Developing and Sustaining a Competent and Confident Clinical Workforce through
Essential Clinical Competencies for Registered Practitioners
Competency Title: Documentation for Registered Nurses
Competency Lead: Jacqueline Hazeldine
Document Author
Authorised Signature
Written by: Jacqueline Hazeldine
Authorised by: Richard Young
Signed:
Signed:
Date:
10/05/2014
Date: 22 May 2014
Job Title: Modern Matron/Practice Educator
Job Title: Head of Clinical Education and Resuscitation
Effective Date: 1st June 2014
Review Date: 1St June 2017
Approval at: Clinical Competency Group
Date Approved: 22 May 2014
1
CF /v10/DB/KB/GS2013
How to use this Competency Framework
This Competency Framework has been developed to enable the assessment of clinical competence. In light of the Francis Report (and the move towards
Foundation Trust status), the Isle of Wight NHS Trust is required to demonstrate that clinical staff are competent to provide quality care for everyone, every
time and are all practising to an agreed level.
Definition of Competence
A definition of competence was agreed by clinical leaders in May 2013 and is detailed below:
“A set of specific and detailed outcomes that need to be achieved in order to a) prove immediate competence in essential skills or b) aid personal and
professional development in desirable skills. The competencies must incorporate knowledge, skill, behaviour and demonstration of how these all equate
to personal professional accountability for competent care of the patient” (Barnett 2013).
This definition focuses attention on the importance of recognising individual personal responsibility and accountability to deliver high quality care. This
means taking appropriate actions following the results of any clinical assessments to ensure the individual needs of the patient are met and this care is
delivered with care and compassion. Competency is not about performing the task in hand in a mechanistic way without patient involvement.
Responsibilities
It is the responsibility of the competency lead to develop the competency statements using the agreed framework, present the competency pack to the competency group
for approval, develop and co-ordinate the delivery of the master classes, undertake competency assessments and ensure the outcome is forwarded to Development and
Training for recording on Pro4.
It is the responsibility of the clinical lead to ensure that they are competent themselves and that their registered staff are competent within their scope of practice. The
clinical lead may undertake competence assessments themselves or delegate to Band 6s/Clinical Educators who have been competency assessed and who have also
attended a recognised course on assessment. The clinical lead should also monitor compliance by ensuring that the essential competencies are reviewed annually at
appraisal. The clinical leads are professionally accountable to the Executive Director of Nursing and Workforce and their relevant professional body. It is the responsibility
of the individual professional to ensure that they are competent within their scope of practice and that the essential competencies are reviewed annually at appraisal.
They are professionally accountable to the Executive Director of Nursing and Workforce and their relevant professional body.
2
CF /v10/DB/KB/GS2013
The Process of Competency Assessment
Clinical Leaders
A master class will be timetabled within the monthly clinical lead development day in addition to
being accessible electronically via the Intranet. This will provide all the relevant underpinning
knowledge needed to inform practice and prepare for the competency assessment.
The clinical lead feels prepared for the competency assessment.
Add wh
Yes
No
http://intranet/index.asp?record=4457
Contact the relevant competency lead to
organise a date for assessment. It is
recommended that the assessment takes
place within 4-6 weeks of accessing the
master class.
The outcome of the competency
assessment is Green.
Contact the relevant competency
lead to arrange further input.
No
The assessor provides feedback to the
assessee and assists them to develop
an individual self directed learning
plan at the time in preparation for the
second re-assessment. NB for the 3rd
re-assessment refer to box below.
Yes
The assessor provides feedback to the
assessee and completes the assessment
documentation.
The outcome of the competency assessment
will be forwarded to Development & Training
within 3 days of the assessment.
The clinical lead is now competent to assess
their clinical staff.
NB If this
The assessor provides feedback to the
assessee and arranges an individual
tutorial led by the Competency Lead,
focusing on specific learning needs in
preparation for the third re-assessment.
NB for a referral refer to the box below.
Referral at the third attempt may lead to capability.
This will be discussed in confidence with the clinical
lead and their line manager.
3
CF /v10/DB/KB/GS2013
The Process of Competency Assessment
Registered Practitioners Bands 5 and 6
A master class will be accessible either face to face or electronically. This will provide all the relevant
underpinning knowledge needed to inform practice and prepare for the competency assessment.
http://intranet/index.asp?record=4457
The registered practitioner feels prepared for the competency
assessment.
Yes
No
Contact the relevant competency
lead to arrange further input.
Contact their clinical lead to organise a date
for assessment. It is recommended that
the assessment takes place within 4-6
weeks of accessing the master class.
The outcome of the competency
assessment is Green.
No
The assessor provides feedback to the
assessee and assists them to develop
an individual self directed learning
plan at the time in preparation for the
second re-assessment. NB for the 3rd
re-assessment refer to box below.
Yes
NB If this
The assessor provides feedback to the
assessee and completes the assessment
documentation.
The outcome of the competency assessment
will be forwarded to Development & Training
by the competency assessor within 48 hours
of the assessment being undertaken for
input onto Pro 4
The assessor provides feedback to the
assessee and arranges an individual
tutorial focusing on specific learning
needs in preparation for the third reassessment. NB for a referral refer to
the box below.
Referral at the third attempt may lead to
capability. This will be discussed in confidence
with the registered practitioner and their line
manager.
4
CF /v10/DB/KB/GS2013
Name:
Role:
Band:
Assessor Role:
Assessor Band:
Work Base:
Assessor Name:
Competency Statement
(Core Competencies to be included in all
Competency Assessments)
Expected Level of Competency
Registered practitioners deliver person centred
care with sensitivity and compassion
respecting the dignity and diversity of patients,
relatives, carers, visitors and colleagues
During this assessment the practitioner is observed acting
with respect, kindness, compassion and sensitivity.
Demonstrates consistent person centred care with very
good professional conduct/behaviour in line with trust
expectations.
The practitioner explains how they would enable people to
understand the rationale for documentation and therefore
give informed consent.
The practitioner consistently recognises the significance of
confidential information and explains the safe storage of
patient information through scenarios.
During this assessment the practitioner is able to
consistently communicate safely, sensitively and
effectively using appropriate methods according to the
situation.
During the assessment the practitioner is observed
practising or is able to explain the standards for
documentation applicable to the Trust and their
professional body, e.g. legibility, confidentiality, accuracy
and contemporaneous with dates, times and signatures.
During the assessment the practitioner consistently
recognises and works within the limitations of their
knowledge, skills and professional boundaries,
understanding their responsibility and accountability for
their own actions and omissions.
During the assessment the practitioner is observed or is
able to recognise and respond correctly when people are
in vulnerable situations, at risk or in need of support and
protection.
Registered practitioners gain consent for all
interventions per Trust policy and professional
body requirements
Registered practitioners consistently maintain
confidentiality as per Trust policy and
professional body requirements
Registered practitioners provide accurate and
meaningful verbal information in a polite and
respectful manner to patients, relatives,
visitors and colleagues
Registered practitioners complete
documentation in accordance with
organisational and professional body standards
Registered practitioners demonstrate
professional accountability and act with a ‘duty
of candour’
Registered practitioners demonstrate how to
safeguard vulnerable adults and children, and
when to raise identified concerns through the
appropriate channels
Level of Competency
Evidenced
Signature of Assessor
5
CF /v10/DB/KB/GS2013
Competency Statement
Subject Specific Competencies
Expected Level of Competency
The practitioner uses only approved
documentation and is able to list the process
for approval
All pages contain patient’s name and IW
number or addressograph labels and the
practitioner is able to explain the rationale for
this
All entries are dated, timed, signed with
designation listed and the name is printed on
the first entry and a sound rationale for this is
given
The practitioner is able to review
documentation written by colleagues and
provide constructive feedback to them
The practitioner is able to discuss the
appropriate use of abbreviations
A full understanding of the professional
responsibility and accountability RNs hold for
delegating care to HCAs should be evident
The practitioner can demonstrate a full
understanding of the professional
responsibility and accountability for accurately
identifying a patient need/problem, with the
patient (where possible)
The practitioner demonstrates full completion
of a risk assessment and accurately identifies
subsequent actions required
The practitioner consistently demonstrates
detailed completion of a nursing needs
assessment
The practitioner is able to clearly discuss the
goal or outcome of care with the patient
(where possible) and clearly document this
The practitioner is able to clearly discuss steps
in the care plan in order to achieve the
patient’s stated goal/outcome of care
Real life documentation will be checked to ensure current
versions are only in use
Level of Competency
Evidenced
Signature of Assessor
Real life documentation will be reviewed to see if this
criteria is met
Real life documentation will be reviewed to see if this
criteria is met
Practitioner will be asked to undertake a review of one
patient’s documentation and explain the feedback they
would provide
Real life documentation will be reviewed to see if this
criteria is met
The practitioner is able to describe the role of the HCA in
completing nursing documentation
Real life documentation will be reviewed to see if this
criteria is met
Real life nursing documentation will be reviewed to
determine whether there is sufficient detail to look after
the patient from the written risk assessment
Real life nursing documentation will be reviewed to
determine whether there is sufficient detail to look after
the patient from the nursing needs assessment
A full understanding of the professional responsibility to
clearly document patient’s goals. Real life documentation
will be reviewed to see if this criteria is met
A clear explanation is provided by the RN regarding the
care to be provided will be recorded in the patient’s notes
6
CF /v10/DB/KB/GS2013
All information and advice given to the
patient/relative/carer is clearly documented, in
line with the NMC guidelines
A full understanding of the professional
responsibility and accountability to evaluate
the care provided
The practitioner consistently demonstrates
sound evaluation and progress reports
A clear statement of the patient’s condition is
documented at the point of discharge or
transfer of care to another clinical area
Real life documentation will be reviewed to see if this
criteria is met
Real life documentation will be reviewed to establish that
an evaluation of care had been undertaken
Real life nursing documentation will be reviewed to
determine whether there is sufficient detail reported to
give a full picture of the patient’s current condition.
Real life documentation will be reviewed to see if this
criteria is met
Competency Statement
Completing a Care Plan Competencies
Expected Level of Competency
The practitioner consistently demonstrates
detailed completion of care plans associated
with the nursing needs identified following
assessment using clinical judgement and sound
rationales
Real life nursing documentation will be reviewed to
determine whether there is sufficient detail to look after
the patient from the care plans and to determine whether
the decision making process is apparent
Level of Competency
Evidenced
Signature of Assessor
7
CF /v10/DB/KB/GS2013
Assessment Outcome – Please sign in relevant box
Rating
Level
Actions
Green
All essential competencies
evidenced
Red
One or more competencies
not evidenced
No action required, review
annually at appraisal. Revisit
any development learning
points listed below as
recommended by assessor.
Clinical practice in relation to
the specific competency not
evidenced is to be supervised
and reassessed within 2
weeks.
Assessor Signature and
date
Initial Assessment
Assessor Signature and
date
2nd Assessment
Assessor Signature and
date
3rd Assessment
Learning points to revisit following successful competency assessment:
Assessor Signature:
Registered Practitioner Signature:
Date:
8
CF /v10/DB/KB/GS2013
Action Plan for Red Rating to be completed following this assessment if required in preparation for second assessment
Agreed plan for practice to be supervised until reassessment undertaken if required
Date for Reassessment:
Name of Assessor:
Registered Practitioner Signature:
9
CF /v10/DB/KB/GS2013
Action Plan for Red Rating to be completed following this assessment if required in preparation for third and final assessment
Agreed plan for practice to be supervised until reassessment undertaken if required
Date for Reassessment:
Name of Assessor:
Registered Practitioners Signature:
10
CF /v10/DB/KB/GS2013