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J Probl Based Learn > Volume 5(2); 2018 > Article
Robertson: Editorial
Nursing, like other health professions, is a self-regulated profession with professional codes and guidelines (NMBA, 2016, NMBA, 2018, ICN, 2012) developed by the profession and approved by representatives of the profession through a range of regulatory bodies, including in the case of nursing, the Nurses and Midwives Board of Australia. Moreover, health professionals have an obligation to practice competently and this means exhibiting behaviours and attitudes reflecting competence as set out in the standards and other codes of professional and ethical conduct. There is an assumption that the standards are widely understood and used by the membership of the profession.
For over 30 years my professional life, as a clinician and an academic, has been informed by a set of Competency Standards for the Registered Nurse (now known as the Registered Nurse Standards for Practice, NMBA, 2016). Originally developed in 1986, there have been three iterations, or renewal in expression, of the ‘domains’ and ‘elements’. However, the intent for their formal use as a means of establishing a minimum standard for professional practice for nurses in Australia has remained the same. Changes to policy occurred in 2016 where the National Competency Standards for the Registered Nurse (NMBA, 2006) was replaced by the Registered Nurses Standards for Practice (NMBA, 2016). This new set of professional standards for nursing practice in Australia was originally designed to articulate a nationally consistent minimum standard, and they continue to serve this purpose.
My interest in the contemporary environment centres on the place that the standards; the ‘what’ and the ‘how’ around professional behaviours, play in curriculum design and implementation. I want to fully appreciate the extent to which these standards are valued or even fully understood by nurses. To begin my reflection on the standards first requires a brief explanation of the historical context of the development of the competency standards in Australia.
Members of the Australian Nurse Registration Authorities Conference (ANRAC, 1990) in the original project to develop the standards, explained that nursing competencies are not skills. It was noted that competencies cannot exist without scientific knowledge, clinical skills and humanistic values, competence transcends each of these. Furthermore, it was argued that competencies cannot be assessed by schemes that focus on these components because health professional competencies are holistic entities, which interact with one another in a manner determined by the context in which the professional provides care. The constituents of competencies are not found in the professional alone, but in the relationships that exist among the professional, the client and the situation at any given time or place. This nurse-client-environment triad is dynamic and must be learned about and assessed.
The position of the nursing profession about competency standards was congruent with a wider Australian government policy agenda in the 1980s. The National Office of Overseas Skill Recognition (NOOSR, 1995) also commissioned research into competence assessment for the professions. This was important because internationalisation within universities emerged as common practice. In the 1990s, the development of professional standards was seen as a way to articulate explicit statements of “what people need to be able to do to successfully practice as a professional” (Gonczi et al 1990 p.7). These authors said “[h]aving clear sets of standards helps to remove misunderstandings both inside and outside the profession” and they provide a “sound basis for judgments about entry to and progression within the profession” (p.7). A competent practitioner is one they said that “has the attributes necessary for job performance to the appropriate standard” (Gonczi et al (1990 p.9). Therefore, to be a competent practitioner, a person needs the appropriate attributes that include knowledge, ability, skills and attitudes articulated in a set of standards. Later,Heywood, Gonczi and Hager (1992) explained that in order to judge whether a person performs competently a set of standards is needed as a benchmark.
Gonczi et al (1990, p. 7) explained that “competency-based standards offer a number of advantages to professions and para-professions whilst at the same time furthering important national objectives, particularly maintenance of professional standards, labour market efficiency and equity”. To establish whether practice reflected theory, in 1990, senior nurses were surveyed to determine their beliefs regarding how the standards should be used (NOOSR, 1995). The intent of the standards articulated were to:
  • Assess eligibility for registration as a practitioner

  • Assess the competence of overseas-qualified professionals

  • Assist in developing curricula in university and vocational colleges

  • Assist professional associations/registration authorities in accrediting educational programs

  • Assist in developing continuing education programs

  • Assess the competence of people re-entering the profession after a lengthy absence, and

  • As a public information document setting out the roles and responsibilities of the professional nurse.

  • As a tool for employers to evaluate employer performance

  • In employment, recruitment, selection and promotion procedures

  • Facilitating articulation within the profession, eg levels of practice or specialist areas

  • As a reference for legal action.

This list also reflects the contemporary intention of the standards. Additionally, the Australian Nursing and Midwifery Accreditation Council (ANMAC) Registered nurse accreditation standards, 2012, require that any outcomes of nursing curricula are mapped to the standards and thus any formal assessment of competence uses the standards (ANMAC, 2012). Therefore, in Australia, the standards remain one central benchmark for competence and confidence in practice, and they are used as minimum practice standards to inform curriculum design and implementation. Assessment of the competence of all RNs entering the profession is a central feature of the processes and outcomes of a university programs that enroll both domestic students and overseas qualified nurses. All RNs when they initially register and re-register, must declare that they meet these standards. Importantly, the declaration does not explicitly indicate that continuing competence means being competent in relation to the Registered nurse standards for practice (NMBA, 2016).
Despite the above list of intentions about how the standards should be used, the extent to which the standards are being used, and in what manner within the profession is unclear. There is literature in relation to the use of competency standards and other standards in education and practice, but the latter it is limited and there are gaps in relation to the use of standards in assessment of continuing competence, performance review and self-assessment. However, based on my experience it appears that many nurses have a poor understanding of the conceptual frameworks informing professional practice as reflected in the standards. It is also clear that nurses need such a frame of reference to understand the elements of professional practice. This can be achieved through appreciation of the application of the standards to practice; more importantly nurses need to be able to judge their own performance using acceptable, formal standards as a benchmark.
Given the profession has agreed these standards are the benchmark it could be assumed that all RNs know about the standards, know how to use the standards and understand their obligation to continue to meet the standards for the purposes of registration. There is a “taken for granted” assumption that all nurses know about the standards and given the historical articulated intention, that they are being used in the ways that were originally envisaged. NOOSR (1995) identified that there may be issues in relation to: i) acceptance of the standards by the profession and higher education sector; ii) flaws in the concept of competency standards; iii) difficulties in disseminating information about/raising awareness of competency standards; iv) difficulties in implementing the assessment strategies; and v) a common understanding of competencies within the profession. Many of these concerns remain within the literature with academics debating the validity and reliability of the standards as a tool to measure competence, and doubt about how well the profession have been informed and educated about the standards and how to use them in practice. At another level, student nurses on returning from professional workplace experience, report poor knowledge and understanding of the standards by some nurse preceptors. The clinical facilitators who work with the Sydney Notre Dame School of Nursing corroborate the students’ experience. This raises issues about the effectiveness of the dissemination of information and education about the standards.
In closing, I believe that it is useful to explore in depth, evidence of the extent to which the standards are used in practice, how they are used and why, and the reasons why they may not be used; in other words, identify any barriers to their use in practice. The other key area to explore is any potential disconnect between how the policy makers envisage the standards should be used in comparison to the reality of their use. This information is critical for those who make policy and decisions about contemporary practice standards.

REFERENCES

ANRAC Nursing Competencies Assessment Project, (1990). Vol 1 _ the project report Vol 2- Assessment technology, Vol 3-Archive and Data. Canberra, ANCI.

Australian Nursing and Midwifery Accreditation Council (ANMAC), (2012). Registered Nurse Accreditation Standards, 2012, https://www.anmac.org.au/sites/default/files/documents/ANMAC_RN_Accreditation_Standards_2012.pdf

Australian Nursing and Midwifery Accreditation Council (ANMAC), (2012). Registered nurse accreditation standards, 2012, Retrieved from https://www.anmac.org.au/standards-and-review/registered-nurse

Gonczi, A., Hager, P. & Oliver., (1990). National office of Overseas Skills recognition research paper No. 1: Establishing competency-based standards in the professions. Australian Government Publishing Service, Canberra.

Heywood, L. Gonczi., (1992). A guide to the development of competency standards for professions. National Office of Overseas Skills recognition research paper no. 7. Canberra, Australian Government Publishing Service.

National Office of Overseas Skills Recognition, (1995). Research Paper No. 9: The implications of the implementation of national Competency Standards in the Professions-Final Report. Australian Government Publishing Service, Canberra.

Nursing and Midwifery Board of Australia, (2018). Code of conduct for nurses, Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx

International Council of Nurses, (2012). Code of ethics for nurses, Retrieved from https://www.nursingmidwiferyboard.gov.au/codesguidelines-statements/professional-standards.aspx

Nursing and Midwifery Board of Australia, (2006). National competency standards for the registered nurse, Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx

Nursing and Midwifery Board of Australia, (2016). Registered nurse standards practice, Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx



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