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Developing a framework to assess competence in leg ulcer care

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Irene Anderson, BSc (Hons), DPSN, RN.

Senior Lecturer, Tissue Viability, Department of Post Registration Nursing, University of Hertfordshire, Hatfield

In tissue viability or, indeed, in any specialist area, practitioners are required to meet certain standards for which specific skills are required. It is important that these skills are taught, practised and maintained to ensure both patient safety and effective patient management.

In tissue viability or, indeed, in any specialist area, practitioners are required to meet certain standards for which specific skills are required. It is important that these skills are taught, practised and maintained to ensure both patient safety and effective patient management.

This paper considers the elements of Doppler assessment and the application of compression bandaging to patients with leg ulcers and presents a means of determining competence in these skills to ensure rigorous and equitable assessment. The title 'student' in this paper refers to the practitioner with a professional qualification who is pursuing a post-registration programme of study in an institute of higher education.

Health-care professionals can be seen as 'performance centred' in their learning because they need and generally wish to apply new skills in their clinical environment (Brookfield, 1986). Although nursing education today has a more academic structure than in the past, nurses require practical skills to care for patients. Assessment is well established in higher education, but there is recognition of the need for more effective strategies in workplace assessment and clearer guidance for practice assessors (Eraut, 1994).

The subject of competence can invoke negative reactions, particularly when incompetence holds such damming connotations. Competence, however, is a positive concept and should be welcomed and encouraged.

Defining competence
There are varying definitions of competence and the word has sometimes been used interchangeably with performance, causing confusion (While, 1994). While (1994) suggests that some perceive competence as a subjective entity, while performance is seen as objective and measurable. This is interesting because competence is the term used most often in clinical practice and, indeed, in many professions (Eraut, 1998), as something that is required - as a measurable quantity - in a qualified person. Competency has been defined as 'the overlap of knowledge with the performance components of psychomotor skills and clinical problem-solving within the realms of affective responses' (Dunn et al, 2000).

Much of the literature on competence in professional nursing practice is concerned with pre-registration programmes and little has been written about the development of competence in post-registration programmes. However, one example of competence development and measurement comes from the RCN (2002).

While (1994) expresses concern that cognitive skills and psychomotor skills could be separated and hence would not take account of decision-making, which can be a used as a quality indicator of professional practice. This is particularly true in areas such as Doppler assessment and compression therapy, where treatment decisions are directly influenced by nuances within the assessment process. For instance, the decision to apply full, or reduced, compression in the light of a patient's holistic assessment and ankle-brachial pressure index (ABPI) (Moffatt, 1997).

Messick (1984) defines 'competence' as what a person knows and can do under ideal circumstances, and 'performance' as actual behaviour in practice. These are debatable definitions today because competence is seen as the goal of the practitioner in clinical practice.

In order for the 'real-life practice' of the clinical person to be deemed competent it is appropriate to take a tripartite approach to skills development, encompassing education, practice in a clinical setting and assessment of the student from a theoretical and clinical perspective.

Although competence is now accepted terminology in the health-care professions (Watson et al, 2002), it can be seen as diametrically opposed to academic endeavour, as though the practitioner has to be one or the other. In relation to leg-ulcer management there is a need for both - for example, practical psychomotor skills, such as the correct use of the hand-held Doppler or any other assessment equipment, must be reinforced by cognitive skills in decision-making, particularly as these intellectual skills help to ensure patient safety and facilitate effective care.

There is a distinct advantage to be gained from testing theoretical knowledge by written assignment and competence through the assessment of performance (the component parts deemed competencies) (Watson et al, 2002). Watson et al reviewed the literature related to competence and established that there were problems with definition; they also found a dearth of testing for the reliability and validity of the tools used to measure competence. This area merits further study.

The issue regarding level of study - that is, diploma or degree level - is also an important consideration. It could be argued that higher education institutions are already conversant with the differences from an academic perspective and in terms of some practical skills, such as Doppler assessment and compression therapy application, the practitioner is either effective and safe at basic level, or not. Higher levels of practice are certainly attainable and desirable, but the framework described is concerned primarily with basic skills.

McMullan et al (2003) distinguish between competence, competences, competency and competencies. The first two relate to action, behaviour or outcome, while the latter two are about the characteristics and qualities of the person. The authors point out that the specific terms have become blurred. It is also true that there is a complex interaction between performance and personal characteristics.

Two criticisms of measurement of competence are its transferability and assessment of knowledge and understanding (McMullan et al, 2003). This is why it is important to assess the student in clinical practice and is much more desirable than relying on assessment in an artificial environment. The issue of measuring competence must be underpinned by assessment of theoretical knowledge to gauge understanding, particularly in a dynamic situation such as that related to leg-ulcer management. Competence should not be divorced from knowledge and understanding and should be set in the context of its application (Tuxworth, 1989).

Leg-ulcer management
Patients presenting with leg ulceration must be screened for arterial disease with the aid of a hand-held Doppler (RCN, 1998). If appropriate, a patient with venous ulceration should be treated with compression therapy. Good clinical practice dictates that screening and management should be carried out by staff trained to undertake these procedures (RCN, 1998; SIGN, 1998).

A post-registration course in leg-ulcer management aims to develop a student's awareness of the issues, and ensure his or her understanding of both the scientific principles underpinning the assessment and management of patients, as well as enable attainment of the practical skills of Doppler assessment and compression therapy. It is vital that health-care professionals involved in caring for people with leg ulcers are knowledgeable about both the theoretical and practical skills involved.

Using this as a starting point, the tissue viability team sought to develop a framework of competencies to facilitate the assessment of student skills and development in the principles and practical elements related to Doppler assessment (Figure 1) and compression bandaging (Figure 2). This competence framework is part of a practice portfolio for students on the Advances in Leg Ulcer Management (formerly ENB N18) module. Other elements of the portfolio relate to other elements of patient care and service delivery for this client group. Demonstration of competence is mandatory for successful completion of the module.

The competency framework is presented as a series of domains with the required competency alongside. The general category headings are then broken down into competency indicators (Figures 1 and 2). The patient domains consider preparation, safety and communication.

Studies have shown (Chase et al, 1997; Charles, 1995) that patients with leg ulcers become frustrated when health-care professionals do not exhibit effective communication skills. The inclusion of this in the framework enables the practice assessor to observe these skills and assess the student's level of understanding as he or she explains complex procedures appropriate to the patient's level of understanding and desire for information.

Consideration of the discrete domains and the use of more than one assessment period allows tracking and recording of development of skills rather than taking a simple task approach. This reflects the complexity of competence and continuous professional development rather than a series of repeated activities (Gee, 1995). The competence framework also enables the student to consider his or her actions and reflect on the micro-elements of the procedures.

Development of the competence framework
The development of the framework arose from the desire to make the assessment of students on the module as overt and structured as possible but none the less relevant to the diversity of patients and environments in clinical practice. The project took place over six months (Box 1).

The development team had to agree on criteria for the levels of competence, such as whether someone can be largely competent or if 100% competence is the only acceptable level (Watson et al, 2002). This is an important question because it could mean the difference between a safe level of compression and the risk of damage to a patient.

It is possible to weight the various components, and this was considered. However, there was still the issue of equity of assessment, so it was agreed that a pass/fail outcome would be appropriate. The framework as it is now is a major step forward in terms of equity but is not static and is open to adaptation.

Practice assessment
The tissue viability team were asked about the possibility of using an objective structured clinical examination (OSCE) as an assessment technique, as a result of which an important point was raised about the value of assessing discrete elements of a procedure, which may give little indication of the ability of the student to perform effectively in a wider context (Watson et al, 2002).

A non-threatening real-life environment with positive, constructive feedback is much more conducive to learning and, while a certain degree of pressure can enhance performance, stress cannot (Brookfield, 1986). It is much better, therefore, to work alongside an assessor in practice, developing a supportive relationship as skills are acquired. This also raises the issue of variations in practice environments, which would be impossible to replicate effectively in a classroom or a skills laboratory. Consider the weeping oedematous leg, the noise of a clinic or the obstacles posed by working in a patient's home.

Practice portfolio
In addition to achieving the competence elements, the students are required to maintain a record of their development and achievement in clinical practice related to leg-ulcer management. This gives students the chance to reflect on their practice and actively plan development of skills pertinent to their individual needs.

The portfolio contains written evidence of personal and professional achievement (McMullan et al, 2003) and crucially must also allow for reflection on that achievement. Surprisingly, many students find this the most challenging part of the course. Almost invariably, they find they can express their thoughts and feelings but hesitate to commit them to paper, although those who overcome their reluctance are generally surprised at the simplicity of the process and the benefits inherent in organising their thoughts and experiences.

There is evidence to suggest that students may not progress in a linear fashion or learning curve when achieving competence (Lauder et al, 1999). Although this has been noted with reference to pre-registration nurses, the same phenomenon can be observed in the qualified practitioner. Students may initially express feelings of 'disassembly', with equilibrium eventually being restored as they continue with the module and develop their skills.

Health-care professionals who attend post-registration courses are often already working in the specialty they are studying and it is always difficult to have your existing practice challenged. This also raises the issue that in many areas practitioners are carrying out procedures for which they have no specific training and may be practising skills with little appreciation of the theoretical concepts underpinning the procedure.

Maintaining competence in practice
The maintenance of competence in a procedure or set of procedures depends on practising the skills. The real success of any programme of study is the extent to which students go on to build on the skills they have learnt and applied in practice. Effective use of the practice portfolio can be a means to achieve this, particularly if there is effective reflection on the experience. Using Kolb's experiential learning cycle (1984) as a framework can help illustrate the way the student achieves competence, learns and develops from the experience, and takes this forward. An example of this in a leg-ulcer context is the development of leadership skills, perhaps extending into the realm of leg-ulcer service delivery and the development of these services to embrace advanced assessment and management techniques.

Competence in this context is the achievement of safe and effective practice, and it is important that the foundations are built on to benefit patients. Competence can be perceived as a stage on the journey towards proficiency and expertise (Eraut, 1994) in the spirit of lifelong learning.

Occasionally, a student who has achieved competence in Doppler assessment and compression bandaging expresses low confidence levels. This feeling usually lasts for a short time only and illustrates the benefit of the relationship with the practice assessor, as the support often continues for a time afterwards, evolving into an informal mentorship role.

The future of the competence framework
Feedback from practice assessors and students has been favourable towards this method of assessing Doppler and bandaging skills. It has improved the student experience and helped to ensure equity of assessment among students. Two added benefits of implementing the framework have become apparent: its development has facilitated a much closer working relationship with many practice assessors through the development and ongoing refinement of this tool and employers and specialist practitioners now have a better understanding of the explicit nature of the skill development in the students who attend the course.

There is a call for all employers to be accountable for the competence of their staff (Jasper, 2001). The attainment of competence in Doppler assessment and application of compression therapy and professional development recorded within a record of achievement supports this requirement.

The future of the measurement of competence in leg-ulcer management may be strengthened by debate on the essential core skills required and working towards consistency in the assessment of that competence.

The author would like to acknowledge the input of colleagues Jacqui Fletcher and Madeleine Flanagan in the development of the Advances in Leg Ulcer Management module at the University of Hertfordshire and the support given throughout the development of the competency framework.

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