OPENING PANDORA'S BOX
Education in Nursing, Midwifery and Health
Science Research Group Symposium:
Confidence in Competence
11 February 2015
Associate Professor Rachael Vernon, RN, PhD
Associate Head of School (Academic)
School of Nursing and Midwifery
University of South Australia
Fulbright Scholar
This presentation seeks to
 Explore the interface between professional
regulation and competence to practice,
particularly in relation to continuing education
and performance of competence
 Explore whether public safety can be assured
through performance of competence, or
awareness of competence or indeed
incompetence
Research Question
Can performance awareness / insight be identified,
measured and assured, and is this preferable to
the measurement of competence in clinical
performance (at a given point of time), or in
relation to requirements for initial registration,
registration renewal / recertification?
Research Overview
 Builds on two previous studies Evaluation of the
Continuing Competence Framework (Vernon, Chiarella,
Papps & Dignam, 2010) and The International
consensus model for the assessment of Continuing
Competence (Vernon, 2013)
 Examines aspects of competence assessment to
differentiate between performance competence and
assessment of insight into, or awareness of competence,
or indeed incompetence...
Purpose
To analyse the assessment and adjudication of nurses with
performance related notifications for competence, to:
 Ascertain any relationship between CPD, recency of
practice and performance competence
 Explore if remediation provides any guarantee of
performance competence
 Identify any relationship between awareness/insight of
competence and performance competence
 Classify how decisions are made related to continuing
registration, sanctions or deregistration
Continuing Education Ensures Competence to Practise and
Assures Public Safety?
Previous Findings
 The purpose of nursing regulation is protection of the public,
in many countries it is a legislative mandate
 Public right to expect that RNs are competent
 Similarities in legislative requirements, role and purpose of
Regulatory Authorities in Australia, Canada, Ireland, New
Zealand, the United Kingdom and the United States of
America
 Education and practice standards for RNs are similar between
countries
 Consensus agreement, revalidation, recertification, reregistration should occur annually, associated with
requirement to declare/demonstrate the ability to meet
required standard of continuing competence
 Strong similarities in definitions of competence and
continuing competence exist
 Similarities in models for assessment of continuing
competence
 Consistency between the indicators of competence,
continuing competence and assurance of public safety
 Most common 'competence' indicator: Examination
 Most common 'continuing competence' indicators: CPD,
Practice Hours, Self Declaration, Self/Peer Evaluation
 Issues of validity, reliability and efficacy within and
between models, and indicators of continuing
competence
 Influenced by individuals - behavioural and attitudinal
traits
 Variation in distinction between core and higher levels of
competence, and the impact of behaviours i.e. ethical
comportment and insight
Competence is defined as…
“the combination of skills, knowledge attitudes, values and
abilities that underpin effective and/or superior performance in a
profession/occupational area and context of practice”
(Nursing & Midwifery Council, 2009).
Practice is defined as…
Any role in which the individual uses their skills and knowledge as
a nurse and/or midwife. For the purpose of the registration
standard, practice is not restricted to providing direct clinical care.
It also includes working in non-clinical relationship with clients,
working in management, administration, education, research,
advisory, regulatory or policy development roles, and any other
roles that impact on safe, effective delivery of services in the
profession and/or use their professional skills
(Nursing & Midwifery Board, 2014)
Historical overview…
 National competency standards first adopted by ANMC in early 1990s
 ANMC worked in conjunction with national state and territory authorities (NMRAs)
 “to help nurses and midwives to deliver safe and competent care”
(http://www.ahpra.gov.au/Search.aspx?q=national%20competency%20standards)
 National legislation - Health Practitioner Regulation National Law 2009 (Qld), came into
effect 1 July 2010
 Health Practitioner Regulation National Law (South Australia) 2010
 Australian Health Practitioner Regulation Agency (APHRA) - supports the national boards
to implement the National Scheme
 NMBA (31/08/09) – Responsible for regulation of nurses & midwives in Australia;
ownership of the national competency standards
 ANMAC (24/11/10) – Independent accrediting authority for nursing & midwifery
professions under the National Scheme

Continuing competence is a requirement stipulated in the National Law.
Continuing Competence
Frameworks
 Principle function – quality assurance mechanism
 Promotes consistency of competence standards and
assessment processes
 Regulatory tool that facilitates the assessment and monitoring of
the continuing competence of the profession, and as such they
have a role in assuring and ensuring public safety
 Ensures consistency in the monitoring of continuing competence
– annual basis
 Demonstrates to public that the nursing profession is cognisant
of / has mechanisms to assess the competence and continuing
competence of the profession
Continuing Competence Frameworks
Australia
Nursing and Midwifery
Board of Australia
(National Legislation and
National Framework)
Canada
Canadian Council of
Registered Nurse
Regulators (CCRNR 2011)
(Incorporated Federated
model - National principles
- no 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
2% Audited Annually
National legislation, Health Practitioner Regulation National Law 2009 (Qld).
Continuing competence is a regulatory requirement stipulated in the Act.
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.
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 States of America
National Council of State
Boards of Nursing (NCSBN,
Council of regulators Incorporated Federal Model)
(National Principles
requirements vary across
States /Territories
United Kingdom
Nursing and Midwifery
Council (NMC)
(National Framework)
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
Separate legislative jurisdictions/Regulatory Boards in each State/Territory. Mutual
recognition agreements some States.
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.
Competency standards (for RN)
 Provide a framework for assessing competence
 Broad and principle-based
 Four Domains

Professional practice

Critical thinking and analysis

Provision and coordination of care

Collaborative and therapeutic practice
 Annual renewal of registration
Framework for assessing
competency standards
 Important measure to ensure initial and continuing competence of
nurses and midwives
 Guides assessment of competence against NMBA national
competency standards for Ens, RNs, NPs & MWs
Assessment principles
Critical issues
 Accountability
 Accountability / responsibility
 Performance based assessment
 Includes - knowledge, skills & attributes
 Evidence based assessment
 Context
 Validity & reliability
 Professional judgement, recognition of
cues
 Participation & collaboration
 Impartiality, confidentiality, communication
Models being used to affirm
continuing competence?
 Occur on continuum, no CC requirements – robust
and comprehensive frameworks
Models include:






Multi – source feedback, including self-assessment
360o evaluation
Portfolio
Continuing Education credits / education
Measurement of hours
OSCE, Examination
Relationship between CPD and
Competence
Evidence of Sufficient
CPD
Competent Not Competent
Sufficient CPD
Competent
No Evidence of Sufficient
CPD
No CPD
NO PROBLEM
NO PROBLEM – they will be
picked up but they are not
dangerous
Sufficient CPD
Not Competent
No CPD
Not Competent
PROBLEM – Won’t get picked POTENTIAL PROBLEM – Should
up as they will meet renewal
be picked up through lack of CPD
requirements but are not safe
(Chiarella and White, 2013)
Continuing Professional Development
 Variation in understandings of what constitutes CPD
 Lack of understanding of how to articulate / demonstrate
CPD
 Limited / lack of engagement in CPD
 Influenced by individuals' - behavioural and attitudinal traits,
attitudes and beliefs
 Systems and operational influences
Active engagement in CPD assures continuing competence
to practise however does not ensure public safety
Responsible and Accountable
 RNs as registered health professionals are: responsible,
accountable, ethical, competent and committed to lifelong learning and nursing practice
 Individual RNs are responsible and accountable for:
ensuring their own 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 and
complies with regulatory requirements i.e. current
validation / licensure / certification
Research Question
Can performance awareness / insight be identified,
measured and assured, and is this preferable to
the measurement of competence in clinical
performance (at a given point of time), or in
relation to requirements for initial registration,
registration renewal / recertification?
Research Method
 Philosophical approach: interpretive and
constructionist
 Mixed-method evaluation research design
 Three independent phases of data collection
 Phase 1- Critical analysis of case law
 Phase 2 - A comparative analysis of competence
assessment (audit) and competence notification data
over previous 3 year period
 Phase 3 - Interviews with key staff employed by the
Regulatory Authorities
Preliminary Findings
 Variation in understandings of what constitutes CPD
 Lack of understanding of how to articulate / demonstrate
CPD
 Limited / lack of engagement in CPD
 Influenced by individuals - behavioural and attitudinal traits,
attitudes and beliefs
 Systems and operational influences
Active engagement in CPD assures continuing competence to
practise however does not ensure public safety
References
Chiarella, M., & White, J. (2013). Which tail wags which dog? Exploring the interface
between professional regulation and professional education. Nurse Education Today, 15. doi: 10.1016/j.nedt.2013.02.002
Vernon, R. (2014). Vernon, R. (2014). Competent or just confident? Nursing Review,
series 2014, 18.
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. (2013). Relationships between legislation, policy and continuing
competence requirements for Registered Nurses in New Zealand. Doctor of Philosophy
Thesis, University of Sydney.
Vernon, R., Chiarella, M., Papps, E., & Dignam, D. (2012). New Zealand nurses'
perceptions of the continuing competence framework. International Nursing Review,
60(1), 59-66. Advance online publication, (2012), 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.
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 http://nursingcouncil.org.nz/Publications/Reports