VOL: 99, ISSUE: 48, PAGE NO: 36
Carol Ward, MBA, DMS, RGN, DipN, is management consultant, Dianne Whitfield, MBA, MIPD, BA, Dip Labour Studies; is management consultant; both in Leamington Spa
Until 2001 a number of different staff nurse development programmes co-existed across the Black Country locality of the West Midlands South Workforce Development Confederation, (now the Birmingham and Black Country Workforce Development Confederation - BBCWDC). An area-wide programme was then initiated, with the aim to:
- Develop a newly qualified staff nurse development programme (SNDP) that would enable the transition from newly qualified staff nurse to confident, competent practitioner;
- Ensure that the programme was transferable across all the trusts involved;
- Use appropriate competency statements to facilitate individual development;
- Ensure that effective assessment and support systems are in place.
Initiating the project
A working group facilitated by consultants Ward Whitfield Associates was set up in April 2001. This included representatives from all nine Black Country trusts, the University of Wolverhampton and a representative from the Workforce Confederation.
Literature reviews were carried out, along with group discussion on competency development, support systems and development programmes. A mapping exercise also looked at current systems in place in the participating trusts. The literature review and mapping exercise identified a number of competency models, including:
- Benner (1984);
- Bondy (1983);
- Eraut (1994);
- Steinaker and Bell (1979).
In addition, they considered professional models of competence (UKCC, 1999) and occupational models (City and Guilds 1992, www.edexcel.org.uk). Literature relating to the assessment of competence, (Calman et al, 2002) and supervision/support systems (Butterworth and Faugier, 1992), was also included.
Locally a small number of trusts were found to be using the Bondy (1983) model for assessment of newly qualified staff nurses’ competence and development. At the time this was the model of choice in local preregistration programmes. Other trusts had adapted Benner’s (1984) five domains of competence or Steinaker and Bell’s (1979) five levels of performance models. The main distinction in the different approaches to assessment was whether practitioners were expected to achieve a specific level of competence - for example Bondy’s model has four dimensions and a five-point rating tool - or whether the individual is considered to pass/fail or be competent/not competent. The latter was particularly the case in the locally adapted tools. A number of frustrations were identified with all of these approaches, including the difficulties that assessors and participants had in terms of understanding the process, and the validity and reliability of the assessment.
The new programme
The outcome of the working groups’ development work was an agreement that the programme should be:
- A one-year programme;
- Based on a set of core competencies that are generic and applicable to all areas of practice;
- Supported by an assessment process based on professional development and competency building; - Supported by effective supervision, performance management and personal development planning; - Supported by local on-the-job training and development, and localised training programmes that meet the needs of the organisation.
The main focus of the programme is personal development and ongoing support and assessment to ensure the achievement of a core set of competencies. Each staff nurse and assessor is given a supporting package that consists of:
- A set of guidelines for the participant and the assessor;
- The core competencies and assessment framework;
- The structure of the programme;
- A set of review forms to record progress at three monthly intervals;
- An example of sources of evidence and application;
- A personal development plan.
The competencies were developed to reflect the expectations of a competent practitioner at the end of their first year postqualification. It was subsequently recognised that the competencies can also be used to assess competence if the participant is undertaking an adaptation programme or a return to practice programme. The core competencies are generic and apply to all practitioners regardless of branch or sector. Local competency statements can be added to the package to reflect specific branch or specialty requirements. The competencies are used to assess performance as part of the structured staff nurse development programme and to identify specific personal development plans for the participant. The UKCC (now the NMC) used the term competence in its Fitness for Practice document to describe ‘the skills and ability to practise safely and effectively without the need for direct supervision’ (UKCC, 1999). This is the underlying premise on which these competencies were developed.
Developing a competency framework
It was recognised that the participant may, as a newly qualified practitioner, have had to demonstrate competency achievements as part of his or her preregistration programme. There is however, a distinction between practising under the direct supervision of other practitioners, and the application of knowledge, skills and personal values in the role of a qualified staff nurse. The period following qualification was therefore recognised as a transitional time when the participant needed support - in the form of a preceptorship and development programme - and a recognition of their personal development needs. To enable the transition to be made, the baseline structure of the competency framework was taken from the NMC framework for entry to the register (NMC, 2002). As in the NMC framework, there are four sections:
- Professional/ethical practice;
- Care delivery;
- Care management;
- Personal/professional development.
This was expanded to include competency statements, in the care delivery section, at the request of the nurse directors in the Black Country, that reflected Essence of Care (Department of Health, 2001) standards. It was deemed appropriate that if the organisations were using Essence of Care standards, it was necessary to identify what nurses need to be able to do. Each section is subdivided into a number of statements of overall competence. These are then subdivided into:
- Associated potential sources of evidence.
An example of a competency statement related to the standards is given in Box 1. The competencies are statements of expected levels of performance at one-year postqualification. Assessors were asked to consider with the participant at regular intervals, defined in the development programme, different sources of evidence to demonstrate the participant’s personal competence.
In relation to assessment, a number of different approaches were reviewed, and detailed discussion took place on the most appropriate modes. It was agreed that it would be inappropriate to use the ‘tick box’ approach, representing a task perspective. A binary approach (pass or fail) was also regarded as inappropriate as this would not reflect the developmental requirements of the programme. Assessment of nursing competence requires a combination of assessing quantitative and qualitative evidence. Examples of modes of evidence were given alongside the competency criteria. These included a combination of evidence regarding performance in the delivery of care such as:
- Observation of care;
- Practice review;
- Documentation and evidence that demonstrates supporting capability;
- Testimony of others;
- Reflective diaries;
- Critical incidents reviews.
Examples of evidence from these different sources are collected throughout the 12-month period (or alternative designated period), and kept alongside the associated competencies to ultimately provide a portfolio of evidence. At the end of the development programme, if the competencies have been achieved to a satisfactory level, the assessor and the participant sign the individual sections of the programme document. This part of the programme proved to be contentious, in that participants often wanted to have competency statements ‘signed off’, when appropriate evidence had been collected. As the purpose of the programme was developmental over a 12-month period, and achievement of the competencies during this period was not a ‘pass/fail’ scenario, participants and assessors were encouraged not to sign the individual sections until the 12-month review. The competencies are assessed as part of an ongoing process of support and supervision.
The programme in practice
When they start in post, newly qualified staff nurses, alongside an induction programme, also meet with their team leader/ward manager and appointed assessor - who may be the same person. This gives an opportunity to discuss the expectations of both the participant and the assessor and to define a future personal development plan. In the first three months the participant meets with the assessor on a monthly basis. Then formal meetings take place at three-monthly intervals to assess progress against the defined competencies and identify any personal development needs. This also gives the participant the opportunity to discuss and arrange attendance at any trust development programmes or to arrange any specific work-based development programme. At each of the meetings the assessor formally records with the participant their progress, any identified development needs, and a personal development plan that may include specific objectives. At the end of the 12-month period the participant should be in a position to complete his or her assessment of the achievement of competencies and identify a new personal development plan to enable career pathway planning. The documentation of the development programme forms a portfolio of evidence that can then be used by the participant to demonstrate competence should they need to do so, for example in relation to:
- Future employment;
- Continuing professional development (CPD) requirements for registration;
- Potential accreditation of prior experiential learning (APEL), for academic purposes;
- Evidence relating to the future knowledge and skills framework (KSF).
Should participants change jobs during the 12-month period, either within the trust or within the Black Country, they can take their portfolio of evidence with them and continue the development programme. It is not known if the transfer facility was tested during the first 12 months of the programme but a number of participants did continue outside the trust, demonstrating that the portfolio and support process was valued and regarded as transferable.
A programme support and evaluation process was agreed at the outset. The original intent was that a trust coordinator would support assessors and participants on an ongoing basis, and would interview both at the end of the first year. In some trusts the coordinators were able to do this, but where there were a large number of participants the task was too great and the coordinator undertook random sampling. Seven of the nine original participating trusts took part in an evaluation meeting in April 2003. A summary of outcomes and common issues raised are listed in Box 2.
At that time approximately 600 staff nurses were undertaking the programme. A significant number of other D grades in the participating trusts were keen to use the competencies and the framework within the programme for their development. It was also felt by those attending the meeting that the approach could be used for all grades of staff. For example one E-grade nurse, who has been in post for 15 years, is using the pack to do a ‘stock take’ of her current competency levels and draw up her personal development plan. The competencies could also be added to, in order to produce additional competencies for senior grades. A career pathway approach could be introduced.
The majority of those interviewed gave positive feedback regarding the principles of the programme. However, a group of staff nurses from one trust said that the immediate start of the staff nurse development programme on qualification felt like a repetition of the requirements for the RN or DipHE qualifications, and recommended that evidence collection begin three months after qualification. This potential problem has been overcome by assuring common understanding of the principles of the programme.
In addition to the positive feedback and future potential of the staff nurse development programme, the evaluation meeting identified a number of challenges. These were mainly regarding issues of leadership, support and maintaining quality. Possible solutions have been highlighted and shared to enable these challenges to be met. Participant and assessor support In the majority of trusts there were issues with resourcing assessor support. In the first instance some areas had had difficulties in recruiting assessors for the programme, particularly where there were perceived to be other priorities, such as preregistration and NVQ students. Some areas had also found it difficult to provide the appropriate level of clinical supervision for participants. This problem had been overcome in some trusts by providing group supervision as part of their in-house training programmes.
Assuring consistent quality of the portfolio assessment was identified as an issue. Some trusts have overcome this by using the current NVQ structures and processes to enable sampling and verification. Quality of assessors A significant need was identified in relation to the development of assessors. In some areas assessors did not have the skills to review qualitative evidence such as reflection and evidence in portfolios. This need has been addressed in some trusts by providing sessions within the annual NVQ and practice assessor updates.
Reflection skills required of participants
The introduction of the programme identified a need for a significant number of staff to understand how to reflect on practice and develop their portfolios. In response, some trusts have introduced additional sessions to teach reflective skills.
Overlaps with other competency systems
It was recognised at the beginning of the project that a number of other competency frameworks may need to coexist alongside the staff nurse development programme. These include the knowledge and skills framework (KSF) (DoH, 2003), as part of Agenda for Change, local specialist competencies and potential professional competencies linked to future professional regulation. During the evaluation of this project Ward Whitfield Associates also worked with the Walsall Hospitals NHS Trust in piloting the knowledge and skills framework as part of the trust appraisal process. From this work, it was clear that the competencies in the development programme can be used in conjunction with the KSF. Supporting evidence and assessment can be used for both processes, minimising repetition.
Should the NMC introduce professional regulation based on competencies, the development programme would enable staff nurses to compile their portfolio of evidence against the current competencies - this would feed into professional regulation. The current competencies were based on NMC competencies, therefore although there may need to be some amendments in the future, these should be minimal. In specialist areas, where local competencies have been developed (theatre, A&E and critical care), these were often given a higher priority than the development programme competencies. There is still a need to ensure all staff are aware of the broader context when using local competencies. Further development is required to enable amalgamation of local competencies in future.
There is also a need in each trust for a recognised lead or coordinator to provide support for the programme in terms of promotion, distribution, facilitation, providing support to participants and assessors, quality assurance and evaluation. One trust - Sandwell and West Birmingham Hospitals - has appointed a lead post specifically for staff nurse development.
The programme is now established in the majority of trusts in the Black Country. A number of significant benefits have been achieved. Future developments include:
- Roll out across the Birmingham trusts;
- Extension of the programme to other levels of staff;
- Identification of additional competencies to match senior posts.
Although this programme was developed to meet the needs of the newly qualified practitioner to enable them to become competent and confident, the approach can and should be used for the majority of practitioners. All staff should have a clear set of defined competencies for their role, portfolios of evidence to demonstrate ongoing achievement, and effective support systems, including ongoing performance review, personal development planning and clinical supervision, in order to work effectively as competent practitioners.
This article has been double-blind peer-reviewed.