meetings
• Practice – minimum of 1,125 hours in previous 5 years *Requirements vary between the legislative jurisdictions - General principles of the CNA implemented in each province *No Audit % stated Separate legislation by Province i.e. Health Professions Act 2009(BC). Continuing competence is a regulatory requirement stipulated in the Act.
36
Ireland Nursing and Midwifery Board of Ireland (Bord Altranais agus Cnáimhseachais na hÉireann)
Annual payment of a ‘retention’ fee to remain on the register of Nurses and / or Midwives Currently no mandated or formally monitored continuing competence requirements – identified as a current project - framework being trialled with Nurse Practitioners *No audit requirements National legislation, Nurses and Midwives Act 2011 (Ireland) signed into legislation 21 December 2011. Continuing competence is a regulatory requirement stipulated in the Act.
New Zealand Nursing Council of New Zealand (NCNZ) (National Framework)
Annual recertification of practising certificate • maintain a professional portfolio • Self-declaration (self-assessment against practice standards,
domains and competencies) o Practice - minimum of 450 hours (60 days) in previous 3 years o Professional Development minimum of 60 hours in previous 3
years o Physically and mentally able to perform in the role of a nurse
*5% Nurses audited Annually National legislation, Health Practitioners Competence Assurance Act 2003 (NZ). Continuing competence is a regulatory requirement stipulated in the Act.
United Kingdom Nursing and Midwifery Council (NMC) (National Framework)
Renewal of registration every 3 years (certification of practise). Annual fee Maintain professional portfolio • Self-declaration – complied with all Prep standards and signed
notification of practice or intent to practice o Prep practice standard - minimum of 450 hours in previous 3
years or undertaken approved return to practice programme o Prep Continuing Professional Development (CPD) standard -
in previous 3 years *No Audit % stated – Risk based approach One regulatory council (NMC) National legislation, The Nursing and Midwifery Order, 2001 (UK), but separate legislative jurisdictions in each country i.e. Scotland, Northern Ireland, Wales, England, Guernsey, Jersey, Isle of Man, Gibraltar, Falkland Islands etc.
United States of America National Council of State Boards of Nursing (NCSBN, Council of regulators - Incorporated Federal Model) (National Principles, and recommendations for a national framework – project on going) Individual Regulatory Boards in each State with variation in terms of requirements
Annual revalidation of registration – models vary significantly between States. Indicators include • Self-declaration, including self-assessment of competence • Declaration of criminal convictions, physical, mental, and drug
related issues that affect the ability to provide safe effective nursing care.
• Continuing Education credits • Practice hours *Audit requirements exist in some States – Risk based approach in some others Separate legislative jurisdictions and Regulatory Boards in each State and Territory. Mutual recognition agreements exist between some States. Continuing competence requirements vary between States and Territories, from comprehensive frameworks to payment of an annual revalidation fee.
37
2.4 Competence and continuing competence
The need for continuing competence is agreed by regulatory authorities to be necessary to
protect the public (Vernon, Chiarella, et al., 2011). Given the multifaceted nature of nursing
practice and the diversity of practice settings, it is evident that the role and context in which
the nurse practises are also critical considerations when assessing continuing competence
(Vernon, et al., 2010). Competency is described by Girot (1993) as the ability to perform and
the integration of cognitive, affective and psychomotor skills, whereas Nolan (1998) proposes
that competency equates to performance, and competence is the capacity of the individual to
perform the functions required in his/her role. Definitions of competence and continuing
competence within legislation and nursing regulatory authorities have strong similarities as
demonstrated by the definitions that follow.
The Nursing Council of New Zealand defines competence as
the combination of skills, knowledge, attitudes, values and abilities that underpin
effective performance as a nurse (Nursing Council of New Zealand, 2010b).
However, in order to determine whether a nurse has maintained the required standard of
continuing competence, and acknowledging that continuing competence occurs within a
practice context, the Nursing Council of New Zealand has defined nursing practice as
using nursing knowledge in a direct relationship with clients or working in
nursing management, nursing administration, nursing education, nursing
research, nursing professional advice or nursing policy development roles, which
impact on public safety (Nursing Council of New Zealand, 2010c).
The definitions stated by the Nursing Council of New Zealand reflect the principles articulated
by the International Council of Nurses (Bryant, 2005), and is consistent with other international
definitions, including the National Nursing and Midwifery Board of Australia, the National
Council of the State Boards of Nursing and the Canadian Nurses Association.
In 2009 the Australian Nursing and Midwifery Council developed and published the ANMC
Continuing Competence Framework. Included in the framework is a glossary of terms.
Competence is defined as
the combination of skills, knowledge, attitudes, values and abilities that
underpin effective and / or superior performance in a profession/occupational
38
area and context of practice (Australian Nursing and Midwifery Council, 2009, p.
11)10.
Continuing competence is defined as
the ability of nurses and midwives to demonstrate that they have maintained
their competence to practise in relation to their context of practice, and the
relevant ANMC competency standards under which they gain and retain their
licence to practise (Australian Nursing and Midwifery Council, 2009, p. 11).
And context of practice is defined as
the conditions that define an individual’s nursing or midwifery practice. These
include the type of practice setting (e.g. healthcare agency, educational
organisation, private practice); the location of the practice setting (e.g. urban,
rural, remote); the characteristics of patients or clients (e.g. health status, age,
learning needs); the focus of nursing or midwifery activities (e.g. health
promotion, research, management); the complexity of practice; the degree to
which practice is autonomous; and the resources which are available, including
access to other healthcare professionals (Australian Nursing and Midwifery
Council, 2009, p. 11).
The National Council of the State Boards of Nursing (USA) has also produced a number of
valuable policy and discussion documents and defines competence as
the application of knowledge and the interpersonal decision-making required for
the practice role, within the context of public health (National Council of State
Boards of Nursing, 2009a).
Similarly the Canadian Nurses Association defines competence as
the ability of a registered nurse to integrate and apply the knowledge, skills,
judgement and personal attributes required to practise safely and ethically in a
designated role and setting (Canadian Nurses Association, 2000).
10 These Nursing and Midwifery Council (NMC) documents were gifted to the Nursing and Midwifery Board of Australia (NMBA) in the transition to the national registration scheme in Australia and after 01/07/2010 are cited as NMBA documents.
39
In 2011 the National Board for Certification of Hospice and Palliative Nurses (USA) Task Force
on Continuing Competence developed a definition of continuing competence that was based
upon the Canadian Nurses Association and Canadian Association of Schools of Nursing
definition (2004) that had previously been endorsed by the International Council of Nurses
(2006). The definition integrates aspects of each of the previously described definitions.
Continuing competence is the ongoing commitment of a registered nurse to
integrate and apply the knowledge, skills, and judgement with the attitudes,
values, and beliefs required to practice safely, effectively, and ethically in a
designated role and setting (Continuing Competence Task Force, 2011, p. 4).
Despite these clear and reasonably consistent definitions of competence there is still
considerable debate, and in some cases a level of confusion, between competence,
performance and continuing competence (Cowan, et al., 2005; Flanagan, Baldwin, & Clarke,
2000; McMullan, 2006). Distinctions between core or initial competence and higher levels of
competence, have contributed to this confusion and is reported frequently in the literature
(EdCaN, 2008; Pearson, Fitzgerald, Walsh, et al., 2002; Torr, 2009; Verma, Paterson, & Medves,
2006; Wilkinson, 2013).
As previously noted in New Zealand, the Nursing Council of New Zealand initially gazetted four
scopes of practice11, however in 2010 an amendment was made and this was reduced to three,
the Nurse Assistant Scope of Practice was subsumed into a new Enrolled Nurse Scope of
Practice. Each scope of practice is clearly defined, each with its own set of registrations
standards and associated competencies. The registration standards and competencies also
form the basis for the development of curricula and assessment tools that include mandated
cultural competence requirements. Whilst the standards for competence at entry to the
register are clearly articulated and relatively well understood, the interpretation by nurses of
what constitutes continued competence is not (Vernon, Chiarella, Papps, & Dignam, 2012).
2.5 Competence frameworks
It has been argued that the principal function of Continuing Competence Frameworks,
implemented by regulatory authorities, is to act as a quality assurance mechanism to ensure
11 Legislated by the Health Practitioners Competence Assurance Act 2003(NZ), Part 2(a) requires “every health practitioner to be registered for a scope of practice” (s3).
40
health professionals are competent in their practice and thereby are able to practice safely
(Australian Nursing and Midwifery Council, 2007; Bryant, 2005; Canadian Nurses Association,
2000; Goodridge, 2007; National Council of State Boards of Nursing, 2009a). Continuing
Competence Frameworks and their associated standards and monitoring activities offer a level
of assurance to health consumers and employers that practitioners are competent whilst
providing a mechanism for identifying those who are not.
These frameworks are identified in the literature as being tools that set the standards for
competence assessment and ensure consistency in the monitoring and on-going assessment of
competence and continuing competence (Australian Nursing and Midwifery Council, 2007;
Bryant, 2005; National Council of State Boards of Nursing, 2009a, 2009c). As such they have a
clear purpose in terms of public protection. However there is on-going debate with regard to
the legitimacy or credibility of Continuing Competence Frameworks within some jurisdictions,
particularly related to their ability to ensure safe and current practice (Cutcliffe, 2010; EdCaN,
2008; International Council of Nurses, 2007; Pearson, 2002). In addition, it has been identified
that the purpose of the framework is also to facilitate career development and promote
lifelong learning, then this must be clearly defined and articulated as it will influence the level
of assessment that is required (Australian Nursing and Midwifery Council, 2007; Campbell &
MacKay, 2001).
It is acknowledged that there are distinctive differences between entry level competence and
continuing competence (Benner, 1984; Chiarella, et al., 2008; Fitzgerald, et al., 2001; Hendry,
et al., 2007; Pearson, Fitzgerald, Walsh, et al., 2002) and that ‘fitness to practise’ goes beyond
mere adequacy of knowledge and skills, and should take account of attitudes and behaviours
in addition to the complexities of nursing practice within the ‘real-world’ context in which it is
occurring (Dolan, 2003; Gibson & Soanes, 2000; National Nursing Research Unit, 2009;
Pearson, Fitzgerald, Walsh, et al., 2002). This point is highlighted when reviewing the various
definitions of competence. However, whilst there is general agreement that Continuing
Competence Frameworks, standards, and assessment criteria should relate to the individual’s
particular scope of practice and area of practice (Bryant, 2005; International Council of Nurses,
2009), consistency of process between jurisdictions does not exist (Vernon, Chiarella, & Papps,
2013).
41
2.6 Professional Standards and competence assessment
Competence assessment of practising nurses is identified as crucial to maintaining professional
standards (McMullan, 2006) and as such has a role in nursing regulation (Chiarella, et al.,
2008). There is agreement that frameworks and indicators for the assessment of continuing
competence, should not only reflect the required standards of practice but also be flexible
enough to relate to the individual’s particular scope and area of practice (Australian Nursing
and Midwifery Council, 2007; International Council of Nurses, 2007). However, in any
competence assessment process the challenge is in ensuring objectivity (Gibson & Soanes,
2000) and identifying competence assessment tools that ensure validity and reliability (EdCaN,
2008; Meretoja, Eriksson, & Leino-Kilpi, 2002; Meretoja, Isoaho, & Leino-Kilpi, 2004; National
Nursing Research Unit, 2009).
It is evident in the literature, that competence assessment of nurses cannot be solely based on
the demonstration of theoretical knowledge or technical skills, but should also involve some
inference about the candidate’s attitudes and professional practice (Canadian Nurses
Association & Canadian Association of Schools of Nursing, 2004; EdCaN, 2008; Nursing and
Midwifery Council (UK), 2011; Vernon, et al., 2010), as it is proposed that there is a direct
relationship between the lack of ‘insight’ of individuals in relation to their expertise and
limitations, and potential or actual unsafe practice (Parsons & Capka, 1997; Pearson, 2002;
Wilkinson, 2013).
While there is general agreement in the literature with regard to the meaning of competence,
confusion exists with regard to what constitutes continuing competence and performance of
competencies (Flanagan, et al., 2000; McMullan, 2006; Wilkinson, 2013). This is particularly
evident in relation to determining what the most appropriate indicators of continuing
competence are, how they should be measured and assessed, and to what level this should
occur, for example is it a minimum standard of competence that is assessed, or is it
competence that meets the required standards of practice and also the requirements of the
individuals role / context of practice. (Cowan, et al., 2005). This lack of consensus increases
the potential for confusion and possibly repetition as nurses attempt to meet the
requirements of a variety of different systems (Storey & Haigh, 2002; Tabari Khomeiran &
Kiger, 2006; Watson, Stimpson, Topping, & Porock, 2002; Wilkinson, 2013). It also highlights a
potential tension between the attainment of academic qualifications and a health
professional’s competence to practise (EdCaN, 2008; Gibson & Soanes, 2000; Pearson, et al.,
1999).
42
Numerous competence assessment tools are identified in the literature (Centre for Innovation
in Professional Health Education and Research, 2007; EdCaN, 2008; Fitzgerald, et al., 2001;
Hendry, et al., 2007; McMullan et al., 2003; Watson, et al., 2002). Many are based on self-
assessment or direct observations by a peer, a mentor, a manager or an assessor, and include
some level of subjectivity (Fitzgerald, et al., 2001). Hence the development of new approaches
that take account of the context in which practice is occurring, and encouragement of inter-
rater reliability is critical (McGrath et al., 2006).
In general, it is agreed that models for assessment of competence should include more than
one competence indicator and assessment method (Australian Nursing and Midwifery Council,
2007; Canadian Nurses Association, 2000; EdCaN, 2008; McGrath, et al., 2006; Pearson,
Fitzgerald, Walsh, et al., 2002; Scott Tilley, 2008). Although there is consensus that
standardised assessment tools can be used to measure technical skills, there is a view that
decision making and behavioural skills require a more complex level of judgement from the
assessor, as they are by nature subjective and difficult to quantify (Davis, Turner, Hicks, &
Tipson, 2008; McGrath, et al., 2006). Pearson et al (2002) caution that, the more subjective in
nature, the more difficult it is to specify a generic criterion for measurement.
Continuing professional development (CPD) is argued to be an important indicator of
competence as it demonstrates that the continuing competence of an individual is relevant to
current nursing practice (Meretoja, et al., 2004). However, the most common indicator of
competence in nursing practice is performance, although there is considerable debate about
the assessment and adequacy of performance as a valid indicator of continuing competence
(EdCaN, 2008; Fitzgerald, et al., 2001; McMullan, 2006). Such debate is concerned with
whether demonstration of a particular skill or activity, in one area or on a particular day, is
indicative of competence in all situations on any given day (Gibson & Soanes, 2000), and
whether competence is directly observable in terms of performance of an activity (McGrath, et
al., 2006; National Nursing Research Unit, 2009).
The literature suggests that observed competent performance of tasks can only be inferred, as
the measurement of underpinning competencies requires evaluation of aspects such as
behaviours, attitudes and insights that are not readily amenable to quantification (National
Nursing Research Unit, 2009). Similar issues have previously been identified in relation to the
assessment of the different levels of nursing practice (Benner, 1984; Calman, Watson, Norman,
Redfern, & Murrells, 2002). Standardisation of nursing practice through the development of
generic competencies that do not take account of the specific context, or the diversity of
43
practice environments, is cautioned against (McGrath, et al., 2006). It is noted that
measurement of competence is a form of regulation that may be limiting if reductionist
approaches are employed, as they may result in restricting or constraining nursing practice
(Pearson, Fitzgerald, Walsh, et al., 2002). In addition failure to achieve competence in post-
registration nursing can have a negative effect on the nurse, the assessor and the profession
(Flanagan, et al., 2000).
2.7 Continuing competence indicators
Whilst there is considerable discussion in the literature with regard to the conceptualisation
and assessment of entry level competence, there are few studies that address the issue of
assessment and validity of competence indicators. The literature suggests that indicators of
continuing competence are not easily defined and go beyond measurement of entry level
skills, and, that a valid inference about continuing competence is not possible using a single
indicator in isolation. Several authors (Australian Nursing and Midwifery Council, 2007;
Campbell & MacKay, 2001; Canadian Nurses Association, 2000; EdCaN, 2008; Fitzgerald, et al.,
2001; Goodridge, 2007; Pearson & Fitzgerald, 2001) have attempted to summarise the most
commonly used indicators of continuing competence.
2.7.1 Self-assessment and self-declaration of competence - Generally this is a process of
self-reflection / assessment by an individual of their practice, set against the relevant
regulatory standards / competencies for practice. Most commonly it involves the individual
signing a self-declaration of competence. It is evident from the literature that whilst the
individual is responsible for their own competence, there is also debate and a level of
confusion about the employers’ responsibility in terms of identifying, facilitating and
supporting continued competence (Australian Nursing and Midwifery Council, 2007; Campbell
& MacKay, 2001; Canadian Nurses Association, 2000; Goodridge, 2007). The main criticism of
self-assessment is that it is subjective in nature and is reliant on the individual’s insight and
ability to assess critically. As such, the assessment may lack validity unless linked with a formal
feedback mechanism that promotes a connection between identified and actual practice
weaknesses and learning needs relevant to the context of practice.
2.7.2 Recency of Practice / Hours of Practice - These terms infer currency of knowledge and
skills, and are quantifiable in terms of assessment of a skill or task and verification of hours of
practice. However, used independently they are not an adequate indicator of continued
44
competence or safety to practise (Australian Nursing and Midwifery Council, 2007; Campbell &
MacKay, 2001; Fitzgerald, et al., 2001).
2.7.3 Continuing Professional Development (CPD) – This is primarily concerned with the
maintenance and updating of professional knowledge and is an indicator which appears in
many Continuing Competence Frameworks (Australian Nursing and Midwifery Council, 2009;
Canadian Nurses Association, 2000; EdCaN, 2008; Fitzgerald, et al., 2001; Nursing and
Midwifery Council, 2008). Continuing professional development is considered to be a valid
indicator of competence as it ensures that the health professional is engaged in learning,
thereby having the potential to improve currency of knowledge, skills, reflective activity,
insight and ultimately safety to practise. However, used independently, there is no evidence
that continuing professional development is a reliable indicator of continuing competence or
safety to practise (Vernon, et al., 2010).
2.7.4 Contribution to the profession – This usually implies participation in research,
committees, policy development, quality assurance programmes, and publication and may
infer involvement in current practice and professional networks but it does not infer
competence or safety to practise (EdCaN, 2008; Fitzgerald, et al., 2001).
2.7.5 Portfolio – This is a tool used to record practice and develop an individual’s reflective
thinking /practice. It is subjective in nature and lacks inter-rater reliability (EdCaN, 2008;
Vandewater, 2004). When used on its own it is not a reliable measure of competence or safety
to practise (Australian Nursing and Midwifery Council, 2007; Canadian Nurses Association,
2000; EdCaN, 2008).
2.7.6 Peer Review – This has been identified as a feasible method of competence
assessment, although it is time consuming for the individual and the reviewer, and can have
issues of inter-rater reliability. It is cautioned that the peer reviewer must have a clear
understanding of the criteria for assessment and the context of practice. There is on-going
debate in the literature as to what constitutes a ‘Peer’. Should a peer reviewer have the same
professional education, qualifications, scope/role of practice, or be a colleague with equal or
higher status from another work area or discipline? (Australian Nursing and Midwifery Council,
2007; Canadian Nurses Association, 2000; Goodridge, 2007; Gopee, 2001). Regardless of the
selected option, the peer review process must produce an auditable trail that demonstrates a
45
valid assessment of competence that would meet requirements of public accountability
(Australian Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000).
2.7.7 Performance appraisal – This generally refers to evaluation of an employee by an
employer / manager is generally undertaken to identify the on-going competence of
employees, to identify learning needs, promotion, and salary increments. Validity and
reliability of performance appraisal is dependent upon the assessment mechanism, tools and
criteria that are used. Used in conjunction with a formal ‘Peer review’ of the individual’s
performance, it may be used to demonstrate continuing competence in practice (Australian
Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000).
2.7.8 Objective Structured Competence Assessment or Evaluation (OSCE) – There is debate
in the literature as to the validity and reliability of simulated clinical skill assessments such as
OSCEs in assessing continuing competence (Canadian Nurses Association, 2000; Fitzgerald, et
al., 2001; Goodridge, 2007). In addition they are resource heavy and the expense of
administering OSCEs is high.
2.7.9 Examination and psychometric testing – In New Zealand and internationally,
examination is commonly used by regulatory authorities as a competence indicator for entry
to the register of nurses. The development of psychometrically sound and legally defensible
examination test banks has occurred over a number of years (Meretoja, et al., 2002;
Vandewater, 2004; Wilkinson, 2013). In the United States of America examination is also
commonly used by the organisations that administer and award nursing education credits.
However, there is no evidence based research to support that examination is an effective
indicator of continuing competence to practise (Fitzgerald, et al., 2001), although examination
does provide a standard form of assessment of, the knowledge and understanding of all
registrants (Vandewater, 2004; Wilkinson, 2013).
2.8 Summary of findings from the literature
2.8.1 Public protection
Within the literature there is general agreement that individual health professionals are
responsible for their continuing competence and that regulatory authorities are responsible
for managing this legislative responsibility within their jurisdiction (International Council of
46
Nurses, 2009; Secretary of State for Health (UK), 2007; Staunton & Chiarella, 2008; Swankin, et
al., 2006). That it is the responsibility of the profession and ultimately the regulatory authority
to determine and implement standards of competence, and codes of conduct and ethical
practice, in order to assure colleagues, employers and the general public that those health
professionals in practice are, and continue to be, competent (International Council of Nurses,
2006, 2009; Secretary of State for Health (UK), 2007).
Increased consumer awareness, technological advances, globalisation and the changing
healthcare environment have contributed to concern raised in relation to public safety,
geographic variations in qualifications, and poor patient outcomes (Health Workforce
Australia, 2012; Secretary of State for Health (UK), 2007; Taskforce on Health Care Workforce
Regulation, 1995).
2.8.2 Competence and continuing competence
The definitions of competence, competencies, and continuing competence have been
extensively debated internationally (Bryant, 2005; Chiarella, 2006; Chiarella, et al., 2008;
Cowan, et al., 2005; EdCaN, 2008; Hendry, et al., 2007; Pearson, Fitzgerald, Walsh, et al., 2002;
Vernon, et al., 2010). Despite clear and reasonably consistent definitions of competence
articulated by a number of nurse regulatory authorities, there is substantial variation in the
conceptualisation of continuing competence and in particular the distinction between core and
higher levels of competence, and the individual behaviours, attitudes and insight of
practitioners. It is acknowledged that there are distinctive differences between entry level
competence and continued competence which move beyond knowledge and skills, and should
take account of the complexities and context in which nursing practice is occurring (Benner,
1984; Chiarella, et al., 2008; Fitzgerald, et al., 2001; Hendry, et al., 2007; Pearson, Fitzgerald,
Walsh, et al., 2002; Vernon, et al., 2010). Given the multifaceted nature of nursing practice
and the diversity of practice settings it is evident that the context in which the nurse practises
is a critical consideration when defining and evaluating continuing competence (Vernon, et al.,
2010).
2.8.3 Continuing Competence Frameworks
The international literature is unequivocal about the importance of Continuing Competence
Frameworks (Australian Nursing and Midwifery Council, 2007; Bryant, 2005; Canadian Nurses
Association, 2000; Chiarella, 2006; EdCaN, 2008; Fitzgerald, et al., 2001; National Council of
47
State Boards of Nursing, 2009a). The registration requirements in the jurisdictions of most
countries contain an expectation that nurses will not only be competent to practise nursing on
registration, but will maintain that competence in respect of their chosen field or scope of
practice as they develop in their careers and renew their registration (Chiarella, et al., 2008;
International Council of Nurses, 2009). Importantly, Continuing Competence Frameworks
demonstrate to the public that the regulatory authority and nursing profession are cognisant
of, and have mechanisms to assess the continued competence of the profession to ensure
public safety. They are tools that have a clear purpose in terms of ‘public protection’, however
the literature suggests that if their purpose is also to promote ‘lifelong learning’ then this must
be clearly articulated (Australian Nursing & Midwifery Council, 2007; Campbell & MacKay,
2001; Goodridge, 2007) as this will influence the level of assessment required.
Competency standards have been developed in New Zealand and internationally as a way of
differentiating and standardising the variations in scopes and levels of practice within the
nursing profession (Chiarella, et al., 2008; International Council of Nurses, 2009; Vernon, et al.,
2010). It is noted that Continuing Competence Frameworks promote consistency of
‘continuing competence’ standards and assessment, and provide a mechanism for the
assessment of competence as a measure of public safety. It is also noted they should be
mandatory for all practising members of the profession, be flexible, have relevance and be
transferable to the differing levels of practice and settings in which nurses practise
(International Council of Nurses, 2007; National Council of State Boards of Nursing, 2009a;
Vernon, et al., 2010).
2.8.4 Communication
The need for clear communication, particularly in relation to the articulation of the purpose of
Continuing Competence Frameworks and competence standards, and how these items relate
to public protection or the relationship between public protection and lifelong learning, is a
common theme within the literature (Flanagan, et al., 2000; Vandewater, 2004). Development
of a common language and lexicon of terms related to continuing competence has been
identified as a communication strategy that assists in the successful implementation of
Continuing Competence Frameworks and understanding of the profession (Canadian Nurses
Association, 2000).
48
2.8.5 Indicators of competence
Self-assessment and self-declaration of competence, peer assessment, recency of practice and
continuing professional development /education are the most commonly used indicators of
continuing competence. Recency of practice and continuing professional development, are
quantifiable indicators (Canadian Nurses Association, 2000; National Council of State Boards of
Nursing, 2009b). However, when used independently they do not infer continuing
competence to practise (EdCaN, 2008; Pearson, et al., 1999; Vernon, et al., 2010). A
combination of competence indicators is recommended as no single indicator used
independently can infer continuing competence or safety to practise (Canadian Nurses
Association, 2000). Valid measurement of indicators which are subjective in nature is difficult.
However, inter-rater reliability is a critical component of this assessment process (EdCaN,
2008; Wilkinson, 2013).
2.8.6 Assessment methods
It is evident in the literature that a variety of assessment methods and tools should be
available, and that assessment tools should be ‘user friendly’ and able to related to the
individuals’ practice context (Australian Nursing and Midwifery Council, 2007; Canadian Nurses
Association, 2000). Tools and assessment criteria should relate directly to the relevant
standards of practice and to the associated requirements for continuing competence. Clear
communication and accessibility to guidelines for the assessment methods and tools is
identified as being critical to this process (EdCaN, 2008; National Nursing Research Unit, 2009).
2.8.7 Research
On-going evaluation of the impact of Continuing Competence Frameworks is essential and
should include outcomes for consumers, employers and nurses (EdCaN, 2008; Lazarus & Genell
Lee, 2006). The viability of existing Continuing Competence Frameworks and the validity of
associated competence indicators and assessment methods require further evaluation in order
to determine if, in fact, requiring and monitoring continuing competence is a strategy that is
effective in terms of assuring and ensuring public safety (Meretoja, et al., 2002; National
Council of State Boards of Nursing, 2009a; National Nursing Research Unit, 2009).
49
2.8.8 Who is responsible?
The literature identifies that confusion exists with regard to which entity is responsible for
ensuring, demonstrating and facilitating continuing competence – the individual, the
employing organisation, the professional body, or the regulatory authority? There is also
ongoing debate in relation to the responsibility and jurisdiction of the regulatory authority
with regard to the implementation of Continuing Competence Frameworks and their
responsibility in terms of assuring the public that they are safe (Secretary of State for Health
(UK), 2007; Swankin, 1995; Swankin, et al., 2006).
2.9 Concluding remarks
An extensive review of the national and international literature has indicated that while there
is significant interest in ensuring the continuing competence of health professionals in order to
ensure public safety, there is a paucity of research relating to the efficacy of continuing
competence requirements and frameworks once such measures are implemented. It is
generally acknowledged that Continuing Competence Frameworks have a role in assuring the
public that health practitioners, in this case nurse’s, continue to be competent. However,
there has been little work done on obtaining consensus as to what might constitute best
practice in demonstrating and assessing continuing competence.
Difficulties with regard to ensuring valid and reliable assessment of continuing competence in
nursing have been highlighted. A range of competence indicators and assessment tools are
identified, however, none of the articles or documents describe approaches that ensure the
validity and reliability of continuing competence assessment tools. No evaluations of existing
Continuing Competence Frameworks, implemented for nurses, have been undertaken and the
majority of the published studies are descriptive in nature, reporting predominantly qualitative
findings. Limitations of these studies include small sample sizes, voluntary participation,
qualitative descriptive methods and a focus on investigating individual competencies rather
than competence or continuing competence. The summary of findings from this literature
review mirror those of previous reviews and should be considered in the context of the on-
going international debate about the challenges of monitoring and ensuring the continued
competence of nurses in practice.
This chapter has presented a summary of the literature that underpins and supports the
significance of this research, and provides the context in which it is situated. Given the
50
legislative mandate in New Zealand and other international jurisdictions with regard to
protection of the public and ensuring the continuing competence of registered health
practitioners, and the current lack of empirical evidence in relation to the efficacy of
Continuing Competence Frameworks, this research has an opportunity to make a valuable
contribution to the national and international literature. Chapter Three will present, in detail,
the overarching theoretical framework, research approach, design and methods used to
undertake this research.
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CHAPTER THREE - RESEARCH DESIGN AND METHOD
3.1 Introduction
This chapter commences by introducing the overarching research approach and discussing the
rationale for using evaluation research methodology. The scope of the research with regard to
the mixed method evaluation design is presented in two research stages. The individual
research methods and ethical considerations are discussed sequentially in association with
each stage. In conclusion the overarching ethical approval processes and relevant
documentation is presented.
Both nationally and internationally the literature reveals there is considerable interest in
existing models of continuing competence and their development. In particular extensive
work has been undertaken by nursing regulatory authorities in the following countries: New
Zealand, Australia, Canada, the United Kingdom, and the United States of America, to identify
valid and reliable mechanisms to monitor the continuing competence of nurses registered in
their jurisdictions. The Nursing and Midwifery Board of Ireland has also recently commenced a
project investigating models for assessment of continuing competence as a result of the
implementation of the Nurses and Midwives Act 2011 (Ireland).
The Nursing Council of New Zealand was the first of these regulatory jurisdictions to propose a
comprehensive evaluation of their Continuing Competence Framework for nurses, which was
in current operation. As discussed in Chapter One (1.2, p. 3), because part of my original
research was overtaken by the evaluation contracted by the Nursing Council of New Zealand
(Stage One) Evaluation of the Nursing Council of New Zealand Continuing Competence
Framework, I took the opportunity to extend my thesis to include a separate international
component that was consistent with, and relevant to my original research questions (Stage
Two) The International Consensus Model for the Assessment of Continuing Competence.
Findings from the evaluation of the Nursing Council of New Zealand Continuing Competence
Framework significantly contributed to the development of this second Stage, and assisted in
positioning it in terms of international relevance. It also provided a platform from which to
investigate the possibility of developing an International Consensus Model for the assessment
of continuing competence.
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3.2 Selection of the Research Approach
The overarching method chosen to investigate this topic was evaluation research. Evaluation
research is distinguished from other kinds of research by why it is undertaken rather than how
it is undertaken (Casswell, 1999). It is an approach to research that seeks to establish the
value and / or impact, to the recipients of the service, of an empirical topic such as a
programme, treatment, practice or policy (Carnwell, 1997; Davidson, 2005; Ovretveit, 2000)
and enables the researcher to determine the value of the topic through the use of inductive,
deductive or mixed method approaches (Clifford, 1997). Evaluation research is a methodology
that is concerned with seeking the views of stakeholders in order to appraise a program,
service provision, or enactment of policy, and to uncover the important factors latent in a
particular situation (Davidson, 2005; Parlett & Hamilton, 1972). Complementary mixed-
methods of data collection and analysis may be derived from the positivist and interpretive
paradigms (Davidson, 2005; Ovretveit, 2000). As such, the paradigm from which the
researcher views the research is reflected in the combination of methodological techniques
used to undertake the research at the process level of sampling, data collection and data
analysis (Sandelowski, 2000). A mixed methods design provides the ability to comprehensively
investigate the overarching research questions, whilst fulfilling the objectives of both of the
embedded studies because the strengths of combining qualitative and quantitative data
collection methods provided the researcher with more complete and more comprehensive
research results (Ovretveit, 2000; Sandelowski, 2000). The evaluation approach was both
interpretive and constructionist (Guba & Lincoln, 1989) with an underlying pluralistic approach
that facilitated the ability to take account of the wider contexts in order to describe, illuminate
and interpret, rather than purely measuring and predicting outcomes (Parlett & Hamilton,
1972). As noted by Tukey (1962, p.13) and cited by Thompson (2001, p. 256) “far better an
approximate answer to the right question, which is often vague, than an exact answer to the
wrong question, which can always be made precise”.
As identified in Chapter Two, a review of the contemporary literature suggests that reliability
and validation of competence frameworks continues to be subjective and problematic. A
sequential mixed-methods evaluation design was developed to ensure that the overarching
research questions were addressed (Table 2, p.5), whilst still complementing and addressing
the specific objectives of the two embedded studies: Stage One - the Evaluation of the Nursing
Council of New Zealand Continuing Competence Framework and Stage Two - the International
Consensus Model for the Assessment of Continuing Competence.
53
Overarching Research Questions
1. What are the relationships between current legislation, policy drivers and the statutory requirements to ensure registered nurses are competent and fit to practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the international consensus view of regulatory experts in relation to: a) best practice for nurses to demonstrate continuing competence; and b) best practice for regulatory authorities to assess continuing competence?
Research Questions - Stage One Research Questions – Stage Two
1. What are the relationships between current legislation, policy drivers and statutory requirements to ensure registered nurses in New Zealand are competent and fit to practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the efficacy of the current Continuing Competence Framework for nurses in New Zealand and does it reflect efficacious best practice?
1. What is the consensus view of regulatory experts in relation to: a) best practice for nurses to demonstrate
continuing competence; and b) best practice for regulatory authorities to
assess continuing competence? 2. What, if any, differences are present between
the current regulatory requirements for the demonstration and assessment of continuing competence in six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America) and the best practice model developed through consensus?
3. What changes, if any, would be required to policy and regulation in these six countries to align their regulatory framework with best practice for demonstration and assessment of continuing competence?
Evaluation research utilising a sequential mixed-methods design is no different from any
other form of research, in that methodological deficits may exist and are not necessarily
obvious until the research is undertaken. However, reliability and validity of results is
dependent upon the rigorous nature in which sampling, data collection, data collation
and analysis is conducted. The sequential nature of the design adds strength to the
research in terms of the ability of the researcher to build on findings as they emerge
(Miller & Fredericks, 2006). Reliability is “the extent to which a data gathering method
will give the same results when repeated (i.e. consistency). It refers to the amount of
random or systematic error (bias) or variance in data which the method gives” (Ovretveit,
2000, p. 214). Validity is “the extent to which a measure or piece of data ‘reflects’ what it
is supposed to measure or give information about” (Ovretveit, 2000, p. 215). The aim is,
to reduce random errors through the use of a reliable measure, and to reduce additional
systematic error (bias) by using a valid measure. Ovretveit (2000) argues that the
importance of validity in evaluation research relates to whether the data collected are
54
relevant for judging the identified criterion for evaluation thus addressing the research
purpose, rather than solely focusing on whether the data gives a valid representation of
some aspect of the study.
The comprehensive nature of the sequential mixed-method design allows establishment of
value judgments based on evidence drawn from a variety of data collection methods,
incorporating inductive descriptive, exploratory and explanatory perspectives (Sandelowski,
2000). This approach was critical in this thesis, in order to elicit the variety of information
required to address the overarching research questions. In addition the internal logic of the
sequential mixed-methods design presented methodological strengths (methodological
triangulation) not evident in other designs (Miller & Fredericks, 2006; Sandelowski, 2000).
Methodological triangulation attempts to overcome the deficiencies inherent in choosing a
single method (Cowman, 2008) to interpret a complex phenomenon. The complementary
strengths of using qualitative and quantitative techniques in this way elicits more
comprehensive results through a process that is outcome orientated, and also exploratory and
confirmatory (Davidson, 2005; Miller & Fredericks, 2006; Neuman, 2000; Ovretveit, 2000;
Sandelowski, 2000). The collation of information from a variety of sources enhances construct
validity and robustness using triangulation, that reveals the convergence of evidence
(Cowman, 2008; Yin, 1994). Evaluation research is judged according to its internal and
external validity, objectivity and ability to be replicated (Parlett & Hamilton, 1972).
3.3 Research Design and Methods
The evaluation research design used for this study was informed by the work of Parlett and
Hamilton (1972), Guba and Lincoln (1989), and the later works of Ovretveit (2000), Davidson
(2005), and Miller and Fredericks (2006), all of whom advocate the importance of identifying
and seeking the views of key stakeholders (Carnwell, 1997), through the use of multiple data
collection strategies. Each phase of the research process detailed in this chapter incorporates
its own distinct sampling, data collection and analysis method which in turn has its own
measures of rigour, dependent upon the qualitative or quantitative perspective being
undertaken, for example, credibility and trustworthiness; or validity, reliability, inference and /
or transferability and ethical implications. The findings derived from each phase of the
research serve to inform the next phase in the research process, and as such, the careful
application of the sequential mixed methods design provides a consistent, rigorous, and
acceptable justification for the research approach (Miller & Fredericks, 2006; Sandelowski,
55
2000). Triangulation, the use of multiple methods to collect and interpret data, facilitates a
more accurate representation of reality (Polit & Hungler, 1995) through validation when one
set of results is confirmed by congruent results from another part of the study (Cowman,
2008).
3.3.1 Evaluation Research Process
The methods used to complete this research are presented below in diagrammatic form
(Figure 2) and further described in Stage One (3.3.2), Stage Two (3.3.3) and Methodological
Triangulation of Summary Data (3.3.4).
Figure 2 Evaluation Research Process
EVALUATON RESEARCH PROCESS
Met
hodo
logi
cal
Tria
ngul
atio
nIn
tern
atio
nal
Cons
ensu
s Mod
elNC
NZ C
ontin
uing
Co
mpe
tenc
e Fr
amew
ork
Literature Review
Stage One Phase 1
Document & Policy Review
Stage One Phase 2
Qualitative Interviews
Stage One Phase 3
QuantitativeE-survey
Data triangulation &
discussion
Stage TwoDelphi Round 1Stakeholder Interviews
(gpA)
Stage TwoDelphi Round 2
Qualitative E-survey (gpB)
Stage Two Delphi Round 3Quantitative
E-survey (gpB)
Stage Two Delphi Round 4
ConsensusE-survey
(gpA)
Discussion of findings
Summary Recommendations
Summary Recommendations
Conclusion and Recommendations
Data triangulation & discussion of summary
findings fromStage One & Stage Two
56
3.3.2 Stage One – Evaluation of the Nursing Council of New Zealand Continuing Competence Framework
Stage One of my thesis is focused on the evaluation of the Nursing Council of New Zealand
Continuing Competence Framework. This aspect of my thesis commenced prior to the call for
tenders by the Nursing Council of New Zealand. However, as my supervisors and I successfully
tendered for the work, great care was taken to separate the work that was undertaken
collectively as the tender team, from work that I undertook independently as part of my thesis,
that was subject only to the level of scrutiny and input that doctoral supervisors would
provide. It was agreed that, should the supervisors feel the need to change my independent
work substantially, that work could not be identified as part of my thesis. However, this did
not occur and as previously noted in Chapter One, a matrix identifying both my individual
contributions that go to my thesis and also the collective contributions of the research team
members, in completing the contracted aspects of this work, is presented in Appendix I.
Table 4 presents the research questions posed in relation to Stage One of this thesis, alongside
the objectives stipulated by the Nursing Council of New Zealand for the evaluation of the
Continuing Competence Framework.
Table 4 Stage One research questions and the Nursing Council of New Zealand objectives
Stage One Research Questions Nursing Council of New Zealand Objectives
1. What are the relationships between current legislation, policy drivers and statutory requirements to ensure registered nurses in New Zealand are competent and fit to practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the efficacy of the current Continuing Competence Framework for nurses in New Zealand and does it reflect efficacious best practice?
• Explore the validity of the stipulated hours of professional development and days/hours of practice over a three-year period, as indicators of competence.
• Provide information on the efficacy of undertaking a random audit of five percent of the nursing workforce to meet recertification requirements.
• Document and track the different forms of written evidence that are currently acceptable to the Nursing Council of New Zealand to demonstrate competence.
• Identify issues related to peer assessment of competence.
• Develop a framework to enable the Nursing Council of New Zealand to complete a further evaluation in five years’ time (Nursing Council of New Zealand, 2008).
57
The mixed methods approach used to complete Stage One; the evaluation of the Nursing
Council of New Zealand Continuing Competence Framework included three phases of inquiry
that were completed from 2009 – 2010, and are described in more detail below. The use of a
sequential design meant that the collated and analysed findings from each phase contributed
to the development of each subsequent phase culminating in the triangulation of all data sets
at the conclusion of Phase Three. As the development of this sequential design was contingent
upon a multi-staged approach it was critical to ensure that each phase of the research was well
planned, documented and executed in a coherent and logical manner in order to mitigate any
potential risk of error building upon error (Creswell, 2003; Sandelowski, 2000).
3.3.2.1 Phase One – Document Review
The purpose of Phase One was to explore and review the documents relating to the regulation
of nursing in New Zealand that led up to the implementation of the Health Practitioners
Competence Assurance Act 2003 (NZ) and the subsequent Nursing Council of New Zealand
Continuing Competence Framework. In order to complete Phase One three separate pieces of
work were undertaken: an historical review, a document and policy analysis, and a collation of
statistical data.
Historical review
A review was completed, and included historical documents relating to the legislation and
regulation of nursing in New Zealand, seminal events that impacted on the evolution of
nursing education and practice in New Zealand, relevant legislation, and Nursing Council of
New Zealand archived documents, policies, procedures, and guidelines. A descriptive analysis
was undertaken and the findings are presented in chronological order in Chapter Four (4.3).
Document and policy analysis
A comprehensive review of all documents relating to the development and implementation of
the Nursing Council of New Zealand Continuing Competence Framework was undertaken.
Documents relating to the twelve years leading up to, and including, the implementation of
the Continuing Competence Framework were examined, reviewed and catalogued. Thomas’s
(2003) general inductive approach to data analysis was used to undertake the critical
document analysis. The primary purpose of this inductive approach is to allow “findings to
emerge from frequent, dominant or significant themes inherent in raw data, without the
58
restraints imposed by structured methodologies” (Thomas, 2003, p. 2). The process follows
five distinct steps:
1. Preparation of raw data files (“data cleaning”).
2. Close reading of text and identification of themes.
3. Creation of categories.
4. Overlapping coding and uncoded text.
5. Revision and refinement of the category system to reduce the data into the most
important thematic categories (Thomas, 2003, p. 3).
This logical and systematic approach to inductive analysis of data, provides a straightforward
structured method that allows the researcher to demonstrate the rigor and trustworthiness of
the data through the visible systematic approach that includes consistency checks.
Consistency checks are used for assessing the trustworthiness of the data analysis process
(Thomas, 2003). For the purpose of this study one of my doctoral supervisors reviewed the
category descriptions and the coding, allocation and interpretation of text to each category.
The overall findings are presented in Section Two, Chapter Four (4.4) in the form of a
descriptive summary related to the development and implementation process undertaken by
the Nursing Council of New Zealand.
Specific Nursing Council of New Zealand policy documents, procedures, and guidelines
associated with the implementation of the Continuing Competence Framework, including the
recertification process and audit requirements were analysed using a structured framework
informed by Musick’s (1998) Structured Approach to Policy Analysis. In general, policy analysis
is an analytical and descriptive process that attempts to define the purpose of the policy and
how it has been developed. Hence it is concerned with two distinct processes; the contents of
the policy, and the process by which it was developed (Musick, 1998).
Musick (1998) identified a systematic framework for policy analysis in medical education. The
framework proposes twelve essential “ingredients” (Musick, 1998, p. 4) to consider when
undertaking policy analysis: Conceptual; Normative; Theoretical; Empirical; Economic; Political;
Cultural; Ideological; Historical; Assumptive; Legal; and Logical. The value of each component
contributes equally to the overall process (Musick, 1998). The systematic utilisation of this
framework for analysis of the Nursing Council of New Zealand Continuing Competence
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Framework policy documents is presented in more detail in Section Two, Chapter Four (4.5)
and summarised in Table 5 (p. 97).
Collation of statistical data
Statistical information relating to recertification (Annual Practising Certificate applications),
recertification audits, and competence notifications were reviewed, and collated from the date
of implementation of the Continuing Competence Framework in 2004, and the recertification
audit process in 2005. These data are presented in Chapter Four (4.6).
In addition, 94 documents pertaining to the development and implementation of the Nursing
Council of New Zealand Continuing Competence Framework were reviewed and analysed.
The collated findings from Phase One of the evaluation (Chapter Four), provided a range of
information that contributed to the development of the semi-structured interview questions
implemented in Phase Two and the web-based e-survey implemented in Phase Three of the
evaluation. This process is consistent with the purpose of a sequential evaluation design
where the findings that emerge from each sequential phase, contribute to the development of
the subsequent phase in the research process (Miller & Fredericks, 2006).
3.3.2.2 Phase Two – Method; Semi-structured interviews with key stakeholders
The purpose of Phase Two was to determine from key nurse stakeholders their knowledge,
understanding and experience of the Nursing Council of New Zealand Continuing Competence
Framework and ultimately their satisfaction with, and confidence in, the Continuing
Competence Framework as a measure to ensure safe professional practice as a nurse in New
Zealand. These included aspects related to the Continuing Competence Framework processes
and procedures and associated professional, legal and ethical issues in relation to the
demonstration of continuing competence and safe practice.
Semi structured interviews with a purposive sample of 26 key nurse stakeholders were
completed. The semi-structured interview process provided a framework with which to pose a
range of open-ended questions related to the topic, and encouraged the participants to talk
freely about their views and experiences (Polit & Beck, 2010). The use of open-ended
questions encourages participants to respond in their own words, and enables richer and more
complex data to be collected (Whittemore & Grey, 2006).
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The purposive sample provided the researcher with the ability to choose participants with the
required specialised knowledge, experience, and status to contribute vital information to the
subject being researched (Whitehead & Annells, 2007). Participants were selected in order to
be representative of the following groups; nurse leaders from the following groups:
• Directors of nursing;
• Nurse managers from the public and private sector;
• Heads of schools of nursing;
• Nursing representatives from the Ministry of Health and professional nursing
organisations;
• Nurses who had been selected to participate in a recertification audit in the four years
since implementation of the Nursing Council of New Zealand Continuing Competence
Framework (2005 – 2009).
Twenty seven participants were selected to take part in the interview process. This was more
than sufficient as the literature identifies that, due to the potentially detailed and complex
data each participant may generate during the qualitative interview process (Polit & Beck,
2010; Whitehead & Annells, 2007), 10 - 15 participants is considered an adequate sample size
(Whitehead & Annells, 2007).
The twenty seven potential participants were contacted initially through an email invitation
that included a copy of the research information sheet and a written consent form (Appendix
II). Twenty six responded indicating that they were interested in participating in the research
and they were then contacted by telephone and the interview appointments were confirmed.
The semi-structured interviews were conducted as scheduled and included the following
elements:
• Understanding and experience of the Continuing Competence Framework including
the recertification audit processes
• Knowledge and understanding of the indicators of competence and evidential
requirements
• Confidence in the Continuing Competence Framework as a measure of safety to
practise
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• Contextual relevance in terms of their own experience, position, understandings and
opinions
• Knowledge and experience related to the professional development and recognition
process (PDRP).
Any additional information offered was noted and organised into themes. The interviews
ranged from 25 – 60 minutes in duration and each was digitally recorded and transcribed
verbatim. By recording the interviews the researcher is able to pay full attention to the
participant and to take note of non-verbal cues (Davies, 2007). It also facilitates the ability to
save a detailed account of the participant’s responses and a verbatim transcript for analysis
(Polit & Beck, 2010).
Data analysis
The transcribed interviews were collated and analysed by the researcher using Thomas’ (2003)
general inductive approach, the purpose being to allow “findings to emerge from frequent,
dominant or significant themes inherent in raw data, without the restraints imposed by
structured methodologies” (Thomas, 2003, p. 2). As previously noted this systematic approach
to inductive analysis provided a logical process for independent consistency checks, and
allowed the researcher to demonstrate the rigour and trustworthiness of the findings which
are reported in Chapter Five. The themes which emerged were then used to inform the
development of Phase Three, the web-based electronic survey (e-survey) reported in Chapter
Six.
Ethical considerations
Participation in the interview process was voluntary. Information about the study, its purpose,
the anticipated participant time commitment, and full contact details of the researcher, were
provided to each potential participant via an emailed information sheet accompanied by an
interview consent form. Informed consent was given prior to the interviews taking place and
all participants signed the consent form that was provided. No identifying information was
recorded and all data was coded, collated and de-identified during the analysis process.
3.3.2.3 Phase Three – Method; E-survey of New Zealand Nurses
A web-based quantitative e-survey was conducted with a representative sample of nurses
registered with the Nursing Council of New Zealand, and active in terms of mandatory
62
participation in the Nursing Council of New Zealand Continuing Competence Framework
between the 1st and 16th December 2009. These nurses had all previously indicated to the
Nursing Council of New Zealand, by completing and signing a specific section on their annual
application for recertification, that they consented to their email addresses being made
available for Nursing Council of New Zealand approved surveys and research purposes. The
Nursing Council of New Zealand computer administrator uploaded a computer generated,
randomly selected sample of email addresses for 12% (n = 5,339) of nurses from this active
register. An invitation to participate in the research including a detailed information sheet that
explained the purpose of the research, what the findings would be used for, the anticipated
time it would take to complete the e-survey, the contact details of the researcher, and an
explanation of ‘implied consent and anonymity’ if the nurse chose to complete and submit the
e-survey, was sent via email to the potential participants. The uniform resource locator (URL)
link to the e-survey was embedded in the invitation and provided potential participants direct
web-based access to the E-survey. Copies of the research information sheet and e-survey are
appended (Appendix III).
For the purpose of this research ‘nurses’ were defined as Nurses Assistants (NA), Enrolled
Nurses (EN) and Registered Nurses (RN), who had applied to the Nursing Council of New
Zealand for recertification within the previous four years and who consented to participate in
web-based surveys. Nurse Practitioners were excluded from this research as they currently
have a different continuing competence process.
Research objectives
To determine the satisfaction of New Zealand nurses with, and confidence in, the Continuing
Competence Framework and to seek feedback from them with regard to:
• Their understanding of and / or ability to demonstrate the indicators of competence
required by the Continuing Competence Framework for safe professional practice;
o the self-declaration in terms of the professional, legal and ethical issues, and safe
practice;
o the required hours of clinical practice;
o the required professional development (continuing education) hours;
• Access to, and engagement with professional development and recognition
programmes;
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• Satisfaction with the recertification audit process;
• Participation in a recertification audit, including:
o Understanding / satisfaction with the process, documentation and requirements in
terms of demonstrating competence
o Role of the peer assessor.
Survey Design
The web-based software platform ‘Zoomerang’ was used to develop and administer the
quantitative e-survey. The themes and questions were developed from the combined findings
of the literature review and the findings from the previous two research phases. In addition to
the demographic data, the questionnaire was based around four main themes, competence
(indicators, assessment, processes), annual practising certificate applications, recertification
audit processes, and professional development and recognition programmes.
The questionnaire was designed to capture a wide range of information through the use of
closed (yes / no) and attitudinal questions, resulting in categorical, nominal and ordinal data.
Nominal data were derived through categorisation of dichotomous data into two groupings,
for example questions with a response of yes or no. Attitudinal questions were measured
using a seven point Likert scale which comprised a list of positively and negatively worded
statements with which the participants were asked to indicate their strength of agreement or
disagreement.
The questionnaire was piloted electronically via ‘Zoomerang’ with a convenience sample of
fourteen nurses, prior to final implementation. This process enabled the questionnaire to be
tested and feedback provided. Following the initial pilot, adjustments were made to the
format, structure, and order of four questions. The questionnaire was then returned to the
pilot group. Anomalies in two questions were corrected, and the questionnaire was
confirmed. In order to reduce the possibility of multiple or unsolicited responses to the
questionnaire the web-link was specifically designed to allow only the original invited recipient
to respond. The questionnaire was designed to be incapable of being forwarded through
progressive email links.
The literature identifies that there are advantages and disadvantages when using e-surveys as
a method to conduct research (Duffy, 2002). However, the decision to use an electronic
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survey in both Stage One and Stage Two of this research was pragmatic, driven primarily by
the following factors:
• The ability to recruit participants from a geographically diverse sample group -
nationally and internationally;
• The ability to elicit asynchronous responses from multiple participants within a
defined time frame and across a variety of time zones;
• The ability to administer follow-up and reminder messages as necessary; the
ability to maintain anonymity within the sample group;
• The ability to manage and store potentially large data bases and to facilitate
electronic collation and coding of the data for analysis;
• The ability to manage costs within the financial constraints of a limited budget
(Duffy, 2002).
It was acknowledged that the use of an e-survey may result in the following disadvantages;
reduced response rates due to inconsistent technological literacy, internet access, or individual
preference of the potential sample group, the absence of the opportunity for discussion with
the participant, the absence of non-verbal cues, the opportunity to ignore or put aside an
electronic invitation, and the fear that their individual privacy and confidentiality of responses
may not be ensured (Duffy, 2002). These potential disadvantages were mitigated as much as
possible by ensuring potential participants were provided with direct access to all required
research information (the detailed research information sheet, researcher contact details,
details with regard to ethical considerations and the direct URL to the e-survey) within the one
email invitation. In addition the e-survey software provided the ability for the researcher to
identify and filter out the participant invitations that had been ‘hard bounced’ due to technical
issues, resulting in the original e-survey invitation not reaching the intended potential
participant.
Confidentiality
Participation in the e-survey was voluntary and anonymous. The electronic email address data
base was randomly generated by computer from the Nursing Council of New Zealand active
data base and uploaded directly by a Nursing Council of New Zealand administrator into the
‘Zoomerang’ web platform. No identifying information of potential participants was provided
to the researcher.
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Data Analysis
Participant responses were initially collated and analysed via ‘Zoomerang’ and then imported
using the software package Statistical Package for Social Sciences (SPSS) for Windows version
17.0, to enable more extensive statistical analysis. Preliminary analysis was completed with
the whole group using basic statistical frequencies, numbers, percentages, means and
distribution. The data were further analysed by cross-tabulating data and examining the
relationship between variables (scope of practice, employment area, and practice setting).
Analysis of variance (ANOVA) was used, when indicated, in order to provide a deeper
understanding of the data within, and between the groups. Detailed findings are presented in
Chapter Six.
3.3.2.4 Data triangulation, discussion and recommendations
A process of methodological triangulation was used to evaluate the Continuing Competence
Framework and to test the degree of convergence and validity of the research findings
(Carnwell, 1997; Davidson, 2005). Triangulation of the data from Phases One, Two and Three
added to the robustness (Ovretveit, 2000) of the research by eliciting a broader range of data
and perspectives, which in turn enhanced the construct validity. Validity and reliability of the
research findings can be directly affected by biases of the researcher (Ovretveit, 2000).
However, the use of mixed method sequential data collection and analysis, reduces the
possibility of this occurring (Sandelowski, 2000).
The triangulated findings of Stage One are presented and discussed in detail in Chapter Seven.
The recommendations specifically made to the Nursing Council of New Zealand following
completion of the evaluation of the Continuing Competence Framework are presented in Table
20 (p. 161).
3.3.3 Stage Two – The International Consensus Model for the Assessment of Continuing Competence
Findings from Stage One; the evaluation of the Nursing Council of New Zealand Continuing
Competence Framework have contributed to the development of Stage Two – the consensus
model for the assessment of continuing competence, and assisted in positioning it in terms of
international relevance by providing a platform from which to investigate the possibility of
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developing an international consensus model for the assessment of continuing competence.
Stage Two was completed during 2011-2012.
In preparation for deciding on the most appropriate method with which to undertake Stage
Two of this study, the following research challenges were considered:
• The geographic spread and diversity of the expert group of potential participants;
• Differing cultural and political influences;
• Variation in regulatory structures, processes and authority;
• Variation in Nursing education standards and qualifications.
Of the research methods considered, the Delphi technique, which is “a method for structuring
a group communication process so that the process is effective in allowing a group of
individuals, as a whole, to deal with a complex problem” (Linstone & Turoff, 2002, p. 3), was
determined to be the most appropriate in order to achieve the research purpose. As
previously noted the research purpose was to determine the consensus view of international
regulatory experts in relation to best practice for nurses to demonstrate continuing
competence and for regulatory authorities to assess continuing competence. The following
research questions were posed:
1. What is the consensus view of regulatory experts in relation to:
a) best practice for nurses to demonstrate continuing competence; and
b) best practice for regulatory authorities to assess continuing competence?
2. What, if any, differences are present between the current regulatory requirements for
the demonstration and assessment of continuing competence in six countries and the
best practice model developed through consensus?
3. What changes, if any, would be required to policy and regulation in these six countries
to align their regulatory framework with best practice for demonstration and
assessment of continuing competence?
3.3.3.1 Method; the Delphi Technique
The Delphi technique offered a structured and logical approach that provided a platform to
engage with, and potentially achieve consensus from, a geographically diverse group of
regulatory experts, through a process of iteration. This process usually comprises four distinct
phases of data collection and analysis:
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• Exploration of the subject under discussion, where each individual is asked to
contribute the views they believe are pertinent to the issue.
• Reaching an understanding of how the whole group understands and views the issue.
For example where members of the expert panel agree or disagree about the issues
with respect to voting scales like importance, desirability, and/or feasibility.
• Exploration of disagreement in order to bring out the underlying reasons for the
differences in opinion, and to evaluate the reasons for them.
• Final evaluation that occurs when all previously gathered information has been initially
analysed and the evaluations have been fed back to the expert panel for consideration
(Linstone & Turoff, 2002).
The Delphi technique is a flexible and widely used method that is useful in achieving consensus
in an area where there is a lack of empirical evidence (Powell, 2003). It is has a structured
approach that is democratic and takes into account the combined knowledge and expertise of
its participants (du Plessis, 2007; Linstone & Turoff, 2002).
The ‘classic approach’ (Linstone & Turoff, 2002) to the Delphi technique was implemented to
undertake Stage Two of this research. This approach follows a prescribed set of procedures
that incorporate both behavioural and statistical elements and is characterised by five distinct
features; the anonymity of participants, iteration, controlled feedback, a statistical group
response, and stability in responses among an expert group of participants, derived from a
series of rounds of questionnaire surveys where summary information and results are fed back
to the expert panel members between each survey round (Linstone & Turoff, 2002; Stewart,
2001).
Typically, up to three rounds of questionnaires are sent to the expert panel (Linstone & Turoff,
2002), to elicit their responses and try to ascertain consensus. However, for the purpose of
this research four Delphi rounds were completed integrating the findings from the literature
review, and the evaluation of the Nursing Council of New Zealand Continuing Competence
Framework.
3.3.3.2 Expert panel
The success of the Delphi technique relies on the experiential knowledge, expertise and
credibility of the participants who make up the ‘expert panel’ (Linstone & Turoff, 2002).
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However, it does not require the expert panel to be a ‘representative sample’ for statistical
purposes (Linstone & Turoff, 2002). The quality of the panel is related to their willingness and
ability to make a valid contribution to the study being undertaken (Stewart, 2001). For the
purposes of this study the combined expertise of two expert panels were involved.
The first expert panel (Group A) was made up of a purposive sample of 14 international
regulatory and professional nursing representatives from the six countries (Australia, Canada,
Ireland, New Zealand, the United Kingdom and the United States of America) previously
identified as the focus for the development of the international consensus model for
assessment of continuing competence. Representatives from these countries were chosen as
they have similar standards of practice, regulatory structures for nursing and, as the literature
indicated, have previously commenced work investigating aspects of continuing competence.
Recruitment of this expert panel was by direct invitation, initially made by email and then
followed up by telephone. This panel was important in terms of initial stakeholder
engagement, consultation and confirmation of the specific legislative and regulatory context
within each country that had previously been identified in the international literature, and also
in providing clarity with regard to the complexity of the separate legislative and regulatory
jurisdictions within each country. It was also important to this work that the expert panel
(Group A), was specifically involved in responding to the summary findings presented to them
in round four that indicated a convergence of opinion and commonality of key principles.
The second panel (Group B) was a larger international group recruited specifically from within
the individual Regulatory Boards in each of the six countries and through the International
Council of Nurses Observatory on Licensure and Registration12. Recruitment was via an
electronic invitation sent directly to each individual Regulatory Board and to the International
Council of Nurses administration office. A snowball technique was used in association with the
recruitment of Group B participants. The snowball sampling technique is a non-probability
sampling technique that is useful to identify potential participants in research, where the
potential participants are unknown or difficult to access (Davies, 2007). This technique allows
12 The International Council of Nurses Observatory on Licensure and Registration consists of a small, invited, cross-sectional group established to provide ICN with advice on emerging and future trends in regulation, strategic initiatives to be undertaken and policy stances ICN should consider (International Council of Nurses, 2013).
69
existing research participants to recruit from among their acquaintances, thus growing the size
of the sample group. The electronic invitation clearly identified the purpose, structure and
ethical considerations of the research. It also stated the expertise required of the participants
in terms of their knowledge, understanding and experience relating to continuing competence
activities. The invitation requested that, if the recipient of the invitation did not feel they had
the relevant expertise to participate in the research, they could then forward the invitation to
an appropriate person within the Board or Council of nursing. Participation was voluntary and
anonymous. No identifying information was sought. The questionnaire rounds were
administered electronically in order to enable participants to access the questionnaire directly
through the web-based data platform Zoomerang.
3.3.3.3 Conduct of the Delphi Survey
Round one
Round one was conducted by completing individual interviews with the 14 members of expert
Group A. The interviews were unstructured and facilitated using open-ended questions. This
method was appropriate as the literature identifies that open ended questions are used to
increase the richness of data by allowing the participants to freely identify their views and
opinions (Schneider, Elliot, LoBiondi-Wood, & Haber, 2003). The following five questions were
posed:
1. Tell me about your experience with, and understanding of, continuing competence
frameworks/models.
2. In your view what is ‘best practice’ for the demonstration and assessment of
continuing competence?
3. What, if any, are the current regulatory requirements for the demonstration and
assessment of continuing competence in your country/jurisdiction?
4. What barriers and enablers exist in relation to the implementation of a
model/framework for assessment of continuing competence?
5. Do you believe it is possible to develop an international consensus model for the
assessment of continuing competence between the following six countries – Australia,
Canada, Ireland, New Zealand, the United Kingdom and the United States of America?
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Each interview ranged from 40 – 75 minutes in length and was recorded and transcribed
verbatim. Detailed information with regard to the specific interview questions and emergent
themes are presented in Chapter Eight.
Round two
Round two was completed using an e-survey administered through the web-based data
platform Zoomerang. The aim of this second round was to seek an open response from the
larger expert panel (Group B). Predominantly open ended questions were used to elicit
feedback from the panel members in order to encourage them to respond without the
influence of the collated findings from round one. In addition the following two closed
questions were posed. The first to determine if the participant had prior knowledge and
expertise in the area of continuing competence, and the second to identify if the participant
considered development of an international consensus model was possible.
• Do you have knowledge and / or experience in the development or implementation of
continuing competence frameworks or models?
• Do you believe it is possible to develop an international consensus model for the
demonstration and assessment of continuing competence?
The participants were provided with the opportunity to add additional comments related to
both questions if they so wished. A copy of the Delphi round two e-survey is appended
(Appendix IV).
Round three
The development of questions for the Delphi round three drew heavily on the responses from
the previous two rounds. The e-survey was structured using themed statements developed
from the combined findings of rounds one and two. The participants were provided with the
summary of responses and asked to either, rate their level of agreement with the statements
on a five point Likert scale, or for some questions, to rank the statements in order of their
importance. This process sought to quantify the earlier findings from rounds one and two, and
determine any convergence and consensus of opinion. A copy of the Delphi round three e-
survey is appended (Appendix V).
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Round four
In round four the summary findings of the first three rounds of the Delphi study (the consensus
view) were presented to the expert panel (Group A) to consider the key principles and
components of an international consensus model for the assessment of continuing
competence. The members of Group A were invited to provide their views on the consensus
findings, the key principles, and the core components of a conceptual model for the
assessment of continuing competence. They were asked to consider the efficacy of the model
within each of their jurisdictions and to identify if any changes would be required to current
policy and / or legislation in order to bring their existing continuing competence processes into
line with the consensus framework. The participants were invited to respond to the
researcher by email or telephone within three weeks of receiving the summary findings.
Copies of the Delphi round four summary documentation and e-survey are provided in
Appendix VI and VII.
3.3.3.4 Data Analysis
The literature indicates that data analysis varies according to the purpose of the Delphi study,
the structure of the rounds, and the type of questions used to elicit information (Linstone &
Turoff, 2002). Content analysis was used to identify the themes generated from the
qualitative data derived from round one and round two. Content analysis is a widely used
qualitative research technique used to interpret meaning from the content of text data
(Schneider, et al., 2003; Shannon, 2005). It enables researchers to sift through large volumes
of data in a systematic fashion and is a technique that allows us to discover and describe the
focus of individual, or group in a logical and systematic way (Stemler, 2001). A summative
content analysis was then used to refine the Delphi round two data. This involved counting
and comparison, of keywords or key content areas, followed by the interpretation of the
underlying context (Schneider, et al., 2003).
Findings from these two data sets were further collated and major themes identified which
formed the basis of the structured e-survey implemented in round three. As the e-survey used
in round three was primarily structured using a rating scale, the data generated was
quantitative in nature and statistically analysed. The use of the five point Likert scale, on
which participants’ rated their level of agreement or disagreement (1 indicating Strongly Agree
and 5 indicating Strongly Disagree), provided the ability to determine percentage scores in
conjunction with the main statistical measures that included distribution of responses
72
(standard deviation and interquartile range), and measures of central tendency (mean,
medium and mode) (Hsu & Sandford, 2007). Detailed discussion related to this process of
statistical analysis is presented in Chapter Eight (8.4). A convergence of opinion was evident at
completion of round three, however confirmation of the data by the expert panel (Group A)
was critical in order to validate the findings and relevance of this work to the six participant
countries and ultimately to confirm a best practice consensus view. In conclusion a collation
and discussion of these summary findings and the emergent consensus view is presented in
Chapter Nine in relation to the two overarching research questions (Table 2, p. 5).
Recommendations for a best practice international consensus model are made.
Determination of consensus
Interpretation of what constitutes consensus in a Delphi survey, is said to be based on the
arbitrary judgement of the researcher and is related to the types of questions and analysis that
have been used in each of the Delphi rounds (Linstone & Turoff, 2002). For the purpose of this
research the consensus view was determined throughout the iterative process by assessing the
stability of the participant responses to each Delphi round (Scheibe, Skutsch, & Schofer, 1975),
in conjunction with the analysis of percentage scores indicating the participants’ level of
agreement with the statements provided via the e-surveys. A percentage score of 90%
agreement or greater, with a mean score of less than two (based on the five point Likert scale),
was deemed as exhibiting a consensus view.
3.3.3.5 Ethical Considerations - Participation, Confidentiality and Rights
Participation in the Delphi e-survey was voluntary. All potential participants were initially
contacted by email and provided with an electronic invitation to participate in the Delphi e-
survey. An information sheet outlining the purpose, design, and possible outcomes of the
intended research, participant involvement, participant’s rights, and the full contact details of
the researcher (doctoral candidate) and doctoral supervisors was provided and is found at
Appendix VIII.
For the participants in Group A (Expert Panel), after the initial email invitation, an information
sheet relating specifically to the interview process and purpose, and the predicted time
commitment of the participant, accompanied by a consent form (Appendix IX) was sent to
each participant by email. Follow-up was then made by telephone and individual interview
times were arranged and scheduled. Whilst the participants in Group A were known to the
73
researcher, their responses were de-identified and their identities were not disclosed to other
members of Group A or Group B.
The participants for Group B were more difficult to access due to their broad geographic
spread internationally, and the lack of access to the specific contact details of individuals. As
previously stated, recruitment to this group was substantially through a second party access,
the International Council of Nurses Regulatory Observatory Committee and the email
addresses of individual nursing Regulatory Boards, in association with a snowball sampling
technique. Participation in the Delphi survey was voluntary and anonymous and, as such,
potential participants were able to opt out of the study by simply choosing not to respond to
the electronic invitation. The Delphi survey was administered through a web-based platform
that does not capture the email address of origin. In addition no identifying details were
required in order to complete the survey. As a result, the identity of participants in Group B is
not known to the researcher or the other participants in the study. Consent of the participants
was implied if they chose to complete and submit the e-survey.
Participation was not influenced by financial reward or duress. Participants in Group A were
able to withdraw from the study up until data had been collated and analysed. Participants in
Group B were unknown, therefore once they had submitted the e-survey it was unable to be
withdrawn however they could choose not to participate in the subsequent survey round. All
information was de-identified, coded, collated and analysed. Only summary data were
provided to participants as feedback. All data remain confidential to the researcher on a
password protected private computer in a locked office.
3.3.4 Methodological triangulation of overall summary data
As previously described (Section 3.2, p. 52), this research follows a sequential mixed methods
design that was completed in two stages. The analysis of findings and discussion relating to
Stage One and Stage Two are presented sequentially. Methodological triangulation of the
cumulative findings from Stages One and Two are discussed and presented in relation to the
three overarching research questions:
1. What are the relationships between current legislation, policy drivers and the
statutory requirements to ensure registered nurses are competent and fit to
practise?
2. Is it competence that is being assessed / measured, or safety to practise?
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3. What is the international consensus view of regulatory experts in relation to:
a) best practice for nurses to demonstrate continuing competence; and
b) best practice for regulatory authorities to assess continuing competence?
A conceptual model for the assessment of continuing competence is discussed.
Recommendations for future development of the best practice international consensus model
for assessment of continuing competence, the associated implications for key stakeholders,
and recommendations for policy change are made and presented in Section Four, Chapter Ten.
3.4 Management of researcher bias
Researcher bias is a well-documented phenomenon that has the potential to occur in any
research process. Biases introduced by the researchers can directly affect the validity and
reliability of research findings (Davidson, 2005; Schneider, et al., 2003). As previously
described this study has incorporated four distinct methods of data collection and analysis
culminating in methodological triangulation of the data to derive the summary findings of this
thesis. Whilst each method has the potential to allow the researcher to guide or mould
participant responses, measures have been put in place to eliminate and manage any potential
bias throughout the data collection, analysis or write up phases of this research.
In order to manage this potential risk, all data collection tools were developed and submitted
for ethical approval prior to implementation. In addition, all interview and e-survey questions
were piloted with selected small sample groups relevant to the intended participant groups,
prior to their administration. The author completed all aspects of the data collection and
analysis process ensuring a consistent and standardised approach throughout each phase.
Consistency and trustworthiness of the data were validated through a process of having my
doctoral supervisors independently review the raw data, the process of analysis, and
subsequent findings in terms of management of researcher bias, consistency, reliability and
validity. A table summarising the qualitative analysis process is provided as Appendix XI.
Methodological triangulation of the data provided the ability to elicit a broader understanding
of the data and information (Sandelowski, 2000).
3.5 Ethical approval
This research conforms with the guidelines prepared by the New Zealand Health Research
Council (2002) for the preparation and undertaking of research involving human subjects and
75
the Australian national statement on ethical conduct in research involving humans (National
Health and Medical Research Council, 2007).
Ethical approval was granted by the Health Research Council of New Zealand Health and
Disability Multi Region Ethics Committee, reference numbers: MEC/09/64/EXP and
MEC/11/EXP/010, the Eastern Institute of Technology, Hawke’s Bay Research Approvals
Committee, reference number Ref-27/09, and ratified by the University of Sydney, Human
Research Ethics Committee, reference number: Ref–12618. Copies of these ethical approval
documents are provided in Appendix X.
3.6 Limitations of the research
3.6.1 Research Design and methods
Evaluation research: As previously noted evaluation research utilising a sequential mixed-
methods design is no different from any other form of research in that methodological deficits
may exist, and are not necessarily obvious until the research is undertaken. However,
reliability and validity of results is dependent upon the rigorous nature in which sampling, data
collection, data collation and analysis is conducted. The sequential nature of the mixed
methods evaluation design and methodological triangulation of the data adds strength to the
design and the findings (Miller & Fredericks, 2006; Scheibe, et al., 1975).
Document review and policy analysis: The document review and policy analysis was extensive
and complex. Policy documents and statistical summaries were supplied by the Nursing
Council of New Zealand administrative staff on request. However, it is possible that some
historical documentation may have been missed, due to the absence of a chronologically
indexed archive of historical documents at the Nursing Council of New Zealand, and
subsequent difficulties associated with sourcing original documents.
Interviews: The face-to-face interviews conducted in Stage One and Stage Two of this
research were consistently administered using open ended or semi-structured questions.
Unfortunately it was not possible to interview all of the participants in Stage Two - Delphi
Round One, face-to-face due to the geographic distances and financial constraints. Hence,
three of the interviews were conducted by telephone. Whilst it is not thought that this was a
significant limitation, it is acknowledged that the interview rapport took slightly longer to
establish due to not being able to see the participant and relate to behavioural cues.
76
E-surveys: The web-based e-surveys were developed to elicit feedback from geographically
diverse participant groups and were used in both Stage One and Stage Two of the research.
Validity of the survey was examined following an initial pilot of each e-survey which indicated
consistency of participant responses and accuracy in interpretation of the questions. The e-
surveys provided the participants with a safe and anonymous means of expressing their views.
Issues relating to participant responses to e-surveys are acknowledged, and it is noted that the
perception of the participant was their perception on the day they completed the e-survey and
may alter over time; that the participant may have adopted what they perceive as a socially
acceptable position when responding to the e-surveys; or the e-surveys may have been
completed by someone other than the specified recipient (Duffy, 2002; Schneider, et al.,
2003). Whilst there is no formal evidence of any of these examples occurring, they are raised
and discussed in relation to the validity of the e-surveys.
Delphi study: Cultural bias of the expert panel participants may be viewed as a limitation, as it
is likely that many of the expert panel participants may have similar views (Linstone & Turoff,
2002). However, as this research is specifically related to nursing regulation and processes
with regard to continuing competence legislation, policy and processes, the criteria for
selection of the expert panels is considered appropriate. Whilst the potential for cultural bias
is acknowledged as a limitation, this issue was not overly apparent and is not considered to be
significant in terms of this research.
The Delphi e-survey Rounds two and three, were conducted via a web-link, in order to
maintain the confidentiality of the participants and to provide them all with consistent web-
access. By conducting the e-surveys in this way it is not possible to guarantee that the
participants in Delphi Round three (Group B) are the same Group B participants that
responded to Delphi Round two.
3.6.2 Language and terminology
The use of terminology related to the regulation of nurses varies across and between the
regulatory jurisdictions. The use of terms may hold a number of meanings and are often
culturally appropriate. It is acknowledged that different terms may, or may not, have the same
meaning in similar jurisdictions, therefore care has been taken to clarify the language and
terminology that has been used to undertake this research particularly when speaking or
corresponding with participants. Clarification was sought to confirm the meaning of any
77
jurisdiction specific terms used by participants, or that were found in the associated legislation
and documents.
3.6.3 Interpreting legislative requirements
The focus of this research is predominantly related to the continuing competence
requirements for nurses in the New Zealand regulatory environment. However, in order to
better understand and situate this research in the wider international regulatory environment
and particularly with regard to the six participant countries, it is necessary to have a broad
understanding of the international legislation and regulatory jurisdictions in which they are
situated. Every effort has been made to correctly interpret, analyse and describe these
documents.
3.6.4 Access to regulatory authorities and information
The geographic spread of the regulatory jurisdictions included in this research and
subsequently the participants, whilst a challenge at times was not insurmountable due to
consistent access to reliable telecommunications and internet services. However, ensuring
currency of data in a national and international regulatory environment that is constantly
changing may be considered a limitation. In this regard every attempt has been made to
confirm and ensure that the most up-to-date information in relation to legislation, policy and
associated regulatory requirements has been used.
3.7 Concluding remarks
This chapter has provided a detailed overview of the research design and methods. The
following section, Section Two; Chapters Four, Five, Six and Seven will present and discuss the
summary findings of Stage One, the evaluation of the Nursing Council of New Zealand
Continuing Competence Framework. Section Three; Chapters Eight and Nine will present and
discuss the findings related to Stage Two, the development of a consensus model for the
assessment of continuing competence and in conclusion Section Four, Chapter Ten presents
the summary findings of both studies in relation to current literature and the overarching
research questions.
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SECTION TWO STAGE ONE: EVALUATION OF THE NURSING COUNCIL OF NEW ZEALAND CONTINUING COMPETENCE FRAMEWORK
Section Two presents Stage One of the research, the evaluation of the Nursing Council of New
Zealand Continuing Competence Framework. As previously noted aspects of Section Two of
this thesis was completed under contract to the Nursing Council of New Zealand to evaluate
the efficacy of the Continuing Competence Framework, which was implemented in 2004
following enactment of the Health Practitioners Competence Assurance Act 2003 (NZ).
Chapter Four presents the findings of Phase One of the study providing an overview of the
legislative history governing the regulation of the nursing profession in New Zealand, and the
findings derived from the document review and policy analysis of Nursing Council of New
Zealand documents leading up to and following implementation of the Health Practitioners
Competence Assurance Act (NZ) 2003.
Chapter Five presents the findings of Phase Two, the interviews with key nurse stakeholders.
Chapter Six presents the findings of Phase Three the e-survey of New Zealand nurses active on
the Nursing Council of New Zealand register.
Chapter Seven provides a triangulation of the cumulative data from Phases One, Two and
Three addressing the project outcomes identified by the Nursing Council of New Zealand and
providing a summary of key research findings to inform the second Stage of this research.
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CHAPTER FOUR - PHASE ONE FINDINGS: DOCUMENT REVIEW AND POLICY ANALYSIS
4.1 Introduction
Chapter Four presents the findings of Phase One of the evaluation of the Nursing Council of
New Zealand Continuing Competence Framework which included a comprehensive document
review and policy analysis.
The document review was completed in two parts. Firstly a focused review of historical
documents relating to the legislation and regulation of nursing in New Zealand leading up to
the implementation of the Health Practitioners Competence Assurance Act (NZ) 2003 was
undertaken. This was followed by a comprehensive review and analysis of Nursing Council of
New Zealand archived documents for the fourteen years preceding implementation of the
Continuing Competence Framework (2004). Whilst a complex and time consuming process,
this aspect of the evaluation was important in order to identify the documented processes by
which the Nursing Council of New Zealand had developed its Continuing Competence
Framework and associated policies and procedures.
Documents reviewed include:
• Papers and memoranda to the Nursing Council of New Zealand
• Nursing Council of New Zealand meeting minutes
• Published Council documents
NCN
Z Co
ntin
uing
Com
pete
nce
Fram
ewor
k
Stage One Phase 1
Document & Policy Review
Stage One Phase 3
QuantitativeE-survey
Data triangulation & discussion
Summary Recommendations
Stage One Phase 2
Qualitative Interviews
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4.2 Framework for the document review and analysis
4.2.1 Historical review
As previously stated, areas of exploration included historical data relating to legislation and
regulation of nurses in New Zealand; the development and implementation of the Nursing
Council of New Zealand Continuing Competence Framework; Nursing Council of New Zealand
projects, policies and procedures associated with the Continuing Competence Framework, and
stakeholder consultation and engagement. A simple descriptive review and analysis of these
documents was undertaken and a summary of events is presented in chronological order in
Chapter Four (4.3).
4.2.2 Policy analysis
Existing and current Nursing Council of New Zealand policies, procedures, and guidelines
associated with the Continuing Competence Framework, including recertification and audit
requirements were analysed using a framework informed by Musick’s (1998) structured
approach to policy analysis. Findings from these analyses are presented in Chapter Four (4.4).
4.3 The evolution of nursing regulation in New Zealand
The development of legislation and policy with regard to the regulation of nursing in New
Zealand has, and continues to be, shaped by a complex tapestry of social, political,
technological, scientific and multidisciplinary forces. Nursing is now the largest health
professional group in New Zealand, having developed from what was a small, largely
undefined and unregulated workforce in the mid-1800s (Gage & Hornblow, 2007; Gauld, 2001;
Sargison, 2001). By the late 1800s, economic growth, a rapidly increasing population,
increased social issues such as high maternal and infant mortality rates, and the arrival of
Nightingale trained nurses, heralded an era of increased political and professional control
(Jacobs, 2005). Local health services that had previously consisted of small cottage hospitals,
generally staffed by unqualified persons began to disappear (Rodgers, 1985). The introduction
of a government controlled public health system (New Zealand Department of Health, 1972)
and national licensure of the health professions followed soon after. It was during this time
that a number of health professions including nursing and midwifery, first became subordinate
to medicine. As noted by Papps (1997) the medical profession exerted power and control over
nursing and other health professions through the use of knowledge, social status and
exclusionary practices.
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4.3.1 Chronology of legislative change 1901 -1971
The Nurses Registration Act 1901 (NZ) was the first legislation that formally regulated the
nursing profession in New Zealand and the first legislation of its kind in the world. Entry
criteria were stipulated and a register of nurses was established. The register contained the
name, and address of each nurse, and details of where and when she trained (Rodgers, 1985;
Sargison, 2001). The Nurses Registration Act 1901 (NZ) stipulated that training programmes
were three years in duration, required that the nurse was 23 years of age, and had achieved a
pass in the state examination prior to entry to the register. The enactment of the Nurses
Registration Act 1901 (NZ) and the associated requirements introduced uniformity and
consistency of standards to the existing hospital based nurse training programmes. A
'grandmother' clause was introduced and those nurses already practising at the time the
Nurses Act 1901 (NZ) was passed, were entitled to go directly onto the register (Burgess, 2008;
Papps, 1997). The introduction of regulation and the subsequent formal education and
training of nurses, marked a considerable change in the status and social position of the nurse
(Papps, 2002). Gage and Hornblow (2007, p. 331) note that regulation of the health
professions also made “certain health-related practices illegal, through the Tohunga
Suppression Act 1907 (NZ)13 and the Quackery Prevention Act 1908 (NZ).”
In 1904, due to increasing public concern about the maternal and infant mortality rate,
legislation was passed for midwives, the Midwives Act 1904 (NZ). This was similar to the
previously enacted Nurses Registration Act 1901 and required standardised training for what
had been a predominantly untrained midwifery workforce. No midwifery training programmes
had been available in New Zealand until this time. The Midwives Act 1904 (NZ) established a
register, entry criteria of training, a state examination, and standards of practice similar to
those stipulated in the Nurses Registration Act 1901 (NZ). Training schools for midwives were
introduced with the establishment of St. Helen's hospitals, which were situated in a number of
regional areas in New Zealand (Papps & Olssen, 1997). The Nurses Registration Act 1901 (NZ)
and the Midwives Act 1904 (NZ) were implemented and administered by the then Department
of Health with the Inspector General of Hospitals being appointed as the Registrar for nurses
and midwives. However, within four years (1908) all legislation relating to nurses and
midwives was reviewed, the aim being to eliminate unnecessary and out of date clauses and
13 The Tohunga Suppression Act 1907 (NZ) was an Act of Parliament in New Zealand that aimed to replace tohunga (traditional Māori healers) with modern medicine.
82
requirements. This review was followed by the enactment of the Nurses Registration
Amendment Act 1920 (NZ) which, amongst other minor changes reduced the required age of
nurses at registration to 22 years (French, 1998; Papps, 2002).
During the 1920s nursing and midwifery legislation underwent a major review and the
previous two separate pieces of legislation, the Nurses Registration Act 1901 (NZ) and the
Midwives Act 1904 (NZ) were combined. This brought both professional groups under the
same statute, the Nurses and Midwives Registration Act 1925 (NZ). The enactment of the
Nurses and Midwives Registration Act 1925 (NZ) resulted in the creation of a six member
Nurses and Midwives Registration Board, and for the first time, stipulated that the Registrar
was the person who held office as the Director of the Division of Nursing in the Department of
Health. At this time the Nurses and Midwives Registration Board, was chaired by the Director
General of Health, who was appointed by statute. It is interesting to note that whilst the
Nurses and Midwives Registration Board included board members who were nurses, if the
Director General of Health was absent, any other Registered Medical Practitioner who was an
officer of the Department of Health was able to chair the Board, rather than one of the
Registered Nurse Board members (Papps & Kilpatrick, 2002). The Nurses and Midwives
Registration Act 1925 (NZ) also created a new category of nurse, the registered maternity
nurse. Less than a year after the implementation of the Nurses and Midwives Registration
Act 1925 (NZ), further changes were made and the Nurses and Midwives Registration
Amendment Act 1926 (NZ) was enacted, resulting in the age requirement for registration being
increased to 23 years again.
By the post-depression era of the 1930s nursing and the other main health professions, were
clearly defined in terms of their legislated title, role, and programmes of education, inter-
professional relationships and social status. However, the election of a Labour government in
1935 introduced the framework for a state funded comprehensive health system. This was to
have a substantial influence on funding, health care delivery and health work force
development for the next 50 years (French, 1998; Gage & Hornblow, 2007). State funding of
hospital based facilities was enacted, however payment for services in the primary sector was
retained and subsidised by the government. This resulted in the majority of nurses being
‘trained’ through apprenticeship programmes, employed in state sector hospitals, under
increasingly hierarchical structures, that included medical oversight of nursing practice. Those
nurses who registered and were employed in the primary sector, fulfilled a role primarily of
supporting the general practitioner (Gage & Hornblow, 2007).
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It is important to note that throughout the 1920s, nurses had debated a potential move of
nursing education to the University sector, and in 1928 the University of Otago established a
diploma programme. History indicates that the university programme was not sustainable due
to a variety of reasons, most notably a lack of political support as the apprenticeship model of
training nurses within the public health system provided a consistent supply of, what was a
relatively inexpensive, health workforce (Papps, 1997). This factor, in association with the
prevailing strong Nightingale ethos and insufficient funding, appears to have resulted in the
collapse of the university based nursing programme (Gage & Hornblow, 2007; Papps, 2002).
Throughout the 1930s the number of registered nurses continued to grow and further
amendments were made through the Nurses and Midwives Registration Amendment Act
(1926). The amendments provided the Nurses and Midwives Registration Board with the right
to approve private hospitals as nurse training institutions, and introduced the ability to limit
both public and private hospitals in terms of their structure and their demographic location
(French, 1998). In 1939 a further amendment to the Act instituted the requirement that all
nurses and midwives must hold an annual practising certificate. The power of the Nurses and
Midwives Registration Board was extended to allow it to impose fines for proven cases of
negligence and/or misconduct. The amendment also identified and approved Public Mental
Hospitals as nurse training schools (French, 1998), however it was not until the enactment of
the Nurses and Midwives Amendment Act 1944 (NZ) that the registration of psychiatric nurses
came under the control of the Nurses and Midwives Registration Board.
During the 1940s a number of amendments to the Act were made, many it would seem in
response to the increased demand for nurses as a result of New Zealand’s involvement in
World War II. The Nurses and Midwives Registration Amendment Act 1943 (NZ) introduced the
recognition of training undertaken by New Zealand nursing students overseas, in particular
those based in hospital ships during World War II, and again the age for general nurses at
registration was reduced, this time to 21 years. The enactment of the Nurses and Midwives
Registration Amendment Act 1944 (NZ) allowed for the creation of new training programmes,
including the registration of psychiatric nurses (introduced in 1944), and the registration of
male nurses (introduced in 1945). In 1945 new legislation, the Nurses and Midwives Act 1945
(NZ), revised and updated all previous revisions and amendments. The Nurses and Midwives
Act 1945 (NZ) remained in place, with amendments, until 1971 and allowed for an increase in
membership of the Registration Board, to nine members who were appointed for a three year
term. It also extended the Board’s disciplinary powers to include suspension of registration for
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up to a 12 month period (Papps, 2002). In the decades following World War II, the New
Zealand health sector was to become one of the largest areas of employment, and the most
expensive in terms of New Zealand government expenditure (Gage & Hornblow, 2007).
In 1957 a noteworthy change in the education of nurses took place as a result of the
implementation of the Nurses and Midwives Amendment Act 1957 (NZ). This legislation
introduced the registration category General and Obstetric Nurse, which in turn resulted in the
development of a new three year curriculum and training programme that combined the
previously separate, general and maternity nurse training programmes. Further amendments
to the legislation, curriculum and training in the 1960s introduced a register of Psychopaedic
Nurses (1961), and a register of Community Nurses (1965). The title ‘community nurse’ was
later changed to ‘enrolled nurse’ (Nurses Act (NZ), 1977). During the 1960s the need for
English language competence for nurses from overseas applying for registration in New
Zealand, was also specified. The clause “and is a fit and proper person to be registered”
(Nurses Act (NZ), 1977, s15) was introduced in association with applications for registration
(French, 1998; Papps, 2002).
4.3.2 Legislative and educative change
The Nurses Act 1971 (NZ) is an important piece of legislation in terms of the history of nursing
regulation in New Zealand. It established the Nursing Council of New Zealand to replace the
previous Nurses and Midwives Board. The Nursing Council of New Zealand was a ‘Body
Corporate’, thus separating the registration function of nursing and midwifery from the
Department of Health for the first time (Papps, 2002). The Nurses Act 1971 (NZ) clearly
stipulated the membership, functions of the chairman and deputy chairman, allowed for the
appointment of a Registrar of nurses, Deputy Registrars and other employees as necessary.
However, it was no longer enshrined in legislation that the position of Registrar be occupied by
a nurse and, as a result, a succession of lay persons were appointed to the position of Registrar
of the Nursing Council of New Zealand until 1989, when the first nurse/midwife was appointed
as the Registrar of the Nursing Council (Papps, 2002). The legislation specified the functions of
the Nursing Council of New Zealand including the authority to register, the authority over
schools of nursing, nursing programmes and experimental programmes, disciplinary and
disability powers, appeal procedures and annual practising certificate requirements (Burgess,
2008; Papps, 2002).
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The omission of the word ‘Midwives’ from the title of the Nurses Act 1971 (NZ), reflected the
position of midwives in the health sector at that time. As Papps (1997) noted, entry to
midwifery training in New Zealand was post nursing registration. The medicalisation of
childbirth and subsequent hospitalisation of women for childbirth, had occurred over a
number of years, and the majority of births at that time took place in maternity hospitals and
wards within general hospitals (Papps, 1997).
In 1971 the report An improved system of nursing education in New Zealand (Carpenter, 1971)
(subsequently referred to as ‘The Carpenter Report’), was released and recommended that
nursing education be moved from the hospital based training programmes, to occur in
educational institutions in cooperation with selected hospitals and health agencies (Carpenter,
1971). Dr Helen Carpenter14 had been contracted by the New Zealand Government to lead
this review of nursing education in New Zealand having previously contributed to the
development of nursing education programmes in Canada. The review was undertaken at a
time when student attrition rates were high and there was public concern that the traditional
apprenticeship scheme of hospital training was exploitative.
In response to the report recommendations, the Minister of Education established a
committee to consider ‘recommendation 1.6’ of The Carpenter Report (1971). The purpose of
the 1.6 Committee was to
…study the proposal for development of colleges of health sciences for the
preparation of nurses and other categories of personnel needed for the health
services; and that the committee make recommendations to the Government
concerning the most suitable educational setting for the development of these
colleges.
The committee, comprised 16 members, and did not include any representation from the
recently disestablished Nurses and Midwives Board nor the newly instituted Nursing Council of
New Zealand. Representatives were drawn from the Departments of Education and Health
(including the Assistant Director of Nursing Education in the Department of Health’s Division of
Nursing), the Vice Chancellors’ Committee of the University sector, the Technical Institutes
Association, the National Council of Women, the New Zealand Nurses Association, the New
14 Dr Helen Carpenter was the Director of the School of Nursing at the University of Toronto and a Consultant for the World Health Organisation. She had been involved in the redesign of nursing education programmes in Canada.
86
Zealand Student Nurses Association, the Medical Association of New Zealand and the Clinical
Dean of Otago University Medical School (Papps, 2002; Papps & Kilpatrick, 2002).
Whilst the 1.6 Committee did not reach consensus over the location of nursing education
programmes, the government agreed to establish two pilot programmes for a three year
comprehensive nursing diploma. Ultimately technical institutions were selected as the most
suitable location to educate student nurses and, as noted by Papps (2002), “the influence of
Helen Carpenter in this regard is apparent, since in Canada, nursing education programmes
were being transferred from hospital based training to community colleges” (p. 7).
Whilst there was acknowledgement that there was a need to review nursing education in New
Zealand, there was prevailing public resistance from hospital boards and many in the health
professions, including nurses, to the shift of nursing and midwifery education from the
traditional hospital based apprenticeship programmes to educational institutions. However,
despite this resistance the transition from hospital based nursing training to nursing education
programmes situated in polytechnics, commenced in March 1973. Two three-year
comprehensive nursing programmes were commenced in polytechnics, one situated in
Wellington and the other in Christchurch (Papps, 2002; Papps & Kilpatrick, 2002).
The enactment of the Nurses Act 1971 (NZ) provided for the registration of Comprehensive
Nurses from the programmes in technical institutions and removed age as a criterion for
registration, except for the enrolment of Enrolled Nurses. The Nurses Act 1977 (NZ) was the
final iteration of the Nurses Act, and for the next 26 years this was the legislation that
regulated nurses and midwives in New Zealand. During this time the Act and accompanying
regulations, were subject to numerous amendments. Most significantly in 1990, the Nurses
Amendment Act 1990 (NZ) restored autonomous practice to midwives and provided for direct
entry midwifery programmes, which meant that intending midwives were no longer required
to be registered as a nurse prior to entering a midwifery programme (Papps, 2002).
4.3.3 Evolving health services, nursing specialisation and health reforms
The 1980s marked the commencement of 20 years of turbulent health reforms and
restructuring within New Zealand. Rapid technological advances not only provided
opportunities for increased specialisation of nursing practice, but also increased the cost and
complexity of health care delivery. A change in government policy in the early 1990s
introduced the market driven business model to a publicly funded health service. Government
scrutiny of health services was intensified and considerable rationalisation and restructuring of
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services, including the health workforce, was commenced. The previous hierarchical systems
that had endured within the hospital sector for nearly one hundred years were dismantled,
resulting in the removal of many traditional nursing leadership roles. Whilst it cannot be
denied these changes had a major impact on the culture of the health workforce, for many
resulting in conflict, disillusionment and mistrust, the environment of constant change and
reform also presented opportunities, and nurses responded to the challenge evolving and
expanding their careers, education and practice (Bamford-Wade & Moss, 2010).
The changes to the health and educational sectors initiated wide ranging debate within nursing
leadership and culminated in the development of the discussion paper A Framework for
Nursing and Midwifery Education in New Zealand (Vision 2000 Committee, 1992), more
commonly referred to as The Vision 2000 document. This discussion paper proposed a
national framework for nursing and midwifery education and was the culmination of national
discussions with nursing leaders, educationalists, professional organisations, nurses and the
regulatory authority. Whilst the framework was never formally adopted, due to the lack of
overall consensus with regard to some recommendations, the Nursing Council of New Zealand
continued to progress and, as the legislation allowed, implemented several of the key issues.
As noted by Papps and Kilpatrick (2002, pp. 10-11) these issues included “entry to practice for
registered nurses by degree; standards and competencies; a post-registration framework, and
competence-based practising certificates”.
Eventually, although the business focused reforms of the 1990s failed, an increased awareness
of the need for a realignment of health service delivery, workforce planning, professional role
expansion and accountability to the public, remained (Bamford-Wade & Moss, 2010). During
the 1990s a new Nurses and Midwives Bill had been drafted but never passed. A major change
in this new legislation was to be a focus on ‘competence based practice’ with the requirement
that all nurses must demonstrate evidence of continuing competence, a requirement not
enshrined in the previous legislation. Initially, changes were expected by way of an
amendment to the Nurses Act 1977 (NZ), however, during the intervening years, a change in
government, the occurrence of a number of high profile medical incidents and subsequent
enquiries, all combined to result in a refocusing of legislative priorities (Kilpatrick, 2009; Papps,
2002). These events contributed to the government implementing a wider review of all
professional regulation, including nursing and as a result the proposed Nurses and Midwives
Bill was destined to never reach Parliament (Burgess, 2008).
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In 1994 as a direct result of the findings made in the Report of the Cervical Cancer Inquiry
198815, the Health and Disability Commissioner Act 1994 (NZ) was passed into law. The
purpose of this Act was to
promote and protect the rights of health consumers and disability services
consumers, and, to that end, to facilitate the fair, simple, speedy, and efficient
resolution of complaints relating to infringements of those rights (Health and
Disability Commissioner Act (NZ), 1994, s6).
This legislation was followed by the implementation of the Code of Health and Disability
Consumers’ Rights 1996 (NZ) which set out ten legally enforceable rights of consumers, and
the corresponding duties of health and disability service providers.
In 1998, the Nursing Council of New Zealand commenced the first major review of nursing
education since the Carpenter Report of 1971. In 2001 the Strategic Review of Undergraduate
Nursing Education: Report to Nursing Council of New Zealand, now commonly known as The
KPMG Report, was published. This report set the direction for nursing education for the next
ten years and introduced substantial developments in post-registration nursing education,
including the development of programme standards and competencies for the clinical Master
of Nursing for the preparation of Nurse Practitioners.
Finally in October 1999, the Nurses Act 1977 (NZ) was further amended, and hope of a new
Nurses Act was overtaken by the proposal for an omnibus type legislation which would
encompass the eleven existing occupational statutes governing 13 separate health professions
(Health Practitioners Competence Assurance Act (NZ), 2003). The policy framework originated
from an inter-departmental working party situated in the then Ministry of Commerce (now the
Ministry of Economic Development); the document was titled Policy Framework for
Occupational Regulation: A Guide for Government Agencies in Regulating Occupations
(Ministry of Commerce, 1999). The Government formally agreed to the policy framework in
August 1998 and, in a Ministry of Health discussion paper (2000), proposed new legislation,
the Health Professionals Competency Assurance Bill 2000 (NZ). Submissions on the various
proposals and options contained in the discussion document were lodged with the Ministry of
15 The Cartwright Report, named after the presiding judge, Judge Dame Silvia Cartwright, was the blueprint for patients' rights in New Zealand and arose after a Committee of Inquiry into unethical study involving women with major cervical abnormalities without definitively treating them undertaken at the country's premier women's hospital between 1966 -1987.
89
Health in November 2000. Although there was optimism that the Health Professionals
Competency Assurance Bill 2000 (NZ) would be introduced into the house during 2001, it did
not occur until June 2002. A number of amendments were made to the Bill including a change
in the name of the Bill – the Health Practitioners Competence Assurance Bill 2002 (NZ). The
Health Practitioners Competence Assurance Bill 2002 (NZ) was received by the Select
Committee for submissions in October 2002, and the Select Committee reported back to the
House in May 2003. The legislation was finally passed through all stages of Parliament and
received Royal Assent on 18 September 2003 - the Health Practitioners Competence Assurance
Act 2003 (NZ).
The Health Practitioners Competence Assurance Act 2003 (NZ) came into force twelve months
later (18 September 2004), and in doing so repealed the existing 11 individual occupational
statutes. At the time of enactment the Health Practitioners Competence Assurance Act 2003
(NZ) applied to 15 registration authorities including nursing, however Section 115 of the Act
allows the Minister of Health to make a recommendation to the Governor-General “that the
Act be extended to include a new health profession if they meet the criteria in Section 116 of
the Act”. In summary Section 116 of the Health Practitioners Competence Assurance Act 2003
(NZ) allows that, should the Minister be satisfied, after consulting with the interested
organisation, that the new profession either “poses a risk of harm to the public” or “it is
otherwise in the public interest to regulate” he may deem the criteria to be met (Health
Practitioners Competence Assurance Act (NZ), 2003). However, neither the term “risk of harm”
nor “public interest” is defined in the Act. These are left to the discretion of the individual
regulatory authority to determine.
It is also important to note that not all health professional groups in New Zealand are
regulated under the Health Practitioners Competence Assurance Act 2003 (NZ), either because
they work under the direct supervision of a regulated health professional, or because they are
deemed to pose little risk to the public. These professional groups are regulated in a variety of
non-statutory ways through their employers or in some instances self-regulated by the
profession (Ministry of Health, 2010). The Health Practitioners Competence Assurance Act
2003 (NZ) does not prevent unregulated or untrained people from operating in the health
sector provided they do not “hold themselves to be a registered health professional” (Ministry
of Health, 2010). Under the Act, the Minister of Health is also responsible for a single shared
Disciplinary Board the Health Practitioners Disciplinary Tribunal, which is administered for all
health professions specified in the Act. This tribunal hears and determines cases against health
90
practitioners, although the regulatory authorities, via professional conduct committees, can
also investigate individual practitioner’s competence and conduct.
4.3.4 Legislation and the New Zealand health system
As previously indicated, the health sector in New Zealand is comprised of a complex system of
legislation, organisations and people. Each has a role in the provision of health and disability
services, the aim being “to achieve better health outcomes for the New Zealand public”
(Ministry of Health, 2011a). The health and disability system’s statutory framework is now
comprised of over 20 separate pieces of legislation. Whilst the most important in terms of this
research is the Health Practitioners Competence Assurance Act 2003 (NZ), it does not function
in isolation and intersects with a number of other Acts, for example the Health Act 1956 (NZ),
the Health and Disability Commissioner Act 2004 (NZ), the New Zealand Public Health and
Disability Act 2000 (NZ) and the Crown Entities Act 2004 (NZ). All of these statutes have an
impact in terms of determining the social and political context in which health professionals
practise.
The Health Act 1956 (NZ) specifies the roles and responsibilities of incumbents to safeguard
the public’s health, including the Minister of Health, the Director of Public Health, and
designated officers for public health. It contains the provisions for environmental health,
infectious diseases, health emergencies and the national cervical screening programme.
As previously noted the Health and Disability Commissioner Act 1994 (NZ) was enacted as a
direct consequence of the findings of the Report of the Cervical Cancer Inquiry (Cartwright,
1988). The New Zealand Public Health and Disability Act 2000 (NZ) establishes the structure of
underlying public sector funding and the organisation of health and disability services. It
establishes District Health Boards (DHBs) and sets out the duties and role of key participants,
including the Minister of Health, Ministerial committees, and health sector provider
organisations. The New Zealand Public Health and Disability (NZPHD) Act 2000 (NZ) sets the
strategic direction and goals for health and disability services in New Zealand. These include
“to improve the health and disability outcomes for all New Zealanders, to reduce disparities by
improving the health of Maori and other population groups, to provide a community voice in
personal health, public health, and disability support services and to facilitate access to, and
the dissemination of information for the delivery of health and disability services in New
Zealand” (Ministry of Health, 2011b).
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A large number of health service provider organisations in New Zealand are owned by the
Crown (from the Commonwealth term Crown), and are termed Crown Entities16. The Crown
Entities Act 2004 (NZ) provides the fundamental statutory framework for the establishment,
governance, and operating of Crown Entities. It clarifies lines of accountability, relationships,
and reporting requirements between Crown Entities, their Board members, the relevant
responsible Ministers, and the House of Representatives.
4.3.5 Review of the Health Practitioners Competence Assurance Act 2003 (NZ)
In 2009 the Psychotherapy Board of New Zealand, which was established in 2007, became the
16th health profession to be regulated under the Health Practitioners Competence Assurance
Act 2003 (NZ). In the same year, concerns had been raised in government, relating to the high
costs associated with the establishment of separate authorities and a perceived ‘proliferation
of registration authorities’ (Ministry of Health, 2010). The Director-General of Health directed
the Ministry of Health to review the operation of the Health Practitioners Competence
Assurance Act 2003 (NZ). A discussion document was released for public consultation. Its
purpose was to:
• outline the policy principles that are relevant to regulating health professions,
• discuss the Ministry’s criteria for regulation and those used in similar jurisdictions,
• propose revised criteria to assist the Ministry in advising the Minister whether a
profession ‘poses a risk of harm’ or ‘it is otherwise in the public interest’ to regulate
that profession (New Zealand Ministry of Health, 2010).
The findings of the review determined that no operational changes were required in terms of
the Health Practitioners Competence Assurance Act 2003 (NZ). However, the criteria for
recommending registration of a profession and any new registration authorities were
amended. The aim was to monitor and reduce future potential for further increases in the
number of registration authorities.
A Ministerial review was commenced in 2011 to investigate the efficacy of the ‘administrative
functions of the sixteen regulatory authorities’. The purpose of this review was primarily
focused on reducing the financial costs related to the administration of separate independent
regulatory authorities, with the proposal that grouping the administrative functions of the
16 A Crown entity is an organization that forms part of New Zealand's state sector established under the Crown Entities Act 2004, a unique umbrella governance and accountability statute.
92
regulatory authorities would reduce costs by several million dollars per annum17. However, to
date, this review has not been completed as no agreement has been achieved between the
individual regulatory authorities and the Ministry of Health.
In August 2012, the National Government of the day initiated a third review of the Health
Practitioners Competence Assurance Act 2003 (NZ). The document Review of the Health
Practitioners Competence Assurance Act 2003: A Discussion Document (Ministry of Health (NZ),
2012a) was released for public consultation on 31 August 2012 and states that it combines the
previous two reviews. Four areas for review are highlighted - Future focus, Consumer focus,
Safety focus, and Cost effectiveness focus. However, a large portion of the document focuses
on the authority and functions of the independent regulatory authorities, and provisions in
relation to the Ministry of Health and health workforce issues. Whilst a public consultation
was undertaken, to date, no outcomes are publicly available.
4.4 Review of Nursing Council of New Zealand documents
Chronologically, there is a well-documented trail mapping the development of the Nursing
Council of New Zealand Continuing Competence Framework over ten years. The Nursing
Council of New Zealand initially signalled this work in its inaugural Strategic Plan 1 April 1994 –
31 March 1997 (Nursing Council of New Zealand, 1994). The four stage project plan identified
a number of critical strategic issues associated with the development of the Continuing
Competence Framework. The implementation of competency based practising certificates,
was identified as a strategic priority. This was closely associated with the requirement to
develop criteria for performance-based annual practising certificates and recertification
processes, development of “registration / enrolment competencies” and the development of
post-registration competencies and standards (Chappell, 1995; Nursing Council of New
Zealand, 1994).
In August 1996, a discussion paper The Development of Performance-based Practising
Certificates, was released by the Nursing Council of New Zealand for consultation. The focus of
this paper was stated as being a “means to ensure public confidence in the continuing
competence of nurses and midwives” (Nursing Council of New Zealand, 1996, p. 1). The
17 The health regulatory authorities in New Zealand are independent of the Ministry of Health and as such the annual fees paid by the health professionals so regulated fund the functions of the individual regulatory authorities.
93
subsequent analysis of submissions relating to this consultation was presented to the Nursing
Council of New Zealand at its meeting on 28-29 April 1997 and as a result the first document
outlining the draft Competency-based Practising Certificate Framework was developed for
consultation in 1997 (Nursing Council of New Zealand, 1997). A working group on
competency-based practising certificates was established in 1997, with representation from a
range of nurses and nursing organisations, including consultation with Maori Nurse
Representatives. In September 1998, draft guidelines for Competency-based Practising
Certificates were developed for wide consultation, and on 1 April 1999 Guidelines for the
Continuing Competence Framework was published (Nursing Council of New Zealand, 1999).
In March 2001, following extensive consultation the Nursing Council of New Zealand published
the document Towards a Competency Framework for Nursing (Nursing Council of New
Zealand, 2001b). Essentially this document described the process and components of the
proposed Continuing Competence Framework, developed in anticipation of the impending
enabling legislation. In November 2001 the Nursing Council of New Zealand went on to
publish Guidelines for Competence Based Practising Certificates for Registered Nurses (Nursing
Council of New Zealand, 2001a). This document aimed to provide nurses with information
about the proposed process for renewal of Annual Practising Certificates (recertification), once
the new legislation was in place. In December 2002 a report to the Nursing Council of New
Zealand proposed a new strategic project to further develop the Competency Assurance
Framework18.
The Nursing Council of New Zealand minutes of 1 July 2003, record discussion related to the
proposed Competency Assurance Framework, and the anticipated impact of the legislative
changes outlined in the Health Practitioners Competence Assurance Bill 2002 (NZ) (Health
Practitioners Competence Assurance Bill (NZ), 2002). It was noted in these minutes that there
was also discussion with regard to the role of the Nursing Council of New Zealand. The
minutes indicate that some Council members perceived that there was confusion and
misunderstanding amongst nurses, with regard to the role and functions of the Council in
relation to continuing competence. A suggestion was made that a video be produced,
outlining the key functions of the Council. However, there is no record that this initiative was
undertaken.
18 It is noted that during this time there were frequent changes in the terminology used in Nursing Council of New Zealand documents, to describe the framework and processes that are now formally named the Continuing Competence Framework.
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A memo to the Council (January 2004) recommended approval of the draft consultation
document Review of the Guidelines for Competence-based Practising Certificates (Nursing
Council of New Zealand, 2004c). The consultation document proposed the level of assessment
required for continuing competence purposes; issues related to the validity of using portfolios
for assessment in this context; the resource implications of a random audit of portfolios; and
the time and effort required by nurses to meet the competence requirements. It was noted
that the Health Practitioners Competence Assurance Act 2003 (NZ) does not define
competence, but does define the required standard of competence in relation to a health
practitioner as “the standard of competence reasonably to be expected of a health practitioner
practising within that health practitioner’s scope of practice” (Health Practitioners Competence
Assurance Act (NZ), 2003, 5) and that this definition suggests more than entry level practice
(Nursing Council of New Zealand, 2004c). However, the memo to the Council included a
recommendation that the assessment of continuing competence should be at ‘low level‘,
although what this terminology means is not specified.
Consultation on the Review of the Guidelines for Competence Based Practising Certificates
(2004c), commenced in March 2004 and submissions were closed on 31 May 2004. The
consultation document was circulated to a wide range of individuals and groups, and included
a number of important appendices: 1: The current guidelines for competence based practising
certificates. 2: Continuing competence requirements of other nursing authorities. 3: Continuing
competency requirements of other professions. 4: Continuing practice competencies for the
renewal of practising certificates.
An in-depth analysis of the submissions derived from the Review of the Guidelines for
Competence Based Practising Certificates (2004) was completed and presented to the Nursing
Council of New Zealand on 1 August 2004, in association with the document Continuing
Competence Framework (Nursing Council of New Zealand, 2004a). This appears to be the final
document outlining the Nursing Council of New Zealand Continuing Competence Framework
requirements prior to implementation.
It is clear that extensive consultation occurred over a number of years during the development
and led to various iterations of the Continuing Competence Framework between 1997 and
2003. However, it is important to note that the Continuing Competence Framework could not
be implemented until the change in the legislation occurred, with the enactment of the Health
Practitioners Competence Assurance Act 2003 (NZ). The following section (4.5) presents the
95
review of Nursing Council of New Zealand policy documents related to the Continuing
Competence Framework and associated recertification processes.
4.5 Analysis of Continuing Competence Framework and Recertification policies
This section (4.5) provides a critique of the clarity and consistency of the Nursing Council of
New Zealand policy documentation associated with the Continuing Competence Framework.
Two policy documents have been developed in association with the implementation of the
Nursing Council of New Zealand Continuing Competence Framework. They are The Continuing
Competence Framework, and The Recertification Audit Process Policy.
The Continuing Competence Framework is a publicly available document on the Nursing
Council of New Zealand website. However, whilst it is called a ‘policy’, it is written in the form
of a guideline. It does not provide any indication of the date on which it came into effect, or a
date when it will be reviewed. In association with the Continuing Competence Framework is a
subordinate in-house procedural guide that is not publicly available. It outlines the in-house
operational and procedural processes and requirements of the Continuing Competence
Framework. This document is written in the form of a Memorandum (dated August 2004).
The Recertification Audit Process Policy (Guideline Policy 05.3) (August 2006; May 2008) is also
an in-house document and not publicly available. This ‘policy’ is also written in the form of a
guideline or procedure document. It does not include a purpose statement or any linkage with
the Continuing Competence Framework. The document focuses solely on the procedural
aspects of the Recertification Audit process. The criteria for exemption from audit, and the
‘evidential requirements’ associated with the Recertification Audit Process are publicly
available on the Nursing Council of New Zealand website. However, there is no purpose
statement or information linking the Recertification Audit to the Nursing Council of New
Zealand Continuing Competence Framework. In addition no information is available to nurses
with regard to the recertification process timelines and document tracking once the audit
process has been commenced.
At the time this document review was undertaken, all aspects of the Continuing Competence
Framework process; the Application for Recertification (Annual Practising Certificate) and the
Recertification Audit Process, were administered in a hard copy format. A package of the
relevant documentation was posted annually to each individual nurse, to either apply for
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Recertification (renewal of the Annual Practising Certificate), or selection for participation in
the Recertification Audit process.
The documentation provided to the nurses applying for Recertification is a package that
includes all of the required documents and the required timeframes for completion. However,
the nurses who are selected for Recertification Audit receive a package that includes:
• A template letter explaining the requirements of the Recertification Audit
• A participant information sheet – why have I been selected for a recertification audit?
• An Audit Checklist
For all other required documents, such as: the Standards of Practice; the Domains and
Competencies of Practice; the assessment criteria and associated assessment forms, the
nurses are directed to source them directly from the Nursing Council of New Zealand website.
At the time that Stage One of this research was completed the Nursing Council of New Zealand
recertification audit documents were available in PDF format as read only, and required the
nurse to download and/or print them. Subsequently, the Nursing Council of New Zealand has
implemented the recommendations of this evaluation and the recertification audit
documentation is now able to be completed electronically.
As noted in Chapter Three section 3.3.2.1, the structured approach to policy analysis proposed
by Musick (1998), provided a useful framework to inform the analysis of the two key Nursing
Council of New Zealand policy documents associated with the Continuing Competence
Framework - The Continuing Competence Framework and The Recertification Audit Process.
According to Musick (1998), policy analysis is concerned with two distinct but related
processes – the contents of the policy and the process by which it was developed. Musick
(1998) notes that often policy initiatives are advocated or described, without an examination
of the process by which they were developed, or who was involved. Table 5 presents the
summarised analysis of the Nursing Council of New Zealand policy documents associated with
the Continuing Competence Framework: Continuing Competence Framework, and
Recertification Audit Process Policy.
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Table 5 Analysis of key Nursing Council of New Zealand policy documents Components of framework The Continuing Competence Framework The Audit Process (Recertification Audit Policy) Conceptual: What are the core concepts under discussion? How are they defined? What are their measurable outcomes?
Competence Continuing competence
Competence Continuing competence Recertification
Normative: What "ought to be" true in regard to the policy? Do current views of key people or groups differ?
Policy developed from an extensive range of submissions from internal and external stakeholders
Policy developed from a range of submissions from stakeholders
Theoretical: Within what theoretical framework(s) does the policy fit?
Legal/regulatory Legal/regulatory
Empirical: Are there research studies in the literature which could be helpful in illuminating the issues? What important facts can be gleaned from these studies?
Literature from other nursing regulatory authorities (United Kingdom Nursing and Midwifery Council, Canadian Nurses Association, Nursing and Midwifery Council of Australia) informed the development of the Continuing Competence Framework. Limited empirical research was evident in the background to the development of the policy. To date it appears no other regulatory authorities internationally have undertaken research into the efficacy of the Continuing Competence Frameworks or associated policies.
Literature from other nursing regulatory authorities i.e. United Kingdom Nursing and Midwifery Council, Canadian Nurses Association, Nursing and Midwifery Council of Australia, and the National Council of State Boards of Nursing, has informed this process. A small body of published empirical research was evident in the background to the development of the policy. However it appears a pragmatic approach was used in determining required criteria.
Economic: What impact would the adoption of the policy have on budgetary resources? What economic structures would need to be in place in order to implement the policy?
Recommendation in 1998 that the Nursing Council of New Zealand documents a full cost-benefit of the introduction of competence based practising certificates.
Significant impact on budget resources noted if the Nursing Council of New Zealand was required to audit all nurses – mitigated to some extent by the development of a framework for the approval of Professional Development and Recognition Programmes (PDRP)
Cultural: How are different organizational, racial, gender and/or professional cultures affected by the policy?
Working party to develop cultural competencies included Maori representation.
Not identified
Ideological: How are the ideological and informational aspects of the policy interwoven? Do various parties participating in the policy development process bring strong ideological frameworks into the discussions?
Decisions from submissions to consultation documents generally went with the majority view.
Decisions from submissions to consultation documents generally went with the majority view.
Framework informed by Musick (1998). Policy analysis in medical education: A structured approach.
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4.6 Nursing Council of New Zealand statistics
Section 4.6 presents the collation and analysis of a selection of statistical data provided by the
Nursing Council of New Zealand since the implementation of the Continuing Competence
Framework in 2004. Of particular interest are the numbers of Annual Practising Certificates
that have been issued, and the comparison between Recertification Audit completions and
Competence Notifications.
Figure 3 depicts the number of practising certificates issued by the Nursing Council of New
Zealand for the years from implementation of the Continuing Competence Framework (2004)
until data collection was undertaken in early 2010. These figures are inclusive of all nursing
scopes of practice, new graduate registrations and registration of internationally qualified
nurses.
Figure 3 Practising Certificates issued
As depicted there was a significant reduction in the number of practising certificates issued
between the 2004/2005 and 2006/2007 years. From 18 September 2004 the Nursing Council
of New Zealand implemented the Continuing Competence Framework and issued interim
practising certificates for periods of three, six, nine or twelve months on a quarterly basis to
correspond with the applicants’ birth date. The numbers for 2004/2005 year reflect this initial
process.
42,00043,00044,00045,00046,00047,00048,00049,00050,00051,00052,000
2004/2005 2005/2006 2006/2007 2007/2008 2008/2009
51,189
48,240
45,774 45,691
48,683
Practising Certificates issued
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In December 2005 the Nursing Council of New Zealand implemented the recertification audit
process. Nurses who did not meet the Nursing Council of New Zealand requirements for
ensuring continuing competence were issued with interim practising certificates under Section
31 of the Health Practitioners Competence Assurance Act 2003 (NZ). These were replaced with
full practising certificates as the nurses met the required conditions. As the numbers fall quite
steeply it appears that a number of nurses who were no longer practising, or who no longer
met the continuing competence requirements elected not to reapply for a practising certificate
during this initial two year period.
Of the 421 nurses selected for audit in the 2005/2006 year, 50 nurses chose not participate in
the Recertification Audit or renew their practising certificates. From 2006 to 2008 issue of
practising certificates remained relatively stable but in the 2008/2009 year there was a
significant increase of 12% recorded. This appears to be due to an increase in registration of
new graduates (6%), and of internationally qualified nurses (12%), and may be the attributed
to the international recruitment strategies employed by several large District Health Boards
(Nursing Council of New Zealand, 2010a).
Figure 4 depicts the recertification audit and competence notification trends over the period
since implementation of the Continuing Competence Framework. Nurses who are levelled on
Nursing Council of New Zealand approved Professional Development and Recognition
Programmes are exempt from the recertification audit process.
Figure 4 Recertification audit trends and competence notifications
2005/2006 2006/2007 2007/2008 2008/2009
421
1,288
1,083 1,075
289
1,129
768 768
82 159
315 307
43 50 40 105
Recertifcation audit Met requirements
Did not meet requirements Competence notifications
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Under the Health Practitioners Competence Assurance Act 2003 (NZ), Section 34, the Nursing
Council of New Zealand may review the competence of a nurse if she/he has not maintained
the required standard of competence; if there is evidence to suggest the nurse’s practice poses
a risk of harm to the public; or at any other time. Notifications are made through the following
mechanisms; by an employer when a nurse has resigned or been dismissed for reasons relating
to competence; by the Health and Disability Commissioner or the Director of Proceedings if he
or she believes that a nurse poses a risk of harm by practising below the required standard of
competence; and by any health professional who believes there is a competence issue.
Whilst this is a process independent of the Continuing Competence Framework, it was
important to review the competence notification trends in association with the Continuing
Competence Framework recertification audit data, as nurses who are reviewed under
competence notification are exempt from the recertification audit process.
4.7 Summary of findings from the document review and policy analysis
This section (4.7) summarises and highlights the findings from the document review, policy
analysis and statistical trends with regard to practising certificate renewal and competence
notifications. These findings will be discussed in more detail in Chapter Seven where the
results are triangulated.
4.7.1 Development of Continuing Competence Framework
There is significant evidence that the development and implementation of the Continuing
Competence Framework was well researched and detailed. It included extensive stakeholder
involvement, consultation, and feedback over an eight year period. However, the historical
documents relating to this project and the associated stakeholder contributions urgently
require professional indexing and archiving.
The selection of the continuing competence indicators – self-declaration, practise hours and
continuing professional development hours was based on the best international evidence at
the time of development and implementation. However, the decision to stipulate recency of
practice and continuing professional development in association with a specified minimum
number of hours required in a three year period appears to have been a pragmatic one, based
on what was considered fair and reasonable at the time.
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The inclusion of the Recertification Audit process in the Continuing Competence Framework
was a decision based on wide consultation and discussion at the time of implementation and
was considered to be an important measure of the reliability and validity of the Framework.
The subsequent decision to select five percent of the nursing population per year to
participate in the Recertification Audit appears to have been pragmatic. However, whilst there
is no documentation that suggests the selection of five percent was based on empirical
evidence the statistical comparison of Recertification Audit outcomes indicate that the process
is working effectively.
4.7.2 Policy documents
The policy documents associated with the Nursing Council of New Zealand Continuing
Competence Framework - Continuing Competence Framework Policy and Recertification Audit
Policy are substantially in-house procedural guidelines rather than overarching policy
documents and as such require review and amendment.
4.7.3 Recertification Audit
It is evident that the Continuing Competence Framework Recertification Audit process is
effective in terms of the statistical outcomes that have been demonstrated. However, a
number of quality improvement initiatives related to the nurses’ experience of the process
were identified during the document and policy review and will be further investigated in the
subsequent Stage One research phases.
Currently there is no facility for online application for Recertification or for submission and
tracking of Recertification Audit documentation. In addition there is not a clear and
transparent process in relation to the submission, assessment, tracking and management of
Recertification evidentiary documentation. Internal moderation of these items is ad hoc and
requires urgent revision in order to assure inter-rater reliability and transparency of audit
processes.
4.8 Concluding remarks
The Health Practitioners Competence Assurance Act 2003 (NZ) was enacted on 18 September
2003. As noted earlier, it was not until the enactment of this legislation that the regulatory
authorities, including the Nursing Council of New Zealand, had a legal mandate to provide a
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mechanism to ensure the competence of nurses. However, the various iterations of guidelines
for competence based practising certificates and other consultative processes clearly
demonstrate that the Nursing Council of New Zealand had prepared the ground well leading
up to enactment of the new legislation, and had developed an extremely comprehensive
evidence based Continuing Competence Framework. The findings of this document and policy
review indicate some areas for attention and these will be further discussed in Chapter Seven
in association with the findings from Phase Two (qualitative interviews) and Phase Three
(quantitative questionnaire) of the research.
The following chapter (Chapter Five) will present the findings derived from the qualitative
interviews undertaken with key nurse stakeholders.
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CHAPTER FIVE - PHASE TWO FINDINGS: INTERVIEW DATA
5.1 Introduction
This chapter will present the findings derived from the qualitative interviews completed with
key nurse stakeholders in relation to the Nursing Council of New Zealand Continuing
Competence Framework and associated recertification processes.
As previously discussed, 26 interviews were undertaken, with a purposive sample of key
stakeholders representative of the following groups: registered nurses who had participated in
a recertification audit; nurse managers and directors of nursing from District Health Boards;
primary and private sector organisations including non-government organisations, elder health
and disability services, Ministry of Health, professional organisations and schools of nursing.
Previous Chairs of the Nursing Council of New Zealand, previous and current Council staff were
also interviewed in order to provide additional data in relation to the historical, developmental
and operational aspects of the Continuing Competence Framework and to provide consistency
and validation of the findings from the document review and policy analysis completed in
Phase One.
Each interview ranged from 25 – 60 minutes in duration and was recorded, coded and then
transcribed. The transcribed data were analysed using Thomas’ (2003) general indicative
approach for qualitative data analysis. This method was used in order to condense the
extensive and varied raw data into a brief summary format, to establish clear links between
the research objectives and the summary findings derived from the raw data, and to allow the
researcher to identify categories and themes evident in the raw data. The general inductive
approach provided an efficient and systematic model for data analysis. Consistency of data
NCN
Z Co
ntin
uing
Com
pete
nce
Fram
ewor
k
Stage One Phase 1
Document & Policy Review
Stage One Phase 3
QuantitativeE-survey
Stage One Data triangulation &
discussion
Summary Recommendations
Stage One Phase 2
Qualitative Interviews
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theming was independently checked by one of my doctoral supervisors following the initial
thematic categorisation, and again by all of my doctoral supervisors following summary
analysis and generation of the sub-themes. The data findings from the interviews are
presented in this chapter and were used to inform the development of the web-based e-
survey. Triangulation of overall findings is presented in Chapter Seven.
It is important to note that the overwhelming response by the participants indicated a positive
commitment to the Continuing Competence Framework process. Further, they reported a
comprehensive understanding of the intention of the Continuing Competence Framework and
the purpose and intentions behind the process were considered imperative and valuable. In
particular, the participants endorsed the importance of the Continuing Competence
Framework process in meeting the Nursing Council of New Zealand agenda of public safety,
and emphasised the value of the Continuing Competence Framework process in addressing the
responsibility of individual nurses to engage with the process and maintain competence. The
three thematic categories and eleven sub themes that emerged from the data are listed in
Table 6 and presented in the subsequent chapter sections.
Table 6 Thematic categories and sub-themes
Thematic category Sub-themes
Competence • Lack of clarity and understanding • Purpose of the Continuing Competence
Framework • Continuing competence indicators • Education and continuing competence
The role of the Nursing Council of New Zealand
• Legal status of framework (indicators, self-declarations)
• Responsibility and accountabilities (role of bodies, people)
• Communication and consultation
The recertification audit process • Peer assessment • Audit requirements (documentation,
timeframes, guidelines and templates) • Transparency of the audit process • Communication and processes • Professional Development and
Recognition Programmes
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5.2 Competence
Competence was a major and underlying theme that emerged from all of the interviews.
Whilst it was generally acknowledged that the Nursing Council of New Zealand has defined
‘competence’ and set standards of ‘practice’, some felt there was a lack of clarity amongst
some nurses that resulted in a level of confusion, particularly with regard to the purpose of the
Continuing Competence Framework; interpretation and enactment of the competencies for
continuing competence; and / or understanding of how to interpret and provide evidence in
relation to the indicators of competence. Issues of validity and consistency were also raised in
relation to the indicators of competence and their relationship with continuing competence.
5.2.1 Lack of clarity and understanding
This theme emerged from a variety of comments made in relation to a general confusion of
nurses with regard to the concepts of ‘competence’ and ‘continuing competence’
I think many nurses perceive competence in terms of clinical tasks and competencies, not the whole picture. The current competencies seem quite repetitive and the language is complicated so this doesn’t help. I don’t think the competencies make it clear that nurses should be assessing their on-going competence – where they are now in terms of practice, rather than just being competent, which could be perceived as a minimum level.
There was a general view that clear guidelines are needed for nurses to help clarify the
concepts of competence and continuing competence, particularly in terms of ensuring that
nurses can accurately complete a self-assessment and the self-declaration for the renewal of
their annual practising certificate. The following quotes reflect some of the comments
Well I know myself the first time I had to fill out that form of course I was going to tick that I’m competent. ‘Cos I think I’m competent. But interestingly if you’re not knowledgeable about what the competencies are then how do you know. So maybe there should be something on the form that shows you what they are.
You know, ticking to say you’re competent actually doesn’t mean ‘Well I think I am competent’. Maybe it should be worded, ‘Can you provide evidence that you [continue] to meet the competencies?’ and ‘as you may be audited’.
5.2.2 Purpose of the Continuing Competence Framework
The opening question for each interview was “Tell me about your understanding of the
Continuing Competence Framework”. Generally the interview participants demonstrated they
clearly understood the purpose and importance of the Continuing Competence Framework in
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terms of requirements of the Health Practitioners Competence Assurance Act 2003 (NZ) and
the role of the Nursing Council of New Zealand as the regulatory authority. However, some
participants raised the issue of confusion regarding the purpose of the Continuing Competence
Framework suggesting that, while the Nursing Council of New Zealand has a role in “ensuring
some degree of competence”, there is a “general misunderstanding on behalf of nurses of
what the Council’s role is in this regard”.
Several participants indicated that the Nursing Council of New Zealand should be concerned
with the ‘minimum standard’ of competence and that it is the employers’ role is to drive a
performance development culture
I know that there is a set of competencies which are essentially minimum competencies for each of the scopes of practice NP, RN and EN or NA. That those are required by law under the HPCA Act and that Council has a - various processes for those three groups in terms of determining that members of the profession meet those [minimum] competencies. That, for the RN scope in DHBs, that process is significantly [related] to the PDRP programme and where there’s an established PDRP 19 programme Council audits the PDRP programme or authorises the PDRP programme as a proxy for Council’s own auditing process for RNs. RNs ‘levelled’ in a PDRP are required to meet higher levels of competency.
Another participant commented
It is how a nurse retains competence on an on-going basis [this is the point]. Nurses who have achieved a level on a PDRP are excluded from random audit because they have demonstrated they have achieved the required Council competence plus whatever additional ones are required for their level on the PDRP.
For others the framework was seen as a positive and necessary process about setting and
maintaining standards and the notion of capturing practice ‘development’
The Continuing Competence Framework is a process whereby Nursing Council has set some standards for the amount of professional development that nurses have to undertake in order to maintain their APC20. Also, the amount of time that they need to be in actual practice in order to maintain their APC, so it’s a way of
19 As noted in section 1.9 (p. 15) PDRPs are programmes offered by health provider organisations to their nursing staff. They are not under the control of the Nursing Council of New Zealand. However, if the PDRP is approved by the Nursing Council of New Zealand as meeting a prescribed set of competence standards, nurses who are members of the PDRP may be exempt from the Nursing Council of New Zealand recertification audit process. 20 Annual Practising Certificate (APC).
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creating a standard which replaces the previous system of having no standard of what people were engaged in.
Another participant expressed the view that “while no system can totally ensure competence it
is important to have some system to review competence”. The notion that the Council’s current
Continuing Competence Framework is just an ‘indicator’ of competence was also expressed by
this participant
...an audit done by a regulatory body in no way can say ... ‘Oh you’re competent to practise’. A PDRP process I think can because it goes into much more depth. But anything a regulatory authority does can only be an indicator really.
Nursing Council should actually clarify the purpose of the process … Because it has, it’s got confused with PDRP, without a shadow of a doubt. The idea of it being minimal and they’ve - and it’s a - just an absolute focus on safety. Public safety as opposed to professional development!
Another participant suggested that
Perhaps the Nursing Council of New Zealand needs to make it really clear what they want from the framework, do they want to monitor competence to ensure public safety or do they want to monitor competence, ensure public safety and promote professional career development. I think many nurses are confused because they think the Nursing Council of New Zealand owns the PDRP process and it all gets tied up with the competence framework – they don’t understand PDRP belongs to the employers and NZNO.
The issue of indicators of competence was also raised as an area that might be better clarified
within the competence assessment process.
5.2.3 Continuing competence indicators – do they infer competence?
Generally the indicators of continuing competence (Self-assessment, hours of practice and
hours of professional development) were thought to be adequate. However, the notion of
hours worked or hours engaged in professional development, as a reflection of competence
was not without some criticism. Issues identified included the actual number of hours in
comparison to other health professions, the determination of the number of hours, and
elements that one might capture in a portfolio to indicate competence relating to hours. The
idea that indicators might actually be a measure of competence was less clear as one
participant reported
The larger question is, are the competencies valid and reliable really? Because that’s the thing that you’re measuring them against. So that’s - if they’re not valid and reliable then actually the process is less important. And whilst they are
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the competencies that we have, there is quite a bit of literature and research around are they - you know are they actually the measures of what makes someone competent? How do we know that? Have we proven that those are the things that we look for?
One participant reported that portfolios are only useful if you can know what should go in
them stating that
You know everyone’s decided that the thing we need to do is create evidence for competence...they’re not quite sure what evidence and so they dump everything into a portfolio of evidence ‘cos they don’t have the ability or energy all the time to discern what is actually needed.
Whilst many participants debated aspects about hours and recency of practice as a valid
representation of practice the overall sentiment is captured in the following quote
Yes but even so just because somebody has met all of those requirements - the 60 hours etcetera I’m not sure you could still stand with your hand on your heart and say that’s a guarantee that somebody’s competent.
It was suggested by a number of the participants that nurses as health professionals need to
engage more in the process – that self-assessment should be a valid and reliable indicator of
competence if undertaken in an honest and thorough manner. The following issue was raised
With self-assessment you rely on the honesty and insight of the nurse, who is a health professional, and in most cases that is fine however there is always a very small group who will fall outside what is acceptable ... so the trick is how to validate a self-assessment...
The question of what constituted education for continuing competence was reported as a
central concern for a number of participants. There was a general feeling that many nurses did
not understand either what constitutes continuing professional development or how it
translates to evidence of competence. This element will be further discussed under the theme
‘Education and continuing competence’.
5.2.4 Education and continuing competence
Generally, participants indicated that the requirement for continuing professional
development/education was an appropriate indicator and expectation for continuing
competence. However, participants cited that there was a range of activities necessary to
maintain clinical skills but raised issues about their direct relevance to competence or public
safety. For example, intravenous accreditation or testing, manual handling, fire drills,
cardiopulmonary resuscitation and infection control updates might all be considered as
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‘continuing education’, and questions arose as to which of these activities were simply
refreshing existing skills, which led to new knowledge and which played any role at all in
assuring that a nurse was competent?
There appears to be several schools of thought around the professional development. And one school of thought is professional development needs to be new knowledge and building new knowledge to show that you’re continuing to build knowledge base. There’s another school of thought that any course could be perceived as professional development.
I think nurses understand how CPR, IV and all those task based clinical updates contribute to professional development; it’s the other stuff that isn’t so clear. The problem really is that people are gathering certificates for this and that purely as evidence, but really it’s more about what did you get out of it – how did .... enhance your practice. That’s what is generally not done well, it requires you to think about your practice and that has to be a good thing.
Several participants commented that consistent guidelines around expectations of what
constitutes continued professional development activities for continuing competence would
be beneficial to a number of nurses.
The only comment that I would make is that I think that there needs to be a line drawn in what constitutes continuing competence ...I know nurses for example who will go to the Nursing Council forum because they know that they will get a lot of hours for the Nursing Council forum. And while that’s professional update it’s not clinical update.
I guess that’s one of the things that isn’t captured very well by Nursing Council is the fact that their professional development contributes to their practice.
One participant was able to differentiate the confusion around educational activities and
competence suggesting that the
...requirement is that people are able to reflect on how a professional development activity enhances their ability to do their job, or enhances their registered nurse role.
Another participant reported that if you take the perspective that educational activities are
those which enhance the effective practitioner, then activities such as volunteering and non-
health related education might be used to “Describe that [activity] in terms in augmenting
their ability to be an effective practitioner”.
Participants broadly reported anxiety amongst nurses about the educational activities that
might count in continuing competence, the framework and indicators. They identified that the
portfolio and the role of portfolios for recording competence also caused some confusion.
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I think there’s a lot of confusion there. People don’t really know what they should be sort of measuring themselves against and what they shouldn’t, I don’t think it’s a straightforward process for them at all and in fact I think what’s happening is they’re tending to find someone else who’s been audited before and seeing how they can match.
They don’t seem to understand that you don’t need a whole portfolio of certificates and exemplars what you need is be able to provide concise evidence that you are competent to practice in the role you are in, so you actually need to focus on the actual competencies and how you meet them....
Both the effort to engage with the process and the lack of clarity around competence
requirements was reported as possibly impacting on an individual nurse’s willingness to
remain in the profession. This issue was also related to the requirements of the recertification
audit process. As two participants commented
I also think that we’ve lost - I mean, with the HPCA we’ve lost health professionals... they’ve said “Oh I can’t”, you know, “this is far too hard”.... There’s been a reaction to that and we have lost some good people as a result of it.
I mean having your competence questioned and going through a formal process is extremely stressful. I know the legislation wants to be helpful and supportive and that’s Council’s policy too but it is extremely stressful. I do think that the Nursing Council of New Zealand in its notification to the nurse that a competence question has been raised with the nurse - and I know it’s probably not the Council’s job to do this but the most difficult thing is if the nurse is so upset and then resigns her position because then they can’t find another place generally speaking to meet the practice requirement conditions Council puts on them.
No evidentiary detail was provided to substantiate this assertion around resigning from the
profession, but the perception of the amount of effort required to maintain a record of
competence was often mentioned. One participant, however, commented
I thought I would leave if I was ever audited. But I’m a good nurse, so I thought ‘why should I leave’ ... that was my motivator.
The other frequently mentioned element was the concern about the effort, the anxiety
invoked by the process and the lack of clarity around responsibility for maintaining
competence
They don’t realise that it’s their individual responsibility. And if you work with nurses who have got issues around competence or issues … or even being audited. They don’t understand that it’s their responsibility. They think it’s the employers or they think “Well you haven’t done this for me.
This issue is further reported in the consideration around accountabilities and responsibilities.
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5.3 The role of the Nursing Council of New Zealand
The role of the Nursing Council of New Zealand in terms of ensuring public safety was
discussed by most participants. Issues with regard to nurses’ general understanding of the
Council’s role, jurisdiction and discretion were raised in relation to the Continuing Competence
Framework.
5.3.1 Legal status of framework (indicators, self-declarations)
The Application for Practising Certificate form requires that nurses make a self-declaration that
they meet the requirements stipulated by Council. Participants identified that there is an
apparent lack of understanding of some nurses with regard to the status of the self-declaration
or that the application for practising certificates had in fact changed as a result of the
Continuing Competence Framework and was now competence based. One commented
I [suspect] many nurses just get the form tick the boxes, pay the money and hope they will never be audited. I don’t think they actually stop and think about am I competent or what they’re signing. That probably only happens if they get called for audit.
Another commented
Actually ... have had the odd case where nurses tick all the boxes and know they haven’t done the number of required hours.
Other comments reported the reaction of nurses to receiving the “package” from the Nursing
Council of New Zealand advising that they were being audited.
But surprisingly even people who should have an understanding of what it all means often get hooked into the providing evidence. And I wonder if that’s a response to the anxiety about ... they think I’m incompetent, so I need to show them everything I’ve got that proves that I have a shred of competence.
5.3.2 Responsibility and Accountabilities (role of bodies, people)
This sub theme identified a view that nurses may not have a clear understanding about the
role of the Nursing Council of New Zealand and their personal responsibility for their own
competence. There was a recurrent theme that nurses did not understand that this was a part
of their professional responsibility and only worried about it if they were audited. One
participant expressed the view that the audit process provided “a good wake-up call for these
nurses.” Other participants commented variously
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...that reflects a general misunderstanding on behalf of nurses of what Nursing Council’s role is. Like Nursing Council couldn’t give a toss if a registered nurse is competent or expert. What they need to know is they’re safe.
If you are a registered nurse in my view you have obviously the obligation as a professional to increase your body of knowledge, be able to demonstrate that you’re competent at all times.
The Nursing Council as a regulatory authority has a responsibility to set the standards, to be clear about the process. But then the health professional has a responsibility to be aware of those standards and to try and meet them.
They don’t realise that it’s their individual responsibility. And if you work with nurses who have got issues around competence or issues, you know that - or even being audited. They don’t understand that it’s their responsibility. They think it’s the employers or they think ... well you haven’t done this for me.
5.3.3 Communication and consultation
This lack of awareness of a nurse’s individual responsibilities for maintaining competence was
linked to the need for the Nursing Council of New Zealand to have good communication and
consultation mechanisms in place. A number of participants commented on the extensive
consultation with the profession, undertaken by the Nursing Council of New Zealand during the
development and implementation of the Continuing Competence Framework, and the
communication with the nursing sector following implementation, through Nursing Council
Forums, web-site information and newsletters to individual nurses. Despite these
communications, it was generally felt that a number of nurses still did not have a clear
understanding of the role and function of the Nursing Council of New Zealand, the Continuing
Competence Framework process or the responsibilities inherent in being registered as a nurse.
The complexity of the Nursing Council of New Zealand form for application and renewal of
practising certificates (Application for Practising Certificate) was commented on by several
participants as being difficult to follow and cluttered. One participant reported
It’s an unmitigated disaster – it’s very cluttered and it doesn’t flow very well. It is difficult to find information about competence until you get to the back page.
Another participant indicated they did not know the Scopes of Practice and associated
competencies were on the form at all.
One of the difficulties is there isn’t any information about the competencies so how do you know how to assess them.
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5.4 Recertification audit process
This theme was specifically related to discussion on the recertification audit process.
However, as will be noted, comments made by some participants also overlapped with other
categories and themes.
5.4.1 Peer assessment
In relation to peer assessment for validation of competence to practise, there was a range of
issues reported as indicated in the following quotes. The question of who should be a peer
assessor was raised on a number of occasions. This included opposing views that on the one
hand the peer assessment must always be undertaken by a nurse and on the other that in
some situations it may be appropriate that another health practitioner who works closely with
a nurse, could undertake peer assessment. In both situations it was agreed that there needed
to be clear and explicit assessment criteria.
I think it has to be a nurse. And I just think it’s all a part of the development of a professional attitude and recognition of your particular skills and knowledge ... so if I’m the nurse being audited and I go down the road to meet someone at an iwi21 provider and say ‘...can I talk to you about how I meet my competencies ... and then of course the Nursing Council of New Zealand need to know about the person that’s signing you off.
I can’t see any reason why a health practitioner who works closely with the nurse cannot be a peer assessor, so long as they have the right criteria and tool to assess the person against. Let’s be realistic nurse’s work in a wide range of settings and sometimes the team they work with doesn’t include another nurse. I might be an OT or doctor or some other health professional... that person probably knows more about the nurse’s practice ... is better able to comment than someone they don’t work with. I know it’s about being a nurse but surely if the criteria are clear, I suppose I mean the competencies, it should be fine.
The validity of the peer assessment process was also discussed at length particularly the issue
of who should be a peer assessor, and importantly, the criteria for their selection. The
following comments were made
I do know that some registered nurses don’t engage formally in a – through the formal processes in a DHB and rely very heavily on peer review to support their practice. And that’s the friends’ thing.
21 In New Zealand society, ‘iwi’ (Māori pronunciation: [iwi]) means peoples or nations (Ballara, 1998).
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I don’t think the process is adequate because it is about peer. And it’s about choice. And that’s why I come back to saying let’s get real about this and have a process which is visible, which is mandatory. So we can say to the public that all our nurses that are engaged in registered nursing duties for the public have met a competency framework that is visible.
...Well it’s hard to know if they’re valid because people will interpret what evidence is required for them the best way they can. I think there could be more guidelines. Peer assessments I think that - that in itself lends it a whole new perspective on people who might sign off that somebody else is competent because they are - they need the staff. And they also - I mean I suppose I could say I know of some cases where people have signed off people as being competent with a peer review, or validated stuff when it’s been thrust under their nose.
We rely on the nurse to choose a peer assessor, we rely on the peer assessor to be honest and base their assessment on evidence – in an ideal world this is fine, but we know there will always be outliers and somehow we need to be sure that the peer assessment is valid – based on evidence – this is about public safety. It’s good… it’s a reasonable expectation to use peer assessment but surely we can tighten up the loop.
5.4.2 Audit requirements (documentation, timeframes, guides and templates)
The audit process itself raised a number of concerns and misunderstandings. While
participants indicated generally that they understood that there were several requirements to
be met in relation to the audit process, what was of most concern was the limited access to
the appropriate forms. Participants reported that they were not supplied with hard copy
forms but were directed to the Nursing Council of New Zealand website to print off forms.
Several participants commented they found this process “frustrating”, and in addition
There was no hard copy of the competence forms – I got one off the website, but couldn’t type into it.
Another participant commented
You know again I think things are complicated ... I’m talking generally, not just with the form. I think there‘s an awful lot of surveillance with nurses that’s unnecessary and just over-reactive...
In terms of timeframes and tracking of documents after the audit documentation is submitted, concern was expressed by two participants. One commented
It [submitted audit documents] just went into a deep hole ... I rang the Nursing Council of New Zealand to say I didn’t have a practising certificate yet, and was told not to worry. But I did worry. My employer worried about liability.
And another two participants commented
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I got my documents in within the timeframe, but I have no idea what had happened to them after that. I heard nothing until my APC arrived in the mail about ten weeks later.
I have conversations with nurses who have been in audit. Some of them are really positive. Feeling that they’ve actually been made to stand back and think about their practice and get peer reviews, and some of them of course are stressed out.
‘Not having clear guidelines’ was reported by a number of participants. This issue appeared to be specifically in relation to completion of the self-assessment and peer assessment documents. Two participants commented that
So rather than ‘you’re competent and we’re not expecting anything else’ it’s more of a feeling that ‘I’m incompetent and I need to prove that I am competent”, which creates anxiety for people. And as they go through the process I think the - as the years have gone by there’s been a streamlining of the evidence that’s required and also I think nurses have got a bit better at understanding what a portfolio of evidence is, rather than the shopping trolley.
I know there was information on who to contact if I needed guidance but don’t you think if the competencies were written in clear language and less repetitive that people wouldn’t need to ask for guidance. It’s OK for people who write this stuff all the time but I’m a practitioner and really I just want to know what evidence they want for each criterion and then I know what to provide. I suppose what I sent must have been OK because I got a practising certificate … I didn’t get any feedback about my documents but I did get a letter to tell me in future to make sure my peer assessor wrote more comments….I thought that was a bit punitive.
Several participants commented on the recertification audit information and documentation
they received. The participant comment below is most representative of the wider discussion
I got the package from Nursing Council and thought oh ….. then I thought well get on with it. But it didn’t have any forms or anything just told me to get them from the website, initially they weren’t all available – I think… the competency form wasn’t there, anyway I got one from someone else who had been through it, but you couldn’t type straight on you had to hand write. I don’t really have a problem with the process [being audited] because I felt good afterwards – I had evidence and proved I was competent, but I felt the documentation you receive should be complete, that would have made the process a lot easier and less stressful…
Elements expressed in this sub-theme overlap with elements which emerged in the following
two sub-themes.
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5.4.3 Transparency of the audit process
Concerns were raised by participants about the transparency of the audit process in terms of
who would be assessing the material provided and against what criteria would the material
provided be assessed. Confidentiality was another concern. One participant commented
There was no indication of how it would be assessed or who would assess it ...[it] really concerned me that I had no idea of who was going to be viewing this information ... So I did worry about the notion of confidentiality.
One participant was concerned about being identifiable, and reported
It wasn’t an objective - well it wasn’t an assessment that was … any nurse making application, it was because I was identifiable. The comments were specific because they knew who I - what my role was.
5.4.4 Communication and processes
Participants commented on a number of issues in relation to communication and processes
associated with submission of evidence for recertification. Other comments related to tracking
the audit process and feedback with regard to the appropriateness and acceptability of the
evidence submitted.
I just received the Annual Practising Certificate... we only hear back from Nursing Council when there’s an issue with a nurse’s submission – and that has happened on two occasions with nurses who have had to resubmit because it has been deemed that they haven’t provided enough evidence for particular criteria. It seems the only feedback that you do get is by way of ... the nurse being rubber stamped with their practising certificate.
I would have liked some feedback, because you put a lot of effort in and in my situation I was working blind, no-one else had been audited – it just seemed to go into a dark hole and I heard nothing then one day my practising certificate turned up in the mail. I presume everything was OK.
The public safety focus was the focus of my audit information which was my - about my clinical practice. And I provided not only a verified list of education but also copies of the certificates that were relevant to my clinical practice. And in my appraisal from the senior nurse it was clearly identified that I had completed a post graduate cert in … and participated in the compulsory education within the workplace. I also had my education verified by another senior nurse …. And yet that was questioned. Now three different pieces of evidence around my professional development which well exceeded the hours required and I was asked to provide more information.
In addition the need for electronic submission and access was also raised.
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We live in an electronic age so why isn’t everything available to be done on line. It would be a lot easier to fill in the forms and to send them to your assessors, rather than printing everything off – providing it’s actually available of course.
We can look up nurses’ current registration online, so surely something could be set up for tracking our audit documents. It might take away the mystery and anxiety if you knew where your documents were and you could say to your employer well I submitted them and at this stage…
Generally, there was a feeling that the recertification process was reasonable. However,
improvements in the availability and access to guidelines, required assessment forms, and
tracking of audit documentation could be improved. Communication in terms of feedback
from the recertification audit was raised as an important area for consideration by some
participants; but others posed the view that feedback is not the role of the regulatory
authority, which should only be concerned with ensuring public safety and administering
associated monitoring processes.
5.4.5 Professional Development and Recognition Programmes (PDRPs)
PDRPs were identified as a sub theme in relation to recertification and audit requirements
because a number of participants referred to confusion about the role of the Nursing Council
of New Zealand and PDRPs. There was a sense that the Nursing Council of New Zealand had
“muddied the waters” by setting the criteria for, and approving PDRPs.
I think people think that the PDRP programme is the work of the Council. When in fact, it is about professional development and career development not competence. That’s why I don’t think the Nursing Council of New Zealand should be involved in approving them. Other than - the competence levels – fine.
So they should only be interested in the programme in the terms of if you have a professional development programme and it meets the minimum competence for continuing competence as per the Nursing Council Framework then your staff that are engaged in that programme can be excluded from audit.
I think part of the confusion is because the Nursing Council of New Zealand has got guidelines for PDRP programmes but it also approves them...I think the Nursing Council of New Zealand dabbled in something that it really shouldn’t have been doing in terms of those PDRP programmes approval when the focus was not on whether the people - the expert and proficient levels - but that clearly the competence - the competent level was the key point.
I had to keep saying to them, no under the Act you do not actually have to be part of a PDRP process because the Act and Council did not require that. The employers could choose to make that a mandatory part of their employment but actually legally under the Act it was not a mandatory part of the process. [What is] ... wanted is evidence. And so I used to say to the staff as long as you can
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provide evidence and you can actually address those competencies and how you meet them. And you can be really clear that your evidence meets them then there’s no reason why you won’t gain registration.
However, not all participants considered the use of PDRPs as a means of providing evidence of
continuing competence to be problematic, as can be seen by the quotes below.
So it’s kind of been two fold I guess. On one hand I know that where the responsibility for the Nursing Council competencies comes in and we have an employer driven PDRP programme. But the two of them actually, I think, are linking in really nicely now and giving clarity about what the expectations are in one and the other. They’re being - if - when - now that they’re keeping their PDRPs up to date it’s not nearly so difficult to translate when they are audited now you know, how those standards are met - how they’re meeting those standards, what - you know, what evidence they can give because they’re starting to build that up within their PDRPs.
What I’m saying about the PDRP thing I think that’s raised the whole profile because they know they’re not going to get audited and so therefore if they talk to their colleagues.
Issues were raised with regard to transferability between programme providers even though
the programmes are all approved by the Nursing Council of New Zealand. Some were of the
view that the Nursing Council of New Zealand should take a more proactive role in the
administration of PDRPs to ensure standardisation and transferability.
I think that even though the Nursing Council approves PDRP to a common standard it’s ... It’s pretty obvious that there’s an inconsistency in what the PDRPs actually relate to. Particularly, in terms of their transferability from one employer to another...I think there needs to be more standardisation of the PDRP...we do need a stronger steer from Council in terms of standardising - towards a national PDRP process.
There were also mixed views expressed about whether PDRPs should be mandatory or
voluntary. Some felt that PDRPs were such a good idea that there was no reason why they
should not be mandatory, and that there would be an underlying reason for anyone who did
not wish to belong.
And I can’t see why ... why being on a PDRP programme is something that you wouldn’t want to do. So the notion of it being voluntary or not voluntary is the case. But really, I would think that nurses who don’t want to be on a PDRP programme should be asking why that is. You know, why would I not want to be engaging with my colleagues. In terms of helping me determine my competence and my fitness to practice and my career progression. If I was thinking that, I would be quite concerned.
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I react to compulsory anything. But I can see that if I was a leader of a DHB that I would want as many as possible in that process. To show them ‘well I know that my workforce is working to a certain standard’. And I would really be concerned with those that aren’t in the process. Especially as usually ... it’s the good people that are going on these processes and it’s the people that are out – the outliers that are actually quite often the trouble, not function quite as well ... sort of people that stay as outliers form it. So yeah, I wouldn’t support compulsory, but I would say strongly encourage people to be on it.
5.5 Summary of findings from the interviews
A summary of the findings from the interviews is presented below. These findings will be
discussed in more detail in Chapter Seven where the results are triangulated.
5.5.1 Competence
It was the consensus view of the interview participants that the Nursing Council of New
Zealand Continuing Competence Framework is an important process for ensuring the
continuing competence of nurses and assuring public safety. However, the participants
identified that there was a general lack of clarity and understanding amongst nurses with
regard to the concepts of competence, and continuing competence. In addition, the
participants indicated that there was also a level of confusion in relation to the assessment of
continuing competence, and the notion of a minimum standard of assessment.
There was general agreement that the Nursing Council of New Zealand indicators of continuing
competence are appropriate. However, the suitability of stipulating a minimum number of
hours of practice and professional development was questioned in terms of its ability to
provide a valid inference of continuing competence. In addition the participants noted that
there was confusion over what constitutes continuing professional (educational) development
activities for continuing competence. The participants identified the need for the
development of clear guidelines as to what constitutes evidence of continuing competence.
5.5.2 Role of the Nursing Council of New Zealand
The interview participants indicated that there had been extensive consultation with the
nursing profession over the development and implementation of the Nursing Council of New
Zealand Continuing Competence Framework. However, they also noted that there was a small
group of nurses for whom there was still a level of confusion in relation to the purpose of the
Continuing Competence Framework and the role of the Nursing Council of New Zealand in
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ensuring the continuing competence of nurses and the safety of the public. They also
perceived a lack of clarity amongst some nurses, with regard to the responsibility and
accountability of the Nursing Council of New Zealand as opposed to the responsibility and
accountability of the employer and the individual nurse. Whilst the PDRP was not the focus of
this research, the interview participants raised it as a confusing issue for nurses in relation to
who is responsible and accountable for the PDRP process.
The legal status of the self-declaration (a section of the Application for a Practising Certificate
form), was questioned by a number of the interview participants as it was noted that there
was no explanation included on the Nursing Council of New Zealand Application for a
Practising Certificate form, that would inform the applicant as to status of the declaration they
were being asked to sign. The participants questioned the veracity of the self-declaration
made on the Application for a Practising Certificate form, which they considered to be
‘cluttered’ and difficult to follow.
5.5.3 Recertification Audit
The Nursing Council of New Zealand recertification audit process was considered by the
interview participants as a useful tool for the promotion of professional responsibility and
accountability amongst nurses and as validation of the Continuing Competence Framework.
However, issues were raised in relation to the validity and reliability of the associated self-
assessment and peer assessment processes.
In addition the participants noted that there was repetition and complex language used on the
competence assessment forms and no guidelines in relation to what constitutes the evidential
requirements for demonstrating continuing competence to practise and continuing
professional development. The interview participants reported difficulties in accessing
recertification audit forms - particularly the peer assessment forms and criteria. It was also
noted that none of the forms were able to be completed online and submitted electronically
and this was perceived by the participants as a barrier. The suggestion was made that, as a
minimum a full hard copy set of recertification audit documentation should be provided to
each recertification audit participant and that the Nursing Council of New Zealand should
investigate and implement a system for electronic submission and management of the
recertification audit process and documentation.
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5.6 Concluding remarks
This chapter has summarised and presented the themes and sub-themes that emerged from
the interviews with key stakeholder participants. The findings include process and delivery
issues and concerns regarding clarity and use of the applications, recognition of competence
activities and the need to validate some indicators of continuing competence. Overall the
participants reported strong support for the Continuing Competence Framework as a
mechanism to ensure continuing competence and were supportive of the influence of the
Continuing Competence Framework to improve individual nurse accountability.
The reported confusion regarding the expression of competence is consistent with a
contextual and subjective stance toward understanding the concept. These findings informed
the development of the e-survey, the results of which are presented in Chapter Six and
contribute to the data triangulation and discussion presented in Chapter Seven.
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CHAPTER SIX - PHASE THREE FINDINGS: E-SURVEY DATA
6.1 Introduction
As described in Chapter Three; Stage One, Phase Three of this research focused on collection
of data from New Zealand nurses via a web-based (Zoomerang) e-survey.
Essentially, the questionnaire was designed to elicit demographic data in addition to
information on four key themes (Competence and fitness to practise, Peer Assessment,
Recertification Audit, PDRPs) which were drawn from the findings of the previous research
phases.
The data were coded and collated independently via the Zoomerang software and server then
further analysed using the Statistical Package for Social Sciences (SPSS) for Windows version
17.0. Any errors or inconsistencies in data were carefully screened out by evaluating the range
of values generated by running the descriptive frequencies. Statistical results are presented in
this chapter in the following sections under the headings of: Demographic data; Competence
and fitness to practise; Recertification Audit; and Professional Development and Recognition
Programmes.
6.2 Demographic data
6.2.1 Distribution and return of the research questionnaire
An email invitation to participate including the URL link to the web-based research
questionnaire was distributed to approximately 12% (n = 5339) nurses registered with the
Nursing Council of New Zealand and active in terms of the Continuing Competence Framework
since 2005. Of the 5339 emailed invitations to participate, 1764 were not viewed or
NCN
Z Co
ntin
uing
Com
pete
nce
Fram
ewor
k
Stage One Phase 1
Document & Policy Review
Stage One Phase 3
QuantitativeE-survey
Data triangulation &
discussion
Summary Recommendations
Stage One Phase 2
Qualitative Interviews
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responded to, 800 invitations were hard bounced - marked as undeliverable, and 461 invitees
elected not to complete the questionnaire by submitting an opt-out response. Two thousand
three hundred and fourteen (n = 2314) potential participants viewed the questionnaire and
1157 submitted completed questionnaires. The questionnaire link was active for a two week
period from 2 – 16 December 2009, during which time access was only available to the
invitees. Data relating to participation and response rates (completed questionnaires) is
presented in Table 7.
Table 7 Participation rates and sample size
Sample size Participation rate
Population size
Margin of error
Confidence level
Response distribution
1157 50% 45,000 2.85% 95% 50%
The data were collated by the overall response, and further analysed using the variables,
scope of practice and practice area.
6.2.2 Scope of Practice
Of the total participant group (n = 1157), 0.6% (n = 7) identified their scope of practice as
Nurse Assistant, 3.9% (n = 45) as Enrolled Nurse, and 95.5% (n = 1105) as Registered Nurse. As
reflected in Figure 5, the participant sample is representative of the overall population of
nurses who held current practising certificates as at 31 December 2009.
Figure 5 Representation of questionnaire participants
0.6% 3.9%
95.5%
0.4% 6.6%
93.0%
Nurse Assistant
Enrolled Nurse
Registered Nurse
Outer circle - Nurses with Practising Certificates n = 44,497 on 31/12/2009 Inner circle - Questionnaire participant group n = 1157
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A cross tabulation of the overall group response to the question “What is your highest
qualification?” by the variable ‘scope of practice’ is presented in Table 8.
Table 8 Cross tabulation highest qualification by scope of practice
Total
What is your scope of practice? Nurse
Assistant Enrolled
Nurse Registered
Nurse 1157 7 45 1105
Hospital Certificate 177 1 30 146 15.3% 14.3% 66.7% 13.2%
Graduate Certificate 34 2 8 24 2.9% 28.6% 17.8% 2.2%
Graduate Diploma 168 0 0 168 14.5% 0.0% 0.0% 15.2%
Bachelor’s Degree 387 1 2 384
33.4% 14.3% 4.4% 34.8%
Postgraduate Certificate 158 1 0 157
13.7% 14.3% 0.0% 14.2%
Postgraduate Diploma 106 0 0 106
9.2% 0.0% 0.0% 9.6%
Master’s Degree 74 0 0 74
6.4% 0.0% 0.0% 6.7%
PhD 11 0 0 11
1.0% 0.0% 0.0% 1.0%
Other, please specify 42 2 5 35
3.6% 28.6% 11.1% 3.2%
A compilation of the overall group response is depicted in Figure 6.
Figure 6 Highest qualification - Overall group response
15%
3%
15%
33%
14%
9%
6% 1% 4%
Hospital CertificateGraduate CertificateGraduate DiplomaBachelors DegreePostgraduate CertificatePostgraduate DiplomaMasters DegreePhDOther, please specify
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Of the overall participant group, 2 participants identified they did not hold a current practising
certificate and 72 participants (6%) were not currently employed as a nurse.
6.2.3 Employment setting and practice area
A collation of current employment settings of the overall participant group (n = 157) is
depicted in Figure 7, and reflects the diversity and range of employment settings across the
overall group. Whilst the greater percentage of participants 58% (n = 671) indicated they
were employed by District Health Boards (DHBs), 42% (n = 486) indicated they worked in a
variety of private, government, and non-government agencies.
Figure 7 Current employment setting - overall group response
A cross tabulation of participants’ current employment setting by their scope of practice is
presented in Table 9 and indicates the diverse demographic spread of the overall participant
group. A proportion of 56% indicated they were employed by District Health Boards (DHB)
and 44% indicated they were employed across the range of private, NGO, PHO, Maori Health,
rural health, education, management, elder health, government and other agencies.
40%
9% 7%
7%
7%
2%
9%
1% 1%
1% 1% 1% 3%
2% 9%
DHB (Acute)
DHB (Primary Health/Community)
DHB (Other)
Private Hospital
Primary health (NGO / PHO)
PHO
Aged Care Sector (Rest home / Residential Care)
Nursing Agency
Self Employed
Maori Health Service Provider
Rural
Health Management
Educational Institution
Government Agency (MOH, ACC, CorrectionsService, Defense Forces)Other please specify
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Table 9 Cross tabulation of current employment settings by scope of practice
Total
What is your scope of practice? Nurse
Assistant Enrolled
Nurse Registered
Nurse 1145 6 44 1095
DHB (Acute) 460 2 6 452
40.2% 33.3% 13.6% 41.3%
DHB (Primary Health/Community) 98 0 6 92
8.6% 0.0% 13.6% 8.4%
DHB (Other) 84 0 6 78
7.3% 0.0% 13.6% 7.1%
Private Hospital 86 0 2 84
7.5% 0.0% 4.5% 7.7%
Primary health (NGO / PHO) 81 0 2 79
7.1% 0.0% 4.5% 7.2%
PHO 22 0 0 22
1.9% 0.0% 0.00% 2.0% Aged Care Sector (Rest home / Residential Care)
101 3 14 84 8.8% 50.0% 31.8% 7.7%
Nursing Agency 14 0 0 14
1.2% 0.0% 0.0% 1.3%
Self Employed 13 0 0 13
1.1% 0.0% 0.0% 1.2%
Maori Health Service Provider 9 0 0 9
0.8% 0.0% 0.0% 0.8%
Rural 8 0 0 8 0.7% 0.0% 0.0% 0.7%
Health Management 15 0 0 15 1.3% 0.0% 0.0% 1.4%
Educational Institution 29 0 1 28 2.5% 0.0% 2.3% 2.6%
Government Agency (MOH, ACC, Corrections Service, Defence Forces)
18 0 0 18 1.6% 0.0% 0.0% 1.6%
Other please specify 107 1 7 99
9.3% 16.7% 15.9% 9.0% * Total n = 1145, 12 participants did not respond to this question
Figure 8 depicts the current practice areas represented by the overall participant group. The
demographic distribution of participants by ‘current nursing practice area’ was extensive with
28 practice areas being identified. By far the largest group of participants were those who
identified as practising in medical (n = 138) and surgical (n = 151) services, with peri-operative
care (operating theatre, n = 89) and continuing care (elder health, n = 82) being the next
largest participant groups. However, overall there was equal representation from both the
primary health and acute service sectors.
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Figure 8 Current nursing practice area – overall participant group
A cross tabulation current area of nursing practice by scope of practice is presented in Table
10 and demonstrates the demographic distribution of participants by number and percentage
distribution.
60
58
89
151
138
25
16
40
3
6
6
33
58
9
54
13
82
47
42
38
3
7
62
46
18
11
13
9
20
0 20 40 60 80 100 120 140 160
Emergency and Trauma
Intensive Care/Cardiac Care
Peri Operative Care (Operating Theatre)
Surgical
Medical
Palliative Care
Obstetrics/Maternity
Child Health, including Neonatology
School Health
Youth Health
Family Planning/Sexual Health
District Nursing
Practice Nursing
Occupational Health
Primary Health Care
Public Health
Continuing Care (Elderly)
Assessment and Rehabilitation
Mental Health (inpatient)
Mental Health (community)
Addiction Services
Intellectually Disabled
Nursing Administration and Management
Nursing Education
Nursing Professional Advice/Policy Development
Nursing Research
Non-nursing health related management or administration
Other non-nursing paid employment
Not in paid employment
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Table 10 Cross tabulation current area of nursing practice by scope of practice
Total
Nurse Assistant
Enrolled Nurse
Registered Nurse
1157 7 45 1105
Emergency and Trauma 60 0 0 60 5.2% 0.0% 0.0% 5.4%
Intensive Care/Cardiac Care 58 0 0 58 5.0% 0.0% 0.0% 5.2%
Peri-operative Care (Operating Theatre) 89 0 1 88 7.7% 0.0% 2.2% 8.0%
Surgical 151 0 3 148 13.1% 0.0% 6.7% 13.4%
Medical 138 1 4 133 11.9% 14.3% 8.9% 12.0%
Palliative Care 25 0 2 23 2.2% 0.0% 4.4% 2.1%
Obstetrics/Maternity 16 0 1 15 1.4% 0.0% 2.2% 1.4%
Child Health, including Neonatology 40 0 1 39 3.5% 0.0% 2.2% 3.5%
School Health 3 0 1 2 0.3% 0.0% 2.2% 0.2%
Youth Health 6 0 0 6 0.5% 0.0% 0.0% 0.5%
Family Planning/Sexual Health 6 0 0 6 0.5% 0.0% 0.0% 0.5%
District Nursing 33 0 0 33 2.9% 0.0% 0.0% 3.0%
Practice Nursing 58 0 3 55 5.0% 0.0% 6.7% 5.0%
Occupational Health 9 0 0 9 0.8% 0.0% 0.0% 0.8%
Primary Health Care 54 0 1 53 4.7% 0.0% 2.2% 4.8%
Public Health 13 0 0 13 1.1% 0.0% 0.0% 1.2%
Continuing Care (Elderly) 82 3 14 65 7.1% 42.9% 31.1% 5.9%
Assessment and Rehabilitation 47 1 8 38 4.1% 14.3% 17.8% 3.4%
Mental Health (Inpatient) 42 1 0 41 3.6% 14.3% 0.0% 3.7%
Mental Health (Community) 38 0 2 36 3.3% 0.0% 4.4% 3.3%
Addiction Services 3 0 0 3 0.3% 0.0% 0.0% 0.3%
Intellectually Disabled 7 0 2 5 0.6% 0.0% 4.4% 0.5%
Nursing Administration and Management 62 0 1 61 5.4% 0.0% 2.2% 5.5%
Nursing Education 46 0 0 46 4.0% 0.0% 0.0% 4.2%
Nursing Professional Advice/Policy Development 18 0 0 18 1.6% 0.0% 0.0% 1.6%
Nursing Research 11 0 0 11 1.0% 0.0% 0.0% 1.0%
Non-nursing health related management or administration 13 0 0 13 1.1% 0.0% 0.0% 1.2%
Other non-nursing paid employment 9 0 0 9 0.8% 0.0% 0.0% 0.8%
Not in paid employment 20 1 1 18 1.7% 14.3% 2.2% 1.6%
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6.3 Competence and fitness to practise
The Nursing Council of New Zealand Continuing Competence Framework includes three
indicators of competence:
A. Self-declaration of competence to practise (based on self-appraisal using the Nursing
Council of New Zealand competencies for the relevant scope of practice);
B. Verification of practice hours (minimum of 450 hours / 60 days in past three years);
C. Verification of professional development (minimum of 60 hours in past three years).
Seven combinations of the indicators were presented to participants who were asked to rank
from 1 (Best) to 7 (Worst), which they believed provided the best evidence of continuing
competence to practise. Of the overall participant group 52% (n = 470) ranked the
combination of the self-declaration (A), evidence of practice hours (B) and evidence of on-
going professional development (C), as the best indicator of continuing competence, and 40%
(n = 311) identified the self-declaration when used independently as the worst indicator of
continuing competence to practise. Overall participant rankings are depicted in Figure 9.
Figure 9 Indicators that provide the best evidence of competence to practise
1 = Best 2 3 4 5 6 7 = WorstA, B & C 52% 15% 9% 9% 5% 4% 6%A & B 9% 24% 28% 16% 12% 10% 2%A & C 5% 14% 25% 27% 17% 11% 2%B & C 25% 24% 12% 22% 9% 5% 3%A only 8% 5% 7% 7% 19% 13% 40%B only 10% 11% 11% 10% 21% 27% 10%C only 7% 11% 12% 7% 14% 23% 26%
0%
10%
20%
30%
40%
50%
60%
130
Participants were then asked to rank the same indicators from 1 (Best) to 7 (Worst) to indicate
which they believed provided the best evidence of continuing professional development. The
overall participant responses were similar with 48% (n = 402) ranking the combination of the
self-declaration (A), evidence of practice hours (B) and evidence of on-going professional
development (C), as the best indicator of professional development. The least popular
indicator of competence to practise was (A) self-declaration only, which represented a
response from 43% (n = 322) of the total participant group. Overall participant rankings are
depicted in Figure 10.
Figure 10 Indicators that provide the best evidence of continuing professional development
It is interesting to note that for both questions, participants ranked a combination of the three
indicators (A, B & C) as providing the best evidence of competence to practise and on-going
professional development. However, it is of note that the participants ranked the self-
declaration of competence (based on self-appraisal of their ‘competence’ using the Nursing
Council of New Zealand competencies for their scope of practice) as the ‘worst’ indicator for
providing evidence of competence to practise when used independently.
1 = Best 2 3 4 5 6 7 = WorstA, B & C 48% 14% 11% 10% 5% 4% 7%A & B 5% 17% 18% 22% 20% 14% 3%A & C 8% 18% 31% 19% 13% 8% 2%B & C 24% 26% 15% 22% 7% 5% 2%A only 6% 5% 6% 7% 18% 16% 43%B only 8% 11% 9% 7% 12% 35% 18%C only 21% 13% 12% 9% 17% 12% 16%
0%
10%
20%
30%
40%
50%
60%
131
Figure 11 A mechanism to ensure nurses are competent and fit to practise
In response to the question “Do you think that the current Nursing Council of New Zealand
Continuing Competence Framework and processes for renewing practising certificates,
provides the mechanism to ensure that nurses are competent and fit to practise?” 76% (n =
876) of participants responded ‘yes’ and 24% (n = 281) responded ‘no’ (Figure 11). This
response is representative of the nursing population with a margin of error of 2.85% and
confidence level of 95%.
Responsibility for maintaining continuing competence to practise was a recurring theme
throughout the Phase Two – interviews. Questionnaire participants were asked to rate their
level of agreement with four statements (Figure 12).
Figure 12 Responsibility for maintaining continuing competence to practise
76%
24%
Yes
No
0
200
400
600
800
1000
1200
1 2 3 4 5 6 7
Num
ber
Strongly Agree Strongly Disagree
As a health professional I amresponsible for maintaining my owncompetence to practise
My employer is responsible formaintaining my competence topractise.
The Nursing Council of New Zealandis responsible for maintaining mycompetence to practise
When completing my NCNZapplication to renew my practisingcertificate I understand that I amsigning a legal declaration
132
Participants indicated on a seven point Likert scale (the score of 1 indicated that they strongly
agreed and the score of 7 indicated that they strongly disagreed with the statement). An
independent t-test was used to collate the responses to the four statements. Table 11 depicts
the collation of responses.
Table 11 Responsibility for maintaining continuing competence to practise 1 2 3 4 5 6 7 Overall
Participant Group Strongly
agree Strongly
disagree Mean Standard
Deviation
1. As a health professional I am responsible for maintaining my own competence to practise.
n 812 226 74 20 10 5 10 1.48 .965
% 70% 20% 6% 2% 1% 0% 1% 2. My employer is responsible for
maintaining my competence to practise.
n 187 267 252 174 109 85 83 3.29 1.769
% 16% 23% 22% 15% 9% 7% 7% 3. The Nursing Council of New
Zealand is responsible for maintaining my competence to practise.
n 145 151 174 203 133 158 193 4.10 1.989
% 13% 13% 15% 18% 11% 14% 17%
4. When completing my NCNZ application to renew my practising certificate I understand that I am signing a legal declaration.
n 1016 89 23 6 7 3 13 1.20 .845
% 88% 8% 2% 1% 1% 0% 1%
*Total participants n = 1157, 95% Confidence Interval
Descriptive statistics were used to calculate the mean (M) scores and standard deviation (SD)
for each of the four items. There was no significant variation in responses between the three
scopes of practice (NA, EN, RN) or employment setting. The overall participant group mean
scores for items 1 and 4 indicated that there was strong agreement that the individual nurse is
responsible for maintaining their own competence to practise (M = 1.48) and understanding
that when signing the self-declaration, they are signing a ‘legal declaration’ (M = 1.20).
However, for items 2 (employer is responsible) and 3 (Nursing Council of New Zealand is
responsible) the mean scores were (M = 3.29; SD = 1.769) and (M = 4.10; SD = 1.989)
respectively, indicating some ambivalence within the overall participant group. The standard
deviation for items 2 and 3 demonstrates the broad distribution of responses across the seven
point continuum (strongly agree – strongly disagree).
When items 2 and 3 were cross-tabulated by employment area, findings indicated that nurses
employed in Health Management (n = 15) and Educational Institutions (n = 29) scored the
highest mean scores for both items. Item 2, “my employer is responsible for maintaining my
competence to practise” (Health Management, M = 4.87, SD = 2.200; Educational Institution,
133
M = 4.07, SD = 1.624) and item 3, “The Nursing Council of New Zealand is responsible for
maintaining my competence to practise” (Health Management, M = 5.33, SD = 1.952;
Educational Institution, M = 5.48, SD = 1.661).
During Stage One, Phase One (policy review) and Phase Two (stakeholder interviews),
misinterpretation of the intent/meaning of the ‘self-declaration questions’ listed on the
Nursing Council of New Zealand ‘Application for Practising Certificate’ form was introduced as
a possible issue in terms of the following: nurses not completing the documentation
accurately; increased numbers of contacts and queries and administrative time for Nursing
Council of New Zealand staff responding to, and following up, information in relation to
incomplete documentation. In response to the identification of these issues, questionnaire
participants were asked to rate their level of understanding with each of the five Nursing
Council of New Zealand questions. Participants indicated on a seven point Likert scale (the
score of 1 indicated excellent understanding and the score of 7 indicated very poor
understanding). Responses are presented in Table 12.
Table 12 Nursing Council of New Zealand recertification application questions 1 2 3 4 5 6 7 Overall Participant
Group Rate your understanding with the following questions…
Excellent understanding
Very poor understanding
Mean Standard Deviation
Have you completed a minimum of 450 hours of nursing practice in New Zealand within the past three years?
n 1051 57 18 12 2 6 11 1.20 .815
% 91% 5% 2% 1% 0% 1% 1% Have you undertaken the minimum number of required professional development hours (i.e. 60 hours) within the past three years?
n 1029 83 22 9 6 2 6 1.19 .703
% 89% 7% 2% 1% 1% 0% 1%
Do you meet the Nursing Council of New Zealand's competencies for your scope of practice?
n 941 122 59 20 6 7 2 1.32 8.12
% 81% 11% 5% 2% 1% 1% 0% Do you have a mental or physical condition that means you are unable to perform the functions required for the practice of nursing?
n 826 92 31 14 9 8 177 2.15 2.185
% 71% 8% 3% 1% 1% 1% 15%
Have you been the subject of an investigation, disciplinary or criminal proceedings or a disciplinary order in New Zealand or any other country since you last applied for a practising certificate?
n 883 58 14 9 3 4 186
2.09 2.214 % 76% 5% 1% 1% 0% 0% 16%
*Total participants n = 1157, 95% Confidence Level, Margin of Error 2.85%
The majority of participants indicated an excellent understanding of the five questions (M =
1.19 – 2.09). However, it is of note that for two questions “Do you have a mental or physical
134
condition that means you are unable to perform the functions required for the practice of
nursing?” and “Have you been the subject of an investigation, disciplinary or criminal
proceedings or a disciplinary order in New Zealand or any other country since you last applied
for a practising certificate?” 18% (n = 208) and 17% (n = 202) of participants respectively
indicated that they had a limited to very poor understanding of the meaning/intent of the
questions.
6.4 Recertification audit
In Phases One and Two of the research the issue of the role and function of the peer assessor
was raised. In order to capture those issues the following questions were included in the
questionnaire. In response to the question “Have you ever been asked to be a Peer Assessor
for a colleague who was being audited?” (Table 13), 22% (n = 252) responded yes, and 78% (n
= 905) responded no. Of the participants who indicated they had been a Peer Assessor, five
identified as Enrolled Nurse and 247 as Registered Nurse. No Nurse Assistants were
represented in the Peer Assessor group.
Table 13 Participation as a Peer Assessor
Total
Scope of Practice
Nurse Assistant
Enrolled Nurse
Registered Nurse
1157 7 45 1105
Yes 252 0 5 247 22% 0% 11% 22%
No 905 7 40 858 78% 100% 89% 78%
Participants were asked six questions in relation to being a Peer Assessor. Twenty five percent
of participants (n = 67) indicated that they were not provided with information about the
recertification audit process, and 18% (n = 48) indicated they were not provided with
documentation about the relevant scope of practice and competencies. Ten percent (n = 27)
were not provided with a competence assessment form. When asked if the assessment was
based on evidence 6% (n = 15) participants indicated it was not. Fourteen percent (n = 37) did
not discuss their assessment with their colleague. Detailed results are depicted in Figure 13.
135
Figure 13 Peer Assessor
Of the overall participant group 90% (n = 1037) indicated they had not been selected for
recertification audit. Ten percent of the overall participant group (n = 120) indicated they had
been audited between the years 2005 and 2009 inclusive. Figure 14 depicts the audit
distribution of participants by audit year.
Of the 120 participants who indicated they had been audited, 111 identified as Registered
Nurse and 9 identified as Enrolled nurse. No Nurse Assistants had been audited.
Figure 14 Recertification audit distribution of participants by audit year
0% 50% 100%
Did you understand you were completing andsigning a legal document?
Did you discuss your assessment with yourcolleague?
Was your assessment based on evidence?
Where you provided with a competenceassessment form?
Were you provided with documentation about therelevant scope of practice and competencies?
Were you provided with information about therecertification audit process?
91%
86%
94%
90%
82%
75%
9%
14%
6%
10%
18%
25%
No
Yes
Yes, 2005 (n = 11)
Yes, 2006 (n = 20)
Yes, 2007 (n = 29)
Yes, 2008 (n = 30)
Yes, 2009 (n = 30)
No (n = 1037)
136
Participants were asked to respond to six questions with regard to the written information
they received from the Nursing Council of New Zealand prior to their recertification audit. It is
interesting to note that whilst 120 participants indicated that they had been audited,
additional participants chose to also respond to these questions. Table 14 presents the results.
Table 14 Recertification audit information n = count of participants selecting the option % is percent of the total participants electing the option
When you were audited did you receive written information about…
Total Yes No
1 …the recertification audit process? 127 n 116 11 % 91% 9%
2 …the recertification audit time frame? 125 n 116 9 % 93% 7%
3 …the domains of practice and competencies for your scope of practice? 124 n 114 10
% 92% 8% 4 …the evidence you would need to provide for the
recertification audit? 125 n 113 12 % 90% 10%
5 …where you could obtain clarification if necessary? 124 n 102 22 % 82% 18%
6 …the process after submission of your documentation? 123 n 96 27 % 78% 22%
Table 15 presents a cross-tabulation of responses by audit year. In response to question 3
“When you were audited did you receive written information about: The domains of practice
and competencies for your scope of practice?” the results improved significantly with 100% of
participants indicating they received the information in 2009. There was no significant
variation in the responses received with regard to the other five questions across the five year
period.
137
Table 15 Recertification audit information – comparison by audit year When you were audited did you receive written information about…
2005 2006 2007 2008 2009
1 …the recertification audit processes? Yes 100% 95% 100% 93% 93% No 0% 5% 0% 7% 7%
2 …the recertification audit time frame? Yes 100% 100% 97% 97% 93% No 0% 0% 3% 3% 7%
3 …the relevant domains of practice and competencies for your practice?
Yes 100% 90% 86% 90% 100% No 0% 11% 14% 10% 0%
4 …the evidence you would need to provide for the recertification audit?
Yes 100% 90% 93% 90% 93% No 0% 11% 7% 10% 7%
5 …where you could obtain clarification if necessary?
Yes 73% 90% 79% 83% 90% No 27% 11% 21% 17% 10%
6 …the process after submission of your documentation?
Yes 70% 84% 72% 87% 79% No 30% 16% 28% 13% 21%
Based on the documentation they had received from the Nursing Council of New Zealand
participants were asked to rate their understanding of how to provide evidence for four items:
practice hours; professional development hours; self-assessment of competencies for their
scope of practice, and peer assessment of competencies for their scope of practice.
Responses to the four items are collated in Table 16.
Table 16 Understanding of evidence required for the Recertification Audit
1 2 3 4 5 6 7
Mean Standard
Deviation
Based on information received rate your understanding of how to provide
Excellent understanding
Very poor understanding
Evidence of practice hours. n 129 16 10 5 5 0 0
1.43 .958 % 78% 10% 6% 3% 3% 0% 0%
Evidence of professional development hours.
n 119 22 10 5 5 0 3 1.58 1.213
% 73% 13% 6% 3% 3% 0% 2% Self-assessment of your competencies for your scope of practice.
n 86 30 16 13 7 6 6 2.19 1.675
% 52% 18% 10% 8% 4% 4% 4%
Peer assessment of your competencies for your scope of practice.
n 84 25 17 14 10 7 6 2.30 1.737
% 52% 15% 10% 9% 6% 4% 4%
138
Participants indicated on a seven point Likert scale (the score of 1 indicated that they had an
excellent understanding and the score of 7 indicated that they had a very poor understanding).
The item “Evidence of practice hours” achieved a mean score of (M = 1.43) with a standard
deviation of (SD = .958) indicating that the overall participant group had an excellent
understanding of the documentation relating to how to provide evidence of practice hours.
The other three items all achieved means scores ranging from 1.58 – 2.30 indicating good to
excellent understanding of the documentation by the majority of participants, however, as
depicted the standard deviation ranged between (1.213 – 1.737) reflecting a greater
distribution of scores across the seven point rating scale.
Based on a list of three options (A., B., & C.) participants were asked to select which option
best reflected the communication or documentation they received from the Nursing Council of
New Zealand following submission of their audit material. Findings are presented in Table 17.
Table 17 Submission of audit documentation
A. No further correspondence 93 66% B. Single correspondence requesting further information 32 23%
C. Multiple correspondence 16 11% Total 141 100%
Of the overall participant group 141, 66% (n = 93) indicated that they received no further
correspondence. Twenty-three percent (n = 32) received a single correspondence requesting
further information and 11% (n = 16) indicated they received multiple correspondence.
Participants were asked to rate their level of agreement with four satisfaction statements in
relation to the recertification audit documentation, communication and process. Ratings were
scored on a seven point Likert scale (the score of 1 indicated they strongly agreed and the
score of 7 indicated they strongly disagreed). Findings are presented Table 18.
139
Table 18 Satisfaction with audit documentation, communication and processes
1 2 3 4 5 6 7 Mean Standard
Deviation Strongly agree
Strongly disagree
The specified time frames were acceptable.
n 60 29 20 11 5 3 9 2.39 1.759
% 44% 21% 15% 8% 4% 2% 7%
The request for information and correspondence from the Nursing Council of New Zealand was clear.
n 62 29 19 12 5 5 6 2.33 1.684
% 45% 21% 14% 9% 4% 4% 4%
The style of correspondence from the Nursing Council of New Zealand was appropriate.
n 62 24 17 17 6 8 2 2.36 1.636
% 46% 18% 12% 12% 4% 6% 1%
I was satisfied with the process. n 57 22 18 13 11 2 14
2.72 1.989 % 42% 16% 13% 9% 8% 1% 10%
Generally, there was a high level of agreement with the four statements producing a range of
means scores from (M = 2.33 – 2.72). However there was a distribution of scores across the
seven point rating scale (SD = 1.636 – 1.989), with a small proportion of participants indicating
they strongly disagreed with each statement.
6.5 Professional Development and Recognition Programmes
Three questions were included in the questionnaire with regard to Professional Development
and Recognition Programmes (PDRPs). Whilst PDRPs are not the focus of this research, there
was significant comment raised throughout the interview process (Phase Two) with regard to
perceived advantages and disadvantages with regard to PDRPs and the perceived overlap / link
with the Continuing Competence Framework. On several occasions the comment was made
that PDRPs should be compulsory for all nurses. However this was not a consistently held
opinion.
Participants were asked if they believed that PDRPs should be compulsory. Eleven hundred
and thirty six participants responded to this question. Figure 15 presents the overall group
response. Forty-nine percent (n = 557) responded ‘yes’ PDRPs should be compulsory and 51%
(n = 579) responded ‘no’ they should not. This response is representative of the nursing
population with a margin of error of 2.87% and 95% confidence level.
140
Figure 15 Should Professional Development and Recognition Programmes be Compulsory?
Table 19 presents a cross-tabulation of responses by employment setting. It is interesting to
note that, of the participants employed by District Health Boards (DHBs), an employment
setting in which participants generally have access to PDRPs, 48% (n = 309) responded yes
PDRPs should be compulsory and 52% (n = 330) responded no they should not.
Table 19 Cross-tabulation of Employment setting by “Should PDRPs be compulsory?”
DHB
(Acu
te)
DHB
(Prim
ary
Heal
th/C
omm
unity
)
DHB
(Oth
er)
Priv
ate
Hosp
ital
Prim
ary
heal
th (N
GO /
PHO
)
PHO
Aged
Car
e Se
ctor
(Res
t hom
e /
Resid
entia
l Car
e)
Nur
sing
Agen
cy
Self
Empl
oyed
Mao
ri He
alth
Ser
vice
Pro
vide
r
Rura
l
Heal
th M
anag
emen
t
Educ
atio
nal I
nstit
utio
n
Gove
rnm
ent A
genc
y (M
OH,
ACC
, Co
rrec
tions
Ser
vice
, Def
ence
For
ces)
Oth
er p
leas
e sp
ecify
1124 458 97 84 84 78 21 96 14 13 9 7 15 29 15 104
Yes 553 228 43 38 38 36 10 56 8 5 5 3 9 11 11 52
49% 50% 44% 45% 45% 46% 48% 58% 57% 39% 56% 43% 60% 38% 73% 50%
No 571 230 54 46 46 42 11 40 6 8 4 4 6 18 4 52
51% 50% 56% 55% 55% 54% 52% 42% 43% 62% 44% 57% 40% 62% 27% 50%
*Total participants n = 1124, 95% Confidence Level, Margin of Error 2.89%
Participants were asked to indicate if they were levelled on a PDRP and if they had access to a
PDRP. Eleven hundred and seventeen participants participated in this question. Fifty-six
49% 51%
Yes
No
141
percent (n = 626) indicated that they were levelled on a PDRP and 44% (n= 491) indicated that
they were not. Figure 16 displays the results.
Figure 16 Professional Development and Recognition Programmes
In response to the question “Do you have access to a PDRP?” 1129 participants participated,
76% (n = 863) responded that they had access to a PDRP and 24% (n = 266) responded that
they did not have access. Twenty percent of the participants who have access to a PDRP have
chosen not to be levelled.
6.6 Summary of findings from the e-survey
This section (6.6) summarises and highlights the findings from the questionnaire. These data
will be discussed in more detail in the Chapter Seven where the overall results are
triangulated.
6.6.1 Demographic data
The e-survey participant sample is representative of the overall population of nurses who hold
current practising certificates in New Zealand (n = 44497), with a 2.85% margin of error and
95% confidence level. The overall participant group represents a diverse demographic sample
in terms of their identified employment setting and practice area.
0 500 1000
Are you levelled on a PDRP, 2.90% Margin ofError, 95% Confidence Level
Do you have access to a PDRP, 2.88% Margin ofError, 95% Confidence Level
Yes 626
Yes 863
No 491
No 266
No Yes
142
6.6.2 Competence and fitness to practise
The majority of participants (76%, n = 876) believe the Nursing Council of New Zealand
Continuing Competence Framework and processes for renewing practising certificates provide
the mechanism to ensure nurses are competent and fit to practise. The combination of three
continuing competence indicators (self-declaration, practice hours, and continuing
professional development) was ranked as providing the best evidence of continuing
competence to practise and on-going professional development. The self-declaration, if used
independently, was ranked by the e-survey participants as the worst indicator of competence.
Seventy percent (n = 812) of the e-survey participants strongly agreed that individual nurses
are responsible for maintaining their own competence to practise, and 16% (n = 187) strongly
agreed that their employer was responsible for maintaining their competence to practise. A
further 13% (n = 145) believed that the Nursing Council of New Zealand was responsible for
maintaining their competence to practise.
The majority of the e-survey participants indicated they understood the statements used on
the Nursing Council of New Zealand application for renewal of practising certificates, with the
exception of “Do you have a mental or physical condition that means you are unable to
perform the functions required for the practice of nursing?” and “Have you been the subject of
an investigation, disciplinary or criminal proceedings or a disciplinary order in New Zealand or
any other country since you last applied for a practising certificate?” Eighteen percent (n =
208) and 17% (n = 202) respectively indicated they had a poor understanding of the meaning
of these questions. Ninety-eight percent (n = 1128) of the nurses who participated indicated
they understood that the self-declaration is a legal document.
6.6.3 Recertification audit
Twenty-two percent (n = 252) of the overall participant group indicated they had been a peer
assessor. Of the peer assessor group 25% (n = 67) indicated they were not provided with
information about the process, 18% (n = 8) indicated they were not provided with
documentation about the scope of practice, 10% (n = 27) indicated they were not provided
with assessment forms, 6% (n = 15) indicated their peer assessment was not based on current
evidence, and 14% (n = 37) indicated that they did not discuss the peer assessment with the
colleague that they had assessed.
143
Ten percent (n = 120) of the overall participant group indicated that they had been audited
from 2005 - 2009. The majority of the audit participants (93%, n = 116) indicated that they had
received written information with regard to the recertification audit process, the required
timeframes, the required competencies and evidential documentation, instructions where
they could obtain further information and / or clarification, and the process following
submission of their documentation. A small number of participants (7%, n = 9) indicated they
did not receive any information.
The majority of participants (78%, n = 129) indicated that they had a good understanding of
what evidence to provide for the recertification audit, based on the information they received
directly from the Nursing Council of New Zealand. However, 34% (n = 48) of the participants
indicated that they had received requests for additional information from the Nursing Council
of New Zealand, following submission of their recertification audit documentation. Overall the
e-survey participants indicated that they were generally satisfied with the recertification audit
documentation, Nursing Council of New Zealand communications and the recertification audit
process.
Seventy-six percent (n = 863) of the e-survey participants indicated that they had access to a
PDRP and 56% (n = 626) of these participants identified that they were members of a PDRP. Of
the overall participant group 49% (n = 557) indicated that PDRPs should be compulsory and
51% (n = 579) indicated that they should not.
6.7 Concluding remarks
This chapter has presented the Stage One, Phase Three e-survey findings. A number of the
findings provided confirmation of the views expressed by the interview participants. Chapter
Seven will present the triangulation and discussion of the summary findings from each
previous phase of the research, in relation to the research questions. Recommendations are
made for on-going development and quality improvement of the Nursing Council of New
Zealand Continuing Competence Framework.
144
CHAPTER SEVEN - DISCUSSION, CONCLUSION AND RECOMMENDATIONS
7.1 Introduction
This chapter presents the triangulation and analysis of the findings from the previous three
research phases and situates these findings in relation to the Stage One research questions:
1. What are the relationships between current legislation, policy drivers and
statutory requirements to ensure registered nurses in New Zealand are
competent and fit to practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the efficacy of the current Continuing Competence Framework for
nurses in New Zealand and does it reflect best practice?
The discussion will respond to these research questions in association with the objectives that
were specified by the Nursing Council of New Zealand (Table 4, p. 54) for the evaluation of the
Nursing Council of New Zealand Continuing Competence Framework.
The chapter will conclude by summarising the Stage One – Evaluation of the Nursing Council of
New Zealand Continuing Competence Framework findings, listing recommendations for the
Nursing council of New Zealand and introducing Stage Two - The international consensus
model for the assessment of continuing competence.
7.2 Data triangulation and discussion
The overwhelming view of key stakeholder participants was that the Continuing Competence
Framework is a critical and important mechanism to ensure nurses are fit and competent to
NCN
Z Co
ntin
uing
Com
pete
nce
Fram
ewor
k
Stage One Phase 1
Document & Policy Review
Stage One Phase 3
QuantitativeE-survey
Stage One Data triangulation &
discussion
Summary Recommendations
Stage One Phase 2
Qualitative Interviews
145
practise. Seventy-six percent of e-survey participants believe that the Nursing Council of New
Zealand’s Continuing Competence Framework and processes for renewing practising
certificates, provides the mechanism to ensure nurses are competent and fit to practise. This
response is representative of the nursing population with a margin of error of 2.85% and
confidence level of 95%.
A number of items for clarification and / or quality improvement have been highlighted in the
data and will be further analysed and discussed in this chapter. The report touches briefly on
the confusion that the interview data seem to indicate exists between; the evidential
requirements of the PDRPs, the evidential requirements of the Continuing Competence
Framework recertification audit, the notion of mandatory versus voluntary participation in
PDRPs, and role confusion between the responsibility and accountability of the Nursing
Council, employers and the individual nurse.
7.2.1 Purpose, roles and responsibilities
The international literature is unequivocal about the importance of Continuing Competence
Frameworks (Australian Nursing and Midwifery Council, 2007; Bryant, 2005; Canadian Nurses
Association, 2000; Chiarella, 2006; EdCaN, 2008; Fitzgerald, et al., 2001). Importantly, they
demonstrate to the public that the regulatory authority and nursing profession are cognisant
of, and have mechanisms, to assess the continuing competence of the profession and ensure
public safety. Continuing Competence Frameworks also promote consistency of continuing
competence standards and assessment, and provide a mechanism for the assessment of
competence as a measure of public safety (Swankin, et al., 2006; Vandewater, 2004). Further,
framework standards and assessment options should be flexible, have relevance and be
transferable to the differing levels of practice and settings in which nurses practise, and
assessment should be mandatory for all members of the profession (Vernon, Chiarella, et al.,
2011).
Interview participants clearly supported the Nursing Council of New Zealand’s
Continuing Competence Framework as a mechanism of setting standards and the notion
of capturing practice development. One participant commented
The Continuing Competence Framework is a process whereby Nursing Council has set some standards for the amount of professional development that nurses have to undertake in order to maintain their APC. Also, the amount of time that they need to be in actual practice in order to maintain their APC. So it’s a way of
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creating a standard which replaces the previous system of having no standard of what people were engaged in.
However, participants raised the issue of confusion regarding the purpose of the Continuing
Competence Framework and the roles and responsibilities inherent in the process, suggesting
that while the Nursing Council of New Zealand has a role in ensuring some degree of
competence, there is a general misunderstanding by nurses as to the nature of the Nursing
Council of New Zealand’s role.
7.2.2 The nature of a protective jurisdiction and the role of the regulatory authority
As discussed in Chapter One and identified by interview participants, the role of the Nursing
Council of New Zealand, the regulatory authority established to administer the legislation in
relation to nurses in New Zealand, is often misunderstood by nurses and indeed other health
professionals. The role of the legislation (Health Practitioners Competence Assurance Act (NZ),
2003) is protective, and therefore the institutions, roles and committees created by it, all exist
to protect the public from the risk of harm, rather than to protect the interests of the
professions so regulated (Vernon, et al., 2010). The functions and powers of the Nursing
Council of New Zealand are defined in the legislation and establish a form of regulatory regime
known as a protective jurisdiction (Staunton & Chiarella, 2008). Hence, the role of the Nursing
Council of New Zealand, amongst other things is to establish and maintain standards of
practice. This particular role includes setting the standards for monitoring the competence
and continuing competence of the profession in order to ensure public safety. Hence
compliance of individual nurses with the requirements of the Continuing Competence
Framework is mandatory. Any health practitioner who is concerned about another health
practitioner’s practice and who considers the standard of practice “may pose a risk of harm to
the public” must notify the Registrar of the relevant authority (Health Practitioners
Competence Assurance Act (NZ), 2003, s34). There are also provisions for both the public and
specified health providers to notify the Registrar about health concerns that may affect a
health practitioner’s ability to practise (Health Practitioners Competence Assurance Act (NZ),
2003, s45).
Clearly if such concerns are raised, even though regulated health professional groups enjoy a
respected public profile, an important aspect of that regulation is that health professionals
who are part of a regulated professional group can be brought to account for their practice
and, if their registration is cancelled, lose their right to practise. In New Zealand, nurses are
held accountable for their practice under the Health Practitioners Competence Assurance Act
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2003 (NZ) and are expected to maintain appropriate standards of professional conduct. Were
these standards to be breached, then a complaint may be lodged against that nurse. However,
having recognisable standards of practice that are upheld by the professional disciplinary
bodies also provides guidance for the profession and assists in setting boundaries for
professional practice.
It is also important to understand where this area of law is situated within the legal system, as
the protective jurisdiction is an area that is often misunderstood and can cause confusion
(Secretary of State for Health (UK), 2007). This is particularly the case when other areas of the
legal system, such as the criminal jurisdiction, coronial jurisdiction or the civil law area of
negligence are also involved in the matter (Adrian & Chiarella, 2010). A protective jurisdiction
forms part of a body of law known as administrative law, a branch of law which deals with the
administrative processes of governments and formal decision making bodies. It has very
different functions and processes from the criminal law which exist “to punish offenders and to
deter potential offenders” (Adrian & Chiarella, 2010; Bates, 1989). In a New South Wales
(NSW) (Australia) Supreme Court decision Health Care Complaints Commission (HCCC) v Bruce
Litchfield, (1997, 41 NSWLR 630) the Court explained that
Disciplinary proceedings against members of a profession are intended to
maintain proper ethical and professional standards, primarily for the protection
of the public, but also for the protection of the profession (Ibid, 635).
The New South Wales Supreme Court in HCCC v Litchfield went on to say that it accepted that
the toll of disciplinary proceedings might be high in terms of “money and emotional stress”
(Adrian & Chiarella, 2010, p. 7), but took pains to explain that this was not the intention of a
protective jurisdiction “These matters would be highly relevant if the purpose of these
proceedings were punitive, but their purpose is entirely protective” (Adrian & Chiarella, 2010, p.
7).
In Condon, (NMT230206JHC) a New South Wales Nurses Tribunal case, the Tribunal explained
the nature of a protective jurisdiction, “To protect the public, maintain the standards of the
nursing profession and maintain public confidence in the profession, guided the decision of the
Tribunal in relation to the protective orders that were made” (Adrian & Chiarella, 2010, p. 7).
The Tribunal went on to explain that protective orders are concerned with maintaining
standards within the nursing profession, maintaining public confidence in the nursing
profession, and providing a general deterrence to make it clear that the type of behaviour in
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which the nurse engaged, is not acceptable behaviour for a registered nurse (Adrian &
Chiarella, 2010).
It is hoped that this discussion assists in developing an understanding of the nature of a
protective jurisdiction. The aim is not to punish the transgressing nurse, although it might be
argued that suspension or de-registration certainly does. However, this is a by-product of the
legislation in a protective jurisdiction, not its primary intent (Secretary of State for Health (UK),
2007). This is an important issue for future discussion in this thesis, as there is significant
misunderstanding about the role of the Nursing Council of New Zealand, with several
comments suggesting that it exercises a punitive jurisdiction over the nursing profession,
rather than a protective jurisdiction for the public.
7.2.3 What is meant by the requirement for continuing competence?
Within any discussion about the requirement for continuing competence, it is important to
differentiate between the original requirement for competence on initial registration, and the
requirements of the Continuing Competence Framework. It is clear from the interview data
(see Chapter Five) that there is a lack of clarity about the nature of the required standard of
continuing competence. Several participants indicated that the Nursing Council of New
Zealand should only be concerned with the minimum standard of competence and that the
employer’s role is to drive a performance development culture. Some of the interview
participants insisted that the standard to be met was “the minimum standard”, and one
participant suggested that they only had to meet the same standard as they met on
registration. This does not correspond to the requirement of “reasonableness” set out in s5(1)
of the Health Practitioners Competence Assurance Act 2003 (NZ). The requirement concerns
the need to demonstrate that nurses continue to be competent to a standard reasonably
expected in their scope of practice. How nurses live out this scope of practice would have to
be dependent upon the roles in which they work – otherwise no-one could ever be held to
account, nor would there be any need to differentiate between nurses working in
management, research, education, policy or other roles that contribute to nursing practice. It
is not enough for a Director of Nursing to demonstrate that [s]he has met the competencies on
review in 2010 in the same way as [s]he met them on graduation in 1990. Her/his competence
today is about the ability to fulfil a management role. Similarly, if someone were a manager
and a clinician, or a manager and an educator, the evidence that they would submit to
demonstrate continuing competence would not be that they attended cardiopulmonary
resuscitation training and an intravenous venous accreditation, although arguably both of
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those would be valuable for the new graduate working in an emergency department. But the
requirement for the manager / educator / researcher would be work experience and
continuing professional development relevant to the context and role in which they practise.
In a protective jurisdiction, “that which is reasonable must always correlate to that which
keeps the public safe” (Bates, 1989).
Discussion with the participants about the assessment of continuing competence
demonstrated a general lack of consensus about what should be assessed and the level of
assessment that is required. As previously noted “health professionals are expected to
maintain appropriate standards of professional conduct”, this does not equate with the notion
of a minimum standard. There was also some confusion identified with regard to who is
responsible for maintaining competence to practise. In response to the e-survey, 70% of
participants strongly agreed that individual nurses are responsible for maintaining their own
competence to practise. However, 16% strongly believed that their employer is responsible
for maintaining their competence to practise, and a further 13% strongly believe the Nursing
Council of New Zealand is responsible for maintaining their competence to practise. Cross-
tabulation of the data by employment area indicated that nurses employed in Health
Management (n = 15) and Educational Institutions (n = 29) scored the highest mean scores for
the item “my employer is responsible for maintaining my competence to practise” and item
“the Nursing Council is responsible for maintaining my competence to practise”. Whilst this
response does not appear to be unique to the New Zealand context (Australian Nursing and
Midwifery Council, 2007; Campbell & MacKay, 2001; Canadian Nurses Association, 2000;
Chiarella, et al., 2008; Fitzgerald, et al., 2001; Goodridge, 2007), it does highlight the need for
the Nursing Council of New Zealand to be explicit and overt in terms of the purpose of the
Continuing Competence Framework, the role and responsibility of the Nursing Council of New
Zealand and the responsibility of the individual Health Professional (nurse), the employer and
the profession in this regard.
The findings of Phase Two and Phase Three of the research indicate some misinterpretation of
the intent/meaning of the self-declaration questions listed on the Nursing Council of New
Zealand’s Application for Practising Certificate Form. This item was introduced as a possible
issue in terms of nurses not interpreting the questions correctly and, as a result, not
completing the documentation accurately. It was felt that this aspect called into question the
veracity and validity of the self- declaration and resulted in increased contact with the Nursing
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Council of New Zealand administrative staff, and an increase in administrative time spent
following up information in relation to incomplete, and inaccurate documentation.
Ninety-eight percent of participants indicated they understood that the self-declaration is a
legal document and yet in response to the question relating to indicators of competence, self-
declaration was scored as the worst indicator of competence. Arguably if a health professional
completes an honest and subjective self-assessment, as required when completing the current
Application for Practising Certificate form, then signs the declaration indicating their
competence and fitness to practise, it should be a valid and verifiable indication of their
competence and hence, safety to practise. However, a number of interview participants
questioned the validity of the declaration made by nurses when completing the Application for
Practising Certificate. They suggested that “its status and significance” is not apparent to
some nurses and “the form is seen purely as a tick box” unless the nurse is actually selected for
recertification audit and required to provide validated evidence.
7.2.4 Communication and consultation
In terms of communication and consultation, the literature identifies that clear articulation of
the purpose of the Continuing Competence Framework is required (public protection or public
protection and lifelong learning). There must also be clear articulation of continuing
competence standards, documentation related to the Continuing Competence Framework
must be accessible and processes transparent, and web-based options should be available
(Australian Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000; Chiarella,
2006; Chiarella, et al., 2008; Goodridge, 2007; McGrath, et al., 2006). Involvement of all levels
of the profession is also noted as essential for Continuing Competence Frameworks (Australian
Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000; National Council of
State Boards of Nursing, 2009a).
It is clear that there has been considerable consultation with the profession and other key
stakeholders over a number of years, and that various iterations of the Continuing
Competence Framework were developed and implemented. Nurses have been kept well
informed. The Nursing Council of New Zealand’s requirements for renewal of Practising
Certificates was provided individually to all nurses in the form of a Nursing Council of New
Zealand News Update, dated 1 November 2004. This newsletter contained a summary of the
Health Practitioners Competence Assurance Act 2003 (NZ), the Nursing Council of New Zealand
definition of practising, the scopes of practice, process for annual practising certificate
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renewal, the competence and fitness to practise requirements for renewal of Practising
Certificates, and an overview of the Continuing Competence Framework.
7.2.5 Indicators of continuing competence
As identified in the literature (Australian Nursing and Midwifery Council, 2007; Bryant, 2005;
Canadian Nurses Association, 2000; National Council of State Boards of Nursing, 2009a),
competence frameworks are tools that have a role in regulating and guiding the profession by
setting the standards for competence assessment and ensuring consistency in the monitoring,
and on-going assessment of competence (Pearson, Fitzgerald, Walsh, et al., 2002). They have
a clear purpose in terms of ‘public protection’, however literature suggests that if their
purpose is also to promote ‘lifelong learning’ then this must be clearly articulated (Australian
Nursing and Midwifery Council, 2007; Campbell & MacKay, 2001; Goodridge, 2007) as it will
influence the level of assessment required.
The international literature identifies that the most commonly used indicators of competence
are self-assessment, peer assessment, recency of practice and continuing professional
development / education. A combination of indicators is recommended - no single indicator
used independently can measure ‘competence’. Valid measurements of indicators which are
subjective in nature, is difficult (Pearson, Fitzgerald, Walsh, et al., 2002; Vandewater, 2004).
Inter-rater reliability is a critical component of the assessment process (EdCaN, 2008;
Wilkinson, 2013). Recency of practice, and practice tasks are quantifiable indicators, however
they should not be used in isolation (Australian Nursing and Midwifery Council, 2007; Campbell
& MacKay, 2001; Fitzgerald, et al., 2001). It is also of note that, despite clear and reasonably
consistent definitions of competence articulated by a number of nurse regulatory authorities,
a level of confusion about the conceptualisation of competence and the distinction between
core and higher levels of competence, behaviours and insight is still apparent (Australian
Nursing and Midwifery Council, 2007; Campbell & MacKay, 2001; Canadian Nurses Association,
2000; Goodridge, 2007; Nursing and Midwifery Council, 2008).
Following a number of consultative processes, the Nursing Council of New Zealand made a
decision in March 2004 with regard to the indicators of competence. The Continuing
Competence Framework includes three indicators of competence: A. Self-declaration of
competence to practise (based on self-appraisal using the Nursing Council of New Zealand
competencies for the relevant scope of practise); B. Verification of practice hours (minimum of
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450 hours / 60 days in past three years); C. Verification of professional development (minimum
of 60 hours in past three years).
Qualitative data revealed that there was some criticism of the notion of the unit of hours as a
reflection of competence. Issues identified ranged from the actual number of hours in
comparison to other health professions, the determination of the hours, and elements that
might be captured in a portfolio to indicate competence. The idea that indicators might
actually represent competence was much less clear, with some comment about validity and
reliability. There was also a range of comments about what constituted professional
development and the role and accountability of peer assessors.
In the e-survey, participants were asked to rank the indicators from 1 (Best) to 7 (Worst) to
indicate which they believed provided the best evidence of continuing competence to practise.
The indicator of competence to practise ranked ‘best’ by participants was the combination of
the self-declaration (A), evidence of practice hours (B) and evidence of on-going professional
development (C), which represented 52% (n = 470) of the total overall responses. The least
popular indicator of competence to practise was (A) self-declaration only, which represented a
response from 40% (n = 311) of the total participant group.
Participants ranked a combination of the three indicators (A, B & C) as providing the best
evidence of competence to practise and on-going professional development. However, it is of
note, that the participants ranked the self-declaration of competence (based on self-appraisal
of their ‘competence’ using the Nursing Council of New Zealand competencies for their scope
of practice) as the ‘worst’ indicator for providing evidence of competence to practise when
used independently. Data from interviews and the survey indicate that there is a general
satisfaction with the stipulated hours for professional development and for clinical practice.
However, it is clear that in terms of competence, these stipulated hours are indicators rather
than guarantees.
Peer assessment is included in the recertification audit process and is used in association with
self-assessment, as a way to validate the continuing competence of individual nurses. The
decision by the Nursing Council of New Zealand to use peer assessment as a measure of
continuing competence, was based on the previously implemented Nursing and Midwifery
Council (UK) Prep Model (2011), which uses peer assessment as a means of validation for self-
assessment.
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In relation to the use of peer assessment for validation, a range of issues was reported in the
qualitative data. The majority of participants indicated that the peer assessor should be a
nurse. However, there was also comment, that in some situations it may be appropriate that
another health practitioner who works closely with a nurse, could undertake peer assessment
– but with the proviso that there needed to be clear and explicit assessment criteria
...well it’s hard to know if they’re valid because people will interpret what evidence is required for them the best way they can. I think there could be more guidelines. … Peer assessments I think that - that in itself lends it a whole new perspective on people who might sign off that somebody else is competent because they are - they need the staff. And they also - I mean I suppose I could say I know of some cases where people have signed off people as being competent with a peer review, or validated stuff when it’s been thrust under their nose.
Concerns were also evident in the participant e-survey findings. In response to a question
about whether participants had ever been asked to be a peer assessor, 21% (n = 242) of the
overall participant group indicated they had previously been a peer assessor. A further
question sought information about a number of issues identified in the interviews: provision of
information; provision of documentation about the relevant scope of practice and
competencies; provision of a competence assessment form and criteria; if the assessment was
based on evidence; if the assessment was discussed with the colleague; and understanding
that which was being competed and signed was a legal document.
Of the peer assessor group, 25% (n = 60) indicated they were not provided with information
about process, 18% (n = 45) were not provided with documentation about the scope of
practice, 10% (n = 24) were not provided with assessment forms, 6% (n = 14) indicated their
assessment was not based on evidence, and 14% (n = 34) did not discuss the assessment with
the colleague they assessed.
7.2.6 The recertification audit
In December 2005, as part of the Continuing Competence Framework, the Nursing Council of
New Zealand initiated the recertification audit process of individual nurses. Five percent of
nurses renewing their practising certificates annually are randomly selected for individual
recertification audit. The decision by the Nursing Council of New Zealand to select 5% of
nurses for audit annually appears to have been based on available international literature and
‘best practice’ at the time. This figure is pragmatic, as no single piece of evidence exists to
prove it is a valid representation of the New Zealand nursing workforce; however statistical
findings from the recertification audits and competence notifications conducted over the past
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five years suggest that the 5% measure is appropriate and effective. In addition the
recertification audit process has provided the Nursing Council of New Zealand with feedback
on the annual recertification processes and validation that nurses are complying with the
Continuing Competence Framework requirements.
Five of the interview participants indicated that they had previously been audited as part of
their recertification process. Concerns were raised about the transparency of the audit
process, such as who would be assessing the material provided. One participant’s comment
below reflects the discussion
There was no indication of how it would be assessed or who would assess it ...[it] really concerned me that I had no idea of who was going to be viewing this information ... So I did worry about the notion of confidentiality.
Another participant was concerned that evidence submitted for recertification was personally
identifiable, and commented
It wasn’t an objective - well it wasn’t an assessment that was … any nurse making application, it was because I was identifiable. The comments were specific because they knew who I - what my role was.
There was also concern expressed about the lack of feedback about the audit process. Inter-
rater reliability and moderation processes in relation to the assessment of evidence are not
apparent in the documents reviewed. The need for processes that ensure inter-rater reliability
is supported by the international literature (McGrath, et al., 2006).
Data from the e-survey indicated that 10% (n = 120) of the overall participant group had been
audited during the previous four years, from December 2005 – December 2009 inclusive. The
majority (90%) of audit participants indicated they received written information with regard to
the audit process, timeframes, competencies, evidence, where to obtain clarification and the
process after submission of documentation. A small percentage (10%) indicated they did not.
Whilst the percentage is small in terms of the overall nursing population, it should be noted
that it still represents a significant cost in terms of Nursing Council of New Zealand
administrative resources responding to and processing additional queries, requests and
documentation.
The majority of participants (88%) indicated that they had a good understanding of what
evidence to provide for the recertification audit based on the information they received from
the Nursing Council of New Zealand. Thirty four percent of participants indicated they received
requests for further information following submission of their audit documentation. This is
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another area that represents a significant cost in terms of the Nursing Council’s administrative
resources.
Overall, participants indicated that they were generally satisfied with the recertification audit
documentation, communication and process. Additionally, in response to the question “when
you were audited did you receive written information about the domains of practice and
competencies for your scope of practice?” there was significant improvement in 2009 from
previous years with 100% of participants indicating they received the information.
Nurses who participate in a Nursing Council of New Zealand approved PDRP process are
exempt from the recertification audit process. Nursing Council of New Zealand documentation
relating to the implementation of the Continuing Competence Framework and recertification
audit process signals that recertification audit numbers were expected to drop significantly
over the initial five year period, due to increased participation of nurses in PDRPs. Whilst,
there has been a slight incremental reduction in recertification audit numbers (n = 1288, 2006-
2007; n = 1075, 2008 – 2009) this has not been significant and may be due to voluntary
participation in PDRPs and relatively low participation nationally.
7.2.7 Continuing Competence Framework policies and documentation
The Nursing Council of New Zealand has three policy documents associated with the
Continuing Competence Framework; these are the Continuing Competency Policy (GPO02.10)
(August 2004, March 2007), the Continuing Competence Policy (RP05.03) (August 2004, June
2009), and the Recertification Audit Process Policy (GPO 05.3) (August 2006; May 2008), all of
which are in-house documents. The Continuing Competency Policy (GPO02.10) is a governance
document, whilst the Continuing Competence Policy (RP05.03) and the Recertification Audit
Process Policy (GPO 05.3) outline the procedural requirements of the Nursing Council of New
Zealand’s Continuing Competence Framework, and the associated recertification audit process.
The policies are written in the format of a guideline or procedure, rather than that of a formal
policy and they are not publicly available. Whilst the policies include a ‘policy statement’ they
do not include a ‘purpose statement’ and they focus solely on procedural aspects of the
Continuing Competence Framework and recertification audit processes.
However, a clear explanation of the criteria for the Continuing Competence Framework;
exemption from the recertification audit; and the recertification audit ‘evidential
requirements’, is available to the public on the Nursing Council of New Zealand website. Again
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there is no ‘purpose statement’ linking the Continuing Competence Framework to the Nursing
Council of New Zealand requirements that are mandated by the Health Practitioners
Competence Assurance Act 2003 (NZ). In addition, there is no information available to nurses
with regard to the recertification process or timelines once their documentation has been
submitted to the Nursing Council of New Zealand for assessment. This is an area of concern
which was raised by the interview participants and confirmed by the e-survey participants.
As noted in Chapter Four, a number of iterations of different forms of written evidence to
demonstrate competence were developed by the Nursing Council of New Zealand. One early
option was for nurses to maintain a personal professional portfolio of evidence which may be
called on for audit. It appears that the later decision not to audit portfolios was pragmatic, and
largely based on administrative and financial considerations. This decision is supported by the
international literature which suggests that a portfolio is not an adequate indicator of
continuing competence or safety to practise. Portfolios are noted as being time-consuming,
difficult to assess and lacking inter-rater reliability, due to their subjectivity (EdCaN, 2008).
They are tools best used to recording practice and developing an individual’s reflective
thinking (Australian Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000;
EdCaN, 2008; Fitzgerald, et al., 2001; Vandewater, 2004).
Currently a package of hard copy documentation is posted to individual nurses selected for
recertification audit. This package includes:
• A form / template letter – recertification audit
• Information sheet – why have I been selected for a recertification audit?
• Nurse audit checklist
Nurses are directed to the Nursing Council of New Zealand website to download and print the
relevant template documents, for example, competencies for the scope of practice and
competence assessment forms. These documents are not included as hard copy in the
recertification audit package and are only available as a PDF template from the Nursing Council
of New Zealand website. Hence nurses are required to source the relevant documentation
and enter their evidential data by hand rather than providing the opportunity to download and
enter their data electronically – or copy the form into a MS-Word document so that
information can be typed in.
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The notion that the Nursing Council of New Zealand’s current process for assessment of
continuing competence is just an ‘indicator’ of competence was expressed by one participant
...an audit done by a regulatory body in no way can say ... ‘Oh you’re competent to practise’. A PDRP process I think can because it goes into much more depth. But anything a regulatory authority does can only be an indicator really.
Additionally, there is confusion with the Nursing Council of New Zealand’s role in
recertification and Professional Development and Recognition Programmes (PDRPs) which are
approved by the Nursing Council of New Zealand. This confusion was highlighted in the
following quote
Nursing Council should actually clarify the purpose of the process … because it has, it’s got confused with PDRP, without a shadow of a doubt. The idea of it being minimal and they’ve - and it’s a - just an absolute focus on safety. Public safety as opposed to professional development. There needs to be some clarification. Who is responsible and what is the purpose?
As demonstrated, the requirements and processes for assessment of continuing competence,
the Nursing Council of New Zealand Continuing Competence Framework and the PDRPs have
become enmeshed, and subsequently have created confusion.
7.3 Key research findings
7.3.1 Legislation, policy and statutory requirements to ensure registered nurses are competent and fit to practise in New Zealand
As previously noted the primary purpose of the Health Practitioners Competence Assurance
Act 2003 (NZ) “is to protect the health and safety of members of the public by providing for
mechanisms to ensure that health practitioners are competent and fit to practise their
professions” (Health Practitioners Competence Assurance Act (NZ), 2003). The Health
Practitioners Competence Assurance Act 2003 (NZ) clearly sets out the conditions and
requirements that health professionals must meet in order to practise under the Act (Health
Practitioners Competence Assurance Act (NZ), 2003, s3(2)), including the mechanisms to
ensure that these practitioners are competent and fit to practise their professions for the
duration of their professional careers. Establishment of these mechanisms is the responsibility
of the regulatory authority (Health Practitioners Competence Assurance Act (NZ), 2003, s11).
Hence, the establishment of the Nursing Council of New Zealand Continuing Competence
Framework in 2004, as the statutory mechanism to ensure and monitor the continuing
competence of nurses for the purpose of public safety (Nursing Council of New Zealand,
2004a).
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7.3.2 The role of the Nursing Council of New Zealand
It was evident from the participant (nurse’s) responses that there was a lack of clarity and
some confusion amongst some nurses with regard to the role, responsibility and
accountabilities of the Nursing Council of New Zealand, in terms monitoring and ensuring
nurses’ continuing competence to practise and public safety. It was also evident that some
participants were unsure of their own responsibility and accountability with regard continuing
competence and safety to practise.
Confusion existed between the evidential requirements of the Nursing Council of New Zealand
Continuing Competence Framework recertification audit processes, and the requirements and
purpose of the union and employer owned Professional Development and Recognition
Programmes (PDRPs). Participant responses indicate that this confusion between the purpose
and ownership of these two separate processes has had a negative impact on the Nursing
Council of New Zealand by introducing a heightened level of anxiety amongst nurses.
7.3.3 Continuing Competence Framework
There was general agreement that the Continuing Competence Framework is a critical and
important mechanism to ensure nurses are competent and fit to practise. It is a mechanism
that the participants believe promotes professional responsibility and accountability. Seventy-
six percent of the e-survey participants identified that the Continuing Competence Framework
and processes for recertification (renewal of Annual Practising Certificates), provide the
mechanism to ensure that nurses are continuing to be competent.
There is historical evidence that the initial development of the Nursing Council of New Zealand
Continuing Competence Framework was well researched, detailed, and included extensive
stakeholder involvement and consultation. However, the historical documents associated with
the development and implementation of the Continuing Competence Framework, require
professional indexing and archiving.
The interview and e-survey participants indicated that there was a lack of clarity and some
confusion with regard to the required standard for the assessment of continuing competence.
Is it a minimum standard of competence that is being assessed, or is it continuing competence
that takes into account required standards and competencies of practice in association with
the nurse’s role and context of practice? In addition, the participants identified that there was
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a lack of clarity and guidelines with regard to what constitutes continuing professional
development and evidence of continuing professional development.
7.3.3.1 Indicators of continuing competence
The indicators of continuing competence (self-assessment, practice hours/recency and
continuing professional development hours) are all considered to be appropriate indicators of
competence, that when used together can imply continuing competence and therefore may
imply safety to practise. However, they do not guarantee that a nurse is safe to practise on
any given day. In addition, the stipulation of a minimum number of practice, and continuing
professional development hours, when used independently, was not considered by the
participants to be a valid measure of competence.
7.3.3.2 Application for recertification (Annual Practising Certificate)
Issues were identified with regard to the verification and legal status of the self-declaration
and the validity and reliability of the self-assessment (Application for Practising Certificate
form). In addition, the e-survey participants indicated that the Application for Practising
Certificate (recertification) form is difficult to read and not user-friendly.
7.3.3.3 Recertification Audit
The recertification audit process is generally considered by the participants as being an
important quality indicator that provides a measure of validity and reliability to the Continuing
Competence Framework. Statistical findings from the recertification audits and competence
notification trends conducted over the past five years (2005 - 2009), suggest that the 5%
measure for audit per annum is appropriate and effective.
As previously noted, issues were identified with regard to the validity and reliability of the self-
declaration and self-assessment documentation. Peer-assessment and the inter-rater
reliability of the Nursing Council of New Zealand recertification audit and assessment
processes were also identified as areas requiring process improvement. In addition, a number
of quality improvement areas were identified with regard to the Nursing Council of New
Zealand recertification audit process. These operational aspects included: improved access to
recertification audit documentation; development of recertification audit process guidelines;
application and document tracking processes, and moderation of assessment materials.
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The findings from Stage One of this research demonstrate that the Nursing Council of New
Zealand Continuing Competence Framework is considered to be an important, valuable and
relevant process. The Continuing Competence Framework promotes consistency of practice
standards and provides a mechanism for the annual assessment of continuing competence as
a measure of public safety. Importantly, the Continuing Competence Framework
demonstrates to the public that the regulatory authority and nursing profession are cognisant
of, and has mechanisms to, assess and monitor the continuing competence of the profession.
7.4 Concluding remarks
The overarching purpose of this thesis is to determine the relationships between current
legislation, policy and statutory requirements to ensure that registered nurses are competent
and fit to practise in New Zealand. Evaluation research using a sequential mixed-methods
design has been used to complete Stage One – The evaluation of the Nursing Council of New
Zealand Continuing Competence Framework. Each sequential phase of data collection and
analysis has focused on a particular evaluand grouping which has served to inform the basis for
the next phase of data collection and analysis.
Chapter Seven has presented the triangulation of the Stage One summary findings in relation
to the research questions, previously identified in Table 2 (p. 5), in association with the
national and international literature. Although Stage One of this research has demonstrated
overarching endorsement of the Nursing Council of New Zealand Continuing Competence
Framework, a number of areas for improvement were identified specifically in relation to
Nursing Council of New Zealand operational processes, documentation, accountabilities and
responsibilities. A list of the operational recommendations made to the Nursing Council of
New Zealand is presented in Table 20.
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Table 20 Summary of recommendations made to the Nursing Council of New Zealand
Recommendation One - Communicate the Nursing Council of New Zealand Role and Responsibilities 1(a) Improve and make overt the ‘public nursing’ profile of the Nursing Council of New Zealand with
regard to its role and responsibility as the regulatory authority for nurses in New Zealand 1(b) Differentiate and communicate the Nursing Council of New Zealand’s expectations with regard to
the responsibility of individual nurses, employers and the profession in terms of the requirements of the Continuing Competence Framework and the Health Practitioners Competence Assurance Act 2003 (NZ).
1(c) Articulate and communicate the Nursing Council of New Zealand’s role and responsibilities with regard to PDRPs.
Recommendation Two - Revise Continuing Competence Framework Documentation 2(a) Revise the Continuing Competence Framework and Recertification Audit policy documentation to
include a clear purpose statement and policy framework principles. 2(b) Provide on all Continuing Competence Framework related documentation (including the Nursing
Council of New Zealand website), a clear and consistent definition of what constitutes ‘continuing competence’ with explicit criteria in relation to how continuing competence may be assessed.
2(c) Revise Continuing Competence Framework documentation available to nurses and provide more explicit and detailed guidelines with regard to Continuing Competence Framework evidentiary requirements, assessment processes, recertification audit process including recertification assessment and timelines.
Recommendation Three - Revise Application for Practising Certificate form 3(a) Provide a clear and more comprehensive definition of the status of the self-declaration on the
‘Application for Practising Certificate’ form. In this regard the Nursing Council of New Zealand should consider taking advice on the inclusion of a statutory declaration.
3(b) Reformat the ‘Application for Practising Certificate’ form to make more explicit and obvious, the crucial information with regard to the self-declaration. For example, the information in relation to the scopes of practice and associated competencies; and the guidelines with regard to questions nine (Do you have a mental.....for the practice of nursing?) and ten (Have you been the subject of an investigation.....since last applied for a practising certificate?). Move demographic information and guidelines and codes to the back of the application.
3(c) Clearly articulate the penalties for providing false and misleading information on all documentation related to the Continuing Competence Framework.
Recommendation Four - Review Recertification Audit Documentation and Procedures 4(a) Provide recertification audit material and guidelines in both hard copy and electronic formats,
with the provision for participants to enter data directly onto electronic forms. 4(b) Move to a system of electronic submission of recertification audit data. 4(c) Move to a system of electronic tracking of recertification audit documents, accessible to nurses
who are participants in the audit process. 4(d) Revise and provide clear criteria and guidelines for the selection of peer assessors. 4(e) Provide peer assessors with guidelines for the ‘peer assessment’ process, in addition to clear and
explicit assessment criteria. Provide documentation options in hard copy or electronic formats. 4(f) Instigate clear internal moderation processes to improve inter-rater reliability and transparency
of audit assessment processes.
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The report prepared for the Nursing Council of New Zealand, specifically addressing the project
objectives stipulated by the Nursing Council of New Zealand (Table 1, p. 3), has been published
Evaluation of the Continuing Competence Framework (Vernon, et al., 2010), and is publicly
available from http://nursingcouncil.org.nz/Publications/Reports.
The findings from Stage One, Evaluation of the Nursing Council of New Zealand Continuing
Competence Framework, in association with the international literature, form the basis for the
development of Stage Two of this thesis. Stage Two – The International Consensus Model for
the Assessment of Continuing Competence, continues to investigate the relationships between
current legislation, policy drivers and statutory requirements to ensure registered nurses are
competent and fit to practise, by evaluating the possibility of developing an international
consensus model for the demonstration of continuing competence. The following section,
Section Three: Chapters Eight and Nine will present and discuss the findings derived from the
Stage Two Delphi Study.
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SECTION THREE STAGE TWO: THE INTERNATIONAL CONSENSUS MODEL FOR THE ASSESSMENT OF CONTINUING COMPETENCE
Section three presents the international component of this research and draws heavily on the
findings of Stage One, and in particular the evaluation of the Nursing Council of New Zealand
Continuing Competence Framework. Findings from the evaluation of the Nursing Council of
New Zealand Continuing Competence Framework have assisted to position this research in
terms of its international relevance and transferability, and provided a platform from which to
evaluate the possibility of developing an international consensus model for the assessment of
continuing competence.
Chapter Eight provides an overview of the Delphi process that was undertaken and
presents the analysis of the findings that emerged from the first three Delphi rounds. A
summary of the consensus views and the key principles derived from the Delphi rounds
(one-three) are presented.
Chapter Nine presents and discusses the analysis of the Delphi Round Four participant
responses and provides a summary of the overall consensus views in relation to the
three research questions, and in association with the contemporary literature.
Recommendations for the development of a best practice international consensus
model for the assessment of continuing competence are proposed.
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CHAPTER EIGHT - STAGE TWO: FINDINGS OF THE DELPHI STUDY
8.1 Introduction
This chapter presents the findings from Stage Two of this research, the international consensus
model for the assessment of continuing competence. As previously described in Chapter
Three (3.3.3), this second Stage of the research was undertaken using the Delphi technique.
It is clearly identified in the literature (Chapter Two) that, internationally there is considerable
interest in models of continuing competence and the development of Continuing Competence
Frameworks. In particular, over the past 14 years considerable work has been undertaken by
nursing regulatory authorities in the following countries, New Zealand, Australia, Canada, the
United Kingdom, and the United States of America to identify valid and reliable mechanisms to
monitor the continuing competence of nurses registered in their jurisdictions. Findings from
Stage One, the evaluation of the Nursing Council of New Zealand Continuing Competence
Framework, provided a platform from which to investigate whether the development of an
international consensus model for the assessment of continuing competence was possible.
Determining the consensus view of these six specified countries (Australia, Canada, New
Zealand, Ireland, the United Kingdom and the United States of America) was the main focus of
the Delphi study. As previously noted in Chapter One (1.2), in order to determine whether
development of an international consensus model for the assessment of continuing
competence was possible, the following overarching questions were posed
1. What is the consensus view of regulatory experts in relation to:
a) best practice for nurses to demonstrate continuing competence; and
b) best practice for regulatory authorities to assess continuing competence?
Inte
rnat
iona
lCo
nsen
sus M
odel Stage Two
Delphi Round 1Stakeholder Interviews
(gpA)
Stage TwoDelphi Round 2
Qualitative E-survey
(gpB)
Stage Two Delphi Round 3Quantitative
E-survey (gpB)
Stage Two Delphi Round 4
ConsensusE-survey
(gpA)
Discussion of findings
Summary Recommendations
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2. What, if any, differences are present between the current regulatory requirements for
the demonstration and assessment of continuing competence in six countries
(Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of
America) and the best practice model developed through consensus?
3. What changes, if any, would be required to policy and regulation in these six countries
to align their regulatory framework with best practice for demonstration and
assessment of continuing competence?
In May 2011, soon after the commencement of Stage Two of this research a Memorandum of
Understanding and Cooperation was signed between the key nursing regulatory authorities in
seven countries Australia, Canada, New Zealand, Ireland, the United Kingdom, the United
States of America and Singapore. The purpose of this memorandum is to
confirm closer links between the organisations in order to develop standards for
the regulation of nurses and nursing practice and to facilitate the free exchange
of professional knowledge that contribute to the development of standards.
The memorandum goes on to state that the organisations recognise that there are potential
benefits to be gained from a closer collaborative relationship to better protect the public
health, safety and welfare22.
8.2 Delphi Round One - Interviews
As previously noted in Chapter Three, the overarching Method chapter (3.3.3.2 Expert Panel
and 3.3.3.3 Conduct of the Delphi Survey), round one of the Delphi study was completed by
interviewing a purposive sample of 14 nurse regulatory experts (Group A) who were recruited
from the six countries identified as the focus for the development of the international
22 Following notification that the Memorandum of Understanding and Cooperation had been signed, the Chief Executive of the Singapore Nursing Board (SNB), the regulatory authority for nurses and midwives in Singapore, was contacted and was invited to nominate a designate to participate in this research as a member of the expert panel (Group A). This was because the other six countries had already been identified to be the reference group and, given Singapore’s inclusion in the Memorandum of Understanding and Cooperation it seemed appropriate to extend an invitation to participate in the research. The invitation was declined, as at that time the Singapore Nursing Board did not require nurses to meet any specific continuing competence requirements. However, the Chief Executive of the Singapore Nursing Board requested that they receive a copy of the final research report and that an invitation be issued to be involved in any subsequent research.
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consensus model (Australia, Canada, Ireland, New Zealand, the United Kingdom and the
United States of America), and from the International Council of Nurses (ICN). The interviews
were largely unstructured and posed the following five semi-structured, open ended questions
as prompts:
1. Tell me about your experience with and understanding of Continuing
Competence Frameworks / models.
2. Describe what you believe is ‘best practice’ for the demonstration and
assessment of continuing competence.
3. What, if any, are the current regulatory requirements for the demonstration and
assessment of continuing competence in your country/jurisdiction?
4. Describe any barriers or enablers that exist in relation to the implementation of
a model/framework for assessment of continuing competence.
5. Do you believe it is possible to develop an international consensus model for the
assessment of continuing competence between the following six countries –
Australia, Canada, Ireland, New Zealand, the United Kingdom and the United
States of America?
Each interview ranged from 40 – 75 minutes in length and was recorded and transcribed
verbatim. The data produced was rich and descriptive in nature. In each case the opening
question “Tell me about your experience with and understanding, of Continuing Competence
Frameworks/models,” was used to set the scene for the interview process, providing the
interviewer with a baseline understanding of each participant’s knowledge and expertise in
relation to the international legislative context in which they practised.
As previously described in Chapter Three (3.3.3.4 Data Analysis), a process of summative
content analysis was used to identify themes and interpret the text data. Consistency of the
initial data analysis, thematic categorisation and generation of sub-themes was independently
checked and verified by a doctoral supervisor. The themes and sub-themes identified in the
data are presented in Table 21 and described in the following sections of Chapter Eight.
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Table 21 Thematic categories and sub-themes - Delphi Round One
Thematic category Sub-themes
Continuing Competence Frameworks - Consistency of purpose and understandings
• Competence and continuing[ed] competence • Purpose of a Continuing Competence
Framework • Public safety
Variation in legislation and policy
• Permissive legislation • Right-touch regulation
Best Practice
• Legal status of framework • A common language • Assessment of continuing competence-
competence indicators • Validity and reliability of competence
indicators • Responsibility and accountability
Barriers and Enablers
• Continuing competence - legislative requirement or career development
• Variation in terminology and language • Consistency in roles and education standards • Administrative and financial viability
8.2.1 Continuing Competence Frameworks - Consistency of purpose and understandings
All of the interview participants identified a common purpose in terms of the role and
responsibility of a regulatory authority and continuing competence requirements, particularly
in relation to protection of the public. It was the unanimous view of the participants that
development of an international consensus model for the assessment of continuing
competence between the six countries was possible. Four participants identified that an
important starting point for this process would be achieving consensus in terms of “common
beliefs, values and core principles”. A number of subthemes emerged within this category and
are described below.
8.2.1.1 Competence and continuing competence
Each interview participant articulated clear understandings of what they believed constituted
and defined competence and continuing competence. The definitions and explanations
provided were consistent in terms of their elements and purpose. Whilst the use of language
varied in some instances, all participants identified that they believed competence was
measured by achieving a predetermined standard of knowledge and skills, attitudes and
behaviours relevant to the approved education and practice standards and a code of
conduct/ethics.
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Whilst the definition of what constituted continuing competence was similar in every case, an
additional element of “competence relevant to the role / context in which the nurse practised”
was also discussed by 11 of the 14 participants. One participant commented
From a continuing competence perspective - obviously we all have competency standards for initial registration or initial endorsement relevant to the registered role for example competency standards for registration as a registered nurse, midwife and enrolled nurse. And those standards are used as a - as a minimum standard. But if you’re talking about defining continuing competence it can’t be based solely on a minimum standard, it needs to be competence relevant to the role the person holds and the context in which they practise. There is a distinct difference from initial competence at registration.
Another participant stated
Continuing competence occurs on a continuum. It is about how we continue to learn and evolve throughout our career. It is not about remaining static and meeting a minimum standard. It is about continuing to be safe to practise and it has to be contextualised.
8.2.1.2 Purpose of a Continuing Competence Framework
The purpose of a Continuing Competence Framework in terms of its value as a tool for
monitoring the continuing competence of the profession was voiced by all participants. One
participant commented
Basically the purpose is to provide the public with some assurance that practitioners continue to be competent and safe in their practice. Nurses need to understand that continuing competence is not about seeing if you’re a good nurse or a great nurse. It’s about the regulator’s role - that is to make sure you’re competent, that you’re not a safety risk. And employers should be working with the nurse to advance their skills and do all of those things, but this continuing competence process is about establishing safety to practise.
Another participant stated
Continuing competence is one of the more challenging pieces to do with nursing: regulation. I think just about anything else we – we can come up with good systems that can measure and do ensure competence, or at least as much as you can…when it comes to continuing competence, it’s not a one-off, it’s on-going and it’s important. Its massive numbers and it’s hard to measure in a cost-effective way… to me comes back to that question: are we looking at trying to have a certain level of competence in every nurse, or are we trying to make sure to take out the, you know, the bad apples, the ones that are the problems. So, if we’re trying to make sure of this certain level of competence in every nurse, that’s – it’s hard to do. But I do think it’s important, and I think we have to keep working at it, until we come out with the best system possible that is – is cost-
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effective as much as possible, and time-efficient as possible. Because both of those are issues, I mean, if you don’t have enough nurses in the workforce, if you’re using resources and time in this piece of work, are you ultimately serving the patient’s needs as well, you should be because after all that’s what the purpose is. So, it’s about all the bits of the framework that have to come together to make it – give you the best result possible.
In addition to discussing the regulatory / monitoring purpose of a Continuing Competence
Framework, four participants also talked about its use as a career development tool. One
participant made the following statement
The notion of Continuing Competence Frameworks has gained momentum. Continuing competence is now a requirement of our legislation, rather than just a presumption that a nurse remains competent purely by virtue of their registration. Another aspect of this is the public expectation and actually right to be assured that the nurse who is treating them is competent. We [regulators] are now required to ensure and monitor the continuing competence of nurses in practice. Obviously a continuing competence model incorporates the policies and tools we use to do that. Basically it can be used as a regulatory tool and also as a career development tool.
Another participant commented
It goes without saying that a Continuing Competence Framework is a mechanism with which regulators can provide the public with some assurance that they do actually monitor the competence of the profession and in some cases this may be linked with a career development plan. The tension arises when some nurses perceive the purpose of the framework is all about them. I mean - they miss the point and perceive it as surveillance or punitive.
8.2.1.3 Public safety
The notion of ‘public safety’ was raised by all participants and was identified as being integral
to the purpose of regulation and the role of the regulator. It was also linked with discussion
about associated responsibilities and public expectations. One participant commented
I guess the bottom line is that the model gives the public some assurance that the people, who are caring for them or, you know, engaging with them as regulated health professionals, in this case nurses, are competent to practise. It is mainly about public assurance, really.
Another participant who noted the purpose of Continuing Competence Frameworks (8.2.1.2)
went on to discuss it in terms of the relationship between the employer, the nurse and safety
to practise.
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Nurses need to understand that continuing competence is not about seeing if you’re a good nurse or a great nurse. It’s about the regulator’s role that is to make sure you’re competent, that you’re not a safety risk. And employers should be working with the nurse to advance their skills and do all of those things, but this is about establishing safety to practise.
Public safety was also strongly linked with the concept of professional responsibility - who is
responsible? One of the participants stated
…actually continuing competence is about public safety. It is a professional responsibility and whilst regulators may be delegated the responsibility [from government] to ensure competence and monitor continuing competence the individual health professional is ultimately responsible.
Another participant stated
Continuing competence… one would hope that in the future nurses will just - you know accept that this is what I do. And do it not with that kind of grumble, grumble but you know “of course I’m a professional this is what I do”.
A further participant stated
We should be encouraging people to take more responsibility for being mature professionals. I’m interested in people stepping up to the plate and feeling positive about this additional thing they can do to enhance their - their role. It is their responsibility after all. I wonder if we’re under-utilising the employer in this in some way, after all they have a responsibility as well.
8.2.2 Variation in legislation and policy
Variation in legislation and policy between and within countries was cited by eight participants
as a possible challenge, but not a barrier in terms of reaching consensus on the development
of an international model for continuing competence. One participant commented
Well I think that now we’re trying to develop a regulatory community. I think these are some of the things that we can certainly put on the table. And try and develop some research projects around and develop new trusts with each other related to - to some consistency of the systems. I think it’s one of our biggest difficulties understanding each other’s systems… in this particular group [six countries] … there’s a level of consistency already in how we approach nursing regulation and actually our legislation isn’t so different, it’s the policies that flow out of it. Continuing competence is a complex process so there is benefit in having consistency.
Another participant suggested that the development of a common Code of Ethics and
Standards of Practice may be a starting point for this process.
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One of the things around continuing competence is that different countries are at different stages. The legislative requirements are different and so some, have very well-developed models and others are – are just starting to look at it. So I think sometimes it’s harder to come to consensus where you’ve got so many at different stages. Whereas, you have the standards for practice for example, or a code of ethics for example, which is much more – I mean, a code of ethics is a code of ethics, right? And, you know, I could envision something like it, a code of ethics that could be agreed on, probably more easily than something like a continuing or competence programme, but I don’t think that’s impossible it’s probably just and easier place to start.
8.2.2.1 Permissive legislation
The importance of “permissive legislation” was a term that was frequently used during the
interviews when participants were describing the context of their current regulatory
environment. However, there was significant variation with regard to the permissiveness of
the legislation and legislative requirements and delegation of responsibility. In some cases
participants described the legislation as prescriptive in terms of what was “required” or
“allowed”, whilst in others the legislation was “high level” and clearly delegated the
responsibility for policy development, implementation and monitoring to the regulatory
authority. One participant commented
The legislation is definitely an enabler – it requires a continuing competence process to be put in place, but it allows the regulator to determine and implement the policy and processes. So the legislation is reasonably permissive in terms of how it is enacted and applied by the regulator. The advantage is the continuing competence process can be mandated, and then basically it becomes a compliance model.
It was apparent that in some cases the physical situation/context and structure of the
regulatory authority, (for example if the regulatory authority was an independent entity or
situated within a Ministry of Health or Health Department) had a significant influence on
powers of the authority in terms of financing, implementing and monitoring new processes.
One of the participants commented
You know, we are here by virtue of the legislation that, you know, government authorises us to act as the regulator, but we are not within the government. We sit independently, however many of the State Boards are within the department of health and they sometimes have a very narrow function. This isn’t a barrier necessarily but it can be a challenge when trying to implement new policy and processes particularly if there are conflicting priorities.
In contrast another commented
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We are fortunate because we are an independent body and are funded by the fees our nurses pay. The legislation is reasonably permissive so we have control over how and what we implement as long as we can demonstrate we are putting in place policy processes that meet the legislative requirements of the ACT.
8.2.2.2 Right-touch regulation
The term right-touch regulation23 was raised in nine of the 14 interviews particularly related to
the enactment of legislative requirements with regard to continuing competence and
implementation of regulatory processes. Seven participants noted that requirements relating
to “continuing competence” were noted in the governing legislation. However, whilst there
was variation in terms of the legislative requirements between jurisdictions, in most cases
development, implementation and monitoring of Continuing Competence Frameworks and
policy was at the discretion of the regulatory authority.
Our legislation requires we monitor the continuing competence of the profession. We work from a basis of trust, you know, that we trust professionals. And we also work from a basis of believing that if the professional has accountability and responsibility for their own behaviour, then light-touch24 [right-touch] regulation is all that’s required. So we shouldn’t be heavy handed in our approach.
Right-touch regulation was mentioned in the context of the financial implications and
managing large nursing work force numbers. In particular, the balance between economics
and continuing competence models that may be perceived as focusing on compliance and
surveillance was discussed. One participant stated
It’s important to come from a pragmatic economical point of view, apart from anything else because all of these things cost a fortune and unfortunately there isn’t an economy in scale. The legislation requires it and I think it is important to have requirements in place in relation to continuing competence but the difficulty is balancing the requirements and assessment of them. Secondly I’m not sure it’s really a proportional response to - to kind of police you know professional people. Because we want to encourage, we want professional behaviour and more autonomous and more self-directed practice. And over regulating, surveillance, this counters to that really, if we’re saying we don’t really believe any of you and we want to check up on you all the time that not really right-touch, do you know what I mean?
23 Right-touch regulation is the minimum regulatory force required to achieve the desired result (Council for Healthcare Regulatory Excellence, 2010, p. 4). 24 Light-touch and right-touch regulation are terms that some research participants used interchangeably.
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Four participants noted an emerging tension between the legislative requirement to ensure
public safety and future workforce implications. One participant stated
probably one of the biggest issues … is the objects and the principles that underpin the legislation so that while public protection is a primary interest for the regulator everything must be right-touch and be balanced against workforce implications. So that’s something that regulators have not in the past had to consider as equally as they would consider public protection. So it is judging and assessing against those two. So it’s changed the - the way in which we do business.
8.2.3 Best Practice
A high level of willingness to work together to achieve agreement in relation to international
best practice principles was apparent when undertaking these interviews. The statement of
one participant reflects a number of the other comments made.
Well I think that now we’re trying to develop a regulatory community. I think these are sort of things that we can certainly put on the table. And try and develop sort of some of the research projects around and -develop new trusts and understandings with each other - and related to - to some consistency of the systems and process. I think it’s one of our biggest difficulties is we are all duplicating … You know in this particular group that we have here [Australia, Canada, Ireland, New Zealand, Singapore, United Sates of America, United Kingdom] there’s a level of consistency in how we have approached regulation and a willingness to work together.
Another participant stated
I think this is exciting – that someone is looking at what is happening internationally. Because of the magnitude of this work, it would be great if we could have some commonality and be able to do some research that informs state of the art regulatory processes. So I think it’s great that this discussion is happening prompted by your research.
A number of subthemes emerged within this category, some of which were identified as
enablers in the development and implementation of existing continuing competence models.
8.2.3.1 Legal status of the framework
The legal status of the Continuing Competence Framework was identified as a component of
best practice that was directly related to the comments previously made in (8.2.2.1)
permissive legislation and the later thematic category (8.2.4) barriers and enablers.
Participants identified strongly that where the particular nursing or health professional
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legislation included statements related to competence, continuing competence and public
safety, then the ability of the regulatory authority to develop, resource and implement policy
and associated frameworks, was significantly enabled as was their ability to ensure the
compliance of the profession.
8.2.3.2 A common language
Development of a common language was highlighted as a critical component of a best practice
model. Differences in the use and meaning of some words, definitions and terminology were
highlighted as a challenge for the development and implementation of a consensus
framework. One of the participants stated
I think what would be really good is to get consensus on the terminology – language that we use. That would be a good start. We seem to have very similar definitions but sometimes the words we use mean something entirely different in another country.
The identification of the need for a common language linked strongly with the following subtheme.
8.2.3.3 Assessment / demonstration of continuing competence - competence indicators
There was general agreement that monitoring the continuing competence of the profession
was a priority for most jurisdictions. Various models and frameworks for the assessment of
continuing competence have been developed and implemented in Australia, Canada, the
United Kingdom, New Zealand and some States in the United States of America. A number of
similarities exist between these frameworks particularly in terms of the philosophy, policy and
combination of competence indicators. When discussing the challenges in developing and
implementing a best practice model, one participant highlighted the following
One of the critical aspects is to put a model together that provides a holistic view of the persons continuing competence, it’s not about surveillance. If we work on the understanding that the person has already met competence for registration, then the continuum we are concerned about starts from that point. The indicators that we choose should reflect that after all these are registered health professionals and as such deserve a level of trust – so are we saying demonstrate to us that you continue to be competent or are we saying prove you’re not incompetent. Those are two totally different standpoints - the model needs to be very clear.
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This item related directly back to the fundamental purpose of the model and the use and
understanding of the language and raises the question; are competence indicators tools for
the assessment of continuing competence or tools that provide the nurse with a mechanism to
demonstrate continuing competence? Another participant stated
Because, in essence, what you want is to create a culture of competence, so that people don’t just prepare for a test or recertification, but continuing competence - it becomes a mind-set, something that you just do as a professional.
The need for the model to be multifaceted in terms of elements that contribute to continuing
competence was indicated by twelve of the participants. One participant stated
I think for me mine are sort of more generic rather than nursing specific principles but for me it’s about - it [Continuing Competence Framework] needs to be multi-faceted. So it needs to have a whole lot of different elements to it. And it needs to have a mix of compliance things like our standards. But also things that are about that kind of sense of professionalism.
It was generally identified by the participants that a combination of competence indicators
should be incorporated into the model in order to provide the opportunity to draw on
information from more than one source, thus enhancing the validity of the overarching
assessment.
The competence indicators most commonly associated with existing continuing competence
models were identified by the participants as: self-assessment; practice hours; continuing
education / continuing education credits; peer or manager observed assessments; observed
structured clinical assessment (OSCE); portfolio assessment and career development plans.
Examination was an indicator proposed by two of the participants as a possible assessment
tool to consider in the future, however it was not an indicator currently embedded in any of
the existing Continuing Competence Frameworks.
The adequacy of the competence indicators related to attitudinal and behavioural
characteristics, for example a ‘person’s insight’ or ability to self-assess was posed as a
challenge in terms of implementing adequate assessment strategies. One participant
commented
It’s the people who come up as competence notifications and we know in nursing, often when you go back to what is the primary issue; it is around communication and lack of insight. And so because they lack insight, they don’t make the right decisions along the way. But, in fact, that may never change, that lack of insight. So it’s those very subjective things that are often the issue,
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not the fact that they can do the task really well, but actually how they decide whether they will or won’t or how they’re going to do it, or are they capable and is it actually within their role. I’m not sure this is a changeable behaviour.
Self-assessment was identified by twelve of the participants as one of the most preferred
indicators of competence when used in combination with other indicators. However, issues
related to the subjectivity of this indicator were also highlighted by all participants as a
potential risk. In particular “lack of insight” was raised by three participants as an issue in
relation to self-assessment of continuing competence. This item linked strongly with the next
subtheme related to the validity and reliability of the competence indicators.
8.2.3.4 Validity and reliability of competence indicators
The validity and reliability of the indicators selected to assess continuing competence was
identified by all participants as a challenge that required attention when developing a best
practice framework. One participant commented
We know we’re not the only discipline that has this struggle about determining competence in an on-going manner. Certainly there’s got to be – we look for a model that is administratively feasible, that is legally sound, that’s acceptable to the profession where the bottom line is definitive in saying “yes, you do this and you’re competent”. I look at the research, you know, for us shows that there is no evidence to show that a certain number of practice hours or CE hours is what does it.
Another participant commented
Validity is an issue. You know, the literature shows, and we knew it intuitively, that self-assessment is not a very robust approach to continuing competence, but we needed to do something and it is cost effective, plus it makes nurses think about what they are actually doing. So if you use it in association with some other measures you start to get a broader picture.
Whilst all participants discussed the importance of being able to demonstrate that the
framework is valid and reliable, issues related to the limitations of individual indicators were
discussed at length. Five of the participants identified that in their experience, a pragmatic
approach to selection of appropriate indicators was required as no single indicator was able to
provide valid reliable information related to continuing competence. In addition the
participants strongly indicated that the benefits also needed to be related to the cost of
administering the framework, the purpose for which it is implemented and the responsibility
of health professionals for maintaining their continuing competence.
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8.2.3.5 Responsibility and accountability
Responsibility and accountability for continuing competence was raised by all interview
participants. “A collective responsibility” for this process was identified as being critical in
terms of providing a more comprehensive and reliable assessment of competence. One
participant commented
I think it’s a multi-pronged approach for sure and multi-level champion role, I think that’s why it is a collective responsibility for the nurse, the employers, the educators, the regulators/government but mostly individual nurses.
Another participant said
So if you have a mechanism/model in place that takes advantage of the individual and the employer, to me that’s a win-win. If you’ve got the employer engaged, you’ve got the professional organisation engaged, you’ve got the nurse engaged, you’ve got the regulatory body engaged by establishing what it needs which is to say they’re competent, then I feel as a regulator my responsibility is met and that is a best practice model.
In all instances, the interview participants highlighted the final responsibility and accountability
for an individual’s continuing competence was with that individual. Below are several quotes
that reflect these responses.
I think that – that we are – we have earned the right to be called professionals, and with that comes some rights and some responsibilities, and in the list of things that I think comes as a responsibility is that if you are a professional, you take responsibility for maintaining your own knowledge and skills and that you certainly are accountable for whether or not you maintain those. And I think we should never forget that, that in the end, it is every individual’s responsibility. Employers have some responsibility but that does not abdicate the responsibility from the individual, because that is accountability and responsibility are inherent in the definition of being a professional as far as I’m concerned.
For me, it starts from the individual professional. I mean, they’re self-regulating professionals. Individual nurses do have a responsibility in terms of trying to demonstrate their commitment to continuing competency, to lifelong learning, reflective practice, and to nursing practice, you know. Certainly ensuring that their competencies are relevant and up-to-date on a continuing basis relative to their practice is important. I think the quality of care starts with the individual professional.
Issues in relation nurses’ understanding or lack of understanding in relation to their
responsibilities as a registered health professional were identified as possible challenges to
development of a model for best practice. This item also overlapped with nurses’
understanding of their responsibilities in terms of public safety. One participant commented
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We have the same issues with regard to who is responsible; some nurses don’t understand their responsibility as a health professional, that actually continuing competence is about public safety. Sometimes nurses confuse the regulator with the union and the professional organisation – often it is about a lack of understanding.
8.2.4 Barriers and Enablers
A number of the participants identified factors that were perceived to be both barriers and
enablers, and this appeared to be dependent upon the context in which they occurred. A
number of the items that emerge in this category also related directly to the development of a
best practice framework.
8.2.4.1 Continuing Competence – legislative requirement or career development
Legislation was raised again within this thematic category particularly in relation to nurses’
understanding of, and participation in, a continuing competence process. Ten participants
perceived the legislation to be a significant enabler in this process. One participant stated
The biggest enabler has probably been the legislation, prescribing it [continuing competence] essentially.
Another participant commented
I think possibly one of the biggest enablers is clear communication, and in our case it was the permissive legislation that gave us the jurisdiction to require compliance of the profession. However legislation may also be a barrier in terms of a consensus model, but I’m not familiar enough with the legislation in the other countries to know.
In contrast another participant made the comment
Until now we have been constrained by the legislation. Well perhaps not constrained, but we have different levels of legislation. Basically if the legislation is silent and there is nothing to require nurses to participate then of course many won’t. Hence implementation and uptake is inconsistent across…
This theme was expanded by another participant who stated
You know, the barriers – the challenges are that the programme that we currently use which is, you know, self-assessment, peer feedback, learning plan, evaluation is not compulsory in terms of the legislation. So, the barrier is nurses’ willingness to participate in the programme and to participate in the way that they are intended to. Some nurses engage really well with the programme, which are usually the ones actually who don’t need it.
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In conclusion one participant stated
Continuing competence requirements will probably separate into what is the regulatory - regulators responsibility, the legislated mandate, and how the profession and professional organisations will support that.
8.2.4.2 Variation in terminology and language
Variation in the terminology and language used within and between countries was raised by
three participants as an issue that had the potential to be a barrier in some jurisdictions. This
was evident from the following two statements
Even in our own country, there are different definitions for what certification means. Variation in language and terminology – use of terms is something that needs to be addressed – a common language, common terminology so everyone has the same understanding, otherwise there are issues.
I’m not sure that we all have the same understandings for the same terms, for example ‘scope of practise’ in some jurisdictions it means the area of practise you work in, and in others it is the registration that the nurse holds. To move forward we need to agree on the language and accepted meanings.
8.2.4.3 Consistency in role definition and education standards
Reaching agreement and common understandings with regard to role definitions and
education standards was identified as a significant enabler in terms of development of a best
practice consensus model. This was linked with the need to reach common understandings on
a code of conduct in order to address the attitudinal and behavioural expectations of a
continuing competence model.
Mobility of the nursing workforce featured within this subtheme in relation to facilitating
movement of nurses between regulatory jurisdictions both within countries and between
countries. This item was identified as challenge that was specifically attributed to the issue of
“trust” and lack of common understandings of consistent role definition, educational
qualifications and practice standards.
8.2.4.4 Administrative and financial viability
The importance of the administrative and financial viability of the continuing competence
model was raised by all participants, particularly in relation to the large number of nurses
within some of the jurisdictions. Aspects such as monitoring the compliance of participants
through audit processes were identified as challenges due to the large numbers of nurses and
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associated administrative costs. Three participants discussed the use of a risk matrix approach
as a strategy that provided a more targeted approach, utilising resources in areas or with
individuals where a potential of identified competence issue had occurred. One of the
participants stated
Logistically with large nurse numbers a risk based approach is manageable. Auditing a percentage would be prohibitive but identifying those individuals or groups that are a potential risk – risk matrix - targets the limited resources to where they are most appropriate.
The second participant stated
Let’s face it the majority of nurses are competent and continue to be competent so the cost comes with those who are not. There comes a point with error where you’re seeing that there’s the scale of the error or the number of errors triggers a response. That’s the model that we are looking at, risk management - not the indicators of competence necessarily, but the indicators that somebody may not be competent and then auditing them. I mean I think you’ve got to look at things like red flags, they’d be two flags, could be with an individual or an area of practice. With large number of nurses in practise we need to develop a model that achieve our goals but is administratively feasible.
Another participant stated
We know how to do a psychometrically sound, a legally defensible and administratively feasible test – we use them for entry to the register. But I’m convinced nurses just don’t want to sit an exam on an on-going basis and do they really need to? Shouldn’t we be targeting our resources where we know there may be an issue? So, you know, then that puts us back to Square One. There’s a lot of money and a lot of resources put into these programmes and I want to make sure we’re not just doing it for the sake of saying we’ve met a legislative requirement.
8.2.5 Summary - Delphi Round One
In summary, it was the unanimous view of the interview participants that development of an
international consensus model for the assessment of continuing competence, between the six
countries identified as the focus of this study is an important initiative, and that such a
consensus is possible. It was felt that the new relationship between these countries in terms
of the recently signed memorandum of understanding would facilitate this on-going work.
Limited knowledge and understanding of the legislative, regulatory and educational
requirements for nurses between countries, was identified as a contributor to the perceived
difficulty for nurses wishing to move between regulatory jurisdictions, within and between
countries. Four participants noted that having a greater understanding of the legislative,
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education and qualification frameworks in each of the six countries was a critical factor in
facilitating greater ease of mobility for nurses both within and between the countries. Another
participant stated that “by working more closely together a greater level of trust would be
developed between regulatory jurisdictions”.
The establishment of common values, beliefs and guiding principles contributing to an
internationally agreed code of conduct, education and practice standards was also identified
by seven participants in relation to the development of a consensus model. The variation in
understandings related to the specific indicators that were embedded in the Continuing
Competence Framework were not considered to be a critical issue provided that ultimately the
model allowed flexibility in terms of its implementation requirements, was administratively
feasible, financially viable and defensible in terms of providing some assurance of public
safety.
Whilst the collated findings from round one (Group A) were not provided to the participants in
round two (Group B), they did form the basis for the development of the semi structured
questions posed in the Delphi round two e-survey.
8.3 Delphi Round Two – E-survey
The aim of round two was to seek an open response from the larger, anonymous international
cohort of expert participants (Group B), and to test the stability of the findings derived from
the round one, face-to-face interviews completed with members of Group A. The design of
the round two e-surveys was predominantly semi-structured with open-ended questions that
were formulated using the findings of round one (Group A). A criterion for participant
inclusion in the e-survey (expert Group B), was knowledge and expertise with regard to
Continuing Competence Frameworks and or / nursing regulation. The questions posed were:
1. Do you have knowledge and or experience in the development or
implementation of Continuing Competence Frameworks?
2. Describe the ways you believe it is possible and appropriate for nurses to
demonstrate continuing competence.
3. Describe how you believe continuing competence should be assessed.
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4. In your experience please describe the barriers and /or enablers that may
exist when implementing a model for the demonstration and assessment of
continuing competence.
5. Do you believe it is possible to develop an international consensus model for
the demonstration and assessment of continuing competence?
The participants were also provided with the opportunity to add any further comments. As
previously noted a copy of the e-survey is attached (Appendix IV).
8.3.1 Distribution and return of the Delphi round two e-survey
As previously noted in Chapter Three (3.3.3.2 Expert panel), an email invitation to participate
including the detailed research information sheet and the URL link to the web-based e-survey,
was sent to the nursing regulatory authorities and professional nursing organisations in
Australia, Canada, Ireland, New Zealand, the United Kingdom, the United States of America,
and to the International Council of Nurses (ICN) for distribution to the ICN Regulatory
Observatory Group.
Summative content analysis, previously described in Chapter Three (3.3.3.4), was used to
interpret the qualitative text data and identify the emergent themes. This logical and
systematic interpretive process involved counting and comparison of keywords and content
areas. Summary data from this process of analysis are presented in relation to each of the five
survey questions. Because of the snowballing technique used to recruit Group B participants,
and the deliberate intent to ensure that participant responses remained anonymous,
participation statistics will not be reported by geographic region.
Fifty-one participants responded to the invitation to take part in the Delphi round two e-
survey, all of whom completed and submitted responses to the e-survey (Table 22).
Table 22 Knowledge and / or experience of Continuing Competence Frameworks?
Sample size Yes No Total n % n % N %
51 67.7 34 33.3 17 100
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Of the 51, participants 33.3% (n = 17) indicated that they did not have experience in the
development or implementation of Continuing Competence Frameworks. The responses from
these 17 participants have been included in the round two data analysis and have also been
used as a sub group for cross tabulation when analysing the data.
8.3.2 Demonstration and assessment of continuing competence
All participants (n = 51) submitted responses to question two “Describe the ways you believe it
is possible and appropriate for nurses to demonstrate continuing competence” and question
three “Describe how you believe continuing competence should be assessed.” Whilst the
majority of the text responses were consistent with the responses from round one, it was
evident that the difference in the terminology used between and within countries, related
directly to how continuing competence was described. The collated responses with regard to
the ways it is possible and appropriate for nurses to demonstrate continuing competence are
presented in Table 23.
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Table 23 The ways it is possible and appropriate to demonstrate continuing competence Responses Response Count Certification/relicensure25 12 Mandatory continuing competence program requirements26 6 Multisource feedback27 8 Multi-pronged approach28 2 360 degree multi source29 14 Continuing education / education credits 15 Professional development hours 3 Approved continuing education programs 1 Mandatory continuing education 2 Evidence of successful educational outcomes 1 Recency of practice 4 Satisfactory and consistent practice at same or higher level/ongoing practice 7 Hours of practice 7 Practice reviews / audit of practice 2 Documentation of current clinical and safe practice 1 Professional portfolios 8 Reflective practice / self-reflection / self-assessment 7 Self-assessment 6 Self-declaration of competence 2 Peer / colleague feedback 5 Peer assessment / review 1 3rd party assessment 2 Employee evaluations indicating competency 3 OSCE 3 Observation/assessment of practice 4 Objective competency evaluation 1 Return demonstration, simulation 4 Skills demonstration 3 Written examination 3 Random audit 2
However, as depicted in Table 24 when they were asked to identify how continuing
competence should be assessed there was significant variation across a number of items.
25 Variation in terminology and associated legislative requirements between countries e.g. New Zealand nurses apply for recertification annually. United States of America nurses apply for relicensure annually. 26 Requirement, based on standards of practice, self-assessment plus ability to draw on tool box of indicators if comprehensive assessment required. 27 Reflection, multi-source feedback, learning plans, chart review, practice visits, multi-source feedback, case studies/chart stimulated recall, OSCE's, written/oral exams, practice interviews. 28 Combination of practice hours, Continuing Education (CE), some other sort of assessment/evaluation. 29 Comprehensive assessment - competencies appropriate to the practice role and approved standards. Senior peer / employer assessment. Examination of actual practice. Evidence of involvement in current nursing education relevant to practice.
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Table 24 How should continuing competence be assessed? Response Response Count Certification / relicensure 6 Self-assessment 10 Self-declaration / assessment of competence 4 Reflective practice / self-reflection / self-assessment 8 Mandatory continuing competence program requirements – combination of indicators30
10
Multisource feedback31 9 Multi-pronged approach32 2 360 degree multi source33 13 In current / recent practice 15 Satisfactory and consistent practice at same or higher level/ongoing practice 8 Hours of practice 6 3rd party assessment 3 Peer / colleague feedback 4 Peer assessment / review 3 Senior nurse assessment 1 Continuing education / education credits 16 Professional development hours 5 Approved continuing education programs 3 Professional review e.g. work based assessment or credentialing education program
8
Evidence of successful educational outcomes 2
Written examination 2 Practice reviews/audit of practice 2 Observation/assessment of practice 4 OSCE 2 Skills demonstration 2 Professional portfolios 12 Random audit 4 Employee evaluations indicating competency 3 Quality monitoring and improvement program 1 Not sure - an objective, external mechanism 1 Toss her in the lake to see if she floats 1
Sixty-seven percent (n = 34) of the participants who responded to this question identified that
a form of multi-source feedback is required for assessment of continuing competence. Whilst
30 Legislative requirement, based on standards of practice, self-assessment plus ability to draw on tool box of indicators if comprehensive assessment required. 31 Reflecting on the feedback and developing, implementing and evaluating a learning plan, chart review, practice visits, multi-source feedback, case studies/chart stimulated recall, OSCE's, written/oral exams, practice interviews. 32 Combination of practice hours, CE, some other sort of assessment/evaluation. 33 Comprehensive assessment - competencies appropriate to the practice role and approved standards. Senior peer / employer assessment. Examination of actual practice. Evidence of involvement in current nursing education relevant to practice. Combination of practice hours, CE, some other sort of assessment/evaluation.
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the participants identified a range of indicators of continuing competence the most frequently
identified items were: current practice / practice hours; continuing education; self-assessment;
peer assessment; and professional portfolios.
8.3.3 Barriers and Enablers when implementing a model for demonstration and assessment of continuing competence
Fifty participants responded to question four, “In your experience please describe the barriers
and / or enablers that may exist when implementing a model for the demonstration and
assessment of continuing competence.” As depicted in Table 25, many of the barriers and
enablers identified by participants in the Delphi round two are consistent with those
previously identified by Delphi round one participants, particularly: 8.2.4.1 Continuing
competence - legislative requirement; 8.2.4.2 Variation in terminology and language; and
8.2.4.4 Administrative and financial viability. Each of these themes again featured as both
barriers and enablers to implementation of a Continuing Competence Framework.
Administrative and financial viability was rated as the most significant barrier to the
development and implementation of a framework, whilst legislation was identified as the most
significant enabler. Validity and reliability of competence indicators (8.2.3.4) was another
theme that again featured strongly in relation to barriers to the implementation of a
Continuing Competence Framework. Participants identified a number of issues previously
noted in Delphi round one, related to the validity and reliability of continuing competence
indicators and their associated assessment processes. This item was also strongly linked to the
items, ‘insufficient evidence based research’ and ‘evidence based best-practice’.
Consistent communication, terminology and understandings was identified by six participants
as a barrier, however it was identified as a significant enabler with regard to best practice and
implementation of a Continuing Competence Framework, and in relation to facilitating
mobility of nurses within and between countries.
It was interesting to note that “Resistance from external agencies” was an item not previously
identified as a barrier. Cross tabulation of the participant responses related to this item,
indicated that all participants who identified this item as a barrier were situated within the
United States of America and Canada.
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Table 25 Barriers and enablers to implementing a model for assessment of continuing competence
Barriers Response Count
Enablers Response Count
1. Financial efficacy and viability 25 1. Legislation 26 • Development, implementation and
ongoing administrative costs 15 • Required to demonstrate to public
attention to public safety 8
• Cost related to large nursing population
7 • Legislative mandate authority of the Regulatory Board
12
• Technology and resources 3 • Consistent policy, processes, understandings
6
2. Insufficient evidence based research
23 2. Consistent communication, terminology and understandings
16
• Validity and reliability of competence indicators
12 • Standardised terminology, definitions, understandings
10
• Efficacy, validity and reliability of models
5 • Clear communication of requirements, processes
6
• Quality of continuing education 2 • Inter-rater reliability of assessment
processes 4
3. Acceptance and buy-in of the profession - nurses
18
3. Evidence based practice – register of competent workforce
15
• Trust / mistrust / fear 6 • Sound statistical data and researched models
3
• Lack of understanding of responsibility
4 • Agreement, consistent processes, practices, languages within and between countries
5
• Cost and time involvement 5 • Statistical data related to improved patient outcomes
2
• Resistance to change 3 • Financial efficacy and viability 5
4. Legislation 17 4. Committed professional champions
10
• Not mandated in the legislation 4 • Culture of high performers 2 • Limited powers of the regulatory
authority 3 • Support and buy-in of professional
organisations 5
• Inconsistent legislation, policy and process
10 • Increased professional awareness 3
5. Resistance from external agencies 12 5. Nurses’ access to resources 8 • Employers 4 • Access to online systems 3 • Professional organisations 1 • Access to continuing education 3 • Unions • Education providers
6 1
• Reasonably priced continuing education opportunities
2
6. Nurses access to resources 8 6. Employer support 3
7. Inconsistent communication, terminology, and understanding
6
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8.3.4 Do you believe it is possible to develop an international consensus model for the demonstration and assessment of continuing competence?
As depicted in Figure 17, in response to the question five “Do you believe it is possible to
develop an international consensus model for the demonstration and assessment of continuing
competence?”, of the overall participant group 88% (n = 45) indicated they believed it was
possible to develop a consensus model and 12% (n = 6) indicated they did not.
Figure 17 Possible to develop a consensus model for the demonstration and assessment of continuing competence?
Thirty six of the 45 participants, who believed development of an international consensus
model is possible, provided additional comments. One participant made the following
statement
Yes I believe it is possible but it’s not going to be easy. Margret Mead said “Never doubt that a small group of committed people can change the world. Indeed it is the only thing that ever has.” This is something that we need to do.
Of the 12% (n = 6) of participants who indicated development of an international consensus
model was not possible, of the original total, 4% (n = 2) of the participants identified that they
had experience in the development / implementation of Continuing Competence Frameworks.
Both participant responses reflected the previously identified theme (Table 20) inconsistent
legislation, policy and process which were perceived as significant barriers. One participant
commented
It would be desirable to have this but individual states laws are not consistent.
And the other commented
Yes 88%
No 12%
Yes
No
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Maybe, not in my lifetime – there are many roadblocks that must be addressed. Continued competence will not become international until, or unless all the countries standardise the core requirements and curriculum for nurses. This current variance in educational requirements for entry to practice is the primary barrier to any international implementation.
Of the original total, the remaining 8% (n = 4) were all participants who stated they had no
experience in the development / implementation of Continuing Competence Frameworks.
One participant from this group provided the following comment that was consistent with the
larger group response.
Probably not possible, unless we can get consensus within our own country.
8.3.5 Summary – Delphi Round Two E-survey
Summary data from round two of the Delphi e-survey reflected stability with the findings of
Delphi round one e-survey. This was particularly evident with regard to the purpose of
Continuing Competence Frameworks, the definition of continuing competence and the
selection of appropriate competence indicators. The data indicated that legislative
frameworks, particularly the jurisdiction of the individual regulatory authority and associated
policy requirements, had a significant impact upon the ability to implement a Continuing
Competence Framework. This item featured significantly as both a barrier and an enabler.
The following items were highlighted for further investigation in the Delphi round three e-
survey:
• The definition of ‘competence’ and ‘continuing competence’.
• An understanding of what constitutes ‘professional responsibility’ and ‘nursing
practice’.
• Responsibility and accountability.
• The purpose and core requirements of a Continuing Competence Framework including
the indicators of continuing competence.
• Implementing a Continuing Competence Framework – barriers and enablers.
8.4 Delphi Round Three – E-survey
Questionnaire development for the Delphi round three e-survey drew heavily on the responses
from the previous two rounds. The e-survey was structured using statements drawn from the
findings of the previous two Delphi rounds, incorporating summary findings from the Delphi
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round two e-survey. The underlying design of the e-survey (Appendix V, Delphi round three e-
survey) was based on a five point Likert (rating) Scale to elicit the participant’s level of
agreement or disagreement with the statement items. The score of one indicated strong
agreement and the score of five indicated strong disagreement. This process sought to
quantify the earlier findings from Delphi rounds one and two and determine any convergence
and consensus of opinion. Participants were provided with a three week timeframe in which
to complete and submit the e-survey. The summary data were coded and collated
independently via the Zoomerang software platform, and then exported to the Statistical
Package for Social Sciences (SPSS) for Windows version 20, for further analysis. Any errors or
inconsistencies in data were carefully screened out by evaluating the range of values
generated by running the descriptive frequencies.
8.4.1 Distribution and return of the Delphi round three e-survey
The Delphi round three e-survey was distributed via the web-based software platform
Zoomerang. As participation in the Delphi rounds two and three e-surveys was anonymous
and administered through the Zoomerang web-based portal it was not possible to determine if
the same participants responded to both e-surveys. However, distribution of the web-based
invitation was administered through the same address data base for both Delphi rounds.
The web-based invitation to participate in the Delphi round three e-survey, including the URL
link to the Delphi round three e-survey, was distributed to 52 prospective participants. Of the
52 web-based invitations six were not viewed or responded to, five were marked as
undeliverable, and two participants elected not to complete the Delphi round three e-survey
by submitting an opt-out response. Thirty-nine participants completed and submitted the
Delphi round three e-survey. Data relating to participation and response rate is presented in
Table 26.
Table 26 Participation rate and sample size
Sample size Participation sample Participation rate
52 39 75%
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8.4.2 Definition of competence and continuing competence
Variation in the definition and interpretation of the terms ‘competence’ and ‘continuing
competence’, particularly in relation to nursing regulation and practice, was identified by
Delphi round two participants as an item for further investigation and agreement. Despite this
belief the published definitions of competence and continuing competence, in the six countries
(Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of
America) appear to be similar. Each definition of competence includes the requirement to
meet a prescribed standard of knowledge, skills and decision making for safe practice. In
addition to these items, the definitions of continuing competence all include items such as, the
on-going ability of the nurse to continue to integrate up-to-date knowledge, skills, judgement
and decision making appropriately in the context / role in which they practise. However, it is
noted that variation does exist in terms of the ‘local’ legislation, policy, and procedures and in
some cases where a Continuing Competence Framework exists, implementation and
ownership.
Delphi round three e-survey participants were asked to rate their level of agreement or
disagreement with a definition of competence and continuing competence derived from the
existing published definitions. Table 27 presents a summary of participant results.
Table 27 Definitions of competence and continuing competence
Strongly Agree
Agree Undecided Disagree Strongly Disagree
Response Count
Competence is the combination of skills, knowledge, attitudes, values and abilities that underpin the effective performance as a nurse.
45% (n=17)
55% (n=21) 0% 0% 0% 38
Continuing Competence is the on-going ability to keep up-to-date the skills, knowledge, values, attitudes, and abilities required to practice effectively and safely in the context / role in which they practise.
45% (n=17)
55% (n=21) 0% 0% 0% 38
Thirty-eight (100%) of the participants who responded to both of the statements indicated
they agreed or strongly agreed with the definitions provided.
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8.4.3 Definition of nursing practice
Inconsistencies in the definition of what constitutes ‘nursing practice’ is an item that was
identified in Delphi round one and round two e-surveys, as a potential barrier to the
implementation of a consensus model for continuing competence. The majority of
participants indicated that the definition should be inclusive of all nursing roles that contribute
to nursing as a profession, for example; nursing education, nursing management, governance
and policy, nursing regulation, nursing research and clinical nursing practice. Thirty-eight
participants responded to this question, all of whom strongly agreed or agreed with the
inclusive definition provided. Figure 18 presents the results.
Figure 18 Definition of nursing practice
The standard deviation and variance for this item (SD = .504; V = .254) demonstrates the close
distribution of participant responses across only two points of the five point continuum
(strongly agree – agree) and is reflected in the mean score of (M = 1.45).
8.4.3 Continuing competence of registered health practitioners – who is responsible?
8.4.3.1 The responsibility of a Registered Nurse
Lack of a common understanding related to what nurses believe constitutes their professional
responsibility with regard to their continuing competence, was identified in the previous two
rounds as being a significant barrier to the development and implementation of a Continuing
Competence Framework. In order to investigate this area more fully, the participants were
asked to rate their level of agreement with five statements. The participant statements are
collated and the findings presented in Table 28.
0% 20% 40% 60% 80% 100%
The definition of nursing practice should beinclusive and encompass: Nursing Management;
Nursing Education; Nursing Research; NursingPolicy; Nursing Regulation; Nursing Governance;
and Clinical Nursing Practice.
21 17
Strongly Agree
Agree
Undecided
Disagree
Strongly Disagree
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Table 28 As a registered health professional individual nurses are responsible for
Strongly Agree
Agree Undecided Disagree Strongly Disagree
Rating Mean
Response Count
Demonstrating a commitment to continuing competence throughout their professional careers.
74% (n=28)
26% (n=10) 0% 0% 0% 1.24 *38
Ensuring that they continue to meet the relevant standards and competencies required for their scope of practice and relevant to the role and context in which they practise.
78% (n=29)
22% (n=8) 0% 0% 0% 1.19 **37
Actively participating in and meeting the requirements specified by their regulatory authority.
81% (n=30)
19% (n=7) 0% 0% 0% 1.16 **37
Participating in on-going educational activities relevant to their scope of practice.
76% (n=28)
24% (n=9) 0% 0% 0% 1.22 **37
Providing an appropriate, safe, ethical and competent standard of nursing practice.
82% (n=31)
18% (n=7) 0% 0% 0% 1.16 *38
*1 participant failed to respond to 2 items, **2 participants failed to respond to 3 items
Descriptive statistics were used to calculate the mean (M) scores and standard deviation (SD)
for each of the five statements. As depicted in Figure 19, 100% of the participants indicated
they strongly agreed or agreed with each of the five statements. The mean scores ranging
from (M = 1.16 – 1.24), standard deviation of (SD = .370 - .431) and variance of (V = 1.37 -
1.86).
The participant group mean score for each statement indicated that overall there was strong
agreement that the individual nurse is responsible for maintaining their own continuing
competence. The standard deviation and variance for each item demonstrated the tight
distribution of participant responses across only two points of the five point continuum
(strongly agree – agree).
194
Figure 19 Individual nurses are responsible for their own continuing competence
8.4.3.2 Responsibility and accountability
Clarification with regard to who else has responsibility for the continuing competence of
registered nurses, was highlighted as an important consideration when implementing a
Continuing Competence Framework. This item was raised by participants in Delphi round one
and two e-surveys, particularly in relation to the role of the employer, the professional
organisation and the regulatory body. Whilst it was unanimously agreed that ultimately the
registered nurse is responsible and accountable throughout their career for their own
continuing competence, the accountability and / or responsibility of associated stakeholders
was identified as being either a significant barrier or enabler to the implementation of a
continuing competence process. Round three participants were asked to rate their level of
agreement or disagreement with five statements in relation to this item. Table 29 presents a
collation of the findings.
0% 20% 40% 60% 80% 100%
Demonstrating a commitment to continuing competencethroughout their professional careers.
Ensuring they continue to meet the standards andcompetencies required for their practice relevant to the
role and context in which they practise.
Actively participating in and meeting the requirementsspecified by their regulatory authority.
Participating in ongoing educational activities relevant totheir scope of practice.
Providing an appropriate, safe, ethical and competentstandard of nursing practice.
28
29
30
28
31
10
8
7
9
7
StronglyAgree
Agree
Undecided
Disagree
StronglyDisagree
195
Table 29 Continuing competence of registered nurses – who is responsible?
Strongly
Agree Agree Undecided Disagree Strongly
Disagree Rating Mean
Response Count
Governments are responsible for passing legislation, and ensuring its enactment.
31% (n=12)
69% (n=27) 0% 0% 0% 1.72 39
Regulatory authorities are responsible for protecting the safety of the public by setting the standards of nursing practice and monitoring the competence of the profession.
39% (n=15)
61% (n=24) 0% 0% 0% 1.62 39
Professional organisations are responsible for facilitating/guiding the development of the nursing profession.
26% (n=10)
71% (n=27) 0% 3%
(n=1) 0% 1.79 *38
Employers are responsible for maintaining quality practice environments that support and facilitate continuing competence opportunities for nurses and monitoring their continuing competence.
40% (n=15)
60% (n=23) 0% 0% 0% 1.61 *38
Nursing education organisations are responsible for providing high quality programmes that prepare competent nurses and provide relevant continuing education opportunities.
31% (n=12)
69% (n=27) 0% 0% 0% 1.69 39
*n = 1 participant failed to respond to 2 items
The majority of participant responses indicated ‘agreement’ with each of the five statements.
However, in response to the statement ‘Professional organisations are responsible for
facilitating / guiding the development of the nursing profession’ one participant indicated they
disagreed. As shown in Figure 20 there was no notable difference in mean scores (M = 1.61 –
1.79) or the distribution of participant responses.
196
Figure 20 Responsibility and accountability
8.4.4 Core requirements of a Continuing Competence Framework
8.4.4.1 Operational requirements
Models and understandings of what constitute a Continuing Competence Framework or model
vary internationally. Delphi round three e-survey participants were asked to indicate their
level of agreement with four statements relating to the operational requirements for a
consensus model.
As depicted in Table 30 the majority of participants strongly agreed with each of the
statements with mean scores ranging from (M = 1.11 – 1.39). In particular 90% of participants
strongly agreed with the first statement ‘CCFs must be financially viable’ and this response is
reflected in the standard deviation and variance score (SD = .311; V = .097).
0% 20% 40% 60% 80% 100%
Governments are responsible for passinglegislation, and ensuring its enactment.
Regulatory authorities are responsible forprotecting the safety of the public by setting thestandards of nursing practice and monitoring the
competence of the profession.
Professional organisations are responsible forfacilitating the development of the nursing
profession.
Employers are responsible for maintaining qualitypractice environments that support and facilitatecontinuing competence opportunities for nurses
and monitoring their continuing competence.
Nursing education organisations are responsiblefor providing high quality programmes that
prepare competent nurses and provide relevantcontinuing education opportunities.
12
15
10
15
12
27
24
27
23
27
1
StronglyAgreeAgree
Undecided
Disagree
StronglyDisagree
197
Table 30 Continuing competence consensus model requirements
Strongly
Agree Agree Undecided Disagree Strongly
Disagree Rating Mean
Response Count
CCFs must be financially viable, flexible, applicable to a variety of settings, provide options for demonstrating competence and be clearly communicated to all stakeholders.
90% (n=34)
10% (n=4) 0% 0% 0% 1.11 *38
CCFs are tools that are used to monitor the continuing competence of the profession and individual practitioners.
73% (n=27)
27% (n=10) 0% 0% 0% 1.27 **37
Competence indicators are measures that assess competence against specified standards.
68% (n=28)
32% (n=9) 0% 0% 0% 1.32 **37
Competence indicators may imply competence but cannot ensure the continuing competence of an individual.
63% (n=24)
34% (n=13)
3% (n=1) 0% 0% 1.39 *38
*n = 1 participant failed to respond to all items, **n = 2 participants failed to respond to 2 items
8.4.4.2 Assessment of continuing competence
Extensive research exists with regard to individual measures of competence and competence
indicators. However, the assessment of the continuing competence of nurses continues to be
a phenomenon that is proving difficult to validate. Current research suggests that no
‘individual measure assures competence or public safety. However, evidence drawn from a
variety of measures provides a strong indication of competence and may be used to imply
continuing competence. Thirty-four (67%) of the Delphi round two e-survey participants
identified that ‘multisource’ or ‘360 degree’ feedback is critical when assessing the continuing
competence of nurses. In addition, responses to the Delphi round two e-surveys highlighted a
general view that the measurement of continuing competence requires contextualising in
terms of the requirements of the practice environment and the individual’s role. Four
statements were posed in relation to the composition and components of a Continuing
Competence Framework and participants were asked to rate their level of agreement with
each item. Figure 21 presents the participant responses.
198
Figure 21 Assessment of continuing competence
Eighty-four percent (n = 32) of the participants strongly agreed with the statement
‘competence indicators must be flexible and relevant to the scope in which the nurse is
practising’ and 78% (n = 29) strongly agreed that ‘assessment of continuing competence
requires the integration of multi-source assessment i.e. a variety of competence indicators’.
However, in response to the statements ‘on its own continuing competence or professional
education is not an adequate measure of continuing competence’ and ‘hours of practice is not
an adequate measure of continuing competence’, the participant responses were divided
between strongly agreed and agreed with four participants indicating they were undecided.
Table 31 presents the collated responses.
Table 31 Assessment of continuing competence
Strongly
Agree Agree Undecided Disagree Strongly
Disagree Rating Mean
Response Count
Assessment of continuing competence requires the integration of multi-source assessment i.e. a variety of competence indicators.
42% (n=16)
47% (n=18)
8% (n=3)
3% (n=1) 0% 1.68 38
Hours of practice are not an adequate measure of continuing competence.
47% (n=18)
50% (n=19)
3% (n=1) 0% 0% 1.55 38
0% 20% 40% 60% 80% 100%
Competence indicators must be flexible and relevantto the scope in which the nurse is practising.
Assessment of continuing competence requires theintegration of multi-source assessment i.e. a variety
of competence indicators.
On its own continuing professional development(CPD) or professional education is not an adequate
measure of continuing competence.
Hours of practice are not an adequate measure ofcontinuing competence.
32
29
16
18
6
6
18
19
2
3
1
1
StronglyAgreeAgree
Undecided
Disagree
StronglyDisagree
199
8.4.4.3 Indicators of continuing competence
In Delphi round two e-survey, five indicators of continuing competence were identified that
received the highest response count in terms of their importance for inclusion in a consensus
model for the assessment of continuing competence. Delphi round three e-survey participants
were asked to rate their level of agreement or disagreement with the inclusion of the five
indicators listed in Figure 22.
Figure 22 Indicators of continuing competence
As depicted in Figure 22, 100% (n = 39) of participants strongly agreed or agreed that
‘continuing professional development’ and ‘hours in current / recent practice’, should be
included as indicators of continuing competence in the consensus framework. Ninety percent
(n = 34) of the participants agree or strongly agreed that ‘self-assessment / self-declaration’
should be included and 10% (n = 4) were undecided.
While 45% (n = 17) of the participants agreed ‘peer assessment’ should be included, 47% (n =
18) were undecided and 8% (n = 3) believed it should not be included. Seventy-one percent (n
= 27) of the participants disagreed or strongly disagreed with the inclusion of ‘professional
portfolio’ as an indicator of competence, 24% (n = 9) indicated that they were undecided, and
5% (n = 2) believed it should be included.
0% 20% 40% 60% 80% 100%
Practice hours i.e. participation/recency of nursing practice
Self assessment/self declaration
Peer assessment
Continuing professional development
Professional portfolio
27
22
6
28
1
12
12
11
11
1
4
18
9
2
13
1
14
Practice hours i.e.participation/recency of
nursing practice
Self assessment/selfdeclaration Peer assessment Continuing professional
development Professional portfolio
Strongly Agree 27 22 6 28 1Agree 12 12 11 11 1Undecided 0 4 18 0 9Disagree 0 0 2 0 13Strongly Disagree 0 0 1 0 14
200
Descriptive statistics were used to calculate the mean (M) scores, standard deviation (SD) and
variance (V) for each of the five competence indicators in order to assist in determining their
inclusion in the consensus framework. Findings are presented in Table 32.
Table 32 Competence indicators
Strongly
Agree Agree Undecided Rating
Mean Standard
Deviation Variance Response
Count
Self-assessment / self-declaration 58% (n=22)
32% (n=12)
10% (n=4) 1.53 .687 .472 *38
Practice hours i.e. current/recent nursing practice
69% (n=27)
31% (n=12) 0% 1.31 .468 .219 39
Continuing professional development
72% (n=28)
28% (n=11) 0% 1.33 .530 .281 39
Peer assessment 16% (n=6)
29% (n=11)
47% (n=18) 2.42 .948 .899 *38
Professional portfolio 2.6% (n=1)
2.6% (n=1) 0% 3.89 1.110 1.232 *38
*n = 1 participant failed to respond to three items
Three indicators of competence; examination, objective structured clinical examination (OSCE)
and audit of practice were also included by a small number of participants who responded to
the Delphi rounds one and two e-surveys. Delphi round three e-survey participants were
asked if these indicators should, or should not, be included in the consensus framework. The
participant responses are collated and depicted in Figure 23.
Figure 23 Outlying competence indicators
0% 20% 40% 60% 80% 100%
Examination
Objective Structured ClinicalExamination (OSCE)
Audit of Practice
1
7
5
2
9
32
36
23
ExaminationObjective StructuredClinical Examination
(OSCE)Audit of Practice
Yes Should be included 1 0 7Undecided 5 2 9No Should not be included 32 36 23
201
Eighty-four percent (n = 32) of the participants indicated that ‘examination’ should not be
included as an indicator of continuing competence, and 95% (n = 36) indicated that ‘OSCE’
should not be included. In contrast 59% (n = 23) of the participants believed ‘audit of practice’
should not be included, however a further 23% (n = 9) were undecided and 18% (n = 7)
believed it should be included as one of the indicators of continuing competence.
8.4.5 Implementing a Continuing Competence Framework – barriers and enablers
Delphi round three e-survey participants were provided with a list of barriers and enablers
identified in round two, and asked to rate those on a five point Likert scale from significant
barrier to significant enabler. Figure 24 provides a summary of the participant responses.
Figure 24 Barriers and enablers
As depicted in Table 33, two items were agreed to be significant enablers by the majority of
the participants; ‘authority of the regulatory body’ (92%, M = 1.77) and ‘communication with
key stakeholders’ (93%, M = 1.62). ‘Legislation’ was also identified as an enabler (85%, M =
2.00), and although ‘differing qualifications’ had previously been identified as a barrier, 80%
(n= 31) of the participants in round three identified ‘differing qualifications’ as not applicable.
‘Number of nurses on the register’ had also previously been identified as a barrier, however
while 27% (n = 10) of the participants again identified it as a barrier, 58% (n = 22) identified it
as not applicable. It is interesting to note that with regard to the item ‘political interests’, 54%
(n = 20) of the participants were undecided.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Communication with key stakeholders
Legislation
Authority of the Regulatory Body
Professional Nursing Organisations
Financial viability
Political Interests
Differing qualification requirements
Expectations of the Public
Number of nurses on the register
19
10
16
1
4
1
17
23
20
24
12
4
4
3
3
3
11
9
20
5
11
6
3
3
13
10
3
1
9
1
1
3
31
22
22
Significant Enabler Enabler Undecided Barrier Significant Barrier N/A
202
Table 33 Barriers and enablers
Significant
Enabler Enabler Undecided Barrier Significant
Barrier N/A Rating Mean
Std. Error
Response Count
Number of nurses on the register 0% 0% 16%
(n=6) 24%
(n=9) 3%
(n=1) 58%
(n=22) 4.92 .211 *38
Expectations of the public
3% (n=1)
10% (n=4)
28% (n=11)
3% (n=1) 0% 57%
(n=22) 4.62 .281 39
Differing qualifications requirements 0% 0% 13%
(n=5) 8%
(n=3) 0% 80% (n=31) 5.36 .196 39
Political interests 0% 11% (n=4)
54% (n=20)
27% (n=10) 0% 8%
(n=3) 3.46 .180 **37
Financial viability 10% (n=4)
31% (n=12)
23% (n =9)
33% (n=13)
3% (n=1) 0% 2.92 .166 39
Professional nursing organisations / unions
3% (n=1)
62% (n=24)
28% (n=11)
8% (n=3) 0% 0% 2.38 .108 39
Authority of the regulatory body
41% (n=16)
51% (n=20)
8% (n=3) 0% 0% 0% 1.77 .100 39
Legislation 26% (n=10)
59% (n=23)
8% ( =3)
8% (n=3) 0% 0% 2.00 .127 39
Communication with Key stakeholders
49% (n=19)
44% (n=17)
8% (n=3) 0% 0% 0% 1.62 .101 39
*n = 1 participant failed to respond to two items, **n = 1 failed to respond to one item
8.4.6 Consensus Model
Eighty-eight percent (n = 31) of round two participants indicated that they believed it was
possible to develop an international consensus model between the six identified countries
(Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States of
America), for the demonstration and assessment of continuing competence. However, the
comments provided by these participants also indicated that whilst they believed this to be
possible, there was a need to gain consensus on the core foundation principles in relation to
common understandings and the transportability and efficacy of the framework. In order to
test the round two responses, participants in round three were asked to rate their level of
agreement or disagreement with the following three statements:
1. It is possible to develop a consensus model for the assessment of continuing
competence.
2. It is possible to develop key principles for the assessment of continuing competence.
3. The consensus model must be flexible and adaptable.
Thirty-nine participants responded to these questions. Table 34 presents the collation of
responses.
203
Table 34 Continuing competence consensus model requirements
Strongly
Agree Agree Undecided Disagree Strongly
Disagree Rating Mean
Response Count
It is possible to develop a consensus model for the assessment of continuing competence.
20% (n=8)
67% (n=26)
8% (n=3)
5% (n=2) 0% 1.95 39
It is possible to develop key principles for the assessment of continuing competence.
46% (n=18)
54% (n=21) 0% 0% 0% 1.56 39
The consensus model must be flexible and adaptable.
67% (n=26)
33% (n=13) 0% 0% 0% 1.31 39
All of the participants agreed or strongly agreed with statements 2 and 3. However, in
response to statement 1 ‘It is possible to develop a consensus model for the assessment of
continuing competence’, 87% (n = 34) of the participants agreed and 13% (n = 5) of the
participants were undecided or disagreed. This response is reflected in the mean score of (M =
1.95) and standard deviation and variance (SD = .724; V = .524).
Figure 25 Consensus model
Figure 25 depicts the comparison of responses. The participant comments reflected those of
round one and two participants, particularly in terms of a willingness to work collaboratively to
facilitate the development of an international consensus framework.
0% 20% 40% 60% 80% 100%
It is possible to develop a consensus model forthe assessment of continuing competence
It is possible to develop key principles for theassessment of continuing competence
The consensus model must be flexible andadaptable
8
18
26
26
21
13
3 2
Strongly Agree
Agree
Undecided
Disagree
Strongly Disagree
204
8.5 Summary of findings from the Delphi rounds (one – three)
8.5.1 The consensus model
The view of the majority of the Delphi participants is that the development of an international
consensus model for the assessment of continuing competence, between the six identified
countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United states
of America) is an important initiative that is possible (Agreement = 87%, M = 1.95, SD = .724, V
= .524).
The consensus view of the participants is that there is initial work required to in order to
determine a common foundation prior to development of the consensus model. It was the
consensus view of the participants that initially the development of key principles for the
assessment of continuing competence be agreed (Agreement = 100%, M = 1.56, SD = .502, V =
.252).
The most commonly expressed requirement identified by the participants is that the
consensus model must be flexible and adaptable (Agreement 100%, M = 1.31, SD = .468,
V.219).
8.5.2 Definitions
It was the consensus view of the participants that the inclusive definitions of ‘competence -
the combination of skills, knowledge, attitudes, values and abilities that underpin the effective
performance as a nurse’ and ‘continuing competence - the on-going ability to keep up-to-
date the skills, knowledge, values, attitudes, and abilities required to practise effectively and
safely in the context/role in which they practise’ were appropriate. Both definitions achieved
the same agreement rating (Agreement 100%, M = 1.55, SD = .504, V = .254).
The inclusive definition of what constitutes nursing practice was agreed to include all ‘nursing
roles’ that contribute to the nursing profession i.e. nursing regulation; nursing governance;
nursing policy; nursing management; nursing education; nursing research; and clinical nursing
practice (Agreement 100%, M= 1.45, SD = .504, V = .254).
8.5.3 Responsibility and accountability
Responsibility and accountability for continuing competence were items that attracted wide
ranging comment. A consensus view was achieved in terms of the understanding of what
205
constitutes the individual registered nurse’s responsibilities for their continuing competence.
There was consensus with regard to the overarching responsibility of the key stakeholder
groups, particularly the employer with 40% (n = 15) of participants indicating they strongly
agreed and 60% (n = 23) that they agreed employers are responsible for maintaining quality
practice environments that support and facilitate continuing competence opportunities for
nurses, and for monitoring their continuing competence.
8.5.4 Continuing Competence Framework
Ninety percent (n = 35) of the participants strongly agreed and 10% (n = 4) agreed (M = 1.11),
that it is important that the continuing competence model must be administratively feasible,
financially viable and defensible in terms of providing some assurance of public safety.
Flexibility in terms of the implementation and utilisation of embedded indicators of continuing
competence was identified as a requirement. It is the consensus view (100%, M = 1.32) that
competence indicators are measures that assess competence against specified standards. In
addition the relevance of these indicators to the scope/context in which the nurse is practising
is agreed to be important by 97% of the participants (M = 1.16).
8.6.5 Indicators or continuing competence
It is the consensus view that the following three indicators of continuing competence, used
together, should be included in the international consensus framework: self-assessment / self-
declaration (Agreement 90%, M = 1.53, SD = .687, V = .472); practice hours /recent nursing
practice (Agreement 100%, M = 131, SD = .468, V = .219); and continuing professional
development (Agreement 100%, M = 1.33, SD = .530, V = .281). Whilst other indicators of
competence were identified, such as portfolio and examination, none achieved a consensus
rating. However, the ability to incorporate a ‘tool box’ of additional optional indicators was
identified as beneficial by 67% (n = 34) Delphi round two participants.
8.5.6 Barriers and enablers agreed
A number of barriers and enablers were initially identified in relation to the development of a
consensus model, however, only two of the identified enablers were rated by the majority of
the participants in round three: authority of the regulatory body (Agreement 92%, M = 1.77,
SD = .627, V = .393); and communication with key stakeholders (Agreement 93%, M = 1.62, SD
= .633, V = .401). Legislation had been identified as a significant enabler and barrier in round
206
two however in round three it was rated an enabler by 85% of participants and a barrier by
only 8% of the participants. A further 8% were undecided. A number of the barriers
previously identified by the participants for example, financial viability, political interests and
the number of nurses on the register, were again rated as barriers. However, none of these
items achieved a consensus rating. Eighty percent (n = 31) of the participants indicated that
‘differing qualifications’ was no longer applicable as a barrier and 56% (n = 22) and 58% (n =
23) respectively indicated that ‘expectations of the public’ and number of nurses on the
register’ were no longer considered to be barriers.
8.6 Key principles and core components underpinning the development of an international consensus model
8.6.1 Key Principles underpinning the consensus model
The following list of key principles have been derived from the findings of the Delphi rounds
(one-three), and have been identified and agreed by the participants as underpinning the
development of an international consensus model for the assessment of continuing
competence between Australia, Canada, Ireland, New Zealand, the United Kingdom and the
United States of America.
• The purpose of nursing regulation is protection of the public.
• The public has the right to expect that Registered Nurses, who are in practice, are and
continue to be, competent.
• Revalidation, recertification, re-registration should occur annually and be associated
with the requirement to declare and/or demonstrate the ability to meet required
standards of continuing competence.
• Education and practice standards for Registered Nurses are similar between the six
participant countries and imply the same expectations.
• Definitions of competence, continuing competence and nursing practice between and
within the six participant countries are similar and imply the same meaning.
• Development of an international model for the assessment of Continuing Competence
Framework requires agreement on a common language - lexicon of terminology in
relation to Continuing Competence.
• Whilst a ‘legislative mandate’ is a significant enabler in terms of implementation and
compliance with Continuing Competence Frameworks, it is not an essential component
for the implementation of a Continuing Competence Framework.
207
• Registered Nurses are registered health professionals who are responsible,
accountable, ethical, competent and committed to life-long learning and nursing
practice.
• Registered Nurses are responsible and accountable for ensuring their own individual
continuing competence, relevant to the required practice standards, code of conduct,
and practice setting.
• Employers and employment settings have a responsibility and role in facilitating and
ensuring that their registered nurse workforce is, and continues to be, competent.
• The Continuing Competence Framework must have a clear and transparent purpose
and processes that are credible and understandable to the public and the nursing
profession.
• Continuing Competence Frameworks are tools that facilitate the assessment and
monitoring of the continuing competence of the profession, and as such they have a
role in assuring and ensuring public safety.
• Assessment of Continuing Competence requires triangulation of data from a selection
of sources.
• No single indicator of competence can measure or appropriately assess ‘continuing
competence’ or ensure valid, reliable and consistent measurement of ‘continuing
competence’.
• The Continuing Competence Framework must be flexible and adaptable,
administratively feasible, financially viable, and publicly defensible.
8.6.2 Core components of the consensus model
The Delphi participants (rounds one - three) identified and agreed that a best practice
consensus model for the assessment of continuing competence requires the development and
inclusion of the following core components:
• An internationally agreed and clearly communicated purpose statement that identifies
the expectations of the Continuing Competence Framework and its functions in terms
of the monitoring and assessment of the continuing competence of nurses and
protection of the public.
• An internationally agreed lexicon of terminology that includes, but is not limited to,
agreed definitions of the terms ‘Competence’, ‘Continuing Competence’ and ‘nursing
practice’.
208
• Development of criterion based assessment guidelines.
• Development of a tool box of indicators for the assessment of continuing competence
including but not limited to the following:
Core indicators Optional indicators
• Self-assessment / Self-declaration • Practice Hours (current and recent
practice) (specified number) • Continuing professional development
/ education hours (specified number)
• Peer Assessment • Professional Portfolio • Observed Structured Clinical
Examination (OSCE) • Examination
8.7 Concluding remarks
This chapter has presented and summarised the findings that have emerged from the first
three Delphi rounds. Whilst a number of the findings provided confirmation of the views
expressed by Group A participants during round one, alternative views have also been
introduced. A summary of the key principles derived from these findings have been
presented.
Chapter Nine will present a discussion of the replies received from the Delphi round four
expert panel (Group A) participants, in response to the consensus views and key principles that
emerged from the previous Delphi rounds (one – three). The overall consensus views will be
presented and discussed in relation to the contemporary literature, and recommendations for
the development of a best practice international consensus model for the assessment of
continuing competence will be proposed.
209
CHAPTER NINE – THE CONSENSUS VIEW; DISCUSSION, CONCLUSION AND RECOMMENDATIONS
9.1 Introduction
Chapter Nine presents a discussion of the replies received from the Delphi round four expert
panel (Group A) participants, in response to the consensus views and key principles that had
emerged from the previous Delphi rounds (one – three). The overall consensus views of
participants are presented and discussed in relation to the contemporary literature and in
response to the three research questions identified earlier and repeated below.
1. What is the consensus view of regulatory experts in relation to best practice for nurses
to demonstrate continuing competence and for regulatory authorities to assess
continuing competence?
2. What, if any, differences are present between the current regulatory requirements for
the demonstration and assessment of continuing competence in six countries
(Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of
America) and the best practice model developed through consensus?
3. What changes, if any, would be required to policy and regulation in these six countries
to align their regulatory framework with best practice for demonstration and
assessment of continuing competence?
Recommendations for the development of a best practice international consensus model for
the assessment of continuing competence are proposed in association with recommendations
for future research.
Inte
rnat
iona
lCo
nsen
sus M
odel Stage Two
Delphi Round 1Stakeholder Interviews
(gpA)
Stage TwoDelphi Round 2
Qualitative E-survey (gpB)
Stage Two Delphi Round 3Quantitative
E-survey (gpB)
Stage Two Delphi Round 4
ConsensusE-survey
(gpA)
Discussion of findings
Summary Recommendations
210
9.2 Delphi Round Four – The consensus view
As described in Chapter Three (3.3.3.3) the expert panel (Group A) participants (n = 12) were
provided with summary findings and consensus views derived from the previous three Delphi
rounds, and invited to consider these findings in terms of their applicability in relation to the
participants’ own regulatory jurisdictions (Australia, Canada, Ireland, New Zealand, the United
Kingdom and the United States of America). The following two questions were posed:
1. What, if any, differences are present between your current regulatory requirements
for the demonstration and assessment of continuing competence and the best
practice model proposed through consensus?
2. What changes, if any, would be required to policy and regulation to align your
regulatory framework with best practice for demonstration and assessment of
continuing competence?
In addition, the expert panel participants were also asked to consider the list of key principles
and core components identified and agreed by the Delphi (round three) participants, for
inclusion in an international best practice consensus model for the assessment of continuing
competence (Appendix VI). The expert panel (Group A) participants were asked to indicate
their agreement or disagreement with these items either by email or by completing a short
web-based e-survey (Delphi round four – E-survey, Appendix VII). Participants were also
provided with the opportunity to provide additional comment in relation to each of the items.
9.2.1 Distribution and return of the Delphi Round Four e-survey
The content that was emailed directly to each of the 12 expert panel (Group A) participants
comprised the summary findings from the Delphi (round three) including the summarised
consensus views, the list of key principles and the list of the core components identified and
agreed for inclusion in the international best practice consensus model. The email invitation
provided the participants with the option of replying directly to the researcher by email or by
responding to the web-based e-survey through the URL link that was provided. The
participants were requested to provide their responses within three weeks of receiving the
email invitation. As presented in Table 35, nine of the expert panel (Group A) participants
completed and submitted responses to the Delphi round four e-survey.
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Table 35 Participation rate and sample size
Sample size Participation sample Participation rate
*12 9 75% * Excludes representation from the Nursing and Midwifery Council (UK)
Due to restructuring within the Nursing and Midwifery Council (UK) and subsequent changes
to the Council and Administrative Staff, the original Nursing and Midwifery Council (UK)
representative on the Delphi Expert Panel (Group A), was not available to participate in the
Delphi round four. It was decided not to introduce any new participants to the expert panel in
this final stage of the Delphi process.
9.2.2 Expert panel responses (Delphi round four)
As noted in 9.2 the expert panel participants were asked to consider the list of key principles
and core components identified and agreed by the Delphi round three participants, for
inclusion in the best practice model for the assessment of continuing competence. The
collation of these responses indicating the expert agreement or disagreement are presented
and further discussed in the following sections.
Table 36 presents the findings relating to the list of key principles that underpin the
development of the best practice consensus model for the assessment of continuing
competence.
Table 36 Key principles underpinning the best practice consensus model
Agree Disagree Undecided Rating Average
Rating Count
The purpose of nursing regulation is protection of the public.
100.0% (9) 0.0% (0) 0.0% (0) 1.00 9
The public has the right to expect that RNs, who are in practice, are and continue to be, competent.
100.0% (9) 0.0% (0) 0.0% (0) 1.00 9
Revalidation/recertification/relicensure should occur annually, associated with requirements to declare and/or demonstrate ability to meet required standards of continuing competence.
62.5% (5) 25.0% (2) 12.5% (1) 1.50 *8
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Education and practice standards for RNs are similar between the six participant countries and imply the same expectations.
44.4% (4) 0.0% (0) 55.6% (5) 2.11 9
Definitions of competence, continuing competence and nursing practice between and within the six participant countries are similar and imply the same meaning.
77.8% (7) 0.0% (0) 22.2% (2) 1.44 9
Development of an international model for the assessment of continuing competence requires agreement on a common language – lexicon of terminology.
100.0% (9) 0.0% (0) 0.0% (0) 1.00 9
A legislative mandate is considered an enabler in terms of implementation and compliance with continuing competence requirements. It is not considered essential for implementation of a Continuing Competence Framework.
50.0% (4) 25.0% (2) 25.0% (2) 1.75 *8
RNs are registered health professionals who are responsible, accountable, ethical, competent and committed to life-long learning and nursing practice.
88.9% (8) 11.1% (1) 0.0% (0) 1.11 9
RNs are responsible for ensuring their own individual continuing competence, relevant to the required practice standards, code of conduct, and practice setting.
88.9% (8) 11.1% (1) 0.0% (0) 1.11 9
Employers and employment settings have a responsibility and role in facilitating and ensuring that their RN workforce is, and continues to be, competent.
88.9% (8) 11.1% (1) 0.0% (0) 1.11 9
The Continuing Competence Framework must have a clear and transparent purpose and processes that are credible and understandable to the public and the nursing profession.
100.0% (9) 0.0% (0) 0.0% (0) 1.00 9
Continuing Competence Frameworks are tools that facilitate the assessment and monitoring of the continuing competence of the profession, and as such they have a role in assuring and ensuring public safety.
100.0% (8) 0.0% (0) 0.0% (0) 1.00 *8
Assessment of continuing competence requires triangulation of multi-source data.
88.9% (8) 0.0% (0) 11.1% (1) 1.22 9
No single indicator of competence can measure or appropriately assess ‘continuing competence’ or ensure valid reliable and consistent measurement of ‘continuing competence’
77.8% (7) 11.1% (1) 11.1% (1) 1.33 9
The Continuing Competence Framework must be flexible and adaptable, administratively feasible, financially viable, and publicly defensible.
100.0% (9) 0.0% (0) 0.0% (0) 1.00 9
* One expert panel participant did not respond to three of the items
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As depicted in Table 36 consensus was achieved across 10 of the 15 listed key principles.
However, for the item “annual revalidation/recertification/relicensure, associated with
requirements to declare and/or demonstrate the ability to meet required standards of
continuing competence”, only five of the eight expert panel participants (62.5%) who
responded to this question, agreed with the requirement for annual assessment. Two
participants indicated they did not agree with annual assessment, and a third participant
indicated they were undecided. One participant commented
Agree that continuing competence requirements should be associated with registration/licensing renewal. Is annual appropriate? What is the evidence on a safe and effective renewal period?
Five of the nine expert panel participants (55.6%), indicated that they were undecided with
regard to similarities between the “Education and Practice Standards across the six focus
countries. One participant stated
Based on practice analysis we know this to be true for Canada and the US. Not aware of evidence to show practice similarities between all six countries.
This response indicates that further discussion and analysis of the education and practice
standards between the six countries is required before any agreement related to reciprocity of
qualifications and practice can occur.
Of the eight participants who responded to the item “A legislative mandate is considered an
enabler in terms of implementation and compliance with continuing competence
requirements. It is not considered essential for implementation of a Continuing Competence
Framework”, four participants (50%) indicated that they agreed, two (25%) indicated that they
disagreed and two (25%) indicated they were undecided. One of the participants who
indicated they disagreed provided the following comment “If the focus is public safety then it
has to be mandated”. This response was consistent with the responses from the previous
Delphi rounds and supported the view that the legislative mandate of regulatory authorities
and the ability to enforce compliance with continuing competence requirements was
considered a significant enabler.
In response to the items “RNs are registered health professionals who are responsible,
accountable, ethical, competent and committed to life-long learning and nursing practice”;
“RNs are responsible for ensuring their own individual continuing competence, relevant to the
required practice standards, code of conduct, and practice setting”; and “Employers and
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employment settings have a responsibility and role in facilitating and ensuring that their RN
workforce is, and continues to be, competent”, eight of the nine participants (88.9%),
indicated they agreed with each statement. One participant identified that they disagreed
with each of the three statements and commented
The responsibility and accountability of employers needs to be clarified particularly with regard to the provision of safe practice environments and ensuring the staff they employ are competent.
The item “No single indicator of competence can measure or appropriately assess continuing
competence, or ensure a valid reliable and consistent measurement of continuing
competence”, received an agreement score of 77.8% (n=7). One participant (11.1%) indicated
that they disagreed with the item and stated “A psychometrically sound and legally defensible
competence assessment is a valid and reliable measure of competence”. One participant
indicated that they were undecided with regard to this question, however no additional
comments were provided. Each of the items that have been identified in Table 36 will be
discussed in more detail in section (9.3).
The findings of the Delphi round three, identified that an international best practice consensus
model for the assessment of continuing competence should include the three core
components listed in Table 37. The expert panel participants were asked to consider and
indicate their agreement or disagreement with the inclusion of these items. As depicted in
Table 37 it was the consensus view of the expert panel that each of these items was “critical to
the successful development and implementation of the best practice framework”. One
participant indicated that they were undecided in relation to the item ‘Criterion based
assessment guidelines’ commenting “Need to be more clear with what is meant in this
statement”.
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Table 37 Core components of the best practice consensus model
Agree Disagree Undecided Rating Average
Rating Count
An internationally agreed and clearly communicated purpose statement that identifies the expectations of the Continuing Competence Framework and its functions in terms of: a) protection of the public; and b) the monitoring and assessment of the continuing competence of nurses.
100.0% (9) 0.0% (0) 0.0% (0) 1.00 9
An internationally agreed lexicon of terminology that includes agreed definitions of the terms ‘Competence’, ‘Continuing Competence’ and ‘Nursing Practice’.
100.0% (9) 0.0% (0) 0.0% (0) 1.00 9
Criterion based assessment guidelines. 88.9% (8) 0.0% (0) 11.1% (1) 1.22 9
Development of a tool box of indicators for multi-source assessment of continuing
competence was previously identified as a component of the best practice consensus model.
Three indicators were identified as being essential for inclusion in this tool box. Table 38
presents the collation of the participant responses, indicating consistently that seven of the
participants agreed with the components, one participant consistently disagreed and one
participant was undecided. The participants who identified that they were undecided or
disagreed both commented that they required further evidence that the components listed in
Table 38 would assure continuing competence.
Table 38 Essential components for tool box of continuing competence indicators
Agree Disagree Undecided Rating Average
Rating Count
Self-assessment / Self-declaration 77.8% (7) 11.1% (1) 11.1% (1) 1.33 9
Practice Hours (current and recent practice) - specified
77.8% (7) 11.1% (1) 11.1% (1) 1.33 9
Continuing professional development / education hours - specified
77.8% (7) 11.1% (1) 11.1% (1) 1.33 9
Four optional indicators of continuing competence were identified in the previous Delphi
rounds for consideration in the best practice consensus model. Table 39 represents the
collation of the expert panel responses. Of these items only ‘Peer Assessment’ was
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consistently identified for inclusion in the tool box of indicators. The following comment was
made “What is the evidence that supports inclusion of these indicators as measures of
continuing competence?”
Table 39 Optional components for tool box of continuing competence indicators
Agree Disagree Undecided Rating Average
Rating Count
Peer Assessment 88.9% (8) 11.1% (1) 0.0% (0) 1.11 9
Professional Portfolio 44.4% (4) 44.4% (4) 11.1% (1) 1.67 9
Observed Structured Clinical Examination (OSCE)
33.3% (3) 44.4% (4) 22.2% (2) 1.89 9
Examination 12.5% (1) 62.5% (5) 25.0% (2) 2.13 8
9.3 What is the consensus view of regulatory experts?
The consensus view of the Delphi participants was that the development of an international
best practice consensus model for the assessment of continuing competence, between
Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America
is an important initiative that is possible to achieve. In addition there was agreement with
regard to many of the key principles (8.6.1) and the list of core components (8.6.2) identified
for inclusion in a best practice consensus model. As previously noted, it was also agreed by the
Delphi participants that there is preliminary work required in terms of developing closer
national and international relationships, and refining the common understandings between
regulatory jurisdictions, which build on the key principles identified by the Delphi participants.
Discussion related to the overall Delphi findings in relation to the key principles and proposed
components of the conceptual consensus framework is presented in the following sections.
9.3.1 Common values, beliefs and guiding principles
The notion of ‘building trust’ was raised by some participants in the Delphi rounds one and
two, in relation to preconceived ideas and / or limited understanding of the nursing education
and practice standards required in other regulatory jurisdictions. Following further analysis
the notions of “dispelling preconceived ideas” and “building trust among the participant
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regulatory authorities” were identified as items critical to the successful development of an
international consensus model.
It is the consensus view of the Delphi participants (Agreement = 100%, M = 1.56) that by
building on the list of key principles previously identified, a set of ‘common values, beliefs and
guiding principles’ for Continuing Competence Frameworks can be developed and agreed
internationally. The commonality of, and agreement on, aspects such as role definitions,
education and practice standards, and the codes of conduct/behaviour required of a nurse, are
items that have been identified by the participants as critical to the development of the
consensus model.
The most commonly expressed requirements identified by the Delphi participants are the
requirements that the best practice consensus model must be flexible and adaptable
(Agreement 100%, M = 1.31), and administratively feasible, financially viable and defensible in
terms of providing some assurance of public safety (Agreement 100%, M = 1.11). Issues
relating to the requirement that Continuing Competence Frameworks must be ‘defensible’, are
frequently identified in the literature (National Council of State Boards of Nursing, 1996,
2009a; Vandewater, 2004), particularly in association with the responsibilities of regulators
with regard to ‘public protection’ (Secretary of State for Health (UK), 2007; Swankin, et al.,
2006). This discussion appears to be strongly linked with the notion of measurement, validity
and reliability. It is evident in the literature (EdCaN, 2008; Vandewater, 2004; Wilkinson,
2013), and is also demonstrated in Stage One and Stage Two of this research that a focus on
measurement, rather than assessment, can inhibit the development of Continuing
Competence Frameworks and constrain assessment processes.
9.3.2 Consistency of purpose
It was the consensus view of the Delphi participants that the development and integration of
commonly agreed principles and approaches to continuing competence (Agreement 100%, M
= 1.56), between the six focus countries was possible, and is a strategy that “would enhance
stakeholder engagement and buy-in”. Whilst there is a commonality of understanding with
regard to the overarching purpose of Continuing Competence Frameworks in nursing
regulation, it is apparent from this research that internationally there is not a consistent
approach to the development, implementation and use of these frameworks.
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The contemporary literature highlights a variety of competence assessment tools, many
associated with measuring competence against specified education standards for entry to
practice and issues related to the validity and reliability of these tools in terms of determining
competence (EdCaN, 2008; Flanagan, et al., 2000; Vandewater, 2004; Vernon, et al., 2010).
However, very little emphasis has been given to actually defining the phenomenon that is
continuing competence, or evaluating the existing models / frameworks for the assessment of
continuing competence.
It is apparent that, whilst a number of jurisdictions have implemented similar Continuing
Competence Frameworks, implementation across the overall sample group is inconsistent, and
is reported by the Delphi participants and in the literature, as being impeded by local
legislation, local policy and / or financial and resourcing constraints (EdCaN, 2008;
International Council of Nurses, 2009; National Council of State Boards of Nursing, 2005,
2009b; Vandewater, 2004). In addition, whilst there was general consensus with regard to the
purpose of Continuing Competence Frameworks as tools that ensure the continuing
competence of nurses and ensure public safety, there is still variation with regard to the
overarching intent of the indicators of competence embedded in the Continuing Competence
Framework. This item is related to a fundamental philosophical question underpinning the
Continuing Competence Framework – Is continuing competence being measured or assessed?
By definition the two words ‘measured’ and ‘assessed’ lend themselves to two different
conceptual approaches to evaluation. To ‘measure’ is “to ascertain the size, amount, or
degree of (something) by using an instrument or device marked in standard units, or by
comparing it with an object of known size: judge someone or something by comparison with (a
certain standard)” (Oxford University Press, 2013). However, to ‘assess’ is “to evaluate or
estimate the nature, ability, or quality of someone or something” (Oxford University Press,
2013).
This variation in terminology may be merely an anomaly, caused by differences in the use of
language and interpretation across and between countries as it is apparent that in some cases
the words ‘measure’ and ‘assess’ are being used synonymously. However, regardless of the
reason, this item highlights the need to clearly define and articulate the different connotations
of these words (measurement and assessment) prior to the development of the Continuing
Competence Framework, as their use will have implications for the selection of the indicators
of continuing competence that are incorporated.
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9.3.3 A common language
It is commonly accepted that words can mean different things to different people, and the
context in which a word or a sentence is used can change the significance or value of the
intended meaning (Canadian Nurses Association, 2000; International Council of Nurses, 2009;
Wilkinson, 2013). The contemporary literature identifies the importance of developing and
clearly defining a common lexicon of terms that specifically pertains to the concept of
‘continuing competence’ (Bryant, 2005; Canadian Nurses Association, 2000). Variation in use
of language and inconsistencies in the interpretation of words was identified as a potential
barrier to the development and implementation of an international consensus model. This
was found to relate particularly to the understanding of the terminology used when describing
continuing competence, within and between countries. Although this item did not meet the
statistical threshold that was set in terms of ‘achieving a consensus view’, it is an item that was
considered to be fundamental in terms of developing and successfully implementing an
international consensus framework. In addition, the significant variation in participant
understanding and the differing use of terminology, within and between countries, was
evident in the written and verbal responses made during each of the Delphi rounds, further
highlighting the requirement to develop an internationally agreed lexicon of terminology.
9.3.4 Definitions
Initially the perceived variations in the definition and interpretation of the terms ‘competence’
and ‘continuing competence’, in relation to nursing regulation and practice, were identified by
the Delphi participants as items for further investigation and agreement. However, despite
this belief, findings from this research indicate that the existing definitions and interpretations
of what constitutes competence and continuing competence, in five of the six focus countries
are very similar. These countries are Australia, Canada, New Zealand, the United Kingdom and
the United States of America (Australian Nursing and Midwifery Council, 2009; Campbell &
MacKay, 2001; Canadian Nurses Association & Canadian Association of Schools of Nursing,
2004; National Council of State Boards of Nursing, 1996; Nursing Care Quality Assurance
Commission, 2009; Nursing Council of New Zealand, 2010b, 2010c). Ireland does not currently
have published definitions of competence and continuing competence. As previously noted,
each of the published definitions of competence currently specifies the requirement for: a
prescribed standard of knowledge; skills; and decision making for safe practice.
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In addition to these items, the definitions of continuing competence all include items such as
the on-going ability of the nurse to continue to integrate up-to-date knowledge, skills,
judgement and decision making appropriately in the context / role in which they practise. The
contextualisation of an individual’s practice is an item that was considered by the Delphi
participants as “essential to the assessment of continuing competence”. It was the consensus
view of the Delphi participants (Agreement 100%, M = 1.55) that the inclusive definitions of
competence and continuing competence were appropriate.
Variation in what is considered to be ‘nursing practice’ also emerged as an item for further
investigation during Delphi rounds one and two. However, the consensus view of the Delphi
round three participants was that the internationally agreed definition of nursing practice
should be inclusive and encompass all nursing roles that contribute to the nursing profession
(Agreement 100%, M = 1.45). This item achieved general agreement from the Delphi round
four participants, with the proviso that further work was required in terms of clearly
articulating what is considered ‘practice’. One participant commented
There is a disconnect between the definition of nursing practice and regulatory accountability for public safety – this is controversial but we need to tackle the historical conviction that nurses who are not in direct practice are still practising nursing!
9.3.5 Professional responsibility and accountability
As previously noted, responsibility and accountability for the continuing competence of nurses
was an item that was identified by participants in response to the Delphi rounds one and two
as being an item that required further clarification, particularly with regard to stakeholder
responsibilities. However, after completion of the Delphi rounds three and four the
participants’ consensus views were confirmed and are discussed below.
Ultimately the individual registered nurse is responsible and accountable throughout their
career for ensuring and maintaining their own continuing competence relative to the required
standards of practice and the relevance to the role that they perform (Agreement 100%, M =
1.19). The individual nurse is also responsible and accountable for providing an appropriate,
safe, ethical and competent standard of nursing practice at all times (Agreement 100%, M =
1.16) and, as a registered health professional, is responsible for actively participating in
ongoing education and other activities required by their regulatory authority, relevant to their
nursing practice (Agreement 100%, M = 1.16).
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With regard to the responsibility and accountability of key stakeholder groups in relation to
continuing competence, the consensus view of the Delphi participants was that employers
have a responsibility to maintain quality practice environments that support and facilitate
continuing competence opportunities for nurses, and for monitoring the continuing
competence and practice of the nurses in their employ (Agreement 100%, M = 1.61). This is an
area of current debate in the international literature, particularly in relation to the
proliferation of specialty and advanced practice roles, expanded nursing practice, privatisation
of the health sector and changing workforce requirements (Donovan, Diers, & Carryer, 2012;
Holloway, 2011), all of which have a significant impact on the continuing competence of
nurses.
It was the consensus view of the Delphi participants (Agreement 100%, M = 1.62) that the
regulatory authority is responsible for protecting the safety of the public by setting the
standards of nursing practice and monitoring the competence of the profession. However, it
was also noted by the participants that, as nurses are registered health professionals, there is
an inherent level of trust afforded to them. As such, an annual self-assessment by the nurse
against their required standards for practice and professional development is a commonly
used and economically viable indicator that implies the nurse is continuing to be competent.
It was considered that professional nursing organisations (Agreement 97%, M = 1.79) also have
a role in facilitating and guiding the career development of the profession. It was further
identified by the participants that career development initiatives are more appropriately
situated with the professional nursing organisations, rather than with the regulatory authority.
The consensus view of the Delphi participants was that the role of government in relation to
responsibility for the continuing competence of nurses was to pass appropriate legislation and
ensure its enactment (Agreement 100%, M = 1.72). However, it was acknowledged that public
safety is also the purview of government, as is the provision of healthcare and health
workforce requirements, all of which intersect with the regulation of health professionals
(Chiarella & White, 2013).
9.3.6 Agreed barriers and enablers
As noted in Chapter Eight, a range of barriers and enablers were initially identified related to
the development and implementation of an international consensus model. However, final
analysis of all Delphi participant responses confirms that it is the consensus view that only two
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items: namely, ‘authority of the Regulatory Body’ (Agreement 92%, M = 1.77, SD = .627, V =
.393); and ‘communication with key stakeholders’ (Agreement 93%, M = 1.62, SD = .633, V =
.401) are considered to be significant in terms of enabling the efficacious implementation of a
Continuing Competence Framework. Both items are highlighted in the international literature
as being critical in terms of ensuring stakeholder engagement (Canadian Nurses Association,
2000; International Council of Nurses, 2009; Vernon, et al., 2010), compliance with Continuing
Competence Framework requirements (Vernon, et al., 2013), and assuring public safety
(International Council of Nurses, 2009; Secretary of State for Health (UK), 2007; Swankin, et al.,
2006).
The following items: number of nurses on the register; expectations of the public; differing
qualifications; political interests; financial viability; and professional organisations / unions,
were initially identified as being potential barriers to the development and implementation of
Continuing Competence Frameworks. These views were consistent with themes previously
identified in the literature (National Council of State Boards of Nursing, 2009a). However, in
the final analysis, the consensus view was that these items were no longer considered to be
applicable as barriers, with the exception of ‘political interests’. Fifty four percent (n = 20) of
the Delphi participants indicated they were undecided as to the status of this item ‘political
interests’ and 27% (n = 10) rated it as a barrier. It was interesting to note that ‘political
interests’ was rated as an enabler by only 11% (n = 4) of the participants. This finding is
consistent with the views expressed in the international literature in relation to the jurisdiction
and positioning of some regulatory authorities, particularly those situated within Departments
of Health (Cutcliffe, 2010; International Council of Nurses, 2009; Taskforce on Health Care
Workforce Regulation, 1995).
9.3.6.1 Authority of the Regulatory Body
It was evident from the participant responses that a significant enabler, in terms of the
participation of nurses in existing Continuing Competence Frameworks, related directly to the
legislative authority of the regulatory authority. To-date, it appears that internationally, the
successful implementation of Continuing Competence Frameworks has occurred mostly in the
jurisdictions where the regulatory authority has the mandate to require the compliance of
nurses in continuing competence activities (Australian Nursing and Midwifery Council, 2009;
International Council of Nurses, 2009; Nursing Council of New Zealand, 2006b). Most
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commonly this has been done by linking the continuing competence requirements with the
annual recertification, revalidation or registration requirements for the individual nurse.
The Delphi participants (Delphi Rounds one, two and four) reinforced the views expressed in
the international literature (International Council of Nurses, 2009; Vandewater, 2004; Vernon,
et al., 2013) indicating that Continuing Competence Frameworks that are implemented solely
for the purpose of ‘career development’ and/or as ‘quality improvement initiatives’, and do
not require mandatory compliance, are often focused solely on educational criteria and
ultimately have more limited engagement from nurses.
9.3.6.2 Legislative mandate
A legislative mandate was identified by 85% (n = 33, M = 2.00) of the Delphi round three
participants as being an enabling factor in the development and implementation of Continuing
Competence Frameworks, and a barrier by only 8% (n = 3). The international literature
(International Council of Nurses, 2009; Swankin, 1995; Swankin, et al., 2006) indicates that the
legislative status of ‘continuing competence requirements’ in relation to public protection, has
a strong influence on the successful implementation, compliance with, and viability of
Continuing Competence Frameworks (Swankin, et al., 2006; Vandewater, 2004). The literature
indicates that, in jurisdictions where the legislation and subordinate regulations are silent,
successful implementation of continuing competence requirements is less likely to occur or to
be implemented successfully (International Council of Nurses, 2009).
9.3.6.3 Communication with key stakeholders
Communication and consultation with key stakeholders is identified in the literature (Canadian
Nurses Association, 2000) and was evident during Stage One of this research, as being a
critical factor in terms of ensuring the active engagement of stakeholders in the development
and implementation of the Continuing Competence Frameworks (Vernon, et al., 2013; Vernon,
et al., 2010). This item was also strongly linked with the items: common values, beliefs and
guiding principles (9.3.1), the development of a common language (9.3.3), and common
understandings in terms of the definitions of competence, continuing competence and nursing
practice (9.3.4), previously discussed in this Chapter.
9.3.7 Assessment of Continuing Competence
Extensive literature exists with regard to individual measures of competence and competence
indicators (Canadian Nurses Association, 2000; EdCaN, 2008; National Nursing Research Unit,
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2009; Vandewater, 2004; Wendt & Alexander, 2007). However, the assessment of the
continuing competence of nurses continues to be a phenomenon that is proving difficult to
validate (National Council of State Boards of Nursing, 2009a). Current research into
international opinion on this matter suggests that no individual measure ensures competence
or public safety (Vernon, et al., 2013; Vernon, et al., 2012). However, evidence drawn from a
variety of measures is considered to provide a strong indication of competence and may be
used to imply continuing competence. The consensus view of the Delphi participants was that
multisource feedback about the nurse, and the context in which the nurse practises, is critical
when making an assessment of continuing competence.
9.3.8 Indicators of continuing competence
It was the overall consensus view of the Delphi participants, that the three indicators of
competence identified in Chapter Eight (8.6.5) and further discussed below, should be included
in the international consensus framework for the assessment of continuing competence: Self-
assessment, in association with a self-declaration (Agreement 90%, M = 1.53, SD = .687);
practice hours (Agreement 100%, M = 131, SD = .468, V = .219); and demonstrated continuing
professional development activities (Agreement 100%, M = 1.33, SD = .530, V = .281) all had
strong indicators of agreement. Peer assessment was identified as a useful, valid and reliable
indicator of continuing competence when used in association with self-assessment, and was
identified as being an indicator that should be used at the discretion of the individual
regulatory authority.
It was agreed by the Delphi participants that, when used together, in association with the
context in which practice is occurring, these indicators of competence are able to suggest
continuing competence (Agreement 97%, M = 1.16). Additionally, the Delphi participants
noted that the best practice consensus framework should include provision for regulatory
authorities to retain flexibility in terms of the inclusion of additional indicators of competence
(a tool box), when deemed necessary.
9.3.9 Mitigating known risk
Throughout this research, mitigating known risk and promoting patient safety have been
clearly identified as fundamental to the development of a best practice Continuing
Competence Framework. It has been agreed that the purpose of a Continuing Competence
Framework is to provide a mechanism for Registered Nurses to demonstrate that they are
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indeed continuing to be competent, and for regulatory authorities to assess and monitor the
continuing competence of nurses in practice. The Delphi participants have agreed that the
regulatory purpose of a Continuing Competence Framework is to assure public safety and, as
such, it is not a process for the management of competence notifications or practice
breakdown, nor is it a process for career development. Clearly competence notifications and
recognition of system breakdown are also important issues, as a Continuing Competence
Framework alone cannot ensure public safety. However, these items require separate
processes in order to achieve their purpose and to maintain the integrity and transparency of
the Continuing Competence Framework. Examples were provided by some of the expert panel
participants of processes that have been implemented in some jurisdictions to address issues
of practice breakdown (Benner, Malloch, & Sheets, 2010), competence notifications (Nursing
Council of New Zealand, 2013a) and career development initiatives (Nursing Council of New
Zealand, 2004b). These processes have been implemented separately but in association with
continuing competence requirements.
The right of the nursing regulatory authority to initiate an audit of individual nurses was
identified as a common risk management strategy (Nursing Council of New Zealand, 2013a),
and this has commonly been used when an individual nurse or practice area has been
identified as being at high risk of practice error (Nursing and Midwifery Council (UK), 2011,
2012). Whilst this method of risk management is identified as administratively feasible,
particularly in relation to monitoring the continuing competence of large nursing populations,
it is reliant on the determination of what is considered to be ‘high risk’. In addition, there is an
inherent implication that nurses who work in an area that is considered to be a high risk area
are more likely to pose a risk to public safety than those nurses who are employed in what are
considered moderate or low risk areas. Examples of this method of monitoring continuing
competence, commonly used in the United Kingdom, demonstrate that this risk management
approach alone is not an adequate method to monitor the continuing competence of nurses in
practice (Council for Healthcare Regulatory Excellence, 2012b). However, when used in
association with mandatory annual continuing competence requirements and random audit of
a number or percentage of a jurisdiction’s nursing population, it can provide further insight
into potential problem areas.
Random audit of a percentage of the nursing population is a method used for monitoring
compliance with continuing competence requirements, particularly in association with self-
assessment (Canadian Nurses Association, 2000), and is evident within a number of the
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Continuing Competence Frameworks currently in operation (Table 3, pp. 35-36). As noted in
the literature, implementation of a random audit system requires administrative resourcing in
terms of the process and associated policy development (Canadian Nurses Association, 2000;
EdCaN, 2008). However, when used in association with continuing competence requirements,
mandatory random audit of a percentage of the nursing population in practice can provide the
following benefits: for the individual nurse, validation that they are indeed continuing to be
competent; for the regulatory authority, verification and validation that continuing
competence requirements and processes are appropriate and being met; and again for the
regulators, in some cases identification of individuals who require remedial action with regard
to demonstrating continuing competence to practise and / or safety to practise (Vernon, et al.,
2010).
9.4 The best-practice international consensus model for the assessment of Continuing Competence
The consensus view of the Delphi participants was that the best practice model should include
an internationally agreed and clearly communicated purpose statement that identifies the
expectations of the Continuing Competence Framework. The functions of the Continuing
Competence Framework in terms of the monitoring and assessment of continuing competence
and protection of the public should be clearly articulated. And an internationally agreed
lexicon of terminology that includes, but is not limited to, agreed definitions of the terms
‘Competence’, ‘Continuing Competence’ and ‘Nursing Practice’ should be developed and
agreed. The development of agreed, criterion-based Standards of Practice and assessment
guidelines were considered to be important, particularly in relation to facilitating mutual
recognition and any future consideration of reciprocity of qualifications and registration
between the regulatory jurisdictions.
The consensus view of the Delphi participants was that development and agreement on a list
of key principles that would underpin the development of the best practice model was critical.
However, not all of the key principles listed in Table 36 (p. 211) achieved consensus from the
expert panel (Delphi round four) participants. As previously noted, one expert panel
participant consistently disagreed with the statements associated with mandatory compliance,
responsibility and accountabilities. However there was overall agreement that risk
management and the defensibility of the Continuing Competence Framework were priorities.
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Therefore, it is proposed that the consensus model includes mandatory audit of a percentage
of the practising population of nurses within each jurisdiction.
Confirmation of consensus was achieved in relation to the core components of the best
practice international consensus model and the inclusion of four indicators of continuing
competence. These four indicators are self-assessment, stipulated practice hours, stipulated
professional development hours and peer assessment. No agreement was achieved with
regard to the inclusion of the following items: observed structured clinical examination (OSCE),
professional portfolio, and examination, as indicators of continuing competence.
Table 40 represents a collation of the components identified by consensus for inclusion in the
proposed best practice international model for the assessment of continuing competence.
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Table 40 Components of the best practice international consensus model
Component Advantages Disadvantages Considerations
Guiding principles • Facilitate the development of a mutually agreed, standardised and consistent framework
• Promote the reciprocity of qualifications and facilitate mobility of nurses between jurisdictions
• Complexity of the consensus process
• Requires a commitment to work together
Common language – Lexicon of terminology
• Consistent interpretation and understanding of concepts, definitions, and assessment measures within and between countries
• Requires extensive consultation and agreement
Best practice Continuing Competence Framework
• Principle function is as a quality assurance mechanism • Mechanism for the assessment of competence as a
potential measure of public safety • Demonstrates to public that the nursing profession is
cognisant of, and has mechanisms to assess the continuing competence of the profession and thereby ensure competence and assure public safety
• Promotes consistency of continuing competence standards and assessment processes
• Large nursing population numbers • Difficulty in identifying valid and
reliable indicators to assess continuing competence
• Regulatory authorities are accountable for ensuring health practitioners safety to practise and assuring public safety
• Framework needs to be administratively feasible, financially viable and legally defensible
Mandatory assessment linked to annual recertification /revalidation / relicensure
• Ensures mandatory compliance • Facilitates the regulatory purpose of public protection • Encourages professional responsibility and
accountability of the nurses as a registered health professional
• May necessitate changes to existing legislation, regulations, policy
• May meet resistance from the profession or professional organisations
• Consultation with key stakeholder groups essential
• Increased cost associated with nursing numbers and assessment requirements
• May necessitate changes to existing legislation, regulations, policy
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Indicators of continuing competence Self-Assessment
• Is completed by the individual • Promotes professional responsibility in terms of being
responsible and accountable for their competence and continuing competence
• Actively involves the nurse • Enhances nurse’s awareness of Standards of Practice
and Ethical Conduct in relation to their role/context of practice
• Issues of validity and reliability • Reliant on the nurse’s judgement,
insight, and ability to reflect on their own practice in relation to the required standards, role and context in which they practise.
• Appropriate for assessing large nursing populations
• Administratively feasible • Economically viable • Should be used in association with
method of validation i.e. audit or peer assessment
Mandatory Practice Hours (specified number/timeframe)
• Quantifiable measurement of practise hours • Implies currency of practice
• Assures but does not ensure continuing competence
• Appropriate for assessing large nursing populations
• Administratively feasible • Economically viable
Mandatory Professional Development hours (specified number/timeframe)
• Quantifiable measurement of professional development hours
• Demonstrates engagement in learning activities • Implies continuing professional development /
learning
• Assures but does not ensure continuing competence
• Access to professional development opportunities
• Appropriate for assessing large nursing populations
• Administratively feasible • Economically viable
Peer Assessment • Can be completed in the work place/practice environment
• Promotes a facility for constructive feedback based on the Standards of Practice
• Requires access to a peer or colleague to perform the assessment
• Requires understanding of the specific criteria (Standards of Practice) and understanding of the requirements of the practice context and role
• Clear guidelines and criteria for peer assessment process
• Criteria for selection of ‘peer’ and assessment responsibilities
Audit of a percentage of practising population of nurses annually
• Provides verification and validation that continuing competence requirements are being met and that the regulatory authority is ensuring and monitoring the competence of the profession
• Used to validate the competence of an individual and may infer the continuing competence of profession
• Provides information with regard to the continuing competence of a sample of the overall nursing population
• Cannot guarantee competence of the profession or individuals
• Requires administrative resourcing and development of clear and transparent policy and processes
• Consideration of economic viability when determining sample size in relation to size of nursing population
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9.5 Changes required to align international regulatory requirements with best practice for the assessment of continuing competence
The Delphi round four participants were asked to consider the summary findings from the
previous three Delphi rounds and identify if differences existed between their current
regulatory requirements for the demonstration and assessment of continuing competence and
the best practice model proposed through consensus. The expert panel responses indicated
there was agreement with the philosophy and definitions proposed in the best practice model.
One of the participants made the following comment
I am aware that whilst differences still exist across the country with regards to the demonstration and measurement of continuing competence. In fact there is a range of self-reporting, peer review, and random testing. That being said, I believe the definitions and understandings are consistent.
Another participant commented
Minimal differences - we use a variable approach to continuing competence that includes the elements identified in the Delphi rounds as well as additional alternatives.
One participant noted that the current variations in regulatory terminology and the
subsequent understandings of these terms required clarification, particularly in relation to
legislative requirements. This response highlighted again the need to develop a common
lexicon of terminology and understandings.
Annual re-registration, re-validation is NOT part of our continuing competence model - there is an annual requirement to meet continuing competence requirements - this may reflect different use of language in different jurisdictions and needs clarification.
The expert panel was asked to identify if any changes would be required in order to align their
current regulatory processes with the proposed best practice framework for the
demonstration and assessment of continuing competence. Whilst no significant changes were
identified by the participants, it was noted that in some jurisdictions there would need to be
amendments made to some subordinate areas of regulatory policy and / or process, in order
to align them with the suggested best practice framework. One participant commented
No changes would be required to existing policy or regulation frameworks. Current legislation provides flexibility around policy and indicators. Changes can be made to sub-ordinate policy without requiring a regulation change.
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Another participant commented
We would need to alter option details in our state regulations.
It was pleasing to note that, whilst some jurisdictions may not currently have an existing
Continuing Competence Framework, there was significant interest in the findings of this
research in terms of informing future consultation and development processes.
Our model is not yet decided. The framework is still being developed and will need consultation at a national level. It is anticipated to have a framework in place by 2014. We will utilise the findings of the study, to inform the process of our own consultation document.
The purpose of the best practice Continuing Competence Framework with regard to public
safety was raised by one participant in response to this question.
One of the key considerations that is missing is the notion of risk - if the purpose of continuing competence is public safety, we should be developing a model that is based on mitigating known risk.
This participant’s comment relates directly to the underlying philosophy of the Continuing
Competence Framework and the need to articulate clearly both the focus and purpose of the
best practice framework and its association / relationship with separate identified strategies
for the management of practice breakdown and competence notifications.
9.6 Recommendations for further development of the international consensus model
As previously noted in section 9.3, there is a consensus view that the development of a best
practice international consensus model for the assessment of continuing competence,
between Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States
of America is an important initiative that will be possible to achieve. It was also identified by
the expert panel participants (Delphi round four), that the Memorandum of Understanding
and Cooperation that was agreed between the key regulatory authorities identified in this
research, may provide an appropriate forum to facilitate future development of the best
practice international consensus model. The following areas for further development have
been identified as:
1. Further refinement of the key principles identified as underpinning the international
best practice consensus model for the assessment of continuing competence, and
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agreement of the regulatory representatives for each of the six identified countries
(Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States
of America) on each of the key principles.
2. Development of the agreed international lexicon of terminology related to nursing
regulation and the assessment of continuing competence.
3. Development of the best practice Continuing Competence Framework, including:
assessment guidelines; assessment criteria (relevant to each of the indicators of
continuing competence); and a rubric for triangulation of continuing competence
assessment data.
9.7 Concluding remarks
Chapter Nine has presented a summary of the findings from the Delphi study and proposed
the beginning conceptual framework for the international consensus model for the assessment
of continuing competence. It has been identified in this research that the international best
practice framework, if adopted, must contribute to the core regulatory purpose in each
regulatory jurisdiction. In the six countries that were the focus of this research (Australia,
Canada, Ireland, New Zealand, the United Kingdom and the United States of America), the core
regulatory purpose is public protection.
The framework must therefore be based on strong research evidence and relate to the
potential risk to public safety presented by nurses who do not continue to be competent
throughout their careers. The best practice framework proposed in this thesis is based on the
consensus view of the Delphi participants and aims to deliver a proportionate, consistent and
affordable system for the assessment of continuing competence that will provide assurance to
the public that nurses in practice are competent.
The following Section (Section Four, Chapter Ten) will discuss the overall findings of this thesis
in terms of the New Zealand and international nursing regulatory environments, and the
overarching research questions. The relevance of this thesis in terms of its contribution to
nursing regulation and practice will be discussed and recommendations for further research
will be made.
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SECTION FOUR CONTINUING COMPETENCE AND PUBLIC SAFETY A RELATIONSHIP BETWEEN LEGISLATION, POLICY AND PRACTICE
Section Four presents the conclusion to this thesis and positions the thesis in terms of the New
Zealand and international nursing regulatory environment.
Chapter Ten presents the triangulation of the cumulative findings from Stages One and Two of
this research in relation to the three overarching research questions:
1. What are the relationships between current legislation, policy drivers and the
statutory requirements to ensure registered nurses are competent and fit to
practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the international consensus view of regulatory experts in relation to:
a) best practice for nurses to demonstrate continuing competence; and
b) best practice for regulatory authorities to assess continuing competence?
A discussion of the findings and the limitations of this thesis are presented, including
recommendations for future development of the best practice consensus model for
assessment of continuing competence, the associated implications for key stakeholders, and
recommendations for future research.
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CHAPTER TEN - DISCUSSION, CONCLUSION AND RECOMMENDATIONS
10.1 Introduction
This Chapter presents a descriptive triangulation of the cumulative findings from Stage One
(Evaluation of the Nursing Council of New Zealand Continuing Competence Framework) and
Stage Two (The International Consensus Model for the Assessment of Continuing
Competence), of this research in relation to the three overarching research questions:
1. What are the relationships between current legislation, policy drivers and the
statutory requirements to ensure registered nurses are competent and fit to practise?
2. Is it competence that is being assessed / measured, or safety to practise?
3. What is the international consensus view of regulatory experts in relation to:
a) best practice for nurses to demonstrate continuing competence; and
b) best practice for regulatory authorities to assess continuing competence?
The discussion of the summary findings is situated in terms of the national and international
regulatory context for nursing and is presented in association with the national and
international literature. The thesis will conclude by identifying its contribution to the
contemporary nursing environment and by presenting recommendations for future research
and further development of the best practice international consensus model for assessment of
continuing competence.
Met
hodo
logi
cal
Tria
ngul
atio
n
Conclusion and Recommendations
Data triangulation & discussion of summary
findings fromStage One & Stage Two
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10.2 Relationships between legislation, policy drivers and statutory requirements to ensure registered nurses are competent and fit to practise
There has been increasing public and political scrutiny of medical, nursing and allied health
errors over the past 25 years. Assuring and ensuring public safety has become a regulatory
imperative in New Zealand and in other jurisdictions (Ministry of Health (NZ), 2012a; Secretary
of State for Health (UK), 2007; Swankin, 1995). International trends with regard to the
regulation of health professions signal that there is a greater focus on consumer protection,
standardisation of legislation and the concomitant responsibility and accountability of health
professionals (Ministry of Health (NZ), 2012a; Secretary of State for Health (UK), 2007). In New
Zealand and internationally, there is also growing scrutiny of the performance of regulatory
authorities and health service organisations in terms of their roles in protecting the health and
safety of the public; individual, team and organisation accountabilities; and workforce
flexibility and value for money (Council for Healthcare Regulatory Excellence, 2012a, 2012b;
Secretary of State for Health (UK), 2007).
As previously noted in sections 1.6 and 2.3.1, the principal purpose of the Heath Practitioners
Competence Assurance Act 2003 (NZ) is to protect the health and safety of the public of New
Zealand (Health Practitioners Competence Assurance Act (NZ), 2003). One of the key
underpinning values of this legislation is the accountability of individual health practitioners for
their own safety to practise and the application of professional judgement in their clinical
practice (Ministry of Health (NZ), 2012a; Nursing Council of New Zealand, 2013b). Until the
Health Practitioners Competence Assurance Act 2003 (NZ) came into force, there was a
presumption that nurses and other health professionals in New Zealand continued to be
competent throughout their careers. However, there was no requirement that they provide
any assurance or demonstrate their continuing competence in any way. The only exception
was an individual who was found to be incompetent as the result of a complaint or the
notification of a practice error, and was therefore subject to separate legislative and regulatory
processes (Forrester, Davies, & Houston, 2013; Health and Disability Commissioner Act (NZ),
1994; Nursing Council of New Zealand, 2013a).
Nursing is a profession that combines the application of substantial knowledge, skills and
abilities in order to provide ethical and safe nursing practice (Chiarella & White, 2013). It is
clearly identified that the unsafe and unethical practice of nurses may result in harm to the
public unless there is a high level of accountability (Secretary of State for Health (UK), 2007;
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Swankin, 1995). Therefore, the complex nature of nursing practice relies on the ethical,
knowledge-based and skilful practice of nurses who are able to use clinical judgement
(decision making), that is appropriate to their role/scope of practice and relevant to the
particular clinical situation at any given time (International Council of Nurses, 2007; National
Council of State Boards of Nursing, 1996; Vandewater, 2004). It was unanimously
acknowledged by the participants in this research that, as regulated health professionals,
nurses are responsible and accountable for their own professional practice. As such, they have
a public and civic responsibility to uphold their standards of practice and to practise in such a
way as to ensure their ongoing competence to practise (Vernon, et al., 2013).
It is the legislated responsibility of the nursing regulatory authorities in all of the six countries
that were the focus of Stage Two of this research (Australia, Canada, Ireland, New Zealand, the
United Kingdom and the United States of America), to hold nurses professionally accountable
for their practice. However, the requirement that the regulatory authority monitors or
ensures the continuing competence of these nurses throughout their careers is not a legislated
requirement in all of these jurisdictions34 (International Council of Nurses, 2009). This research
has demonstrated that, whilst a specific legislative mandate is certainly considered by the
research participants to be beneficial in terms of ensuring the compliance of nurses with
continuing competence requirements, it was not considered to be an essential requirement in
terms of implementing a Continuing Competence Framework. As ‘protection of the public’ is
deemed a primary function of a regulatory authority, the research participants considered that
implementation of regulatory processes, policy or frameworks associated with protection of
the public, such as a Continuing Competence Framework, were functions already within their
mandate and therefore at the discretion of each individual regulatory authority.
There is a strong link between a nurse’s continuing competence and their workplace
environment. It is acknowledged that the health care environment has become increasingly
complex and, as the pace of technological and scientific developments accelerate increasing
demands are made on limited health funding resources, resulting in changes to the provision
of health services, health workforce skill mix, nurse-patient staffing ratios and ultimately the
continuing competence requirements of nurses. These demands, in association with the
increased complexity of care, higher patient acuity, and shorter hospital stays cannot be
34 Predominantly the differences exist in the United States of America, due to the fact that it is a federated system. The legislation and requirements for registration varies significantly from State to State in terms of the presence or absence of a mandate to monitor continuing competence.
237
underestimated in terms of the impact they have on the context in which the nurse practises
(Health Workforce Australia, 2012; Ministry of Health (NZ), 2012a; Swankin, et al., 2006; Tabari
Khomeiran & Kiger, 2006). It is well documented that suboptimal practice environments can
impede safe practice and therefore jeopardise patient safety (Benner, et al., 2010; Secretary of
State for Health (UK), 2007). Keeping pace with the speed of these changes is challenging for
many nurses and may have a substantial influence in terms of enabling or impeding their
continuing competence and therefore their safety to practise (Aiken et al., 2001; Finlayson,
Aiken, & Nakarada-Kordic, 2007). The challenge for nursing regulatory authorities is to ensure
that appropriate and efficacious mechanisms for the demonstration, assessment and
monitoring of the continuing competence of individual nurses and the profession are available
and defensible.
As noted in section 4.3.4, the New Zealand health sector is a complex system of legislation,
organisations and people. The statutory framework that governs the health sector and the
provision of health services is comprised of over 20 separate pieces of legislation (Ministry of
Health, 2011b), that together work to protect the safety of the public and in doing so,
determine the social, fiscal and political context in which health professionals practise. Public
scrutiny and political agendas have both played roles in driving the development of legislation
and associated regulations and policy. This has been demonstrated by the New Zealand
Government’s response to various sentinel events, one example being the Cervical Cancer
Inquiry (Cartwright, 1988), which instigated the introduction of the Health and Disability
Commissioner Act 1994 (NZ), followed by the New Zealand Public Health and Disability Act
2000 (NZ) and the Health Practitioners Competence Assurance 2003 (NZ).
The independent structure and authority of the Nursing Council of New Zealand under the
provisions of the Health Practitioners Competence Assurance Act 2003 (NZ) facilitates their
focus on their core business, which is protecting the public and ensuring the safety of nurses to
practise. This model of regulation is considered to be permissive (International Council of
Nurses, 2009), in that the legislation (Health Practitioners Competence Assurance Act (NZ),
2003) allows the Nursing Council of New Zealand significant powers in terms of the
development and implementation of its regulatory policies, processes and operational
functions, without the conflicting priorities that result from increasing constraints on health
funding, health system error/failure, workforce shortages and political interference.
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Figure 27 depicts the New Zealand healthcare environment and the relationships between
legislation, regulatory authorities, health care organisations, health care professionals and the
public as consumers of healthcare services. The diagram sets out to show how relationships
exist between the legislation, policy drivers and the regulatory requirements with regard to
the competence and continuing competence of health professionals in New Zealand.
Figure 26 Healthcare Environment (New Zealand)
As noted in section 4.3.5, during the past four years (2009 – 2012) in New Zealand, three
Ministerial reviews of different aspects of the Health Practitioners Competence Assurance Act
2003 (NZ) have been undertaken. The first two reviews focused on operational aspects of the
Act, including the role and function of the regulator. The third consultation document 2012
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Review of the Health Practitioners Competence Assurance Act 2003: A Discussion Document
(Ministry of Health (NZ), 2012a) purports to combine the previous two reviews and introduces
four areas of focus for the 2012 review: future focus, consumer focus, safety focus, and cost
effectiveness focus. An underlying theme throughout the discussion documents appears to be
the intent to review the independent structure, authority and functions of the regulatory
authorities seeking to remove what are perceived as being ‘regulatory barriers’ in terms of
future workforce requirements and attaining financial efficiencies. It is acknowledged that the
Government has a legitimate interest in the registration and regulation of health professionals
(Chiarella & White, 2013), and indeed ensuring access to, and provision of affordable health
services. However, ensuring public safety is the function and purpose of the regulatory
authority (Health Practitioners Competence Assurance Act (NZ), 2003). Cost cutting, political
agendas and health workforce needs should not become the primary drivers for the
development of registration standards and the regulation of the health professions (Chiarella
& White, 2013; Duffield et al., 2007), and these aspects should be carefully balanced in terms
of their potential impact on public safety.
A report on the public consultation has not yet been published, nor has any evidence that the
existing regulatory requirements for nurses in New Zealand do not meet the needs of
“complex clinical environments” (Ministry of Health (NZ), 2012a, p. 4), or indeed the four areas
of focus identified in the discussion document: future focus, consumer focus, safety focus, and
cost effectiveness focus (Ministry of Health (NZ), 2012b). In addition, in 2012 the Nursing
Council of New Zealand sought an independent external review of its performance as a
regulatory authority. The Review conducted for the Nursing Council of New Zealand (Council
for Healthcare Regulatory Excellence, 2012a), by the British Council for Healthcare Regulatory
Excellence (CHRE) determined that the Nursing Council of New Zealand has effective processes
for handling conduct, competence and health related cases and thereby fulfils its role of
protecting the public by ensuring that the individual nurses they regulate are fit to practise
(Council for Healthcare Regulatory Excellence, 2012a).
Stage One of this research has evaluated the Nursing Council of New Zealand Continuing
Competence Framework (Vernon, et al., 2010) as the statutory mechanism to ensure and
monitor the continuing competence of nurses for the purpose of public safety (Nursing Council
of New Zealand, 2004a). It has been identified that the Continuing Competence Framework is
a cost effective mechanism that is fulfilling its regulatory purpose in terms of increasing the
understanding and compliance of nurses with the required Standards of Practice and
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associated continuing competence requirements, monitoring the continuing competence of
nurses in practice, and thereby providing an assurance of public safety.
10.3 Is it competence that is being assessed / measured, or safety to practise?
As previously noted, the safety of health professionals to practise has gained increasing public
attention over recent years, particularly in relation to public safety (Secretary of State for
Health (UK), 2007). Assuring the public that robust processes exist to ensure and monitor the
continuing competence and safety of nurses to practise has become a priority for nursing
regulatory authorities (Ministry of Health (NZ), 2012a). However, in some jurisdictions, the
requirement to provide a quantifiable and defensible ‘measurement’ of continuing
competence appears to be driven more by the public and political scrutiny and/or the litigious
nature of the society, rather than the notion of public protection and safety to practise.
Registered Nurses must meet a minimum standard of competence for initial registration.
However, continuing competence is a concept that, as implied by the terminology, occurs on a
continuum from the time of initial registration throughout the nurse’s professional career. It is
therefore associated with, and influenced by, a number of internal and external factors, for
example: individual behavioural traits such as insight, judgement and decision making; and
environmental factors such as the context of practice, access to resources, and patient acuity
(Adrian & Chiarella, 2010). All of these traits and environmental factors have the potential to
significantly influence the safety of an individual to practise at any given time and in any given
situation.
It is evident from the literature and the findings of this research that, whilst there are many
common philosophies and processes related to measuring and / or assessing continuing
competence, up until this research was undertaken, no consensus had been agreed
internationally with regard to the most appropriate and efficacious model for regulatory
authorities to assess and monitor this complex phenomenon. In addition, there is a
presumption that the measurement and / or assessment of the competence and continuing
competence of nurses, assures and ensures their safety to practise. Whilst it is argued that it is
the professional responsibility of all practising nurses to maintain their competence to
practise, and that well developed and comprehensive Continuing Competence Frameworks
provide assurance to the regulator and the public that the nurse is indeed continuing to be
competent to practise, no independent indicator of competence has been identified that can
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ensure the continuing competence of a nurse. The assessment of a nurse’s competence at any
time during their career is a predictor that demonstrates their continuing competence, or not,
and therefore implies their safety to practise, or not. However, it cannot ensure the safety of
the individual nurse to practise at any given time.
The words ‘measured’ and ‘assessed’ are used synonymously when describing the assessment
of competencies, competence and continuing competence. However, the variation in meaning
implied by these terms arguably goes to the heart of this debate. “To measure” is “to
ascertain the size, amount, or degree of (something) by using an instrument or device marked
in standard units or to judge someone or something by comparison with (a certain standard)”
(Oxford University Press, 2013), and “to assess” is “to evaluate or estimate the nature, ability,
or quality of someone or something” (Oxford University Press, 2013). Frequently there is a
singular approach by the regulatory authorities to the quantitative ‘measurement’ of
competence, rather than a more qualitative approach to the ‘assessment and monitoring’ of
continuing competence (National Nursing Research Unit, 2009). The reductionist approach
associated with the perceived need to ‘measure’ and quantify continuing competence has
resulted in stalling the development and implementation of Continuing Competence
Frameworks in some jurisdictions, moving the focus to what the nurse can do as opposed to
what they know (Manley & Garbett, 2000; Watson, et al., 2002), and how they translate that
knowledge into safe nursing practice (National Nursing Research Unit, 2009).
Translation of knowledge into safe nursing practice requires the nurse to have the ability to
make clinical judgements, based on sound knowledge, skills, and assessment of potential risk
(Dolan, 2003; Gibson & Soanes, 2000; National Nursing Research Unit, 2009; Pearson,
Fitzgerald, Walsh, et al., 2002). A lack of self-awareness or personal insight has been identified
as a key contributor to unsafe practice (Adrian & Chiarella, 2010). Nurses who lack personal
insight are less likely to reflect on, or assess their own practice, to seek continuing professional
development opportunities or, to recognise when their practice is unsafe (Chiarella & White,
2013; Pearson, Fitzgerald, Walsh, et al., 2002). However, in the absence of a quantifiable and
defensible mechanism for the assessment of continuing competence, many jurisdictions have
implemented models of continuing competence assurance that are comprised of an amalgam
of competence indicators.
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The indicators of continuing competence (self-assessment, practice hours/recency and
continuing professional development hours) are all considered to be appropriate indicators of
competence, that when used together can predict continuing competence and therefore may
imply safety to practise (EdCaN, 2008; Vandewater, 2004). However, they cannot guarantee
that a nurse is safe to practise on any given day (Vernon, et al., 2013; Vernon, et al., 2010). In
addition, the stipulation of a minimum number of practice, and continuing professional
development hours, when used independently, are pragmatic and / or arbitrary requirements
and not considered to be a valid measure of competence, continuing competence or safety to
practise. However, evidence of recency of practice and active engagement in professional
development / education opportunities arguably provides a more robust indication that the
nurse’s knowledge and skills are continuing to be current, and that the nurse might be aware
of what they do not know or what skills and knowledge they lack. The assessment of
competence therefore can be used as the yardstick that will predict continuing competence
and imply safety to practise.
10.4 The consensus view of regulatory experts in relation to best practice for nurses to demonstrate continuing competence; and best practice for regulatory authorities to assess continuing competence
The consensus view of the regulatory experts was that the international consensus model for
the assessment of continuing competence set out in Chapter Nine, was a framework that
provides a mechanism for nurses to demonstrate continuing competence and for regulatory
authorities to assess and monitor the continuing competence of nurses in practice. It is a
mechanism that provides information about a nurse’s continuing competence at a given time,
but it does not ensure the safety of nurses in every practice situation (Kohn, Corrigan, &
Donaldson, 2000). This is a view that is consistent with the international literature, which
identifies that implementation of Continuing Competence Frameworks should contribute to
the core regulatory purpose, that is, public protection (Bryant, 2005; Secretary of State for
Health (UK), 2007; Swankin, 1995).
Chapters Eight and Nine have presented the consensus views of regulatory experts with regard
to the development of a best practice international consensus model for nurses to
demonstrate continuing competence and for regulatory authorities to assess and monitor the
continuing competence of the profession. A conceptual framework for the assessment of
continuing competence has been proposed. Table 40 (pp. 228-229) lists the components
243
identified for inclusion in this framework, in association with the perceived advantages and
disadvantages and points for consideration by the regulatory authorities. The framework aims
to encourage the professional accountability and reflexivity of the nurse and provides for the
combination of multi-source data. However it is developmental and requires further
agreement, particularly in relation to the underlying guiding principles and existing
recertification / relicensure / revalidation or registration requirements within the regulatory
jurisdictions.
It is agreed that any best practice framework must be based on sound evidence and address
the issues of assuring and ensuring the ‘continuing competence’ and ‘continuing safety to
practise’ of nurses. However, whilst the terms continuing competence and continuing safety
to practise are often used synonymously, the implementation of a Continuing Competence
Framework cannot guarantee public protection, nor can it ensure the continuing safety to
practise of nurses in every circumstance. In the current context of health care delivery and in
the face of the public scrutiny of health system error, the continuing competence of individual
nurses is only one component of ensuring patient safety. Patient safety initiatives must also
focus on, and address system error, system redesign and improvement (Benner, et al., 2010;
Secretary of State for Health (UK), 2007). This includes the acknowledgement that health
service providers who employ nurses and other health professionals, also have a joint
responsibility and accountability for providing safe and supportive practice environments and
for ensuring patient safety (Callender, Hastings, Hemsley, Morris, & Peregrine, 2007; Duffield,
et al., 2007; National Council of State Boards of Nursing, 2005).
The best practice Continuing Competence Framework must therefore assure the public that
nurses who are in practice continue to be competent to practise, whilst mitigating the
potential risk to public safety that is presented by nurses who do not continue to be
competent throughout their careers (Adrian & Chiarella, 2010; Citizen Advocacy Center, 2004;
Swankin, et al., 2006). In addition, the consensus framework must be appropriate for
implementation across extremely large nursing populations and provide a mechanism that is
accessible, proportionate, consistent, defensible and affordable (National Council of State
Boards of Nursing, 2009a; Nursing and Midwifery Council (UK), 2012).
244
10.5 Contribution to the national and international research environment
This thesis makes a contribution to the national and international research environment, in
particular the relatively small body of literature relating to nursing regulation, continuing
competence and public safety. Whilst there has been considerable international interest in
the concept of continuing competence, up until this research was undertaken there was
limited research-based evidence to support a particular competence assessment process. No
research had evaluated the acceptability of an existing Continuing Competence Framework for
nurses, or sought to determine the consensus view of international nursing regulatory experts
with regard to the concept of continuing competence. This research has sought to understand
the relationships between legislation, policy drivers and the continuing competence
requirements for nurses in New Zealand, in association with determining an international best
practice consensus model for the assessment of continuing competence.
Stage One of the research focused on the relationship between legislation, policy and the
continuing competence requirements for nurses in New Zealand since the enactment of the
Health Practitioners Competence Assurance Act 2003 (NZ), and the subsequent
implementation of the Nursing Council of New Zealand Continuing Competence Framework in
2004. The evaluation of the efficacy of the Nursing Council of New Zealand Continuing
Competence Framework was completed in 2010 and contributes to Stage One of this thesis.
All of the recommendations that were made to the Nursing Council of New Zealand at that
time (Table 20, p. 161), have now been acted upon, resulting in revisions to the Nursing
Council of New Zealand website, policies, procedures and processes. In addition the full
evaluation report Evaluation of the Continuing Competence Framework (Vernon, et al., 2010)
was published by the Nursing Council of New Zealand in October 2010.
The findings from Stage One of the research were used as the foundation from which to launch
the second stage of the research, which commenced in 2011 and focused on determining the
consensus view of international regulatory experts from six countries: Australia, Canada,
Ireland, New Zealand, the United Kingdom and the United States of America, with regard to a
best practice international consensus model for the assessment of Continuing Competence.
Overall the research has demonstrated that the Nursing Council of New Zealand Continuing
Competence Framework is a well-accepted and recognised regulatory tool for the assessment
and monitoring of continuing competence, providing an acknowledged level of functionality in
terms of ensuring public safety. In addition, this research has determined (where evidence
245
existed) the consensus view of international nurse regulatory experts with regard to the
concept of continuing competence and the development of a best practice consensus model
for the assessment of continuing competence. Preliminary data and recommendations for
future development of the international consensus model have been collated, confirmed and
distributed to the expert panel (Group A) participants. The subsequent international
publications and presentations resulting from the research presented in this thesis are listed
on pages xiii-xv.
10.6 Recommendations for future research
It is clear that further research is needed to investigate and evaluate the phenomenon of
continuing competence, particularly as it relates to health professionals and their safety to
practise. In addition, there is a growing public expectation, and in many regulatory
jurisdictions, legislative requirements, that health professionals demonstrate that they are,
and continue to be, competent throughout their careers. However, to date a legally
defensible, administratively feasible and financially viable model for the assessment of
continuing competence remains elusive.
As identified in Chapter Two, the literature indicates that limited research has been
undertaken that has evaluated and critiqued the various models proposed for the assessment
of continuing competence. To date, it appears that only one study has been published
(Vernon, et al., 2010), that has comprehensively evaluated an existing Continuing Competence
Framework implemented by a regulatory authority for the purpose of public protection.
Despite the acknowledged limitations of this evaluation research, there is potential to replicate
either stage of this mixed methods evaluation. Sufficient methodological description has been
provided in the body of this thesis to make transparent the research design and process and
thereby to enable replication.
It is acknowledged that the understandings of continuing competence, associated assessment
frameworks and indeed evaluation research are evolving. Future researchers may wish to
benchmark with similar international Continuing Competence Frameworks. It would be
possible to collect and undertake a comparative analysis of the baseline data between
regulatory jurisdictions as more regulatory authorities develop and implement frameworks for
evaluation of their continuing competence standards. Urgent research is required in this area
246
in order to ensure that the continuing competence strategies that are implemented are
effective and evidence based.
This research has demonstrated that, whilst a large body of research exists in relation to the
independent indicators of competence and their applicability to the assessment of continuing
competence, many of the suggested assessment approaches are based on subjective and
comparative data. It is therefore proposed that another area of research that would
significantly contribute to the audit process, would be the development of a criterion
referenced assessment rubric for the triangulation of qualitative and quantitative data derived
through the combination of competence indicators. Development of such a tool would have
the benefit of introducing a greater degree of consistency, validity and reliability to the
assessment process, thereby providing an element of defensibility to the Continuing
Competence Framework.
10.7 Conclusion
Chapter Ten has discussed and presented the summary findings of this thesis in relation to the
overarching research questions and the New Zealand and international regulatory
environments. Recommendations for policy change and future research have been proposed.
The relationships between legislation, policy and continuing competence requirements of
registered nurses in New Zealand have been investigated, presented and discussed in
conjunction with:
a) A comprehensive evaluation of the Nursing Council of New Zealand Continuing
Competence Framework; and
b) the development of a conceptual best practice model for assessment of
continuing competence based on the consensus views of international nurse
regulatory experts.
It has been identified throughout this research that the adoption and implementation of
Continuing Competence Frameworks by regulatory authorities contributes to their primary
regulatory purpose, which is public protection. Therefore, development of the best practice
international consensus model for the assessment of continuing competence must be based
on research evidence, and related to, the potential risk to public safety presented by nurses
who do not continue to be competent throughout their careers. The aim of the best practice
247
Continuing Competence Framework that has been proposed in this research is to provide a
publicly credible, transparent, proportionate, consistent and affordable process for the
assessment of continuing competence, which provides assurance to the public that nurses in
practice are, and continue to be, competent.
248
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261
APPENDICES
APPENDIX I Evaluation Matrix ......................................................................................... 262
APPENDIX II Stage One – Phase Two (Interviews): Research Information Sheet and Interview Consent Form ............................................................................... 263
APPENDIX III Stage One – Phase Three (E-survey): Research Information Sheet and E-survey ........................................................................................................ 264
APPENDIX IV Stage Two – Delphi (Round Two): E-survey .................................................. 265
APPENDIX V Stage Two – Delphi (Round Three): E-survey ............................................... 266
APPENDIX VI Stage Two – Delphi (Round Four): Summary Documentation ...................... 267
APPENDIX VII Stage Two – Delphi (Round Four): E-survey ................................................. 268
APPENDIX VIII Stage Two – Delphi E-survey: Research Information Sheet ......................... 269
APPENDIX IX Stage Two – Delphi Group A (Expert Panel Interviews): Research Information Sheet and Consent Form .......................................................... 270
APPENDIX X Ethics Approval Documentation ................................................................... 271
APPENDIX XI Process of Qualitative Analysis ..................................................................... 271
262
APPENDIX I Evaluation Matrix
EVALUATION MATRIX Evaluation of the Nursing Council of New Zealand Continuing Competence Framework
Research Phases Distribution of research activities
Phase One – Document /Review and Policy Analysis
Data Collection: Data collection, review and descriptive analysis of NCNZ CCF documents
• Data collection, review, descriptive analysis – Rachael Vernon
• Oversight of process and confirmation of descriptive findings - Dr Elaine Papps
Data Collection: Review of NCNZ CCF policy documents and analysis of data
• Policy analysis and categorisation - Rachael Vernon • Review and confirmation Dr Elaine Papps
Statistical data Collation: Comparative analysis of NCNZ statistical data
• Rachael Vernon
Compilation and write-up of findings • Write up - Rachael Vernon. Confirmation/validation of findings and suggested revisions Dr Elaine Papps
Phase Two – Qualitative Interviews
Development of interview questions • Rachael Vernon – Reviewed by Prof. Mary Chiarella and Dr Elaine Papps
Data Collection: Select participants, organise, and conduct interviews
• Rachael Vernon
Thematic analysis • Initial categorisation and theming - Rachael Vernon • Review and confirmation of categorisation and
suggestions for refinement of themes - Prof. Mary Chiarella, Dr Elaine Papps and Dr Denise Dignam
Compilation and write-up of qualitative interview findings
• Initial write-up of findings - Rachael Vernon • Review, confirm and edit findings - Prof. Mary
Chiarella, Dr Elaine Papps
Phase Three – Quantitative E-survey
E-survey development • Development and implementation of E-Survey -Rachael Vernon
• Confirmation of E-questions - Dr Elaine Papps and Dr Denise Dignam
Data Collection: E-Survey implementation; collation and statistical analysis; write-up of quantitative statistical findings
• Rachael Vernon
Phase Four – Compilation and Write-up of NCNZ Report
Triangulation of data (phases 1, 2, 3) • Rachael Vernon. Review and suggestions for editing and refinement Prof. Mary Chiarella, Dr Elaine Papps
Compilation of NCNZ report • Rachael Vernon – write-up of first draft. • Review and edits of NCNZ report, review,
confirmation, validation of legislative data interpretation – Prof. Mary Chiarella and Dr Elaine Papps
• Suggestions on final edits – Prof. Mary Chiarella and Dr Denise Dignam
263
APPENDIX II Stage One – Phase Two (Interviews): Research Information Sheet and
Interview Consent Form
05/08/09 1
Evaluation of the Nursing Council of New Zealand Continuing Competence Framework
Information Sheet – Interview Questions
Introduction
We invite you to participate in the evaluation of the Nursing Council of New Zealand “Continuing Competence Framework.” In doing so, you will have the opportunity to express your point of view and to have a role in influencing the framework in the future.
Why are we doing this research?
The continuing competence framework established by the Nursing Council of New Zealand was implemented in 2004. Five years on it is now timely for its effectiveness to be evaluated. The purpose of this research is to explore, evaluate and determine if the Nursing Council of New Zealand Continuing Competence Framework provides the mechanisms to ensure that nurses are competent and fit to practise their profession as stipulated in section 1 of the HPCA Act 2003 (NZ).
To explore the model on which the ‘Continuing Competence Framework’ is based
To explore the validity of the stipulated hours of professional development and day/hours of clinical practice over a three year period, as indicators of competence
To provide information on the efficacy of undertaking a random audit of five percent of the nursing workforce to meet recertification requirements.
To document and track the different forms of written evidence that is currently acceptable to the Council to demonstrate competence.
To identify any issues related to peer assessment of competence.
To develop recommendations for the ‘Continuing Competence Framework’ to enable the Council to complete a further evaluation in five years time.
The research is being undertaken using a sequential mixed-method evaluation research design, and will be completed in four phases. Ethical approval has been granted by the New Zealand Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP and lodged with the University of Sydney Human Research Ethics Committee, and the Eastern Institute of Technology Research Approvals Committee.
Participation, Confidentiality and Rights
We invite you to participate in a short confidential interview. We anticipate the interview will take approximately 30-40 minutes of your time and is comprised of questions relating to your experiences and understanding of the “Continuing Competence Framework.”
The interview will be recorded and then transcribed. All responses will be treated in confidence by the researcher and all data will have any identifying information removed. You may request to see your interview transcripts if you wish; decline to answer any questions; withdraw from the study at any time; ask any questions about the study at any time during participation; provide information on the understanding that your name will not be used unless you give permission to the researcher.
05/08/09 2
This evaluation research is being carried out under contract to the Nursing Council of New Zealand. The information collected will de-identified and will be coded, collated and analyzed. It will remain confidential to the researcher on a password protected computer in a locked office. The de-identified data will contribute to the final written report submitted to the Nursing Council of New Zealand. Aspects of the research may also contribute to Rachael Vernon’s Doctoral thesis through the University of Sydney, Australia.
Members of the research team are listed below. If you have any questions in relation to this study please contact Rachael Vernon (Lead Researcher).
Research Team
Rachael Vernon (Lead Researcher) Head of School Nursing Faculty of Health & Sport Science, EIT Hawke’s Bay Private Bag 1201 Taradale New Zealand [email protected]
Telephone (06) 974 8000
Professor Elaine Papps Professor of Nursing EIT Hawke’s Bay & Director of Nursing, HBDHB Faculty of Health & Sport Science, EIT Hawke’s Bay Private Bag 1201 Taradale New Zealand
Professor Mary Chiarella Professor of Nursing & Chair Australian Nursing and Midwifery Council Faculty of Nursing & Midwifery University of Sydney New South Wales Australia
Professor Denise Dignam Associate Dean (External Engagement) Faculty of Nursing, Midwifery & Health University of Technology Sydney New South Wales Australia
Thank you for considering participating in this research. If you agree to participate please complete the consent form included with this information sheet and return it to Rachael Vernon.
New Zealand Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP
Evaluation of the Nursing Council of New Zealand Continuing Competence Framework
Interview Consent Form
I have read the Information Sheet and have had the details of the study explained to me. My questions have been answered to my satisfaction, and I understand that I may ask further questions at any time.
I understand I have the right to withdraw from the study at any time and to decline to answer any particular questions.
I agree to provide information to the researcher on the understanding that my name will not be used without my permission.
I understand that the information will be used for this research (Evaluation of the Continuing Competence Framework), that it may also contribute to Rachael Vernon’s Doctoral thesis, and publications arising from both research projects.
I agree / do not agree to the interview being audio taped.
I also understand that I have the right to ask for the audio tape to be turned off at any time during the interview.
I agree to participate in this research under the conditions set out in the Information Sheet.
Signed: ...................................................................................... Name: ...................................................................................... Date: ......................................................................................
264
APPENDIX III
Stage One – Phase Three (E-survey): Research Information Sheet and E-survey
Evaluation of the Nursing Council of New Zealand Continuing Competence Framework
Information Sheet
We invite you to participate in the evaluation of the Nursing Council of New Zealand “Continuing Competence Framework.” In doing so, you will have the opportunity to express your point of view and to have a role in influencing the framework in the future.
Why are we doing this research? The continuing competence framework established by the Nursing Council of New Zealand was implemented in 2004. Five years on it is now timely for its effectiveness to be evaluated. The purpose of this research is to explore, evaluate and determine if the Nursing Council of New Zealand Continuing Competence Framework provides the mechanisms to ensure that nurses are competent and fit to practise their profession as stipulated in section 1 of the HPCA Act 2003 (NZ).
To explore the validity of the stipulated hours of professional development (60 hours) and hours of clinical practice (450 hours/60 days) over a three year period, as indicators of competence.
To provide information on the efficacy of undertaking a random audit of five percent of the nursing workforce to meet recertification requirements.
To document and track the different forms of written evidence that is currently acceptable to the Council to demonstrate competence.
To identify any issues related to peer assessment of competence.
To develop recommendations for the ‘Continuing Competence Framework’ to enable the Council to complete a further evaluation in five years time.
The research is being undertaken using a sequential mixed-method evaluation research design, and will be completed in four phases. Ethical approval has been granted by the New Zealand Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP and lodged with the University of Sydney Human Research Ethics Committee, and the Eastern Institute of Technology Research Approvals Committee.
Participation, Confidentiality and Rights In order to participate, all you need to do is to fill in and return the attached anonymous questionnaire. We anticipate the questionnaire will take approximately 20 minutes of your time and is comprised of questions relating to your experiences and understanding of the “Continuing Competence Framework.”
Your participation in this research is entirely voluntary and you have the right to refuse to participate by simply not responding to this invitation. Completing and returning this ‘anonymous’ questionnaire implies your consent to participate in this research.
This evaluation research is being carried out under contract to the Nursing Council of New Zealand. The information collected will de-identified and will be coded, collated and analyzed. It will remain confidential to the researcher on a password protected computer in a locked office. The de-identified data will contribute to the final written report submitted to the Nursing Council of New Zealand. Aspects of the research may also contribute to Rachael Vernon’s Doctoral thesis through the University of Sydney, Australia.
Members of the research team are listed below. If you have any questions in relation to this study please contact Rachael Vernon (Lead Researcher).
Rachael Vernon (Lead Researcher) Head of School Nursing Faculty of Health & Sport Science, EIT Hawke’s Bay Private Bag 1201 Taradale New Zealand [email protected]
Professor Elaine Papps Professor of Nursing EIT Hawke’s Bay & Director of Nursing, HBDHB Faculty of Health & Sport Science, EIT Hawke’s Bay Private Bag 1201 Taradale New Zealand
Professor Mary Chiarella Professor of Nursing & Chair Australian Nursing and Midwifery Council Faculty of Nursing & Midwifery University of Sydney New South Wales Australia
Professor Denise Dignam Associate Dean (External Engagement) Faculty of Nursing, Midwifery & Health University of Technology Sydney New South Wales Australia
2-EVALUATION OF THE NURSING COUNCIL OF NEW ZEALAND CONTINUING COMPETENCE FRAMEWORK Created: November 23 2009, 8:20 PM Last Modified: November 23 2009, 8:20 PM Design Theme: Oceanic Aqua Language: English Button Options: Labels Disable Browser “Back” Button: False
EVALUATION OF THE NURSING COUNCIL OF NEW ZEALAND CONTINUING COMPETENCE FRAMEWORK
Page 1 - Heading
Demographic details
Page 1 - Question 1 - Choice - One Answer (Bullets) [Mandatory]
What is your scope of practice (Registration)?
Nurse Assistant
Enrolled Nurse
Registered Nurse
Page 1 - Question 2 - Choice - One Answer (Bullets) [Mandatory]
What is your highest qualification? (Select one)
Hospital Certificate
Graduate Certificate
Graduate Diploma
Bachelors Degree
Postgraduate Certificate
Postgraduate Diploma
Masters Degree
PhD
Other, please specify
Page 1 - Question 3 - Yes or No [Mandatory]
Do you hold a current Practising Certificate?
Yes
No
Page 1 - Question 4 - Yes or No
Are you currently employed as a nurse?
Yes
No
Page 1 - Question 5 - Choice - One Answer (Bullets)
Which area of employment most closely describes your current employment setting? (Select one)
DHB (Acute)
DHB (Primary Health/Community)
DHB (Other)
Private Hospital
Primary health (NGO / PHO)
PHO
Aged Care Sector (Rest home / Residential Care)
Nursing Agency
Self Employed
Maori Health Service Provider
Rural
Health Management
Educational Institution
Government Agency (MOH, ACC, Corrections Service, Defense Forces)
Other please specify
Page 1 - Question 6 - Choice - One Answer (Bullets) [Mandatory]
Which statement most closely describes your current area of nursing practice? (Select one)
Emergency and Trauma
Intensive Care/Cardiac Care
Peri Operative Care (Operating Theatre)
Surgical
Medical
Palliative Care
Obstetrics/Maternity
Child Health, including Neonatology
School Health
Youth Health
Family Planning/Sexual Health
District Nursing
Practice Nursing
Occupational Health
Primary Health Care
Public Health
Continuing Care (Elderly)
Assessment and Rehabilitation
Mental Health (inpatient)
Mental Health (community)
Addiction Services
Intellectually Disabled
Nursing Administration and Management
Nursing Education
Nursing Professional Advice/Policy Development
Nursing Research
Non-nursing health related management or administration
Other non-nursing paid employment
Not in paid employment
Page 1 - Heading
Competence and fitness to practise
Page 1 - Question 7 - Ranking Question [Mandatory]
The Nursing Council of New Zealand (NCNZ) indicators of continuing competence are: A. Signing a legal self-declaration of competence to practice (based on self-appraisal using the NCNZ competencies for practice). B. Verification of practice (minimum of 450 hours / 60 days in past 3 years). C. Verification of professional development (minimum of 60 hours in past 3 years). Rank the indicators below from 1 (Best) - 7 (Worst) which you believe provide the best evidence of continuing competence to practice. (Each ranking number can only be used once)
1 2 3 4 5 6 7
A, B, and C.
A and B.
A and C.
B and C
A only.
B only.
C only.
Page 1 - Question 8 - Ranking Question [Mandatory]
Rank the indicators below from 1 (Best) - 7 (Worst) which you believe provide the best evidence of continuing professional development. A. Signing a legal self-declaration of competence to practice (based on self-appraisal using the NCNZ competencies for practice). B. Verification of practice (minimum of 450 hours / 60 days in past 3 years). C. Verification of professional development (minimum of 60 hours in past 3 years). (Each ranking number can only be used once)
1 2 3 4 5 6 7
A, B, and C.
A and B.
A and C.
B and C
A only.
B only.
C only.
Page 1 - Question 9 - Yes or No [Mandatory]
Do you think that the current NCNZ Continuing Competence Framework and process for renewing practising certificates, provides the mechanism to ensure that nurses are competent and fit to practise?
Yes
No
Page 1 - Question 10 - Rating Scale - Matrix [Mandatory]
Rate your agreement with each of the following statements: (1 indicates you strongly agree and 7 indicates you strongly disagree)
Strongly
agree 2 3 4 5 6
Strongly disagree
As a health professional I am
responsible for maintaining my own
competence to practice.
My employer is responsible for
maintaining my competence to
practice.
The Nursing Council of New Zealand
is responsible for maintaining my
competence to practice.
When completing my NCNZ
application to renew my practising
certificate I understand that I am
signing a legal declaration.
Page 1 - Question 11 - Rating Scale - Matrix [Mandatory]
Rate your understanding of each of the the following questions: (1 indicates excellent understanding and 7 indicates very poor understanding)
Excellent understan
ding 2 3 4 5 6
Very poor understan
ding
Have you completed a minimum of
450 hours of nursing practice in New
Zealand within the past three years?
Have you undertaken the minimum of
required professional development
hours (i.e. 60 hours) within the past
three years?
Do you meet the Council's
competencies for your scope of
practice?
Do you have a mental of physical
condition that means you are unable to
perform the functions required for the
practice of nursing?
Have you been the subject of an
investigation, disciplinary or criminal
proceedings or a disciplinary order in
New Zealand or any other country
since you last applied for a practicing
certificate?
Page 1 - Heading
Professional Development and Recognition Programmes
Page 1 - Question 12 - Yes or No
With regard to Professional Development and Recognition Programmes (PDRP): Do you think PDRP's should be compulsory?
Yes
No
Page 1 - Question 13 - Yes or No
Are you levelled on a PDRP?
Yes
No
Page 1 - Question 14 - Yes or No
Do you have access to a PDRP?
Yes
No
Page 1 - Heading
Recertification audit
Page 1 - Question 15 - Yes or No [Mandatory]
Have you ever been asked to be a Peer Assessor for a colleague who was being audited?
Yes
No
Page 1 - Heading
If you responded NO to question 15 please go directly to question 17.
Page 1 - Question 16 - Rating Scale - Matrix
Peer Assessor:
Yes No
Were you provided with information
about the recertification audit process?
Were you provided
with documentation about the relevant
scope of practice and competencies?
Where you provided with a
competence assessment form?
Was your assessment based on
evidence?
Did you discuss your assessment with
your colleague?
Did you understand you were
completing and signing a legal
document?
Page 1 - Question 17 - Choice - One Answer (Bullets) [Mandatory]
When renewing your practising certificate with the NCNZ, have you ever been selected for recertification audit? If yes, please select the year.
No
Yes, 2005
Yes, 2006
Yes, 2007
Yes, 2008
Yes, 2009
Page 1 - Heading
If you responded NO to question 17 please scroll down and SUBMIT your questionnaire now. If you responded YES please complete questions 18 - 21.
Page 1 - Question 18 - Rating Scale - Matrix
When you were audited did you receive written information about:
Yes No
The recertification audit process?
The recertification audit time frame?
The domains of practice and
competencies for your scope of
practice?
The evidence you would need to
provide for the recertification audit?
Where you could obtain clarification if
necessary?
The process after submission of your
documentation?
Page 1 - Question 19 - Rating Scale - Matrix
From the documentation provided to you by the NCNZ, rate on a scale of 1 - 7 your understanding of how to provide evidence for each of the following requirements. (1 indicates excellent understanding and 7 indicates very poor understanding)
Excellent understan
ding 2 3 4 5 6
Very poor understan
ding
Evidence of practice hours.
Evidence of professional development
hours.
Self assessment of your competencies
for your scope of practice.
Peer assessment of your competencies
for your scope of practice.
Page 1 - Question 20 - Choice - One Answer (Bullets)
Following submission of my audit material I received (Select one).
A. No further correspondence
B. Single correspondence requesting further information
C. Multiple correspondence
Page 1 - Question 21 - Rating Scale - Matrix
With regard to your audit, rate your level of agreement with the following statements: (1 indicates you strongly agree and 7 indicates you strongly disagree)
Strongly
agree 2 3 4 5 6
Strongly disagree
The specified time frames were
acceptable.
The request for information and
correspondence from the Nursing
Council was clear.
The style of correspondence from the
Nursing Council was appropriate.
I was satisfied with the process.
Page 1 - Heading
Thank you for participating in this questionnaire.
Thank You Page
Evaluation of the Nursing Council of New Zealand Continuing Competence Framework Thank you for your participation in this research. Your feedback is important to us.
Screen Out Page
(Standard - Zoomerang branding)
Over Quota Page
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Survey Closed Page
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265
APPENDIX IV Stage Two – Delphi (Round Two): E-survey
[SURVEY PREVIEW MODE]
International Consensus Model for the Demonstration and Assessment of Continuing Competence
Delphi Round Two - Electronic Questionnaire (E-survey)
Thank you for agreeing to participate in this research
Please complete and submit this electronic questionnaire by Tuesday 12 July 2011
1
Do you have experience in the development and/or implementation of Continuing Competence Frameworks?
Yes
No
2
Describe the ways you believe it is possible and appropriate for nurses to demonstrate continuing competence:
3 Describe how you believe continuing competence should be assessed:
4 In your experience please describe the barriers and /or enablers that may exist when implementing a model for the demonstration and assessment of continuing competence:
[SURVEY PREVIEW MODE]
5 Do you believe it is possible to develop a ‘consensus model for the demonstration and assessment ofcontinuing competence' for implementation across countries?
Yes
No
Additional Comment
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266
APPENDIX V Stage Two – Delphi (Round Three): E-survey
[SURVEY PREVIEW MODE] Delphi Round Three - International Consensus Model for the Assessment of Continuing Competence Survey
http://www.surveymonkey.com/...IS_LINK_FOR_COLLECTION&sm=w7DmGQ4XLl69PlHackmi8nOF1XNWVNzJs7I2vZXMV8w%3d[23/04/2013 6:42:55 p.m.]
Delphi Round Three - International Consensus Model for the Assessment of Continuing
Competence
Definition of the term 'competence' and 'continuing competence' for nursing are similar in the jurisdictions
of Australia, Canada, Ireland, UK, USA, and New Zealand. Each definition includes the requirement to
meet a prescribed standard of knowledge, skills and decision making for safe practice. Definitions of
continuing competence also include the ongoing ability of the nurse to continue to integrate up-to-date
knowledge, skills, judgement and decision making appropriately in the context/role in which they practice.
Please rate your level of agreement with the following definitions:
Strongly Agree Agree Undecided Disagree
Strongly
Disagree
Competence is the
combination of
skills, knowledge,
attitudes, values
and abilities that
underpin the
effective
performance as a
nurse (NCNZ,
2009).
Continuing
Competence is the
ongoing ability to
keep up-to-date the
skills, knowledge,
values, attitudes,
and abilities
required to practice
effectively and
safely in
the context/role in
which they practice.
Please rate your agreement with the following statements:
As a registered health professional individual nurses are responsible for:
Strongly Agree Agree Undecided Disagree
Strongly
Disagree
Demonstrating a
commitment to
continuing
competence
throughout their
professional careers.
1
2
Exit this survey
[SURVEY PREVIEW MODE] Delphi Round Three - International Consensus Model for the Assessment of Continuing Competence Survey
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Ensuring that they
continue to meet the
relevant standards
and competencies
required for their
scope of practice
and relevant to the
role and context in
which they practice.
Actively participating
in and meeting the
requirements
specified by their
regulatory authority.
Participating in
ongoing educational
activities relevant to
their scope
of practice.
Providing
an appropriate, safe,
ethical and
competent standard
of nursing practice.
The definition of nursing practice varies between countries. However, the majority of responses to the
DELPHI survey R2 strongly indicated that a definition of 'nursing practice' should include all nursing roles
that contribute to Nursing.
Please rate your level of agreement with the following statement:
Strongly Agree Agree Undecided Disagree
Strongly
Disagree
The definition of
nursing practice
should be inclusive
and encompass:
Nursing
Management;
Nursing Education;
Nursing Research;
Nursing Policy;
Nursing Regulation;
Nursing
Governance; and
Clinical Nursing
Practise.
Models and understanding of Continuing Competence frameworks (CCF) vary internationally. Thirty-four
3
4
[SURVEY PREVIEW MODE] Delphi Round Three - International Consensus Model for the Assessment of Continuing Competence Survey
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(67%) of participants of the DELPHI Survey R2 identified that 'multi-source' or '360 degree' feedback is
critical when assessing continuing competence of nurses.
Please indicate your level of agreement with the following statements:
Strongly Agree Agree Undecided Disagree
Strongly
Disagree
CCFs must be
financially viable,
flexible, applicable
to a variety of
settings, provide
options for
demonstrating
competence and be
clearly
communicated to all
stakeholders.
CCFs are tools that
are used to monitor
the continued
competence of the
profession and
individual
practitioners.
Competence
indicators are
measures
assess competence
against specified
standards.
Competence
indicators may imply
competence but
cannot ensure the
continuing
competence of an
individual.
Extensive research exists with regard to individual measures of competence / continuing
competence. Current research suggests that no 'individual' measure assures competence or public
safety. However evidence drawn from a variety of 'measures' provides a strong indication of competence
and may imply continuing competence.
Responses to the DELPHI survey R2 highlighted a general view that the measurement of continuing
competence requires contextualising in terms of the requirements of the practice environment and
individuals role.
Please indicate your level of agreement with the following statements:
Strongly Agree Agree Undecided Disagree
Strongly
Disagree
Competence
5
[SURVEY PREVIEW MODE] Delphi Round Three - International Consensus Model for the Assessment of Continuing Competence Survey
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indicators must be
flexible and relevant
to the scope in
which the nurse is
practising.
Assessment of
continuing
competence
requires the
integration of multi-
source assessment
i.e. a variety of
competence
indicators.
On its own
continuing
professional
development (CPD)
or professional
education is not an
adequate measure
of continuing
competence.
Hours of practice
are not an adequate
measure of
continuing
competence.
The following five 'competence indicators' received the highest count in terms of their importance for
inclusion in a consensus model for the demonstration and assessment of continuing competence.
Please rate your level of agreement with the indicators below that should be included in the consensus
model:
Strongly Agree Agree Undecided Disagree
Strongly
Disagree
Practise hours i.e.
participation /
recency of nursing
practise.
Self assessment /
self declaration
(based on the
required standards
of nursing practise).
Peer assessment
(based on required
standards of nursing
practise).
6
[SURVEY PREVIEW MODE] Delphi Round Three - International Consensus Model for the Assessment of Continuing Competence Survey
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Participation in
continuing
professional
development and /
or continuing
education.
Professional
portfolio
Three additional 'competence indicators' were identified by 6 participants (12%), as being important
indicators of competence for inclusion in a consensus model.
Please rate you level of agreement for their inclusion in a model.
Yes
Should be included Undecided
No
Should not be included
Examination
Objective Structured
Clinical Examination
(OSCE)
Audit of Practice
The following list of items were identified as both enablers and barriers to implementing a consensus
model for the demonstration and assessment of continuing competence.
From you experience please rate the importance of each item:
Significant
Enabler Enabler Undecided Barrier
Significant
Barrier N/A
Communication with
key stakeholders
Legislation
Authority of the
Regulatory Body
Professional Nursing
Organisations
Financial viability
Political Interests
Differing qualification
requirements
Expectations of the
Public
Number of nurses
on the register
7
8
[SURVEY PREVIEW MODE] Delphi Round Three - International Consensus Model for the Assessment of Continuing Competence Survey
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Clarification with regard to who is responsible for the continuing competence of practitioners was
highlighted as an important consideration when implementing a CCF.
Please rate your agreement with the following statements:
Strongly Agree Agree Undecided Disagree
Strongly
Disagree
Governments are
responsible for passing
legislation, and ensuring its
enactment.
Regulatory authorities are
responsible for protecting the
safety of the public by setting
the standards of nursing
practice and monitoring the
competence of the
profession.
Professional
organisations are responsible
for facilitating the
development of the
nursing profession.
Employers are responsible
for maintaining quality
practice environments that
support and facilitate
continuing competence
opportunities for nurses and
monitoring their continuing
competence.
Nursing education
organisations are responsible
for providing high quality
programmes that prepare
competent nurses and
provide relevant continuing
education opportunities.
88% of participants in R2 indicated that they believed it was possible to develop an international
consensus model for the demonstration and assessment of continuing competence (Australia, Canada,
Ireland, UK, USA, New Zealand)
Please rate your level of agreement with the following statements:
Strongly Agree Agree Undecided Disagree
Strongly
Disagree
It is possible to
develop a
consensus model
9
10
[SURVEY PREVIEW MODE] Delphi Round Three - International Consensus Model for the Assessment of Continuing Competence Survey
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for the assessment
of CCF.
It is possible to
develop consensus
on key principles in
relation to the
assessment of
continuing
competence.
The consensus
model must be
flexible and
adaptable to comply
with the legislative
and fiscal
requirements
of each country.
Any further comments?
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11
267
APPENDIX VI Stage Two – Delphi (Round Four): Summary Documentation
Rachael Vernon Page 1
Delphi Round Four – Consensus Model for the Assessment of Continuing Competence
The Purpose of this research was to investigate the possibility of developing an international consensus model for the demonstration and assessment of continuing competence across six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America).
The research has been undertaken using the Delphi Technique. Three overarching questions were posed:
1. What is the consensus view of regulatory experts in relation to best practice for nurses to demonstrate continuing competence and for regulatory authorities to assess continuing competence?
2. What, if any, differences are present between the current regulatory requirements for the demonstration and assessment of continuing competence in the six countries and the best practice model developed through consensus?
3. What changes, if any, would be required to policy and regulation in the six countries to align their regulatory framework with best practice for demonstration and assessment of continuing competence?
Three Delphi Rounds have been completed with two participant groups. The first expert panel (Group A) was made up of a purposive sample of 14 international regulatory and professional nursing representatives from the six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America). The second panel (Group B) was a larger international group recruited specifically from within the individual regulatory boards in each of the six countries and through the International Council of Nurses, Regulatory Observatory. Recruitment of Group B participants used a snowball technique that was initiated by sending an electronic invitation directly to each individual regulatory board in each of the six countries and to the International Council of Nurses administration office in Geneva.
Summative content analysis was used to identify the themes generated from the qualitative data derived from the Delphi rounds one and two. Findings from these two data sets were further collated and major themes identified which formed the basis of the structured E-survey implemented in round three.
The round three e-survey was structured using statements drawn from the findings of the previous two Delphi rounds. The underlying design of the e-survey was based on a five point Likert (rating) Scale to elicit the participant’s level of agreement or disagreement with the statement items. This process sought to quantify the earlier findings from rounds one and two and to determine any convergence and consensus of opinion. The summary data were coded and collated independently and statistically analysed. Errors or inconsistencies in data were carefully screened out by evaluating the range of values generated by running the descriptive frequencies.
Determination of consensus
The consensus view was determined by assessing the stability of the participant responses to each Delphi round, in conjunction with the analysis of percentage scores indicating the participants’ level of agreement with the statements provided via the E-survey. A percentage score of 90% agreement or greater with a mean score of less than 2 (based on the five point Likert scale) was deemed as exhibiting a consensus view.
Findings were detailed and comprehensive, and full copies are available on request. However for the purpose of this review a summary of the overall findings is presented below.
Rachael Vernon Page 2
Delphi Round One – Interviews (Participant sample -14 regulatory experts from the six participant countries).
Questions posed:
1. Tell me about your experience with, and understanding of, continuing competence frameworks/models.
2. In your view what is ‘best practice’ for the demonstration and assessment of continuing competence?
3. What, if any, are the current regulatory requirements for the demonstration and assessment of continuing competence in your country/jurisdiction?
4. What barriers and enablers exist in relation to the implementation of a model/framework for assessment of continuing competence?
5. Do you believe it is possible to develop an international consensus model for the assessment of continuing competence between the following six countries – Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America?
Summary Findings - Delphi Round One (Interviews)
Four thematic categories and associated sub-themes emerged:
1. Continuing Competence Frameworks - Consistency of purpose and understandings • Competence and continuing[ed] competence • Purpose of a Continuing Competence Framework • Public safety
2. Variation in legislation and policy • Permissive legislation • Light touch regulation
3. Best Practice • Legal status of framework • A common language • Assessment of continuing competence- competence indicators • Validity and reliability of competence indicators • Responsibility and accountability
4. Barriers and Enablers • Continuing competence - legislative requirement or career development • Variation in terminology and language • Consistency in roles and education requirements • Administrative and financial viability
In summary it was the unanimous view of the interview participants that development of an international consensus model for the assessment of continuing competence, between the six countries identified as the focus of this study is an important initiative that is possible. It was felt the new relationship between these countries in terms of the recently signed memorandum of understanding would facilitate this on-going work. Limited knowledge and understanding of the legislative, regulatory and educational requirements for nurses between countries was identified as a contributor to the perceived difficulty for nurses wishing to move between regulatory jurisdictions, within and between countries. Four participants noted that having a greater understanding of the legislative, education and qualification frameworks in each of the six countries was a critical factor in facilitating greater ease of mobility for nurses both within and between the countries. Another participant stated that “by working more closely together a greater level of trust would be developed between regulatory jurisdictions”.
Rachael Vernon Page 3
The establishment of common values, beliefs and guiding principles contributing to an internationally agreed code of conduct, education and practice standards was also identified by seven participants in relation to the development of a consensus model. The variation in understandings related to the specific indicators that were embedded in the Continuing Competence Framework were not considered to be a critical issue provided that ultimately the model allowed flexibility in terms of its implementation requirements, was administratively feasible, financially viable and defensible in terms of providing some assurance of public safety.
Delphi Round Two – E-survey (Participant sample - 51 regulatory experts)
Questions posed:
1. Do you have knowledge and or experience in the development or implementation of Continuing Competence Frameworks?
2. Describe the ways you believe it is possible and appropriate for nurses to demonstrate continuing competence.
3. Describe how you believe continuing competence should be assessed.
4. In your experience please describe the barriers and /or enablers that may exist when implementing a model for the demonstration and assessment of continuing competence.
5. Do you believe it is possible to develop and international consensus model for the demonstration and assessment of continuing competence?
Summary Findings – Delphi Round Two (Qualitative E-survey)
Summary data from round two of the Delphi survey reflected stability with the findings of round one. This was particularly evident with regard to the purpose of Continuing Competence Frameworks, the definition of continuing competence and the selection of appropriate competence indicators. The data indicated that legislative frameworks particularly the jurisdiction of the individual regulatory authority and associated policy requirements, had a significant impact upon the ability to implement a Continuing Competence Framework. This item featured significantly as both a barrier and an enabler. The following items were highlighted for further investigation in the Delphi round three e-surveys:
• The definition of ‘competence’ and ‘continuing competence’. • An understanding of what constitutes ‘professional responsibility’ and ‘nursing practice’. • Responsibility and accountability. • The purpose and core requirements of a Continuing Competence Framework including the indicators
of continuing competence. • Implementing a Continuing Competence Framework – barriers and enablers.
Delphi Round Three – E-survey (Participant sample - 39 regulatory experts)
Overall Summary Findings - Delphi Round Three (Quantitative E-survey)
The consensus model
The view of the majority of the Delphi participants is that the development of an international consensus model for the assessment of continuing competence, between the six identified countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America) is an important initiative that is possible (Agreement = 87%, M = 1.95, SD = .724, V = .524).
The consensus view of the participants is that there is initial work required to in order to determine a common foundation prior to development of the consensus model. It was the consensus view of the
Rachael Vernon Page 4
participants that initially the development of key principles for the assessment of continuing competence be agreed (Agreement = 100%, M = 1.56, SD = .502, V = .252).
The most commonly expressed requirement identified by the participants is that the consensus model must be flexible and adaptable (Agreement 100%, M = 1.31, SD = .468, V.219).
Definitions
It was the consensus view of the participants that the inclusive definitions of ‘competence – the combination of skills, knowledge, attitudes, values and abilities that underpin the effective performance as a nurse’ and ‘continuing competence – the on-going ability to keep up-to-date the skills, knowledge, values, attitudes, and abilities required to practice effectively and safely in the context/role in which they practice’ were appropriate. Both definitions achieved the same agreement rating (Agreement 100%, M = 1.55, SD = .504, V = .254).
The inclusive definition of what constitutes nursing practise was agreed to include all ‘nursing roles’ that contribute to the nursing profession i.e. Nursing regulation; nursing governance; nursing policy; nursing management; nursing education; nursing research; and clinical nursing practice (Agreement 100%, M= 1.45, SD = .504, V = .254).
Responsibility and accountability
Responsibility and accountability for continuing competence were items that attracted wide ranging comment. A consensus view was achieved in terms of the understanding of what constitutes the individual registered nurses responsibilities for their continuing competence. There was consensus with regard to the overarching responsibility of the key stakeholder groups, particularly the employer with 40% (n = 15) of participants indicating they strongly agreed and 60% (n = 23) that they agreed employers are responsible for maintaining quality practice environments that support and facilitate continuing competence opportunities for nurses and for monitoring their continuing competence.
Continuing Competence Framework
Ninety percent of the participants ‘strongly agreed’ and 10% ‘agreed’ (M = 1.11) that it is important that the continuing competence model being administratively feasible, financially viable and defensible in terms of providing some assurance of public safety.
Flexibility in terms of the implementation and utilisation of embedded indicators of continuing competence was identified as a requirement. It is the consensus view (100%, M = 1.32) that competence indicators are measures that assess competence against specified standards. In addition the relevance of these indicators to the scope/context in which the nurse is practising is agreed to be important by 97% of the participants (M = 1.16).
Indicators or continuing competence
It is the consensus view that the following three indicators of continuing competence should be included: self-assessment / self-declaration (Agreement 90%, M = 1.53, SD = .687, V = .472); practise hours /recent nursing practise (Agreement 100%, M = 131, SD = .468, V = .219); and continuing professional development (Agreement 100%, M = 1.33, SD = .530, V = .281).
Barriers and enablers
A number of barriers and enablers were initially identified in relation to the development of a consensus model however, only two of the identified enablers were rated by the majority of the participants in round three: authority of the regulatory body (Agreement 92%, M = 1.77, SD = .627, V = .393); and communication with key stakeholders (Agreement 93%, M = 1.62, SD = .633, V = .401). Legislation had been identified as a significant enabler and barrier in round two however in round three it was rated an
Rachael Vernon Page 5
enabler by 85% of participants and a barrier by only 8% of the participants. A further 8% were undecided. A number of the barriers previously identified by the participants for example, financial viability, political interests and the number of nurses on the register were again rated as barriers. However, none of these items achieved a consensus rating. Eighty percent (n = 31) of the participants indicated that ‘differing qualifications’ was no longer applicable as a barrier and 56% (n = 22) and 58% (n = 23) respectively indicated that ‘expectations of the public’ and number of nurses on the register’ were no longer considered to be barriers.
Key Principles
The following key principles have been derived from the findings of the Delphi rounds (one-three), and have been identified by the participants as underpinning the development of an international consensus model for the assessment of continuing competence between Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America.
General
• The purpose of nursing regulation is protection of the public.
• The public has the right to expect that Registered Nurses, who are in practice, are and continue to be, competent.
• Revalidation, recertification, re-registration should occur annually and be associated with the requirement to declare and/or demonstrate the ability to meet required standards of continuing competence.
• Education and practice standards for Registered Nurses are similar between the six participant countries and imply the same expectations.
• Definitions of competence, continuing competence and nursing practice between and within the six participant countries are similar and imply the same meaning.
• Development of an international model for the assessment of Continuing Competence Framework requires agreement on a common language - lexis of terminology in relation to Continuing Competence.
• Whilst a ‘legislative mandate’ is a significant enabler in terms of implementation and compliance with Continuing Competence Frameworks it is not an essential component for the implementation of a Continuing Competence Framework.
Responsibility
• Registered Nurses are registered health professionals who are responsible, accountable, ethical, competent and committed to life-long learning and nursing practice.
• Registered Nurses are responsible for ensuring their own individual continuing competence, relevant to the required practice standards, code of conduct, and practice setting.
• Employers and employment settings have a responsibility and role in facilitating and ensuring that their registered nurse workforce is, and continues to be, competent.
Rachael Vernon Page 6
Continuing Competence Framework
• The Continuing Competence Framework must have a clear and transparent purpose and processes that are credible and understandable to the public and the nursing profession.
• Continuing Competence Frameworks are tools that facilitate the assessment and monitoring of the continuing competence of the profession, and as such they have a role in assuring and ensuring public safety.
• Assessment of Continuing Competence requires triangulation of data from a selection of sources.
• No single indicator of competence can measure or appropriately assess ‘continuing competence’ or ensure valid reliable and consistent measurement of ‘continuing competence’
• The Continuing Competence Framework must be flexible and adaptable, administratively feasible, financially viable, and publically defensible.
Core components of a best practice consensus model
The Delphi participants identified that an international consensus model for the assessment of continuing competence should include the following core components:
• An internationally agreed and clearly communicated purpose statement that identifies the expectations of the Continuing Competence Framework and its functions in terms of a) protection of the public; and b) the monitoring and assessment of the continuing competence of nurses.
• An internationally agreed lexicon of terminology that includes agreed definitions of the terms ‘Competence’, ‘Continuing Competence’ and ‘nursing practice’.
• Criterion based assessment guidelines.
• Development of a tool box of indicators for ‘multisource assessment’ of continuing competence including but not limited to the following:
Core indicators Optional indicators
• Self-assessment / Self-declaration • Practice Hours (current and recent
practice) • Continuing professional development /
education hours
• Peer Assessment • Professional Portfolio • Observed Structured Clinical
Examination (OSCE) • Examination
268
APPENDIX VII Stage Two – Delphi (Round Four): E-survey
[SURVEY PREVIEW MODE] Delphi Round Four - International Consensus Model for the Assessment of Continuing Competence Survey
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Delphi Round Four - International Consensus Model for the Assessment of Continuing
Competence
* After considering the summary findings of the previous three Delphi Rounds what, if any, differences are
present between your current regulatory requirements for the demonstration and assessment of
continuing competence and the best practice model proposed through consensus?
* What changes, if any, would be required to policy and regulation to align your current regulatory
framework with best practice for demonstration and assessment of continuing competence?
The following key principles were identified by the participants in the previous Delphi rounds as
underpinning the development of an international consensus model for the assessment of continuing
competence.
Please indicate your agreement or disagreement with the following statements:
Agree Disagree Undecided
The purpose of nursing regulation is
protection of the public.
Other (please specify)
The public has the right to expect that
Registered Nurses, who are in practice,
are and continue to be, competent.
Other (please specify)
Revalidation, recertification, re-
registration should occur annually and
be associated with the requirement to
declare and/or demonstrate the ability
to meet required standards of
continuing competence.
Other (please specify)
Education and practice standards for
Registered Nurses are similar between
1
2
3
[SURVEY PREVIEW MODE] Delphi Round Four - International Consensus Model for the Assessment of Continuing Competence Survey
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the six participant countries and imply
the same expectations.
Other (please specify)
Definitions of competence, continuing
competence and nursing practice
between and within the six participant
countries are similar and imply the
same meaning.
Other (please specify)
Development of an international model
for the assessment of Continuing
Competence Framework requires
agreement on a common language -
lexis of terminology in relation to
Continuing Competence.
Other (please specify)
Whilst a ‘legislative mandate’ is a
significant enabler in terms of
implementation and compliance with
Continuing Competence Frameworks it
is not an essential component for the
implementation of a Continuing
Competence Framework.
Other (please specify)
Registered Nurses are registered
health professionals who are
responsible, accountable, ethical,
competent and committed to life-long
learning and nursing practice.
Other (please specify)
Registered Nurses are responsible for
ensuring their own individual continuing
competence, relevant to the required
practice standards, code of conduct,
and practice setting.
Other (please specify)
[SURVEY PREVIEW MODE] Delphi Round Four - International Consensus Model for the Assessment of Continuing Competence Survey
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Employers and employment settings
have a responsibility and role in
facilitating and ensuring that their
registered nurse workforce is, and
continues to be, competent.
Other (please specify)
The Continuing Competence
Framework must have a clear and
transparent purpose and processes
that are credible and understandable to
the public and the nursing profession.
Other (please specify)
Continuing Competence Frameworks
are tools that facilitate the assessment
and monitoring of the continuing
competence of the profession, and as
such they have a role in assuring and
ensuring public safety.
Other (please specify)
Assessment of Continuing Competence
requires triangulation of data from a
selection of sources.
Other (please specify)
No single indicator of competence can
measure or appropriately assess
‘continuing competence’ or ensure valid
reliable and consistent measurement of
‘continuing competence’
Other (please specify)
The Continuing Competence
Framework must be flexible and
adaptable, administratively feasible,
financially viable, and publically
defensible.
Other (please specify)
[SURVEY PREVIEW MODE] Delphi Round Four - International Consensus Model for the Assessment of Continuing Competence Survey
http://www.surveymonkey.com/...THIS_LINK_FOR_COLLECTION&sm=L5imAREssdFvcYIH1tQCfyWirEx9VyJnHoSWStVX8LU%3d[23/04/2013 6:59:16 p.m.]
The Delphi participants identified that an international best practice consensus model for the assessment
of continuing competence, should include the following core components.
Please indicate your agreement or disagreement?
Agree Disagree Undecided
An internationally agreed and clearly
communicated purpose statement, that
identifies the expectations of the
Continuing Competence Framework
and its functions in terms of: a)
protection of the public; and b) the
monitoring and assessment of the
continuing competence of nurses.
Other (please specify)
An internationally agreed lexicon of
terminology that includes agreed
definitions of the terms ‘Competence’,
‘Continuing Competence’ and ‘nursing
practice’.
Other (please specify)
Criterion based assessment guidelines.
Other (please specify)
Development of a tool box of indicators for ‘multi-source assessment’ of continuing competence was
identified as a core component of a best practice Continuing Competence Framework.
The following three items were identified as essential components:
Please indicate your level of agreement or disagreement?
Agree Disagree Undecided
Self-assessment /
Self-declaration
Practice Hours
(current and recent
practice) - specified
Continuing
professional
development /
education hours -
specified
4
5
Other (please specify)
[SURVEY PREVIEW MODE] Delphi Round Four - International Consensus Model for the Assessment of Continuing Competence Survey
http://www.surveymonkey.com/...THIS_LINK_FOR_COLLECTION&sm=L5imAREssdFvcYIH1tQCfyWirEx9VyJnHoSWStVX8LU%3d[23/04/2013 6:59:16 p.m.]
The following four items were identified as optional and may be used for audit purposes.
Please indicate your agreement or disagreement?
Agree Disagree Undecided
Peer Assessment
Professional
Portfolio
Observed Structured
Clinical Examination
(OSCE)
Examination
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6
Other (please specify)
269
APPENDIX VIII Stage Two – Delphi E-survey: Research Information Sheet
Conceptual model for the demonstration and assessment of continuing competence
Information Sheet – Questionnaire/Delphi E-surveys We invite you to participate in this research. In doing so, you will have the opportunity to express your point of view and to have a role in influencing the development of a conceptual model and best practice framework for continuing competence for nurses.
Why are we doing this research? The purpose of this research is to develop a consensus view of best practice for nurses to demonstrate continuing competence, and for regulatory authorities to assess continuing competence.
The need for continuing competence is agreed by regulatory authorities to be necessary to protect the public in health processional regulation. Definitions of continuing competence within legislation and policy across developed nations have strong similarities. However, recent research conducted within New Zealand indicates that there is confusion over the level to which continuing competence needs to demonstrated and the criteria against which continuing competence should be assessed. This study aims to develop a consensus view amongst regulatory experts and authorities for a conceptual model for demonstration and assessment of continuing competence. In addition, a gap analysis will be undertaken to analyze the conceptual model against existing requirements. Recommendations will be made for legislative and policy change to align best practice with existing conditions. This research is the second stage of a larger study, completed under contract to the Nursing Council of New Zealand which focused on the evaluation of the continuing competence framework for nurses in New Zealand, and contributes to Rachael Vernon’s Doctoral thesis through the University of Sydney, Australia. The research is being undertaken using a sequential mixed-method evaluation research design. Ethical approval has been granted by the Health Research Council of New Zealand Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP and MEC/11/EXP/010, and ratified by The University of Sydney, Human Research Ethics Committee: Ref – 12618.
Participation, Confidentiality and Rights In order to participate, we invite you to respond to the attached questionnaire and describe the ways you believe it is possible for nurses to demonstrate continuing competence; how continuing competence is assessed; and the barriers and/or enablers that may exist. We anticipate this will take approximately 25-30 minutes of your time.
Your participation in this research is entirely voluntary and you have the right to refuse to participate by simply not responding to this invitation. Completing and submitting your written views about continued competence implies your consent to participate in this research. The information collected will be de-identified, coded, and analyzed. A summary of data findings from the first round will be sent to you for further comment and refinement. It will remain confidential to the researcher on a password protected computer.
The overall findings will contribute to the final written report submitted to Fulbright (NZ), participating Regulatory Authorities, Rachael Vernon’s Doctoral thesis, and publications arising from the research.
Rachael Vernon and her PhD research supervisors are listed below. If you have any questions in relation to this study please contact Rachael Vernon by email.
Rachael Vernon (Lead Researcher) Head of School, Nursing Eastern Institute of Technology New Zealand Fulbright Visiting Scholar School of Nursing University of Washington Seattle, WA, USA Email: [email protected] or [email protected]
Professor Mary Chiarella (Principal Supervisor) Professor of Nursing Sydney Nursing School University of Sydney New South Wales Australia
Dr Elaine Papps (Associate Supervisor) Health and Research Consultant Hawke’s Bay New Zealand
Professor Denise Dignam (Associate Supervisor) Associate Dean Faculty of Nursing, Midwifery & Health University of Technology Sydney New South Wales Australia
To participate in this research go directly to http://www.zoomerang.com/Survey/WEB22CAXLVKEL6/
270
APPENDIX IX Stage Two – Delphi Group A (Expert Panel Interviews):
Research Information Sheet and Consent Form
Conceptual model for the demonstration and assessment of continuing competence
Information Sheet - Interviews We invite you to participate in this research. In doing so, you will have the opportunity to express your point of view and to have a role in influencing the development of a conceptual model and best practice framework for continued competence for nurses.
Why are we doing this research?
The purpose of this research is to develop a consensus view of best practice for nurses to demonstrate continuing competence, and for regulatory authorities to assess continuing competence.
The need for continuing competence is agreed by regulatory authorities to be necessary to protect the public in health processional regulation. Definitions of continuing competence within legislation and policy across developed nations have strong similarities. However, recent research conducted within New Zealand indicates that there is confusion over the level to which continuing competence needs to demonstrated, and the criteria against which continuing competence should be assessed. This study aims to develop a consensus view amongst regulatory experts and authorities for a conceptual model for demonstration and assessment of continuing competence. In addition, a gap analysis will be undertaken to analyze the conceptual model against existing requirements. Recommendations will be made for legislative and policy change to align best practice with existing conditions.
This research is the second stage of a larger study, completed under contract to the Nursing Council of New Zealand which focused on the evaluation of the continuing competence framework for nurses in New Zealand, and contributes to Rachael Vernon’s Doctoral thesis through the University of Sydney, Australia. The research is being undertaken using a sequential mixed-method evaluation research design. Ethical approval has been granted by the Health Research Council of New Zealand, Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP and MEC/11/EXP/010, and ratified by The University of Sydney, Human Research Ethics Committee: Ref – 12618.
Participation, Confidentiality and Rights
We invite you to participate in a confidential interview. We anticipate the interview will take approximately 30-40 minutes of your time and is comprised of questions relating to your experiences and understanding of the assessment and demonstration of continuing competence; barriers and/or enablers that may exist; and your views with regard to the development of a conceptual model for the demonstration of continuing competence between six countries – Australia, Canada, Ireland, New Zealand, United Kingdom, United States of America. The interview will be recorded and then transcribed. All responses will be treated in confidence by the researcher and any identifying information removed. You may request to see your interview transcripts; decline to answer any questions; withdraw from the study at any time; ask any questions about the study at any time during participation; provide information on the understanding that your name will not be used unless you give permission to the researcher.
The information collected will de-identified, coded, collated and analyzed. It will remain confidential to the researcher on a password protected computer. The overall findings will contribute to the final written report submitted to Fulbright (NZ), participating Regulatory Authorities, Rachael Vernon’s Doctoral thesis, and publications arising from the research.
Rachael Vernon and her PhD research supervisors are listed below. If you have any questions in relation to this study please contact Rachael Vernon by email.
Rachael Vernon (Lead Researcher) Head of School, Nursing Eastern Institute of Technology New Zealand Fulbright Visiting Scholar School of Nursing University of Washington Seattle, WA, USA Email: [email protected] or [email protected]
Professor Mary Chiarella (Principal Supervisor) Professor of Nursing Sydney Nursing School University of Sydney New South Wales Australia
Dr Elaine Papps (Associate Supervisor) Health and Research Consultant Hawke’s Bay New Zealand
Professor Denise Dignam (Associate Supervisor) Associate Dean Faculty of Nursing, Midwifery & Health University of Technology Sydney Australia
Conceptual model for the demonstration and assessment of continuing competence
Interview Consent Form
I have read the Information Sheet and have had the details of the study explained to me. My questions have been answered to my satisfaction, and I understand that I may ask further questions at any time.
I understand I have the right to withdraw from the study at any time and to decline to answer any particular questions.
I agree to provide information to the researcher on the understanding that my name will not be used without my permission.
I understand that the information I provide will be used for this research and that it may also contribute to Rachael Vernon’s Doctoral thesis, and publications arising from both research projects.
I agree / do not agree to the interview being audio taped. (Please circle your choice)
I understand that I have the right to ask for the audio tape to be turned off at any time during the interview.
I agree to participate in this research under the conditions set out in the attached Information Sheet.
Signed: ................................................................................. Name: ................................................................................. Date: .................................................................................
271
APPENDIX X Ethics Approval Documentation
Human Research Ethics Committee
Web: http://www.usyd.edu.au/ethics/
ABN 15 211 513 464
Marietta Coutinho Deputy Manager Human Research Ethics Administration
Telephone: +61 2 8627 8176 Facsimile: +61 2 8627 8177
Email: [email protected]
Mailing Address: Level 6
Jane Foss Russell Building – G02 The University of Sydney NSW 2006 AUSTRALIA
Ref: MC/KR 3 March 2010 Professor Mary Chiarella Sydney Nursing School The University of Sydney Email: [email protected] Dear Professor Chiarella
Title: Evaluation of the Nursing Council of New Zealand Continuing Competence
Framework (Ref. No.12618)
PhD student: Ms Rachael Vernon Your application was reviewed by the Executive Committee of the Human Research Ethics Committee (HREC), and in doing so the Committee has ratified your study to include the PhD student – Ms Rachael Vernon. The Executive Committee acknowledges your right to proceed under the authority of Multi-region Ethics Committee, New Zealand. Please note, this ratification has been given only in respect of the ethical content of the study. Any modifications to the study must be approved by Multi-region Ethics Committee, New Zealand before forwarding a copy to The University of Sydney Human Research Ethics Committee. Yours sincerely
Marietta Coutinho Deputy Manager Human Research Ethics Administration cc Ms Rachel Vernon [Email: [email protected]]
From: Karen Greer on behalf of Human EthicsTo: Mary ChiarellaCc: Rachael VernonSubject: Noted CorespondenceDate: Friday, 13 July 2012 11:59:16 a.m.
Dear Prof Chiarella & Rachel
Title: Evaluation of the Nursing Council of New Zealand Continuing Competence Framework
Protocol No: 12618
Thank you for your correspondence dated 3 July 2012 providing additional documentation which
has been approved by the Health and Disability, Multi-Region Ethics Committee, New Zealand
This correspondence has been noted and placed on file for future reference.
Yours sincerely
Human Research Ethics Committee
The University of Sydney
KAREN GREER | Ethics Administration Officer
Office of Research Integrity | Research Portfolio
THE UNIVERSITY OF SYDNEY
Lvl 6, Jane Foss Russell Building G02 | The University of Sydney | NSW | 2006
T +61 2 8627 8171 | F +61 2 8627 8177
E [email protected] | W http://sydney.edu.au
CRICOS 00026A
This email plus any attachments to it are confidential. Any unauthorised use is strictly prohibited. If you receive this
email in error, please delete it and any attachments.
Please think of our environment and only print this e-mail if necessary .
Multi-region Ethics Committee c/- Ministry of Health
PO Box 5013 1 the Terrace
Wellington Phone: (04) 816 2655
Email: [email protected]
12 April 2011 Rachael Vernon Faculty of Health and Sports Medicine EIT Hawke’s Bay Private Bag 1201 Taradale Dear Ms Vernon - Re: Ethics ref: MEC/11/EXP/010 (please quote in all correspondence)
Study title: Developing a conceptual model for the demonstration and assessment of continuing competence.
Investigators: Rachael Vernon This study was given ethical approval by the Multi-region Ethics Committee on 5 April 2011. This approval is valid until 31 December 2011, provided that Annual Progress Reports are submitted (see below). Access to ACC For the purposes of section 32 of the Accident Compensation Act 2001, the Committee is satisfied that this study is not being conducted principally for the benefit of the manufacturer or distributor of the medicine or item in respect of which the trial is being carried out. Participants injured as a result of treatment received in this trial will therefore be eligible to be considered for compensation in respect of those injuries under the ACC scheme. Amendments and Protocol Deviations All significant amendments to this proposal must receive prior approval from the Committee. Significant amendments include (but are not limited to) changes to:
the researcher responsible for the conduct of the study at a study site the addition of an extra study site the design or duration of the study the method of recruitment information sheets and informed consent procedures.
Significant deviations from the approved protocol must be reported to the Committee as soon as possible. Annual Progress Reports and Final Reports The first Annual Progress Report for this study is due to the Committee by 5 April 2012. The Annual Report Form that should be used is available at www.ethicscommittees.health.govt.nz. Please note that if you do not provide a progress report by this date, ethical approval may be withdrawn. A Final Report is also required at the conclusion of the study. The Final Report Form is also available at www.ethicscommittees.health.govt.nz.
We wish you all the best with your study. Yours sincerely [e-signed] Rohan Murphy Administrator Multi-region Ethics Committee Email: [email protected]
272
APPENDIX XI Process of Qualitative Analysis
Process of Qualitative Analysis and Associated Data Files
Stage One - Evaluation of the NCNZ Continuing Competence Framework
Reference in document / Coded Data Files Page Number Phase One: Document Review and Policy Analysis (Chapter 4) 79-102 • Historical review
Descriptive analysis (4.3, p.80)) 80-92
• Document Review 94 separate NCNZ documents related to CCF; o Summary Table Document Code NC95/09 (RV) o Individual Documents #NC1/09 - #NC94/09 (RV)
92-95
• Policy Analysis – Musick’s (1998) Framework for Policy Analysis o Document Codes #CCF/09, #RAPP/09
57-59, 95-100
Phase Two: Interview Data (Chapter 5) Analysis - Thomas’s General Inductive Approach (2003)
103-121 61
• Qualitative Interviews (26) o Research information sheet and consent forms (Appendix II) o Findings (5.0)
59-61 263
103-121 Recorded interviews / Audio files o Document codes #A01/09 - #A26/09 (NVIVO_RV)
Interview transcripts o Document codes #T01-T26/09 (NVIVO_RV)
59-61, 103-104
Thematic categorisation and generation of sub-themes o Document codes #TC-QI/09, #ST-QI/09 (NVIVO_RV)
104-119
Summary Analysis o Document code #SA-QI/09 (NVIVO_RV)
119-121
Raw data and consistency of data theming at each phase of analysis was independently checked by Doctoral supervisors
103-104
Stage Two - The International Consensus Model for Assessment of Continuing Competence
Reference in document / Coded Data Files Page Number Delphi Technique Stage Two: Delphi Findings (Chapter Eight) • Delphi Round One – Qualitative Interviews (14)
o Expert Panel Research information sheet and consent forms (Appendix IX)
o Analysis – Content Analysis o Findings (8.2)
65-69, 71-73 164-208
67-70
270 71-72
165-181 Recorded interviews / Audio files o Document codes #A01/12 - #A14/12 (MP3_RV)
165-166
Interview transcripts o Document codes #T01-T12/12 (NVIVO_RV)
Thematic categorisation o Document codes #TC-QI/09, #ST-QI/12 (NVIVO_RV)
167-180
• Delphi Round Two – Analysis - Summative Content Analysis o Research information sheet (Appendix VIII) o Findings (8.3)
70-71 269
181-189 Consistency of initial data analysis and thematic categorisation and generation of sub-themes independently checked by a doctoral supervisor
166
• Delphi Round Three - Quantitative (statistical) E-Survey (8.4) 70, 203 • Delphi Round Four - The Consensus View (9.2)
o Summary Document (Appendix VI) o Qualitative Data Files #SM_DELPHI/R4_2013
71, 210-215 267
Ethical Approval (3.5) o Ethical Approval Documents (Appendix X)
74-75 271