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RELATIONSHIPS BETWEEN LEGISLATION, POLICY AND CONTINUING COMPETENCE REQUIREMENTS FOR

REGISTERED NURSES IN NEW ZEALAND

A thesis presented in fulfilment of the requirements for the degree of

Doctor of Philosophy

in

Nursing

The University of Sydney

Rachael Anne Vernon

2013

i

ABSTRACT

The regulatory requirements in the jurisdictions of most countries contain an expectation that

nurses will be competent to practise nursing on registration, and that they will maintain their

competence to practise throughout their nursing careers (Chiarella, Thoms, Lau, & McInnes,

2008). However, whilst nursing regulatory authorities internationally agree that monitoring

the continuing competence of the profession is necessary to protect the public, there is limited

research-based evidence to support a particular approach to the monitoring and assessment

of continuing competence.

The purpose of this research was to explore the relationships between legislation, policy

drivers and the continuing competence requirements for nurses in New Zealand, in association

with determining international best practice for the assessment of continuing competence.

The research was completed in two stages. Stage One focused on the relationship between

legislation, policy and continuing competence requirements for nurses in New Zealand since

the enactment of the Health Practitioners Competence Assurance (HPCA) Act 2003 (NZ), and

the subsequent implementation of the Nursing Council of New Zealand Continuing

Competence Framework in 2004. A mixed method evaluation of the efficacy of the Nursing

Council of New Zealand Continuing Framework was completed in 2010 and significantly

contributed to development of the second stage of the research. Stage Two was completed in

2012, using a Delphi technique to determine the international consensus views of regulatory

experts from six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and

the United States of America), with regard to the development of a best practice international

consensus model for the assessment of continuing competence.

Overall this research has analysed the relationships between legislation, policy and continuing

competence requirements for nurses in New Zealand and concluded that the Nursing Council

of New Zealand Continuing Competence Framework is a well-accepted and recognised

regulatory tool for the assessment and monitoring of continuing competence, providing an

acknowledged level of functionality in terms of assuring the safety to practise of nurses and

ensuring public safety. In addition, the consensus views of international nurse regulatory

experts, with regard to the concept of continuing competence and the development of a best

practice consensus model for the assessment of continuing competence, have been

determined, collated and are presented in association with the recommendations for further

development of the international best practice model for the assessment of continuing

competence.

ii

ACKNOWLEDGEMENTS

This thesis signifies the culmination of an important chapter of my life in terms of my personal,

professional and academic goals. During this research journey I have been privileged to work

with some truly exceptional people to whom I will always be grateful.

Firstly I wish to thank my husband Malcolm, who has unreservedly supported and encouraged

me throughout my research journey and my professional career.

To my research supervisors Professor Mary Chiarella (Professor of Nursing and Research Chair,

University of Sydney) and Dr Elaine Papps (Senior Lecturer, Eastern Institute of Technology), I

thank you for your unfailing encouragement, knowledge, expertise, mentorship and above all

your friendship. You are truly exceptional professional women and I am indeed privileged to

have worked so closely with you.

Professor Denise Dignam, thank you for your colleagueship and input during the evaluation of

the Nursing Council of New Zealand Continuing Competence Framework.

I am grateful for the financial support I have received from the University of Sydney and the

Eastern Institute of Technology during my candidature that has allowed me to participate in

international forums and present my work at a number of international conferences.

I would like to acknowledge my employer the Eastern Institute of Technology for allowing me

leave to undertake the Nursing Council of New Zealand Evaluation and my Fulbright Senior

Scholar Award. In particular I would like to acknowledge and thank Dr Susan Jacobs and the

team within the School of Nursing to whom, during my absence, much of the day-today work

fell.

Last but not least, I would particularly like to acknowledge and thank the research participants

and the many other people who have contributed to this research, without whom completion

of this thesis would not have been possible.

Undertaking this work has afforded me with many professional and personal challenges,

opportunities and experiences. I have learned an immeasurable amount, not only in terms of

the research I have undertaken, but also about myself. Whilst, tortuous at times I have

enjoyed this experience. I now look forward to what the next chapter will bring. As Alexander

Graham Bell said “When one door closes, another opens” (Alexander Graham Bell, n.d.).

iii

TABLE OF CONTENTS

ABSTRACT .................................................................................................................................................................. i

ACKNOWLEDGEMENTS ..................................................................................................................................... ii

LIST OF FIGURES ................................................................................................................................................. vii

LIST OF TABLES .................................................................................................................................................... ix

LIST OF AUTHORITIES ...................................................................................................................................... xi

LIST OF ABBREVIATIONS ............................................................................................................................... xii

LIST OF PUBLICATIONS AND CONFERENCE PRESENTATIONS ................................................. xiii

STATEMENT OF AUTHORSHIP AND ORIGINALITY .......................................................................... xvi

SECTION ONE INTRODUCTION AND POSITIONING OF THE THESIS ..................... 1

CHAPTER ONE - INTRODUCTION AND BACKGROUND ...................................................................... 2

1.1 Introduction ...................................................................................................... 2

1.2 Positioning of the thesis .................................................................................... 2

1.3 Structure of the thesis ....................................................................................... 5

1.4 Background ....................................................................................................... 7

1.5 The purpose of professional regulation ............................................................. 8

1.6 Health Practitioners Competence Assurance Act 2003 (NZ) .............................. 9

1.7 Legislation and the Nursing Council of New Zealand ...................................... 11

1.8 Continuing competence in New Zealand ......................................................... 13

1.9 Professional development and recognition programmes (PDRP) .................... 15

1.10 Continuing competence in the international context ...................................... 16

1.11 The impact of undertaking this work on my professional career .................... 17

1.12 Section and Chapter Descriptions ................................................................... 18

1.13 Concluding remarks ........................................................................................ 20

CHAPTER TWO - LITERATURE REVIEW ................................................................................................. 21

2.1 Introduction .................................................................................................... 21

2.2 Search strategy ............................................................................................... 21

2.3 Background – national and international regulatory context ......................... 22

2.4 Competence and continuing competence ....................................................... 37

iv

2.5 Competence frameworks ................................................................................ 39

2.6 Professional Standards and competence assessment ..................................... 41

2.7 Continuing competence indicators .................................................................. 43

2.8 Summary of findings from the literature ......................................................... 45


CHAPTER THREE - RESEARCH DESIGN AND METHOD ................................................................... 51

3.1 Introduction .................................................................................................... 51

3.2 Selection of the Research Approach ................................................................ 52

3.3 Research Design and Methods ........................................................................ 54

3.4 Management of researcher bias ..................................................................... 74

3.5 Ethical approval .............................................................................................. 74

3.6 Limitations of the research ............................................................................. 75


SECTION TWO STAGE ONE: EVALUATION OF THE NURSING COUNCIL OF NEW ZEALAND CONTINUING COMPETENCE FRAMEWORK .................................. 78

CHAPTER FOUR - PHASE ONE FINDINGS: DOCUMENT REVIEW AND POLICY ANALYSIS ................................................................................................................................................................. 79

4.1 Introduction .................................................................................................... 79

4.2 Framework for the document review and analysis ......................................... 80

4.3 The evolution of nursing regulation in New Zealand ....................................... 80

4.4 Review of Nursing Council of New Zealand documents .................................. 92

4.5 Analysis of Continuing Competence Framework and Recertification policies . 95

4.6 Nursing Council of New Zealand statistics ...................................................... 98

4.7 Summary of findings from the document review and policy analysis ........... 100

4.8 Concluding remarks ...................................................................................... 101

CHAPTER FIVE - PHASE TWO FINDINGS: INTERVIEW DATA .................................................. 103

5.1 Introduction .................................................................................................. 103

5.2 Competence .................................................................................................. 105

5.3 The role of the Nursing Council of New Zealand ........................................... 111

v

5.4 Recertification audit process ......................................................................... 113

5.5 Summary of findings from the interviews ..................................................... 119


CHAPTER SIX - PHASE THREE FINDINGS: E-SURVEY DATA ..................................................... 122

6.1 Introduction .................................................................................................. 122

6.2 Demographic data ........................................................................................ 122

6.3 Competence and fitness to practise .............................................................. 129

6.4 Recertification audit...................................................................................... 134

6.5 Professional development and recognition programmes .............................. 139

6.6 Summary of findings from the e-survey ........................................................ 141


CHAPTER SEVEN - DISCUSSION, CONCLUSION AND RECOMMENDATIONS ...................... 144

7.1 Introduction .................................................................................................. 144

7.2 Data triangulation and discussion ................................................................ 144

7.3 Key research findings .................................................................................... 157


SECTION THREE STAGE TWO: THE INTERNATIONAL CONSENSUS MODEL FOR THE ASSESSMENT OF CONTINUING COMPETENCE ...................................... 163

CHAPTER EIGHT - STAGE TWO: FINDINGS OF THE DELPHI STUDY .................................... 164

8.1 Introduction .................................................................................................. 164

8.2 Delphi Round One - Interviews ...................................................................... 165

8.3 Delphi Round Two – E-survey ........................................................................ 181

8.4 Delphi Round Three – E-survey...................................................................... 189

8.5 Summary of findings from the Delphi rounds (one – three) .......................... 204

8.6 Key principles and core components underpinning the development of an international consensus model ..................................................................... 206


vi

CHAPTER NINE – THE CONSENSUS VIEW; DISCUSSION, CONCLUSION AND RECOMMENDATIONS ................................................................................................................ 209

9.1 Introduction .................................................................................................. 209

9.2 Delphi Round Four – The consensus view ...................................................... 210

9.3 What is the consensus view of regulatory experts? ...................................... 216

9.4 The best-practice international consensus model for the assessment of Continuing Competence ................................................................................ 226

9.5 Changes required to align international regulatory requirements with best practice for the assessment of continuing competence ................................ 230

9.6 Recommendations for further development of the international consensus model ............................................................................................................ 231


SECTION FOUR CONTINUING COMPETENCE AND PUBLIC SAFETY A RELATIONSHIP BETWEEN LEGISLATION, POLICY AND PRACTICE .................. 233

CHAPTER TEN - DISCUSSION, CONCLUSION AND RECOMMENDATIONS ........................... 234

10.1 Introduction .................................................................................................. 234

10.2 Relationships between legislation, policy drivers and statutory requirements to ensure registered nurses are competent and fit to practise...................... 235

10.3 Is it competence that is being assessed / measured, or safety to practise? .. 240

10.4 The consensus view of regulatory experts in relation to best practice for nurses to demonstrate continuing competence; and best practice for regulatory authorities to assess continuing competence .............................. 242

10.5 Contribution to the national and international research environment ......... 244

10.6 Recommendations for future research .......................................................... 245

10.7 Conclusion ..................................................................................................... 246

REFERENCES...................................................................................................................... 248

APPENDICES ...................................................................................................................... 261

vii

LIST OF FIGURES

Figure 1 Structure of the Thesis ............................................................................................... 6

Figure 2 Evaluation Research Process .................................................................................... 55

Figure 3 Practising Certificates issued .................................................................................... 98

Figure 4 Recertification audit trends and competence notifications ..................................... 99

Figure 5 Representation of questionnaire participants ........................................................ 123

Figure 6 Highest qualification - Overall group response ...................................................... 124

Figure 7 Current employment setting - overall group response .......................................... 125

Figure 8 Current nursing practice area – overall participant group ..................................... 127

Figure 9 Indicators that provide the best evidence of competence to practise ................... 129

Figure 10 Indicators that provide the best evidence of continuing professional development ............................................................................................................................... 130

Figure 11 A mechanism to ensure nurses are competent and fit to practise ......................... 131

Figure 12 Responsibility for maintaining continuing competence to practise ....................... 131

Figure 13 Peer Assessor ......................................................................................................... 135

Figure 14 Recertification audit distribution of participants by audit year .............................. 135

Figure 15 Should Professional Development and Recognition Programmes be Compulsory? ............................................................................................................................... 140

Figure 16 Professional Development and Recognition Programmes ..................................... 141

Figure 17 Possible to develop a consensus model for the demonstration and assessment of continuing competence .......................................................................................... 188

Figure 18 Definition of nursing practice ................................................................................. 192

Figure 19 Individual nurses are responsible for their own continuing competence .............. 194

Figure 20 Responsibility and accountability ........................................................................... 196

Figure 21 Assessment of continuing competence .................................................................. 198

Figure 22 Indicators of continuing competence ..................................................................... 199

Figure 23 Outlying competence indicators ............................................................................ 200

viii

Figure 24 Barriers and enablers ............................................................................................. 201

Figure 25 Consensus model ................................................................................................... 203

Figure 26 Healthcare Environment (New Zealand) ................................................................ 238

ix

LIST OF TABLES

Table 1 Nursing Council of New Zealand evaluation objectives ................................................ 3

Table 2 Summary of Research Questions .................................................................................. 5

Table 3 Continuing competence requirements for nurses across six countries ...................... 35

Table 4 Stage One research questions and the Nursing Council of New Zealand objectives ... 56

Table 5 Analysis of key Nursing Council of New Zealand policy documents ............................ 97

Table 6 Thematic categories and sub-themes ....................................................................... 104

Table 7 Participation rates and sample size .......................................................................... 123

Table 8 Cross tabulation highest qualification by scope of practice ...................................... 124

Table 9 Cross tabulation of current employment settings by scope of practice .................... 126

Table 10 Cross tabulation current area of nursing practice by scope of practice .................... 128

Table 11 Responsibility for maintaining continuing competence to practise .......................... 132

Table 12 Nursing Council of New Zealand recertification application questions ..................... 133

Table 13 Participation as a Peer Assessor ............................................................................... 134

Table 14 Recertification audit information.............................................................................. 136

Table 15 Recertification audit information – comparison by audit year ................................. 137

Table 16 Understanding of evidence required for the Recertification Audit ........................... 137

Table 17 Submission of audit documentation ......................................................................... 138

Table 18 Satisfaction with audit documentation, communication and processes .................. 139

Table 19 Cross-tabulation of Employment setting by “Should PDRPs be compulsory?” ......... 140

Table 20 Summary of recommendations made to the Nursing Council of New Zealand ........ 161

Table 21 Thematic categories and sub-themes - Delphi Round One ....................................... 167

Table 22 Knowledge and / or experience of Continuing Competence Frameworks? .............. 182

Table 23 The ways it is possible and appropriate to demonstrate continuing competence.... 184

Table 24 How should continuing competence be assessed..................................................... 185

Table 25 Barriers and enablers to implementing a model for assessment of continuing competence .............................................................................................................. 187

x

Table 26 Participation rate and sample size ............................................................................ 190

Table 27 Definitions of competence and continuing competence .......................................... 191

Table 28 As a registered health professional individual nurses are responsible for ................ 193

Table 29 Continuing competence of registered nurses – who is responsible? ........................ 195

Table 30 Continuing competence consensus model requirements ......................................... 197

Table 31 Assessment of continuing competence .................................................................... 198

Table 32 Competence indicators ............................................................................................. 200

Table 33 Barriers and enablers ................................................................................................ 202

Table 34 Continuing competence consensus model requirements ......................................... 203

Table 35 Participation rate and sample size ............................................................................ 211

Table 36 Key principles underpinning the best practice consensus model ............................. 211

Table 37 Core components of the best practice consensus model ......................................... 215

Table 38 Essential components for tool box of continuing competence indicators ................ 215

Table 39 Optional components for tool box of continuing competence indicators ................ 216

Table 40 Components of the best practice international consensus model ............................ 228

xi

LIST OF AUTHORITIES

STATUTES

Health Practitioners Competence Assurance (HPCA) Act 2003 (NZ)

Health Practitioners Competency Assurance Bill 2002 (NZ)

Nurses Amendment Act 1990 (NZ)

Nurses Act 1977 (NZ)

Nurses Act 1971 (NZ)

Nurses Regulations, 1986 (NZ)

Nurses Registration Act 1901 (NZ)

Tohunga Suppression Act (NZ) (1907)

The Health Act 1956 (NZ)

New Zealand Public Health and Disability Act 2000 (NZ)

Health and Disability Commissioner Act 2004 (NZ)

Crown Entities Act 2004 (NZ).

Nurses Act 1950 (Ireland)

Nurses Act 1985 (Ireland)

Nurses and Midwives Act 2011 (Ireland)

Nurses, Midwives and Health Visitors Act 1997 (UK)

Health Practitioner Regulation National Law Act 2009 (Qld)

CASES

Condon, NMT230206JHC in NSW NMB (2010) Professional Conduct casebook 2nd edition NSW

NMB: Sydney

Health Care Complaints Commission v Bruce Litchfield, (1997, 41 NSWLR 630)

http://www.nursingboard.ie/GetAttachment.aspx?id=7f64b1a4-97d7-40c0-8608-e50e69f386ae

xii

LIST OF ABBREVIATIONS

APC Annual Practising Certificate

CCF Continuing Competence Framework

CNA Canadian Nurses Association

CPD Continuing Professional Development

DHB District Health Board

EN Enrolled Nurse

HPCA Health Practitioners Competence Assurance Act

ICN International Council of Nurses

MECA Multi-Employer Contract Agreement

NA Nurse Assistant

NCNZ Nursing Council of New Zealand

NCSBN National Council of State Boards of Nursing

NCQAC Nursing Care Quality Assurance Commission

NMC Nursing and Midwifery Council (UK)

NP Nurse Practitioner

NZ New Zealand

NZNO New Zealand Nurses Organisation

PDRP Professional Development and Recognition Programme

RN Registered Nurse

UK United Kingdom

UKCC United Kingdom Central Council for Nursing, Midwifery and Health Visiting

USA United States of America

xiii

LIST OF PUBLICATIONS AND CONFERENCE PRESENTATIONS

International Journal publications:

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., Chiarella, M., Papps, E., & Dignam, D. (2012). New Zealand nurses' perceptions of

the continuing competence framework. International Nursing Review. Advance online

publication, 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.

Book Chapter:

Vernon, R., Papps, E., & Dignam, D. (2012). Continuing competence: preparing for professional

practice. In Chang, E. M. L., & Daly, J. Transitions in Nursing: Preparing for professional

practice 3e. Sydney: Elsevier Australia.

Reports:

Vernon, R., Chiarella, M., Papps, E., & Dignam, D. (2010, March). Evaluation of the Nursing Council of New Zealand Continuing Competence Framework. Confidential Report. Napier, Author. ISBN 978-0-908662-33-3

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

International Conference Presentations:

Vernon, R. (2012, September). Continuing competence: consensus or not? National Council of

State Board of Nursing 2012 Scientific Symposium: From Research to Policy. Alexandria,

Virginia, United States of America.

xiv

Vernon, R., Chiarella, M. & Papps, E. (2011, November). Confidence in competence: Developing

a conceptual model for the demonstration and assessment of continuing competence.

Keynote Speaker. Paper presented at the International Council of Nurses (ICN)

Credentialing and Regulators Forum, Taipei, Taiwan.

Vernon, R., Chiarella, M. & Papps, E. (2011, July). Public safety: Confidence in competence.

Paper presented at the 22nd STTI International Nursing Research Congress, Cancun,

Mexico.

Vernon, R. (2010, April). Burden of proof or an issue of public safety. NEP/NET 2010. 3rd

International Nurse Education Conference. Nursing Education in a global community:

collaboration and networking for the future. Sydney, Australia.

Vernon, R. & Doole, P. (2010, October). Confidence in Competence - Nursing Council of New

Zealand Continuing Competence Framework. Western Pacific and South East Asian

Regulators (WP/SEAR) Meeting. Singapore.

Vernon, R. (2008, September). Legislation and policy drivers in competence requirements for

registered nurses in New Zealand. Nurse education Tomorrow, Cambridge University,

United Kingdom.

Invited Presentations:

Vernon, R. (2011, May). Legislation, policy and competence requirements for registered nurses

in New Zealand. Presentation to Washington State Department of Health – Nursing Care

Quality Assurance Commission (NCQAC) Special Meeting, Tumwater, WA, United States

of America.

Vernon, R. (2011, June). Public safety, competence and nursing in New Zealand. Presentation

to Faculty and Students, School of Nursing, University of Washington, Seattle, WA,

United States of America.

Vernon, R. (2011, July). Nursing in New Zealand. Presentation to North Carolina Board of

Nursing and invited University and Community College Nursing Programmes, Raleigh,

NC, United States of America.

xv

Vernon, R. (2010, June). Evaluation of the Nursing Council of New Zealand Continuing

Competence Framework. Presentation at Nursing Council of New Zealand – Learning

Curve Programme. Wellington, New Zealand.

Vernon, R. (2010, July). Evaluation of the Nursing Council of New Zealand Continuing

Competence Framework. Presentation to Nursing Council of New Zealand. Wellington,

New Zealand.

Vernon, R. (2009, August). Competence to Practise? Innovations in Nursing Forum, Nursing

Council of New Zealand and Ministry of Health (NZ).

Conference Poster Presentations:

Vernon, R. & Reed, C. (2012). Public safety, confidence and competence, Poster Presentation

at the National Council of State Board of Nursing, 2012 Scientific Symposium: From

Research to Policy. September 2012, Alexandria, Virginia, United States of America.

Awards:

Fulbright (NZ) Senior Scholar Award – (2011). University of Washington, Seattle, WA, United

States of America. Research title: Development of an international consensus model for

the assessment of continuing competence.

Scholarships:

The University of Sydney, Postgraduate Research Support Scheme (PRSS) Scholarship - 2009,

2011, & 2012.

Eastern Institute of Technology (NZ) Performance Based Research Funding (PBRF) - Research

Scholarship – 2008.

xvi

STATEMENT OF AUTHORSHIP AND ORIGINALITY

I certify that the work presented in this thesis has not previously been submitted for a degree nor has it been submitted as part of the requirements for a degree except as fully acknowledged within the text.

I also certify that this thesis has been written by me and any assistance that I have received while undertaking this research and in the preparation of the thesis itself is acknowledged. In addition, I certify that all information sources and literature used in this thesis are acknowledged and referenced.

Signature: Rachael Anne Vernon

Date: 10 May 2013

1

SECTION ONE INTRODUCTION AND POSITIONING OF THE THESIS

Section One of this thesis provides an overview of the purpose and structure of the research

undertaken and is comprised of three chapters.

Chapter One provides the introduction and the contextual background in which this research is

situated. An overview of the structure of the thesis is provided.

Chapter Two presents a review of national and international literature relating to the

development, implementation and assessment of continuing competence models and

frameworks. It also provides a brief summary of the current regulatory practices relating to

the continuing competence of requirements for nurses, in the six countries identified as

participants in this research, Australia, Canada, Ireland, New Zealand, the United Kingdom, and

the United States of America. The conceptualisation of competence, continuing competence,

competence assessment and the validity and reliability of competence indicators, in as much

as these relate to public safety, is examined and key findings are presented. The literature will

also be used to inform the key research outcomes in Chapters Seven, Nine and Ten.

Chapter Three sets out the overarching theoretical framework, research perspective, and

method used to undertake this research, including the rationale for the research design and

the ethical considerations. Detail of the data collection processes, analysis and findings of the

research undertaken are presented sequentially in Section Two – Evaluation of the Nursing

Council of New Zealand Continuing Competence Framework and in Section Three – Consensus

Model for the Assessment of Continuing Competence.

2

CHAPTER ONE - INTRODUCTION AND BACKGROUND

1.1 Introduction

Chapter One provides an introduction to the research that has been undertaken and provides

an overview of the contextual background in which this thesis is situated. The structure of the

thesis is described and chapter descriptions are provided.

1.2 Positioning of the thesis

This research grew from my interest in the relationship between legislation, policy drivers and

competence requirements for nurses in New Zealand, particularly in relation to the way in

which the legislative requirements related to competence in the Health Practitioners

Competence Assurance Act 2003 (NZ), were translated into practice. The primary purpose of

my research was to evaluate the current regulatory mechanism implemented in New Zealand

to ensure that nurses are competent and fit to practise their profession. In order to situate the

New Zealand findings within the wider international context of nursing regulation, it is

important to understand also the views of international nursing experts. The overarching

questions posed are:

1. What are the relationships between current legislation, policy drivers and the statutory

requirements to ensure registered nurses are competent and fit to practise?

2. Is it competence that is being assessed / measured, or safety to practise?

3. What is the international consensus view of regulatory experts in relation to:

a) best practice for nurses to demonstrate continuing competence; and

b) best practice for regulatory authorities to assess continuing competence?

The issues of safety to practise and the monitoring and assessment of continuing competence

in the health professions, including nursing are gathering momentum. The demonstration of

both competence and continuing competence for nurses, have become increasingly important

nationally and internationally. Internationally many nursing regulatory jurisdictions have

developed and implemented Continuing Competence Frameworks in response to national

legislative mandates that require registered health professionals to maintain and demonstrate

their continuing competence throughout their career. The overall purpose of these

3

frameworks is to ensure on-going safe, competent and ethical practice by registered nurses

and in turn protect the public (Australian Nursing and Midwifery Council, 2009; Canadian

Nurses Association, 2000; National Council of State Boards of Nursing, 2009a; Nursing Council

of New Zealand, 2006b).

In September 2008, soon after commencing this doctoral research, the Nursing Council of New

Zealand (the regulatory authority for nursing in New Zealand) put out a public ‘Request for

Proposals’ to examine the efficacy of the Continuing Competence Framework (CCF) for nurses

that had been implemented as a requirement of the Health Practitioners Competence

Assurance Act 2003 (NZ). Recognising the significant similarities between my research, which I

had already commenced for my thesis, and the requirements of the Nursing Council of New

Zealand request for proposals, my doctoral supervisors and I responded to the request for

proposals. Subsequently we were awarded the contract to undertake the evaluation of the

Nursing Council of New Zealand Continuing Competence Framework.

The overarching purpose of this commissioned research was to evaluate the efficacy of the

Nursing Council of New Zealand Continuing Competence Framework in relation to its success

in assuring nurses’ competence in terms of the requirements of the Health Practitioners

Competence Assurance Act 2003 (NZ), and to seek to determine the understanding and

attitudes of New Zealand nurses to these requirements. The five objectives listed below in

Table 1 were those identified by the Nursing Council of New Zealand at the commencement of

this work.

Table 1 Nursing Council of New Zealand evaluation objectives

• Explore the validity of the stipulated hours of professional development and days/hours of practice over a three-year period, as indicators of competence.

• Provide information on the efficacy of undertaking a random audit of five percent of the nursing workforce to meet recertification requirements.

• Document and track the different forms of written evidence that are currently acceptable to the Nursing Council of New Zealand to demonstrate competence.

• Identify issues related to peer assessment of competence.

• Develop a framework to enable the Nursing Council of New Zealand to complete a further evaluation in five years’ time (Nursing Council of New Zealand, 2008).

The Evaluation of the Nursing Council of New Zealand Continuing Competence Framework

contributes significantly to Stage One of my thesis. By undertaking this contracted work my

4

doctoral supervisors and I were fortunate to be provided with access to a wide range of data,

personnel and resources to which, as a doctoral student, I would not normally have been privy.

The contracted component of this work was completed in March 2010 and published by the

Nursing Council of New Zealand in October 2010 (Vernon, Chiarella, Papps, & Dignam, 2010).

Agreement was made at the outset with the Nursing Council of New Zealand to allow me to

use aspects of this contracted work for the purposes of my doctoral thesis, and for the

associated conference presentations and publications listed on pages xiii-xv. In addition my

doctoral supervisors took great care to enable me to lead and undertake large sections of this

contracted work completely independently, thus enabling its substantial contribution to my

final thesis. A matrix demonstrating the contributions of my doctoral supervisors as co-

researchers for the evaluation of the Nursing Council of New Zealand Continuing Competence

Framework is included as Appendix I. Care has been taken throughout this thesis to maintain

the confidentially of the research participants, and to adhere to the agreements made with the

Nursing Council of New Zealand in relation to intellectual property.

To date, little research has been undertaken internationally in the area of nursing regulation

overall and even less in relation to the efficacy of Continuing Competence Frameworks.

International interest from nursing regulatory authorities with regard to the work that was

being undertaken in New Zealand, Stage One – Evaluation of the Nursing Council of New

Zealand Continuing Competence Framework; led me to expand my thesis and develop a

second stage of research, Stage Two – Consensus model for the assessment of continuing

competence.

The findings from Stage One - the evaluation of the Nursing Council of New Zealand Continuing

Competence Framework, contributed to the development of Stage Two - the international

consensus model for the assessment of continuing competence, and assisted in positioning the

New Zealand findings in terms of their international relevance. Stage One also provided the

platform from which to investigate if there were a consensus view amongst regulatory nurse

experts in the following six countries: Australia, Canada, Ireland, New Zealand, the United

Kingdom, and the United States of America.

Table 2 presents a summary of the overarching research questions that were initially posed

and the associated research questions that relate specifically to Stage One and Stage Two of

this research.

5

Table 2 Summary of Research Questions

Overarching Research Questions 1. What are the relationships between current legislation, policy drivers and the statutory

requirements to ensure registered nurses are competent and fit to practise? 2. Is it competence that is being assessed / measured, or safety to practise? 3. What is the international consensus view of regulatory experts in relation to:

a) best practice for nurses to demonstrate continuing competence; and b) best practice regulatory authorities to assess continuing competence?

Research questions - Stage One Evaluation of the Nursing Council of New Zealand Continuing Competence Framework

Research questions – Stage Two Consensus model for the assessment of continuing competence

1. What are the relationships between current legislation, policy drivers and statutory requirements to ensure registered nurses in New Zealand are competent and fit to practise?


3. What is the efficacy of the current Continuing Competence Framework for nurses in New Zealand and does it reflect efficacious best practice?

1. What is the international consensus view of regulatory experts in relation to: a) best practice for nurses to demonstrate

continuing competence; and b) best practice for regulatory authorities to

assess continuing competence? 2. What, if any, differences are present between

the current regulatory requirements for the demonstration and assessment of continuing competence in six identified countries?

3. What changes, if any, would be required to policy and regulation in these six countries to align their regulatory framework with best practice for demonstration and assessment of continuing competence?

1.3 Structure of the thesis

This thesis is presented in four Sections; each Section presenting the chapters pertaining to a

particular aspect of the research process. Figure 1 (p. 6) represents a diagrammatic map of the

overall thesis structure. A summary of each Section and associated Chapter Descriptions is

provided in 1.12 (pp. 18-20).

6

Figure 1 Structure of the Thesis

The following section (1.4) provides a background overview of the national and international

regulatory scene in which this research is situated.

7

1.4 Background

This section will introduce and provide a background to the concept of continuing competence

and its relationship to public safety, in New Zealand and internationally. Continuing

competence has been a regulatory focus of many jurisdictions for over a decade and, in many

cases, is associated with the notion of public protection. The registration requirements in

most resource rich countries contain an expectation that nurses will not only be competent to

practise nursing on registration, but will maintain that competence in respect of their chosen

field or scope of practice, as they develop in their careers and renew their registration

(Chiarella, et al., 2008). However, internationally, the development and implementation of

credible frameworks for the demonstration and assessment of continuing competence is still

acknowledged as being a complex issue (Vandewater, 2004; Vernon, et al., 2010). A key factor

in the successful implementation of such frameworks appears to be related to the ‘legislative

authority’ of the regulatory body (International Council of Nurses, 2009; Vernon, Doole, &

Reed, 2011), in particular the powers that are bestowed to the regulatory authority by

legislation in the jurisdiction in which they function. In addition the conceptualisation of what

constitutes competence, competence assessment, and continuing competence has been

extensively debated (Bryant, 2005; Chiarella, 2006; Chiarella, et al., 2008; Cowan, Norman, &

Coopamah, 2005; Hendry, Lauder, & Roxburgh, 2007; Pearson, Fitzgerald, Walsh, & Borbasi,

2002). Recurring themes include the lack of consensus, the need for flexibility, and the

subjective nature of assessment processes (Vernon, Chiarella, & Papps, 2011; Vernon, et al.,

2010).

New Zealand is no different in this regard and, whilst the nursing profession has been

regulated for over 100 years, the enactment of the Health Practitioners Competence Assurance

Act 2003 (NZ) heralded a significant change in the regulation of all health practitioners,

including nurses (Vernon, Chiarella, et al., 2011). This new legislation brought fifteen health

professional groups under one Act and repealed previous separate statutes relating to

individual regulatory bodies. The principal purpose of the Health Practitioners Competence

Assurance Act 2003 (NZ) is stated as being

to protect the health and safety of members of the public by providing for

mechanisms to ensure that health practitioners are competent and fit to

practise their professions (Health Practitioners Competence Assurance Act

(NZ), 2003, s3).

8

The Health Practitioners Competence Act 2003 (NZ) delegates particular responsibilities to the

named regulatory authorities whose statutory role it is to regulate its practitioners. The

Nursing Council of New Zealand is the regulatory authority established to administer the

legislation in relation to nurses in New Zealand, and among other responsibilities, it establishes

and maintains the standards of education and practice, including continuing competence.

During the first years following implementation of the Health Practitioners Competence Act

2003 (NZ), there was vigorous public debate from some health professional groups with regard

to a perceived loss of their professional regulatory autonomy, and a perceived increase in

political and external government control (Briscoe, 2004). However the purpose of statutory

professional regulation is “to protect the public from harm – physical, mental or financial”

(Ministry of Economic Development (NZ), 2005a, 2005b), and, as such, it is the role of the

regulatory authority to implement and administer mechanisms to ensure the public are safe.

1.5 The purpose of professional regulation

Nurses and indeed other health professionals often misunderstand that the role of the

professional regulatory legislation is protective (Chiarella, 2002; Swankin, 1995). The

legislation, and therefore the institutions, roles and committees created by it, all exist to

protect the public from the risk of harm, rather than to protect the interests of the professions

so regulated (Adrian & Chiarella, 2010). The functions and powers of a regulatory authority

are defined in legislation and establish a form of regulatory regime known as a ‘protective

jurisdiction’ (Staunton & Chiarella, 2008, pp. 213-214). This form of professional regulation

provides:

• a barrier to entry to the professions by untrained persons;

• a mechanism for standards of education and practice to be established and enforced;

• an avenue for consumers to have complaints against practitioners addressed (National

Nursing and Nursing Education Taskforce, 2006).

This need for professional regulation is always a balancing act between public safety and the

risk of exclusionary practices or elitism. In New Zealand the Health Practitioners Competence

Assurance Act 2003 (NZ) was passed by Parliament on 11 September 2003 and received the

Royal Assent on 18 September 2003. The Act came fully into force one year later, on 18

September 2004. In doing so, the Act repealed eleven occupational statutes governing

9

thirteen health professions. The Health Practitioners Competence Assurance Act 2003 (NZ)

specifies the regulatory authorities that are responsible for the registration and oversight of

practitioners in the named health professions. These regulatory authorities are bodies

corporate, legislated for by the Health Practitioners Competence Assurance Act 2003 (NZ).

They have their own staff and premises and are funded by a levy on their professions. There

are now sixteen health professional groups regulated under this Act.

As previously noted, the purpose of the Health Practitioners Competence Assurance Act 2003

(NZ) is to protect the health and safety of the public; the responsible authorities1 fulfil this

purpose by ensuring that all health practitioners registered in that profession, are competent

in the practice of their profession. While in New Zealand the Minister of Health appoints the

members of all the regulatory authorities, there is a power in the Health Practitioners

Competence Assurance Act 2003 (NZ) for the Minister to make regulations so that a proportion

of the health professional members of an authority may be appointed according to elections

held among the profession. These provisions relating to elections have been enacted in New

Zealand with respect to two regulatory authorities; the Nursing Council and the Medical

Council.

1.6 Health Practitioners Competence Assurance Act 2003 (NZ)

The Health Practitioners Competence Assurance Act 2003 (NZ) names the regulatory

authorities, stipulates their legislative functions and related requirements, and affords them

individual discretion in relation to setting standards of professional competence, fitness to

practise and quality assurance (Vernon, Chiarella, et al., 2011). As previously noted, the

purpose of professional regulation in statute is “to protect the public from harm – physical,

mental or financial” (Ministry of Economic Development (NZ), 2005a), as such the Health

Practitioners Competence Assurance Act 2003 (NZ) affords regulatory authorities significant

power in relation to professional competence and requires them “to set standards of clinical

competence, cultural competence, and ethical conduct to be observed by health practitioners

of the profession” (Health Practitioners Competence Assurance Act (NZ), 2003, s118). These

1 The authority appointed in respect of the profession, the regulatory authority.

10

three standards are translated into the cornerstones of health professional education and are

afforded equal significance under the Act.

The Health Practitioners Competence Assurance Act 2003 (NZ) also stipulates that the

regulatory authority is responsible for the on-going assessment and monitoring of competence

throughout the professional’s career in practice. This does not remove the onus of

responsibility from the individual nurse to ensure they are, and continue to be, safe and

competent practitioners. However, at the time of its inception, it did provide the Nursing

Council of New Zealand, the regulatory authority for nurses in New Zealand since 1971, with

the opportunity to implement a mandatory process for the monitoring, assessment and

demonstration of continuing competence (Vernon, et al., 2010).

An additional provision of the Health Practitioners Competence Assurance Act 2003 (NZ) Part 1

s3 is that any health practitioner who is concerned about another health practitioner’s practice

and who considers the standard of practice “may pose a risk of harm to the public” is

mandated to notify the Registrar of the relevant authority (Health Practitioners Competence

Assurance Act (NZ), 2003, s34). On receipt of any complaint an investigation must be

completed. There are also mandatory provisions for both the public and specified health

providers to notify the Registrar about health concerns that may affect a health practitioner’s

ability to practise (Health Practitioners Competence Assurance Act (NZ), 2003, s45). However,

primarily it remains the responsibility of each individual health professional to ensure they are,

and continue to be, a safe practitioner.

Part 2 of the Health Practitioners Competence Assurance Act 2003 (NZ) is specific in terms of

setting out the conditions that a health practitioner is required to meet in order to practise. To

a large extent these conditions relate to the competence, and continuing competence, of

health practitioners and include, but are not limited to, having the qualifications prescribed by

the responsible regulatory authority; being competent to practise within the gazetted scope of

practice; and being ‘fit for registration’, which includes the ability to communicate effectively

for the purpose of practising within the specified scope of practice (Health Practitioners

Competence Assurance Act (NZ), 2003).

Part 3 of the Act provides the mechanisms for “improving the competence of health

practitioners and for protecting the public from health practitioners who practise below the

required standard of competence” (Health Practitioners Competence Assurance Act (NZ),

2003, s4). These mechanisms include provision for competence programmes, competence

11

reviews, recertification programmes, medical examinations and protected quality assurance

activities. This section of the Act contains provisions that allow health practitioners to notify

the regulatory authority if they have reason to believe another health practitioner may “pose a

risk of harm to the public by practising below the required standard of competence” (Health

Practitioners Competence Assurance Act (NZ), 2003, s34). It also enables the regulatory

authority to take any actions that they deem appropriate, to prevent a practitioner, who is

believed to pose a risk of serious “harm to the public by performing below the required

standard of competence” (Health Practitioners Competence Assurance Act (NZ), 2003, s34),

from practising. Part 3 of the Act also mandates the establishment of a single interdisciplinary

tribunal, the Health Practitioners Disciplinary Tribunal. The role of the Health Practitioners

Disciplinary Tribunal is to “hear and determine charges brought against health practitioners by

the Director of Proceedings or by a professional conduct committee” (Health Practitioners

Competence Assurance Act (NZ), 2003, s4). Part 4 of the Act provides for the establishment of

professional conduct committees to investigate offences (including those relating to

competence) made by health practitioners and to investigate complaints referred by the

Health and Disability Commissioner2.

1.7 Legislation and the Nursing Council of New Zealand

The legislation previously regulating the registration of nurses in New Zealand, the Nurses Act

1977 (NZ) and its subsequent amendments, was the last iteration of separate professional

legislation regulating nurses, and had its origins in the Nurses Registration Act 1901 (NZ).

Between 1901 and 1977, there were various changes to this legislation that quite specifically

addressed issues of public safety, but made no reference to competence. Instead, other terms

such as ‘fitness’ and ‘properness’ were used (Burgess, 2008; Papps & Kilpatrick, 2002). These

terms are arguably more associated with the notion of suitability to practise rather than

capability or ability to practise, which is more the focus of competence. Furthermore the

terms “fitness” and “properness” were not clearly defined under the Nurses Act 1977 (NZ), as

they were considered matters for judgment by the Nursing Council of New Zealand (Nurses

Regulations (NZ), 1986, R19(3)). Additionally, on payment of an annual fee, a practising

certificate was issued to each nurse on the register. There was no regulated requirement to

2 The Health and Disability Commissioner is appointed under the Health and Disability Commissioner Act 1994 (NZ).

12

demonstrate continuing competence for the practising certificate to be issued. It was assumed

that, on the basis of being registered, the practitioner was competent to practise.

The Health Practitioners Competence Assurance Act 2003 (NZ) clearly specifies the legislative

functions of the sixteen regulatory authorities, including the Nursing Council of New Zealand.

The statute does not provide a definition of competence, as this is a legislative function

delegated to the regulatory authority. However, as previously noted it does specify the

behaviour, accountability and responsibility required of health practitioners who are deemed

competent by the regulatory authority. The Nursing Council of New Zealand has defined

competence as “the combination of skills, knowledge, attitudes, values and abilities that

underpin effective performance as a nurse” (Nursing Council of New Zealand, 2010b).

Additionally the Health Practitioners Competence Assurance Act 2003 (NZ) s12 requires that

each regulatory authority appointed in respect of a health profession must, “by notice

published in the Gazette, describe the contents of that profession in terms of one or more

scopes of practice” (s12). “Scope of practice” means any health service that forms part of a

health profession described under section 11 of the Act and in relation to a “health

practitioner of that profession” means

One or more of such health services that the practitioner is, under an

authorisation granted under section 21, permitted to perform, subject to any

considerations for the time being imposed by the responsible authority (Health

Practitioners Competence Assurance Act (NZ), 2003, s5).

A scope of practice may be described in any way the regulatory authority sees fit and may be

by reference to a name or words commonly understood by persons who work in the health

sector (Health Practitioners Competence Assurance Act (NZ), 2003, s11). The regulatory

authority is also responsible for setting the standards for each scope of practice and, in doing

so, sets the boundaries in which a practitioner may practise, prescribes the necessary

qualifications and programmes of education required, is responsible for registering and

maintaining the register of practitioners, issues annual practising certificates, and monitors the

continuing competence of registered practitioners. The regulatory authorities have autonomy

in making such decisions as setting scopes of practice or fees. The instruments that give effect

to those decisions are known as ‘regulations’ and are subordinate legislation under the Act.

13

In 2004 the Nursing Council of New Zealand specified and gazetted four scopes of practice,

each with registration and competence requirements - Nurse Assistant, Enrolled Nurse,

Registered Nurse and Nurse Practitioner. In 2010 the Nurse Assistant scope of practice was

incorporated into the Enrolled Nurse scope of practice, thus there are now three registered

scopes of practice for nurses in New Zealand: Enrolled Nurse, Registered Nurse and Nurse

Practitioner. Each scope of practice has its own specified standards, domains and

competencies, which are required to be met on an on-going basis by all nurses registered

under the scope of practice.

The ‘profession specific’ registration authorities have the legal responsibility for monitoring the

educational institutions accredited and approved to provide programmes leading to

registration in a particular scope of practice. All Nurse Assistant, Enrolled Nurse, Bachelor of

Nursing, Master of Nursing (for preparation of Nurse Practitioners), and Competence

Assessment Programmes (CAP) are under the scrutiny of the Nursing Council of New Zealand,

which approves, monitors, and audits all nursing programmes for preparation for entry to the

register of nurses. Currently the Nursing Council of New Zealand also approves and monitors

some nursing programmes at graduate and postgraduate level, which do not lead to

registration in a scope of practice, for example, the Nurse Entry to Practice (NETP)

programmes, and some postgraduate programmes that contribute to the development of

Nurse Practitioner and advanced practice roles.

1.8 Continuing competence in New Zealand

In 2004, following the enactment of the Health Practitioners Competence Assurance Act 2003

(NZ), the Nursing Council of New Zealand established and implemented a Continuing

Competence Framework (Nursing Council of New Zealand, 2004a). Its primary purpose was to

provide mechanisms to ensure that nurses are “competent and fit to practise their profession”

as stipulated in s1 Health Practitioners Competence Assurance Act 2003 (NZ).

This new requirement introduced a significant change to the process for on-going nurse

registration that was neither possible nor necessary prior to the implementation of the new

legislation. Before the introduction of the Health Practitioners Competence Assurance Act

2003 (NZ), the only requirement for a nurse upon renewal of their certification of registration

was that they paid an annual fee and signed the renewal form. There was no requirement to

14

declare competence or to provide evidence of being competent (Papps, 1997; Vernon, et al.,

2010).

The changes following the introduction of the Health Practitioners Competence Assurance Act

2003 (NZ) were significant. The process for the on-going monitoring of the ‘continuing

competence’ of nurses, once registered and in practice is now the responsibility of the Nursing

Council of New Zealand. The Nursing Council of New Zealand now has the authority to decline

to issue an annual practising certificate (APC) if the applicant has, at any time, failed to meet

the required standard of competence, failed to comply with conditions, not completed an

ordered competence programme, or if they have not held an annual practising certificate or

practised for three years preceding application (Health Practitioners Competence Assurance

Act (NZ), 2003). The “required standard of competence” is identified under the Health

Practitioners Competence Assurance Act 2003 (NZ) as “the standard of competence reasonably

to be expected of a health practitioner practising within that health practitioner’s scope of

practice” (s5(1)).

The Nursing Council of New Zealand initially signalled the introduction of competence-based

practising certificates in 1994 with the publication of the ‘Strategic Plan 1st April 1994 to 31st

March 1997’. This, and further review of the historical progress of competence-based practice

in New Zealand, will be discussed in Chapter Four. However, it should be noted that the

original concept of the Nursing Council of New Zealand in 1994 varied from the Continuing

Competence Framework actually implemented by the Nursing Council of New Zealand in 2004

(Nursing Council of New Zealand, 2004a), which specified three indicators of continuing

competence. The original framework also specified the requirement for nurses to maintain a

personal professional profile and make a self-declaration of competence annually on

application for recertification.

The three current Nursing Council of New Zealand requirements for the Continuing

Competence Framework are:

A Evidence of on-going professional practice,

• Nursing practice is using nursing knowledge in a direct relationship with clients or

working in nursing management nursing administration, nursing education, nursing

research, nursing professional advice or nursing policy development roles, which

impact on public safety (minimum of 60 days or 450 hours within the last three

years).

15

B Evidence of on-going professional development,

• On-going education (minimum of 60 hours in the last three years, relevant to work

environment and practice as a nurse).

C Evidence of meeting the Council’s competencies for the “nurse” scope of practice,

• Self-declaration that states the individual meets the Council's competencies for

their scope of practice i.e. Registered Nurse, applied to the area or context in which

you practise (Nursing Council of New Zealand, 2006a).

The Nursing Council of New Zealand annually calls to audit, a random selection of 5% of the

nurses identified as ‘practice active’ on the register. In addition the Nursing Council of New

Zealand may call to audit any nurse who may be indicated as not meeting the continuing

competence requirements.

1.9 Professional development and recognition programmes (PDRP)

A point of confusion amongst nurses in the outcomes of Stage One of this research has been

the relationship of the Continuing Competence Framework, developed by the Nursing Council

of New Zealand, to the Framework for Professional Development and Recognition

Programmes, developed by the National Nursing Organisation (NNO)3 group. For this reason it

is included here in the background to the scheme, as it is an affiliated, although not an integral

system, to the Continuing Competence Framework.

Nationally the Professional Development and Recognition Programmes are offered by health

provider organisations to their nursing staff. These programmes have been approved and

audited by the Nursing Council of New Zealand, thus meeting a minimum set of continuing

competence standards. These programmes, whilst not leading to entry to the register, are

approved by the Nursing Council of New Zealand because they are a means of monitoring the

continuing competence of nurses within the approved health provider organisation. Following

the implementation of the Continuing Competence Framework (Nursing Council of New

Zealand, 2004a) the Nursing Council of New Zealand implemented guidelines for the approval

3 The National Nursing Organisation (NNO) group includes the Chief Nurse (MOH), Nurse Executives of New Zealand, New Zealand Nurses Organisation, Nurse Educators in the Tertiary Sector, college of Nurses (Aotearoa), Council of Maori Nurses, Nursing Council of New Zealand, Samoan Nurses’ Association, Australian and New Zealand College of mental Health Nurses and the College of Midwives.

16

of Professional Development and Recognition Programmes (PDRP) (Nursing Council of New

Zealand, 2004b). The National Framework for Nursing Professional Development and

Recognition Programmes and Designated Role Titles (2004) is the template for the

development of Professional Development and Recognition Programmes in New Zealand and

was developed by the National Nursing Organisation group as a tool that enables career

development of nurses.

Nurses that are identified as participating in a Professional Development and Recognition

Programme that has been approved by the Nursing Council of New Zealand, are then exempt

from the Nursing Council of New Zealand continuing competence audit process (Gunn et al.,

2009; Nursing Council of New Zealand, 2004b). It is not mandatory for employers to participate

in or administer a Professional Development and Recognition Programme. Nor is it a

requirement, in many employment situations, that nurses participate in a Professional

Development and Recognition Programme (Brinkman 2007). However, in addition to the tool

being used to monitor the continuing competence of nurses in some organisations, it has been

attached to salary increments, and is a component of Multi-Employer Collective Agreements

(MECAs)4.

1.10 Continuing competence in the international context

Continuing competence and public safety have been a focus of the International Council of

Nurses (ICN) and many regulatory jurisdictions internationally for over a decade. Regulatory

authorities in a number of countries make reference to “their duty to protect the public”

(Cutcliffe, 2010, p. 1343) and the relationship between continuing competence and safety to

practise (Bryant, 2005; International Council of Nurses, 2009). Implementation of credible

frameworks for the demonstration and assessment of continuing competence is acknowledged

as being a complex issue. It is also acknowledged that Continuing Competence Frameworks

are quality improvement tools that have a role in assisting regulators to guide and monitor the

continuing competence of the profession (Bryant, 2005; Canadian Nurses Association, 2000;

National Council of State Boards of Nursing, 2009a; Nursing and Midwifery Council (UK), 2011;

Nursing Council of New Zealand, 2006b).

4 Employment contracts between District Health Boards in New Zealand and the New Zealand Nurses Organisation (professional organisation and union representing the nurses).

17

Internationally a number of nursing regulatory jurisdictions have implemented continuing

competence models. However, over the past decade extensive debate has continued to occur

with regard to the efficacy of Continuing Competence Frameworks and, in particular the

purpose they have in terms of ensuring the safety to practise of health professionals. Issues

such as the validity and reliability of the competence indicators, and the financial viability and

administrative feasibility of these frameworks continue to be raised. To date no consensus

had been reached with regard to the most appropriate and efficacious model for regulatory

authorities to implement, in order to assess and monitor appropriately, the continuing

competence of the profession.

1.11 The impact of undertaking this work on my professional career

In the political climate where the health workforce is a matter of major concern, the regulation

of health professionals, in this case nurses, has become the subject of intense political scrutiny

and fast moving intervention. This has meant that my supervisors and I have had to move

quickly and be able to capitalise on opportunities made available to us in this political

environment. As a result, the design of my thesis has adapted according to the opportunities

and changing political context, and has therefore taken some paths that were not envisaged at

the commencement of the thesis. I believe that these opportunities have had a positive

impact on my final thesis. In fact, it would be fair to say that this work has had a beneficial

impact on my career, my personal and professional development.

I have held a variety of clinical leadership and management positions in the New Zealand

health sector and in nursing education during the past twenty years, and throughout this

journey I have become increasingly interested in the standards required for nursing education

and practice and the associated regulatory mechanisms required to protect the public. It was

primarily my interest in the latter that led me to undertake my doctoral studies.

Throughout my studies I have continued to develop my research platform with a particular

focus on nursing regulation and continuing competence. During this time I am privileged to

have been awarded a Fulbright Scholarship, and to have had the opportunity to work closely

with some inspirational nurse leaders, including my doctoral supervisors. I have presented my

research at a number of national and international conferences and have co-published with my

doctoral supervisors. A list of these research outcomes is provided (pp. xiii-xv).

18

1.12 Section and Chapter Descriptions

1.12.1 Section One introduces and positions the thesis and is divided into three chapters.

Chapter One has provided the introduction and the contextual background in

which the study is situated and presented the thesis structure and chapter

descriptions.

Chapter Two presents a review of national and international literature relating

to the development, implementation and assessment of continuing competence

models and frameworks. A brief summary of the current regulatory practices

relating to the continuing competence of requirements for nurses, in the six

countries identified as participants in this research (Australia, Canada, Ireland,

New Zealand, the United Kingdom, and the United States of America) is

provided. The conceptualisation of competence, continuing competence,

competence assessment and the validity and reliability of competence

indicators, in as much as these relate to public safety, is examined and key

findings are presented. The literature will also be used to inform the key

research outcomes in Chapters Seven, Nine and Ten.

Chapter Three sets out the overarching theoretical framework, research

perspective, and method used to undertake this research including a

justification for the research design, methods and the ethical considerations

taken. The detailed methods associated with the data collection and analyses,

for each of the two Stages of this research are presented sequentially in Section

Two and Section Three of the thesis.

1.12.2 Section Two presents Stage One of the research; the Evaluation of the Nursing Council

of New Zealand Continuing Competence Framework which was completed in three phases as

depicted in Figure 2 (p. 55). As previously noted, aspects of this thesis were completed under

contract to the Nursing Council of New Zealand to evaluate the efficacy of the Continuing

Competence Framework, which was implemented by the Nursing Council of New Zealand in

2004 following enactment of the Health Practitioners Competence Assurance Act 2003 (NZ).

Chapter Four presents the findings of Phase One of the evaluations of the

Nursing Council of New Zealand Continuing Competence Framework and

19

provides an overview of the legislative history governing the regulation of the

nursing profession in New Zealand. The collated findings derived from the

document review and policy analysis of Nursing Council of New Zealand

documents leading up to and following implementation of the Health

Practitioners Competence Assurance Act (NZ) 2003 are presented.

Chapter Five presents the findings of Phase Two of the evaluation, the

interviews with key nurse stakeholders.

Chapter Six presents the findings of Phase Three, the e-survey of New Zealand

nurses active on the Nursing Council of New Zealand register.

Chapter Seven provides a triangulation of the cumulative data from Phase One,

Two and Three addressing the project outcomes identified by the Nursing

Council of New Zealand and providing a summary of key research findings to

inform the second Stage of this research.

1.12.3 Section Three presents Stage Two; The consensus model for the assessment of

continuing competence. The international component of this thesis draws on the findings of

Stage One, and in particular the evaluation of the Nursing Council of New Zealand Continuing

Competence Framework. Findings from Stage One assisted to position the research in terms

of its international relevance and transferability, providing a platform from which to evaluate

the possibility of developing an international consensus model for the assessment of

continuing competence.

Chapter Eight provides an overview of the Delphi processes that were

undertaken and presents the analysis of the findings that emerged from the first

three Delphi rounds. A summary of the consensus views and the key principles

derived from the Delphi rounds (one-three) are presented.

Chapter Nine presents and discusses the analysis of the Delphi Round Four

participant responses and provides a summary of the overall consensus views in

relation to the three research questions, and in association with the

contemporary literature. Recommendations for the development of a best

practice international consensus model for the assessment of continuing

competence are proposed.

20

1.12.4 Section Four focuses on positioning the thesis in terms of the New Zealand and

international nursing regulatory environment.

Chapter Ten presents the triangulation of the cumulative findings from Stages

One and Two of the research in relation to the three overarching research

questions:

1. What are the relationships between current legislation, policy drivers and the

statutory requirements to ensure registered nurses are competent and fit to

practise?





A discussion of the findings and the limitations of this thesis are presented,

including recommendations for future development of the best practice

consensus model for the assessment of continuing competence, the associated

implications for key stakeholders, and recommendations for policy change.

1.13 Concluding remarks

This chapter has provided an introduction and background to the thesis. The thesis structure

has been described and presented in association with the Section and Chapter descriptions.

Chapter Two will provide a summary of the contemporary literature in relation to the concept

of continuing competence, understandings of competence frameworks, validity and reliability

of assessment processes, and the relationship of legislation, regulatory authorities, and public

safety, to models of continuing competence.

21

CHAPTER TWO - LITERATURE REVIEW

2.1 Introduction

This chapter reviews and summarises national and international literature relating to the

development and implementation of Continuing Competence Frameworks. A brief summary

of the current regulatory practices relating to the continuing competence of requirements for

nurses, in the six countries identified as participants in this research (Australia, Canada,

Ireland, New Zealand, the United Kingdom, and the United States of America is provided). The

conceptualisation of competence, continuing competence, competence assessment and the

validity and reliability of competence indicators, in as much as these relate to public safety, will

be examined. Key findings are summarised and presented at the conclusion of this chapter.

2.2 Search strategy

An extensive search of national and international literature relating to nursing, and health

professional disciplines was completed using the following search engines and data bases –

CINAHL, Google, ProQuest, and Ovid. In addition, the websites of nursing regulatory

authorities in New Zealand, Australia, Canada, Ireland, the United Kingdom and the United

States of America were searched. The International Council of Nurses and nursing regulatory

authorities and / or professional organisations in Australia, Canada, Ireland, the United

Kingdom, the United States of America and New Zealand were contacted directly by email,

telephone and/or face-to-face to ascertain and discuss the ‘continuing competence models’

currently being used in each jurisdiction.

The key search terms were – nursing regulation, competence, nurse competence,

continuing[ed]5 competence, competence frameworks, competence indicators, continuing[ed]

professional development, continuing[ed] nursing education, competence indicators, and

recency of practice. These words and terms were searched for in combination and

individually. Publication in the English language was an additional search criterion.

Of particular note to this literature review were eight important international reviews related

to nursing regulation and continuing competence in nursing completed between, 2000 and

5 The terms ‘continuing competence’ and ‘continued competence’ appear to be synonymous, and are frequently used interchangeably in the literature. For the purpose of this research the term continuing competence will be used.

22

2012 (Australian Nursing and Midwifery Council, 2007; Bryant, 2005; Canadian Nurses

Association, 2000; Chiarella, et al., 2008; EdCaN, 2008; Fitzgerald, Walsh, & McCutcheon, 2001;

International Council of Nurses, 2009; National Council of State Boards of Nursing, 2009a;

Vandewater, 2004).

2.3 Background – national and international regulatory context

Nationally and internationally the understandings of competence, and continuing competence

have been extensively debated (Bryant, 2005; Chiarella, 2006; Chiarella, et al., 2008; Cowan, et

al., 2005; EdCaN, 2008; Hendry, et al., 2007; Pearson, Fitzgerald, Walsh, et al., 2002; Vernon, et

al., 2010). This is particularly evident when reviewing the international literature published in

the period from 1995 to 2010. During this time, work was undertaken worldwide by the

various groups including the International Council of Nurses, nursing regulatory authorities and

professional nursing organisations in an attempt to define and understand the concept of

continuing competence, how it can be measured, and its relationship to public protection

(Australian Nursing and Midwifery Council, 2007; Brunke, 1997; Bryant, 2005; Campbell &

MacKay, 2001; Canadian Nurses Association, 2000; Nursing and Midwifery Council (UK), 2011;

Nursing Council of New Zealand, 1999; Pearson et al., 1999; Swankin, 1995).

Traditionally the system for regulating health professionals, once qualified and deemed fit to

practise, was that the relevant regulatory authority placed their name on the professional

register, where it remained for the period of their life unless a serious reason for removal was

proven. Members of the profession and public trusted that registrants continued to be fit to

practise throughout their careers (Secretary of State for Health (UK), 2007). Swankin (1995)

reports that in 1995 the Citizen Advocacy Centre (USA) asked the question “Can the public be

confident that health care professionals who demonstrated minimum levels of competence

when they earned their licenses continue to be competent years and decades after they have

been in practice?” (Swankin, Arnold LeBuhn, & Morrison, 2006, p. 3). Whilst there is general

agreement that the “purpose of assuring the continuing competence of nurses, is the

protection of the public” (International Council of Nurses, 2006, p. 1) and this is the reason

regulatory authorities exist, the ultimate responsibility and accountability to continue to be

competent lies with the individual health professional (Canadian Nurses Association &

Canadian Association of Schools of Nursing, 2004; National Council of State Boards of Nursing,

2005; Nursing Council of New Zealand, 2006b). However, assuring the continued competence

of health professionals is still an item of debate that continues to receive attention as

23

consumers of health care have greater access to information, and are more questioning of the

services that they receive (International Council of Nurses, 2006). Health professionals no

longer work in an environment where trust alone is proof of continuing competence. The

public expectation is that any trust that is bestowed is underpinned by objective assurance

(Secretary of State for Health (UK), 2007). How to assure the continuing competence of health

professionals is at the core of this international debate.

As previously noted, the regulatory requirements in the jurisdictions of most countries contain

an expectation that nurses will be competent to practise nursing on registration, and that they

will maintain their competence to practise throughout their nursing careers (Chiarella, et al.,

2008). In addition the regulatory authorities within many of these countries also have a legal

mandate to ensure professional competence (Vandewater, 2004) and assure public safety.

An international comparative study was undertaken in 2009 by the International Council of

Nurses (International Council of Nurses, 2009) focusing on the role and identity of the

regulator. An aspect of this study examined the legislation and continuing competence

requirements of the 172 participant nursing jurisdictions. The study reported that 59% of the

jurisdictions specified requirements for ongoing registration and relicensure including

demonstrated hours of practice, continuing education and /or continuing competence. The

report noted that the requirement to provide evidence of hours of practice for ongoing

relicensure was significantly higher within the United States of America (65%) and Canada

(78%) than in other participant countries. Continuing professional development (hours and

education credits) were also requirements within these two regions and also in African

countries. Continuing competence requirements were identified in the African, Australian

[New Zealand was included in this grouping] and Canadian jurisdictions (International Council

of Nurses, 2009).

In 46% (n = 49) of the nursing jurisdictions, continuing professional development was required

by legislation. Practice hours were required by legislation in 38% (n = 41) of jurisdictions and

continuing competence was required by legislation in 47% (n = 50) of jurisdictions. Audit of a

registrant’s compliance with the continuing competence requirements was identified as being

required in only 18% (n = 19) jurisdictions. Frequency of recertification / relicensure / renewal

processes ranged from annually to every six years (International Council of Nurses, 2009, p.

19). Of note is that ongoing relicensure and/or continuing competence requirements were

more evident in the legislation in jurisdictions in the United States of America, Canada, and

Australia where legal challenges are far more prevalent. In other jurisdictions, such as the

24

United Kingdom, the primary legislation is silent; however provision for continuing

competence is located in subordinate legislation (International Council of Nurses, 2009).

It is acknowledged that the nursing profession is a mobile workforce, nationally and

internationally. The literature indicates that globalisation, rapid technological advances,

changes in the provision of health services and health workforce requirements, have gone

hand-in-hand with nursing workforce challenges including nursing shortages in some

jurisdictions (Cutcliffe, 2010; International Council of Nurses, 2009; Vandewater, 2004). These

factors have increased the need to provide timely, consistent and streamlined regulatory

processes to facilitate the movement of nurses (Cutcliffe, 2010). A number of countries and/or

states or provinces within countries have instituted mutual recognition agreements. An

example of a mutual recognition agreement is the Trans-Tasman Mutual Recognition

Agreement (TTMRA) between Australia and New Zealand (Council of Australian Governments

Committee on Regulatory Reform, 1998), that exists to provide a mechanism for “reducing or

eliminating regulatory impediments to trade in goods and in the movement of skilled

practitioners between Australia and New Zealand” (Council of Australian Governments

Committee on Regulatory Reform, 1998, p. 10). The Nurse Licensure Compact (USA) (National

Council of State Boards of Nursing, 2013c), which was enacted in 2000 to expand the mobility

of nurses within the United States requires them to have one multistate license, with the

ability to practice in their home state and other party states. These agreements provide

reciprocity of equivalent qualifications and are based on the premise that the standards of

education and practice, including competence requirements, are of an equivalent standard

between the regulatory jurisdictions who are party to the agreement. The challenge now

being faced by regulators, is how to equate continuing competence requirements without

producing undue barriers (Cutcliffe, 2010; International Council of Nurses, 2009).

2.3.1 New Zealand

Competency standards have been developed in New Zealand and internationally as a way of

differentiating and standardising the variations in scopes and levels of practice within the

nursing profession (Chiarella, et al., 2008; EdCaN, 2008; International Council of Nurses, 2007;

Vernon, et al., 2010). In New Zealand the implementation of the Health Practitioners

Competence Assurance Act 2003 (NZ) brought with it a major shift in emphasis, and mandated

a greater focus on health practitioners’ competence and continuing[ed] competence (Health

Practitioners Competence Assurance Act (NZ), 2003). With this change in legislation has come

an increased consumer awareness and a focus on public safety (Health and Disability

25

Commissioner Act (NZ), 1994; Vernon, Chiarella, et al., 2011). Prior to this, the system for

regulating health professionals in New Zealand once they had qualified in their respective

discipline, and demonstrated that they were fit to practise, was registration for life. For nurses,

practising certificates were renewed annually on application to the Nursing Council of New

Zealand and by paying a fee (Vernon, Chiarella, et al., 2011; Vernon, et al., 2010), and was not

unlike many of the other regulatory jurisdictions of the time.

As previously noted the Health Practitioners Competence Assurance Act 2003 (NZ) requires the

Nursing Council of New Zealand (the regulatory authority) to set the requirements for

programmes that lead to entry to the register of nurses and also the requirements for, and

monitoring of, the continuing competence of nurses once registered. The Nursing Council of

New Zealand is the product of a protective jurisdiction6 and its Continuing Competence

Framework is a mechanism of recertification that allows nurses to demonstrate annually that

they remain competent and fit to practise. These changes have been the subject of

considerable debate in New Zealand following the introduction of the Continuing Competence

Framework (2004), but the prevailing view of government is that trust alone is insufficient to

guarantee individuals are “competent and fit to practise in their profession”(Health

Practitioners Competence Assurance Act (NZ), 2003, s3). For the large majority of New Zealand

nurses, this mechanism of recertification provides reassurance and reinforcement of their

continued competence and performance. However, for a small minority, it is a mechanism for

identifying noncompliance with the recertification requirements and in some instances

continuing competence issues (Vernon, et al., 2010).

In 2010 the Nursing Council of New Zealand requested the Council for Healthcare Regulatory

Excellence (UK) to undertake a review of the effectiveness of the Nursing Council of New

Zealand governance arrangements, and the conduct, competence and health functions. The

review was carried out in 2012. The review considered that overall the Nursing Council of New

Zealand

has satisfactory governance arrangements and that it generally has effective

processes for handling cases under the conduct, health and competence

procedures, researches appropriate decisions that protect the public and

6 The legislation, and therefore the institutions, roles and committees created by it, all exist to protect the public from the risk of harm, rather than to protect the interests of the professions so regulated (Staunton & Chiarella, 2008).

26

provides a good level of service to those who are involved (Council for

Healthcare Regulatory Excellence, 2012a, p. 3).

The review determined that the Nursing Council of New Zealand has effective processes for

handling conduct, competence and health related cases and thereby fulfils its role of

protecting the public by ensuring that the individual health professionals they regulate are fit

to practise (Council for Healthcare Regulatory Excellence, 2012a).

2.3.2 Australia

During the past decade the Australian Nursing and Midwifery Council (ANMC), the peak

regulatory body in Australia until 2010, undertook a considerable amount of work related to

continuing competence and the assessment of continuing competence (Australian Nursing and

Midwifery Council, 2007, 2009; Chiarella, 2006; Chiarella, et al., 2008). In 2009 the Australian

Nursing and Midwifery Council presented a Continuing Competence Framework (2009) for

nurses that is similar to, and references the Nursing Council of New Zealand Continuing

Competence Framework (Australian Nursing and Midwifery Council, 2009). In October of 2009

the Nursing and Midwifery Board of Australia (the newly formed national regulatory authority

for nurses in Australia) consulted on six mandatory registration standards relating to

registration, continuing competence and licensure.

The Health Practitioner Regulation National Law Act 2009 (Qld) was enacted on the 1 July 2010

and with it, the National Registration and Accreditation Scheme (NRAS) came into force. The

National Scheme amalgamated “eight state and territory jurisdictional registration and

accreditation schemes into one national scheme for fourteen separate health professions”

(Chiarella & White, 2013, p. 3). The introduction of the National Registration and

Accreditation Scheme involved a shift of separate 65 pieces of legislation into one National

Law (Chiarella & White, 2013), the Health Practitioner Regulation National Law Act 2009 (Qld).

National registration of nurses in Australia is now a legislated requirement. The

implementation of the mandatory Continuing Competence Registration Standards (Health

Practitioner Regulation National Law Act (Qld), 2009) took effect at the same time. These

Standards incorporate similar indicators of competence to those found in the Nursing Council

of New Zealand Continuing Competence Framework: self-assessment; practice hours; and

continuing professional development (CPD). However, they provide more comprehensive

detail in terms of their specific requirements, definitions and terminology and are situated in

the primary legislation.

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2.3.3 Canada

Throughout the Canadian regulatory jurisdictions continuing competence assessment

programs exist and are instituted with either voluntary or mandatory requirements. The

continuing competence programs instituted by Canadian regulatory bodies draw heavily on

the work completed by the Canadian Nurses Association in 2000 – Development of a national

framework for continuing competence programmes for registered nurses (Canadian Nurses

Association, 2000). This document provides an in depth overview of the concept of continuing

competence in nursing, including the advantages, limitations and regulatory considerations, of

nine tools currently in use by nursing regulatory bodies within Canada.

In 2011 the Canadian Council of Registered Nurse Regulators (CCRNR) Incorporated, a national

organisation of registered nurse regulators in Canada, was formed bringing together

representation from all twelve nursing regulatory bodies in Canada:

• College of Registered Nurses of British Columbia

• College and Association of Registered Nurses of Alberta

• Saskatchewan Registered Nurses’ Association

• College of Registered Nurses of Manitoba

• College of Nurses of Ontario

• Ordre des infirmières et infirmiers du Québec

• Nurses Association of New Brunswick

• College of Registered Nurses of Nova Scotia

• Association of Registered Nurses of Newfoundland and Labrador

• Association of Registered Nurses of Prince Edward Island

• Registered Nurses Association of the Northwest Territories and Nunavut

• Yukon Registered Nurses Association (Canadian Council of Registered Nurse Regulators, 2011).

Prior to 2011, the individual Regulatory Boards in each Canadian province and territory, except

for Quebec, belonged to the Canadian Nurses Association (CNA). Introduction of this

incorporated federated model has provided the ability to institute national regulatory

principles, however to date there is not a national Continuing Competence Framework.

The central premise of the continuing competence programmes instituted in Canada is that

the individual nurse has the primary responsibility for demonstrating continued competence

and each Regulatory Board has a legal mandate, through its province’s legislation to ensure

28

professional competence (Canadian Nurses Association & Canadian Association of Schools of

Nursing, 2004; Vandewater, 2004). The regulatory jurisdictions in Australia and New Zealand

also consider that the individual nurse is responsible and accountable for their own continuing

competence. However, in New Zealand the Government, through the legislation (Health

Practitioners Competence Assurance Act (NZ), 2003), also holds the organisations that employ

nurses responsible for enabling competent practice (New Zealand Public Health and Disability

Act (NZ), 2000).

2.3.4 The United States of America

The United States of America and its territories has a federated system of government,

containing the largest number of regulatory bodies and the largest number of nurses

registered / licensed to practice in the world (International Council of Nurses, 2009). The

National Council of State Boards of Nursing (NCSBN) is defined as a

not-for-profit organization whose purpose is to provide an organization through

which Boards of nursing act and counsel together on matters of common

interest and concern affecting the public health, safety and welfare, including

the development of licensing examinations in nursing (National Council of State

Boards of Nursing, 2013a, p. 1).

The National Council of State Boards of Nursing has an important role in: promoting uniformity

of the regulation of nursing practice; collaboratively setting national standards and policy

direction lobbying Federal Government; monitoring trends in public policy, nursing practice

and education; and conducting research on nursing practice issues (National Council of State

Boards of Nursing, 2013a). Although having no authority in terms of specific regulatory

functions, the National Council of State Boards of Nursing has 60 Member Boards. The

member boards are comprised of the Regulatory Boards of nursing in the following

jurisdictions:

• Fifty U.S. states;

• District of Columbia;

• Four United State territories-American Samoa, Guam, Northern Mariana Islands,

and the Virgin Islands;

29

• Four states have two Boards of nursing, one for registered nurses (RNs) and one

for licensed practical/vocational nurses (LPN/VNs): California, Georgia, Louisiana

and West Virginia;

• One state, Nebraska, has both the Board of nursing and the Board for Advanced

Practice Nurses (APRNs) represented (National Council of State Boards of

Nursing, 2013b).

The National Council of State Boards of Nursing has long acknowledged that continued

competence is a critical regulatory issue and has undertaken a substantial amount of work

attempting to establish an economically feasible, valid and reliable tool. In addition nursing

Licensing Boards within the United States jurisdictions are increasingly being challenged to

provide assurance to the public that licensees (nurses) continue to be competent throughout

their careers (National Council of State Boards of Nursing, 2005, 2009a). However, nationally

across the states and territories “there is no agreement on who should be responsible for

continuing competence” (National Council of State Boards of Nursing, 2005, p. 1), nor has

there been consistent implementation of Continuing Competence Frameworks or

requirements for evaluating and ensuring continuing competence (National Council of State

Boards of Nursing, 2009c). A number of individual nursing Regulatory Boards have developed

and implemented comprehensive continuing competence requirements and associated

frameworks, for example the North Carolina Board of Nursing, the Texas Board of Nursing, and

the Washington State Nursing Care Quality Assurance Commission. However, at the other end

of the continuum there are Boards of nursing that still do not require any demonstration of

continuing competence in order for their nurses to gain relicensure.

In the United States of America as early as 1991 the National Council of State Boards of

Nursing was considering the measurement of competence from an empirical and standard

setting perspective. The NCSBN Conceptual Framework for Continued Competence was

published in 1991 (National Council of State Boards of Nursing, 1991). This paper stressed the

importance of the assessment of learning needs and strategies to promote continued

competence. In 1995 the Pew Health Professions Commission7 Task Force on Health Care

Workforce Regulation report Reforming healthcare workforce regulation: Policy consideration

for the 21st century (Taskforce on Health Care Workforce Regulation, 1995) was published.

7 The Pew Health Professions Commission (USA) is a leader in health force policy in the United States of America.

30

This (1995) report advocates the periodic demonstration of competence by health

professionals throughout their careers, and has become a landmark document in the ongoing

‘continuing competence’ debate. The report made ten recommendations, two of which relate

specifically to the continued competence of health professionals in the United States.

Recommendation (3) - States should base their practice acts on demonstrated

initial and continued competence…

Recommendation (7) - States should require each Regulatory Board to develop,

implement and evaluate continuing competency requirements to assure the

continuing competence of regulated health professions (Taskforce on Health

Care Workforce Regulation, 1995, p. ix).

In 1996, in response to the recommendations of the Pew Report (1995) the National Council of

State Boards of Nursing issued the position paper Assuring Competence: A Regulatory

Responsibility. This paper included the following definition of competence “the application of

knowledge and the interpersonal, decision-making, and psychomotor skills expected for the

Nurse’s practice role, within the context of public health, safety and welfare” (National Council

of State Boards of Nursing, 1996). This definition remains current today (National Council of

State Boards of Nursing, 2011, p. 12) and reflects the importance of nurses being able to apply

knowledge, interpersonal skills and decision making within a practice context rather than

purely retaining factual information (National Council of State Boards of Nursing, 2005).

The American Nurses Association Expert Panel (1999) developed and published a summary of

key assumptions relating to continuing competence. These key assumptions are of particular

relevance to the research being undertaken for this thesis:

• Continuing competence is for the protection of the public and advancement of

the profession.

• It is the public’s right to expect competence.

• Competency assurance must be shaped by the profession.

• Assurance of continued competence is a shared responsibility of the profession,

regulatory bodies, employers, and individual nurses.

• Nurses are individually responsible for maintaining competence.

• It is the employers’ responsibility to provide an environment conducive to

competent practice.

31

• Competence is considered in the context of level of expertise, responsibility, and

domains of practice (Whittaker, Carson, & Smolenski, 2000).

An important research project Evaluating the Efficacy of Continuing Education Mandates

(Smith, 2003) was completed for the National Council of State Boards of Nursing in 2003. This

research explored the link between mandatory continuing education for relicensure and the

development of professional competence. A survey was sent to 4000 randomly selected

nurses from the following groups: 2000 licensed practical or vocational nurses, and 2000

registered nurses. This statistically significant study identified that nurses perceived that work

experience, their basic professional education, and mentors / preceptors were stronger

contributors to their professional development than continuing education (Smith, 2003). This

research contributed to the development of the NCSBN Model of Nursing Practice Act and

Model Nursing Administrative Rules adopted by the National Council of State Boards of

Nursing Delegate Assembly8 in 2004, that requires 900 practice hours over the preceding three

year period, rather than specified continuing education (National Council of State Boards of

Nursing, 2005) for relicensure.

2.3.5 Ireland

The Nursing and Midwifery Board of Ireland (Bord Altranais agus Cnáimhseachais na

hÉireann), the Regulatory Board for the nursing profession in Ireland was established by the

Nurses Act 1950 (Ireland). In 1985 the Board was re-constituted and had its functions re-

defined and expanded to operate under the provisions of the Nurses Act 1985 (Ireland). The

Nurses and Midwives Act 2011 (Ireland) was signed into legislation on 21 December 2011,

however to date only Sections 1 and 2 and Part 12 have been enacted. At the present time

the Nursing and Midwifery Board continues to operate under the provisions of the old Nurses

Act, 1985 pending commencement of the various provisions of the new national legislation.

The Nurses Act 1985 (Ireland) is silent on the issue of continuing competence and instead

refers to fitness to practice. Currently the Nursing and Midwifery Board of Ireland do not

require nurses to demonstrate continuing competence. Annual payment of a ‘retention’ fee is

all that is required for nurses and midwives to remain active on the register. However nurses

and midwives are encouraged by the Nursing and Midwifery Board to engage in approved

8 NCSBN Delegate Assembly has representation from all the United States and Territories Regulatory Boards.


32

continuing education programmes. Continuing competence is a regulatory requirement

stipulated in the Nurses and Midwives Act 2011 (Ireland). Development of a Continuing

Competence Framework is a project currently being undertaken by the Planning and

Development Department of the Nursing and Midwifery Board of Ireland and is being trialled

with Nurse Practitioners.

2.3.6 The United Kingdom

Improved regulation has been a theme of government action in the United Kingdom (UK) since

the establishment of the Better Regulation Task Force9 in 1997, whose task it was to advise the

Government on action to reduce unnecessary regulatory and administrative burdens, and

ensure that regulation and its enforcement are proportionate, accountable, consistent,

transparent and targeted” (Better Regulation Task Force, 1997). The Task Force identified five

core principles as a test of whether regulation is fit for purpose:

Proportionality: Regulators should intervene only when necessary. Remedies

should be appropriate to the risk posed, and costs identified and minimised.

Accountability: Regulators should be able to justify decisions and be subject to

public scrutiny.

Consistency: Government rules and standards must be joined up and

implemented fairly.

Transparency: Regulators should be open, and keep regulations simple and

user-friendly.

Targeting: Regulation should be focused on the problem and minimise side

effects (Better Regulation Task Force (UK), 2005, pp. 26-27).

The concept of ‘right-touch’ regulation emerged from the European financial crisis and the

application of the UK Principles of better regulation (Better Regulation Task Force (UK), 2005,

pp. 26-27). It has since been applied to the regulation of health professions, with the addition

in 2009, of a sixth core principle “agile and adaptive” (The House of Commons Regulatory

Reform Committee (UK), 2009, p. 3). It is described as regulation that exists to protect people,

but does not unduly control how they live their lives. It occurs through “laws, regulations and

standards that restrain those who intend ill, those who are careless of the wellbeing of others

9 A quasi-autonomous public body who worked under the oversight of the Department for Business, Enterprise and Regulatory Reform (UK).


33

and those whose greed or incompetence causes harm” (Council for Healthcare Regulatory

Excellence, 2010, p. 4). It is defined as “the minimum regulatory force required to achieve the

desired result” (Council for Healthcare Regulatory Excellence, 2010, p. 4).

A landmark document Trust, Assurance and Safety – The Regulation of Health Professionals in

the 21st Century (Secretary of State for Health (UK), 2007), commonly known as The White

Paper, was presented to the parliament of the United Kingdom by the Secretary of State for

Health in 2007. This document outlines a programme of reform for the regulation of health

professionals in the United Kingdom and draws on the findings of two previous reviews of

professional regulation Good doctors, safer patients (Chief Medical Officer of Health (UK),

2006) and The regulation of the non-medical healthcare professions (Department of Health

(UK), 2006). The report presents a proposed programme of reform for the regulation of health

professionals in the United Kingdom. An important aspect of this paper is the proposal to

ensure that all statutorily regulated health professions have as part of their revalidation, a

requirement to demonstrate their continued fitness to practise, and for employees of an

approved body, for example nurses working in a National Health Service organisation,

evidence to support revalidation will be provided by the employer to the regulatory Council

(Secretary of State for Health (UK), 2007). The report proposes that for the majority of health

professionals, revalidation provides reassurance and reinforcement of performance and

encourages improvement. However for a minority of health professionals revalidation

provides a way of identifying problems and an opportunity to address them (Secretary of State

for Health (UK), 2007).

As previously noted the legislation that governs nurses and midwives in the United Kingdom,

the Nurses, Midwives and Health Visitors Act 1997 (UK) is silent with regard to continuing

competence requirements. However, The Nursing and Midwifery Order 2001 (UK) Part V s21

clearly stipulates the Nursing and Midwifery Council’s functions in respect of “fitness to

practise, ethics and other matters” (The Nursing and Midwifery Order 2001 (UK) 2001, p. 13).

For over 20 years the Nursing and Midwifery Council (NMC) has had in place the Post-

registration Education and Practice (Prep) model. This model is designed to assist nurses and

midwives to provide a high standard of practice and care and is comprised of the Nursing and

Midwifery Council standards and guidelines (Nursing and Midwifery Council (UK), 2011) in

association with The code: Standards of conduct, performance and ethics for nurses and

midwives (Nursing and Midwifery Council (UK), 2008). Aspects of the Prep model contributed

34

to the development of the Continuing Competence Frameworks in Canada (Canadian Nurses

Association, 2000) and New Zealand (Nursing Council of New Zealand, 1999) in the late 1990s.

The Prep Handbook - A post-registration ongoing education and practice resource for nurses,

midwives and specialist community public health nurses (Nursing and Midwifery Council (UK),

2011) specifies the “professional standards” (Nursing and Midwifery Council (UK), 2011, p. 4)

required of nurses who are applying to renew their registration. The Prep Practice Standard

requires that nurses complete a minimum of 450 hours of nursing or midwifery practice; and

the Prep Continuing Professional Development Standard requires completion of a minimum of

35 hours of learning activity (relevant to practice) in the three years prior to renewal of

registration, or the successful completion of a return to practice course (Nursing and

Midwifery Council (UK), 2011). In addition, a nurse or midwife must keep a record of all

continuing professional development undertaken in the three years prior to renewal of

registration and comply with any request from the Nursing and Midwifery Council to audit

these requirements (Nursing and Midwifery Council (UK), 2011). Whilst an annual registration

fee is paid, renewal of registration is only required every three years. Since April 2000 nurses

have been required to declare on the ‘notification of practice (NoP) form’ that they have met

these standards.

Despite the recommendations of the White Paper (2007), the Nursing and Midwifery Council

Prep requirements, and the previous United Kingdom Central Council for Nursing, Midwifery

and Health Visiting (UKCC) Fitness for Practice Review (1999), concerns continued to be raised

about skill deficits and lack of national approaches to competence assessment (National

Nursing Research Unit, 2009). In 2012 the Council for Healthcare Regulatory Excellence was

commissioned by the government of the United Kingdom (UK) to undertake a strategic review

of the Nursing and Midwifery Council (UK) following criticisms about its performance, including

a failure to deal with a longstanding backlog of fitness to practise cases (Council for Healthcare

Regulatory Excellence, 2012b). The report findings stated

A regulator is charged with two key responsibilities: to protect the public and to

uphold public confidence. In the NMC’s [Nursing and Midwifery Council] case, this

means to uphold confidence in the practice of nurses and midwives. The NMC has

continued to carry out its public protection duties, although not as well as it

should but, as its stakeholders make clear, it is not inspiring confidence in the

professions or in professional regulation (Council for Healthcare Regulatory

Excellence, 2012b, p. 3).

35

In response to the findings of the Strategic review of the Nursing and Midwifery Council

(Council for Healthcare Regulatory Excellence, 2012b) and building on the recommendations of

The White Paper (2007), the Nursing and Midwifery Council is currently undertaking a

substantial review of their continuing competence requirements and systems for revalidation

of nurses and midwives. The Nursing and Midwifery Council states that the aim of this review

is to “deliver a proportionate, risk-based and affordable system that will provide greater public

confidence in the professionals regulated by the NMC” (Nursing and Midwifery Council (UK),

2012, p. 1). This work is not anticipated to be completed before 2015.

A summary of the current continuing competence requirements for nurses across the six

countries that are identified as the primary focus of this research (Australia, Canada, Ireland,

New Zealand, the United Kingdom, and the United States of America) are presented in Table 3.

Table 3 Continuing competence requirements for nurses across six countries

Australia Nursing and Midwifery Board of Australia (National Legislation, and 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

*Percentage of nurses to be audited annually – pilot to be commenced in 2013 National legislation, Health Practitioner Regulation National Law Act 2009 (Qld). Continuing competence is a regulatory requirement stipulated in the Act.

Canada Canadian Council of Registered Nurse Regulators (CCRNR 2011) Incorporated organisation. (Incorporated Federated model - National principles - no National Framework) Prior to CCRNR individual Regulatory Boards in each province and territory except for Quebec belonged to the Canadian Nurses Association (CNA)

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.

36

Ireland Nursing and Midwifery Board of Ireland (Bord Altranais agus Cnáimhseachais na hÉireann)

Annual payment of a ‘retention’ fee to remain on the register of Nurses and / or Midwives Currently no mandated or formally monitored continuing competence requirements – identified as a current project - framework being trialled with Nurse Practitioners *No audit requirements National legislation, Nurses and Midwives Act 2011 (Ireland) signed into legislation 21 December 2011. 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 Kingdom Nursing and Midwifery Council (NMC) (National Framework)

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.

United States of America National Council of State Boards of Nursing (NCSBN, Council of regulators - Incorporated Federal Model) (National Principles, and recommendations for a national framework – project on going) Individual Regulatory Boards in each State with variation in terms of requirements

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 others Separate legislative jurisdictions and Regulatory Boards in each State and Territory. Mutual recognition agreements exist between some States. Continuing competence requirements vary between States and Territories, from comprehensive frameworks to payment of an annual revalidation fee.

37

2.4 Competence and continuing competence

The need for continuing competence is agreed by regulatory authorities to be necessary to

protect the public (Vernon, Chiarella, et al., 2011). Given the multifaceted nature of nursing

practice and the diversity of practice settings, it is evident that the role and context in which

the nurse practises are also critical considerations when assessing continuing competence

(Vernon, et al., 2010). Competency is described by Girot (1993) as the ability to perform and

the integration of cognitive, affective and psychomotor skills, whereas Nolan (1998) proposes

that competency equates to performance, and competence is the capacity of the individual to

perform the functions required in his/her role. Definitions of competence and continuing

competence within legislation and nursing regulatory authorities have strong similarities as

demonstrated by the definitions that follow.

The Nursing Council of New Zealand defines competence as

the combination of skills, knowledge, attitudes, values and abilities that underpin

effective performance as a nurse (Nursing Council of New Zealand, 2010b).

However, in order to determine whether a nurse has maintained the required standard of

continuing competence, and acknowledging that continuing competence occurs within a

practice context, the Nursing Council of New Zealand has defined nursing practice as

using nursing knowledge in a direct relationship with clients or working in

nursing management, nursing administration, nursing education, nursing

research, nursing professional advice or nursing policy development roles, which

impact on public safety (Nursing Council of New Zealand, 2010c).

The definitions stated by the Nursing Council of New Zealand reflect the principles articulated

by the International Council of Nurses (Bryant, 2005), and is consistent with other international

definitions, including the National Nursing and Midwifery Board of Australia, the National

Council of the State Boards of Nursing and the Canadian Nurses Association.

In 2009 the Australian Nursing and Midwifery Council developed and published the ANMC

Continuing Competence Framework. Included in the framework is a glossary of terms.

Competence is defined as

the combination of skills, knowledge, attitudes, values and abilities that

underpin effective and / or superior performance in a profession/occupational

38

area and context of practice (Australian Nursing and Midwifery Council, 2009, p.

11)10.

Continuing competence is defined as

the ability of nurses and midwives to demonstrate that they have maintained

their competence to practise in relation to their context of practice, and the

relevant ANMC competency standards under which they gain and retain their

licence to practise (Australian Nursing and Midwifery Council, 2009, p. 11).

And context of practice is defined as

the conditions that define an individual’s nursing or midwifery practice. These

include the type of practice setting (e.g. healthcare agency, educational

organisation, private practice); the location of the practice setting (e.g. urban,

rural, remote); the characteristics of patients or clients (e.g. health status, age,

learning needs); the focus of nursing or midwifery activities (e.g. health

promotion, research, management); the complexity of practice; the degree to

which practice is autonomous; and the resources which are available, including

access to other healthcare professionals (Australian Nursing and Midwifery

Council, 2009, p. 11).

The National Council of the State Boards of Nursing (USA) has also produced a number of

valuable policy and discussion documents and defines competence as

the application of knowledge and the interpersonal decision-making required for

the practice role, within the context of public health (National Council of State

Boards of Nursing, 2009a).

Similarly the Canadian Nurses Association defines competence as

the ability of a registered nurse to integrate and apply the knowledge, skills,

judgement and personal attributes required to practise safely and ethically in a

designated role and setting (Canadian Nurses Association, 2000).

10 These Nursing and Midwifery Council (NMC) documents were gifted to the Nursing and Midwifery Board of Australia (NMBA) in the transition to the national registration scheme in Australia and after 01/07/2010 are cited as NMBA documents.

39

In 2011 the National Board for Certification of Hospice and Palliative Nurses (USA) Task Force

on Continuing Competence developed a definition of continuing competence that was based

upon the Canadian Nurses Association and Canadian Association of Schools of Nursing

definition (2004) that had previously been endorsed by the International Council of Nurses

(2006). The definition integrates aspects of each of the previously described definitions.

Continuing competence is the ongoing commitment of a registered nurse to

integrate and apply the knowledge, skills, and judgement with the attitudes,

values, and beliefs required to practice safely, effectively, and ethically in a

designated role and setting (Continuing Competence Task Force, 2011, p. 4).

Despite these clear and reasonably consistent definitions of competence there is still

considerable debate, and in some cases a level of confusion, between competence,

performance and continuing competence (Cowan, et al., 2005; Flanagan, Baldwin, & Clarke,

2000; McMullan, 2006). Distinctions between core or initial competence and higher levels of

competence, have contributed to this confusion and is reported frequently in the literature

(EdCaN, 2008; Pearson, Fitzgerald, Walsh, et al., 2002; Torr, 2009; Verma, Paterson, & Medves,

2006; Wilkinson, 2013).

As previously noted in New Zealand, the Nursing Council of New Zealand initially gazetted four

scopes of practice11, however in 2010 an amendment was made and this was reduced to three,

the Nurse Assistant Scope of Practice was subsumed into a new Enrolled Nurse Scope of

Practice. Each scope of practice is clearly defined, each with its own set of registrations

standards and associated competencies. The registration standards and competencies also

form the basis for the development of curricula and assessment tools that include mandated

cultural competence requirements. Whilst the standards for competence at entry to the

register are clearly articulated and relatively well understood, the interpretation by nurses of

what constitutes continued competence is not (Vernon, Chiarella, Papps, & Dignam, 2012).

2.5 Competence frameworks

It has been argued that the principal function of Continuing Competence Frameworks,

implemented by regulatory authorities, is to act as a quality assurance mechanism to ensure

11 Legislated by the Health Practitioners Competence Assurance Act 2003(NZ), Part 2(a) requires “every health practitioner to be registered for a scope of practice” (s3).

40

health professionals are competent in their practice and thereby are able to practice safely

(Australian Nursing and Midwifery Council, 2007; Bryant, 2005; Canadian Nurses Association,

2000; Goodridge, 2007; National Council of State Boards of Nursing, 2009a). Continuing

Competence Frameworks and their associated standards and monitoring activities offer a level

of assurance to health consumers and employers that practitioners are competent whilst

providing a mechanism for identifying those who are not.

These frameworks are identified in the literature as being tools that set the standards for

competence assessment and ensure consistency in the monitoring and on-going assessment of

competence and continuing competence (Australian Nursing and Midwifery Council, 2007;

Bryant, 2005; National Council of State Boards of Nursing, 2009a, 2009c). As such they have a

clear purpose in terms of public protection. However there is on-going debate with regard to

the legitimacy or credibility of Continuing Competence Frameworks within some jurisdictions,

particularly related to their ability to ensure safe and current practice (Cutcliffe, 2010; EdCaN,

2008; International Council of Nurses, 2007; Pearson, 2002). In addition, it has been identified

that the purpose of the framework is also to facilitate career development and promote

lifelong learning, then this must be clearly defined and articulated as it will influence the level

of assessment that is required (Australian Nursing and Midwifery Council, 2007; Campbell &

MacKay, 2001).

It is acknowledged that there are distinctive differences between entry level competence and

continuing competence (Benner, 1984; Chiarella, et al., 2008; Fitzgerald, et al., 2001; Hendry,

et al., 2007; Pearson, Fitzgerald, Walsh, et al., 2002) and that ‘fitness to practise’ goes beyond

mere adequacy of knowledge and skills, and should take account of attitudes and behaviours

in addition to the complexities of nursing practice within the ‘real-world’ context in which it is

occurring (Dolan, 2003; Gibson & Soanes, 2000; National Nursing Research Unit, 2009;

Pearson, Fitzgerald, Walsh, et al., 2002). This point is highlighted when reviewing the various

definitions of competence. However, whilst there is general agreement that Continuing

Competence Frameworks, standards, and assessment criteria should relate to the individual’s

particular scope of practice and area of practice (Bryant, 2005; International Council of Nurses,

2009), consistency of process between jurisdictions does not exist (Vernon, Chiarella, & Papps,

2013).

41

2.6 Professional Standards and competence assessment

Competence assessment of practising nurses is identified as crucial to maintaining professional

standards (McMullan, 2006) and as such has a role in nursing regulation (Chiarella, et al.,

2008). There is agreement that frameworks and indicators for the assessment of continuing

competence, should not only reflect the required standards of practice but also be flexible

enough to relate to the individual’s particular scope and area of practice (Australian Nursing

and Midwifery Council, 2007; International Council of Nurses, 2007). However, in any

competence assessment process the challenge is in ensuring objectivity (Gibson & Soanes,

2000) and identifying competence assessment tools that ensure validity and reliability (EdCaN,

2008; Meretoja, Eriksson, & Leino-Kilpi, 2002; Meretoja, Isoaho, & Leino-Kilpi, 2004; National

Nursing Research Unit, 2009).

It is evident in the literature, that competence assessment of nurses cannot be solely based on

the demonstration of theoretical knowledge or technical skills, but should also involve some

inference about the candidate’s attitudes and professional practice (Canadian Nurses

Association & Canadian Association of Schools of Nursing, 2004; EdCaN, 2008; Nursing and

Midwifery Council (UK), 2011; Vernon, et al., 2010), as it is proposed that there is a direct

relationship between the lack of ‘insight’ of individuals in relation to their expertise and

limitations, and potential or actual unsafe practice (Parsons & Capka, 1997; Pearson, 2002;

Wilkinson, 2013).

While there is general agreement in the literature with regard to the meaning of competence,

confusion exists with regard to what constitutes continuing competence and performance of

competencies (Flanagan, et al., 2000; McMullan, 2006; Wilkinson, 2013). This is particularly

evident in relation to determining what the most appropriate indicators of continuing

competence are, how they should be measured and assessed, and to what level this should

occur, for example is it a minimum standard of competence that is assessed, or is it

competence that meets the required standards of practice and also the requirements of the

individuals role / context of practice. (Cowan, et al., 2005). This lack of consensus increases

the potential for confusion and possibly repetition as nurses attempt to meet the

requirements of a variety of different systems (Storey & Haigh, 2002; Tabari Khomeiran &

Kiger, 2006; Watson, Stimpson, Topping, & Porock, 2002; Wilkinson, 2013). It also highlights a

potential tension between the attainment of academic qualifications and a health

professional’s competence to practise (EdCaN, 2008; Gibson & Soanes, 2000; Pearson, et al.,

1999).

42

Numerous competence assessment tools are identified in the literature (Centre for Innovation

in Professional Health Education and Research, 2007; EdCaN, 2008; Fitzgerald, et al., 2001;

Hendry, et al., 2007; McMullan et al., 2003; Watson, et al., 2002). Many are based on self-

assessment or direct observations by a peer, a mentor, a manager or an assessor, and include

some level of subjectivity (Fitzgerald, et al., 2001). Hence the development of new approaches

that take account of the context in which practice is occurring, and encouragement of inter-

rater reliability is critical (McGrath et al., 2006).

In general, it is agreed that models for assessment of competence should include more than

one competence indicator and assessment method (Australian Nursing and Midwifery Council,

2007; Canadian Nurses Association, 2000; EdCaN, 2008; McGrath, et al., 2006; Pearson,

Fitzgerald, Walsh, et al., 2002; Scott Tilley, 2008). Although there is consensus that

standardised assessment tools can be used to measure technical skills, there is a view that

decision making and behavioural skills require a more complex level of judgement from the

assessor, as they are by nature subjective and difficult to quantify (Davis, Turner, Hicks, &

Tipson, 2008; McGrath, et al., 2006). Pearson et al (2002) caution that, the more subjective in

nature, the more difficult it is to specify a generic criterion for measurement.

Continuing professional development (CPD) is argued to be an important indicator of

competence as it demonstrates that the continuing competence of an individual is relevant to

current nursing practice (Meretoja, et al., 2004). However, the most common indicator of

competence in nursing practice is performance, although there is considerable debate about

the assessment and adequacy of performance as a valid indicator of continuing competence

(EdCaN, 2008; Fitzgerald, et al., 2001; McMullan, 2006). Such debate is concerned with

whether demonstration of a particular skill or activity, in one area or on a particular day, is

indicative of competence in all situations on any given day (Gibson & Soanes, 2000), and

whether competence is directly observable in terms of performance of an activity (McGrath, et

al., 2006; National Nursing Research Unit, 2009).

The literature suggests that observed competent performance of tasks can only be inferred, as

the measurement of underpinning competencies requires evaluation of aspects such as

behaviours, attitudes and insights that are not readily amenable to quantification (National

Nursing Research Unit, 2009). Similar issues have previously been identified in relation to the

assessment of the different levels of nursing practice (Benner, 1984; Calman, Watson, Norman,

Redfern, & Murrells, 2002). Standardisation of nursing practice through the development of

generic competencies that do not take account of the specific context, or the diversity of

43

practice environments, is cautioned against (McGrath, et al., 2006). It is noted that

measurement of competence is a form of regulation that may be limiting if reductionist

approaches are employed, as they may result in restricting or constraining nursing practice

(Pearson, Fitzgerald, Walsh, et al., 2002). In addition failure to achieve competence in post-

registration nursing can have a negative effect on the nurse, the assessor and the profession

(Flanagan, et al., 2000).

2.7 Continuing competence indicators

Whilst there is considerable discussion in the literature with regard to the conceptualisation

and assessment of entry level competence, there are few studies that address the issue of

assessment and validity of competence indicators. The literature suggests that indicators of

continuing competence are not easily defined and go beyond measurement of entry level

skills, and, that a valid inference about continuing competence is not possible using a single

indicator in isolation. Several authors (Australian Nursing and Midwifery Council, 2007;

Campbell & MacKay, 2001; Canadian Nurses Association, 2000; EdCaN, 2008; Fitzgerald, et al.,

2001; Goodridge, 2007; Pearson & Fitzgerald, 2001) have attempted to summarise the most

commonly used indicators of continuing competence.

2.7.1 Self-assessment and self-declaration of competence - Generally this is a process of

self-reflection / assessment by an individual of their practice, set against the relevant

regulatory standards / competencies for practice. Most commonly it involves the individual

signing a self-declaration of competence. It is evident from the literature that whilst the

individual is responsible for their own competence, there is also debate and a level of

confusion about the employers’ responsibility in terms of identifying, facilitating and

supporting continued competence (Australian Nursing and Midwifery Council, 2007; Campbell

& MacKay, 2001; Canadian Nurses Association, 2000; Goodridge, 2007). The main criticism of

self-assessment is that it is subjective in nature and is reliant on the individual’s insight and

ability to assess critically. As such, the assessment may lack validity unless linked with a formal

feedback mechanism that promotes a connection between identified and actual practice

weaknesses and learning needs relevant to the context of practice.

2.7.2 Recency of Practice / Hours of Practice - These terms infer currency of knowledge and

skills, and are quantifiable in terms of assessment of a skill or task and verification of hours of

practice. However, used independently they are not an adequate indicator of continued

44

competence or safety to practise (Australian Nursing and Midwifery Council, 2007; Campbell &

MacKay, 2001; Fitzgerald, et al., 2001).

2.7.3 Continuing Professional Development (CPD) – This is primarily concerned with the

maintenance and updating of professional knowledge and is an indicator which appears in

many Continuing Competence Frameworks (Australian Nursing and Midwifery Council, 2009;

Canadian Nurses Association, 2000; EdCaN, 2008; Fitzgerald, et al., 2001; Nursing and

Midwifery Council, 2008). Continuing professional development is considered to be a valid

indicator of competence as it ensures that the health professional is engaged in learning,

thereby having the potential to improve currency of knowledge, skills, reflective activity,

insight and ultimately safety to practise. However, used independently, there is no evidence

that continuing professional development is a reliable indicator of continuing competence or

safety to practise (Vernon, et al., 2010).

2.7.4 Contribution to the profession – This usually implies participation in research,

committees, policy development, quality assurance programmes, and publication and may

infer involvement in current practice and professional networks but it does not infer

competence or safety to practise (EdCaN, 2008; Fitzgerald, et al., 2001).

2.7.5 Portfolio – This is a tool used to record practice and develop an individual’s reflective

thinking /practice. It is subjective in nature and lacks inter-rater reliability (EdCaN, 2008;

Vandewater, 2004). When used on its own it is not a reliable measure of competence or safety

to practise (Australian Nursing and Midwifery Council, 2007; Canadian Nurses Association,

2000; EdCaN, 2008).

2.7.6 Peer Review – This has been identified as a feasible method of competence

assessment, although it is time consuming for the individual and the reviewer, and can have

issues of inter-rater reliability. It is cautioned that the peer reviewer must have a clear

understanding of the criteria for assessment and the context of practice. There is on-going

debate in the literature as to what constitutes a ‘Peer’. Should a peer reviewer have the same

professional education, qualifications, scope/role of practice, or be a colleague with equal or

higher status from another work area or discipline? (Australian Nursing and Midwifery Council,

2007; Canadian Nurses Association, 2000; Goodridge, 2007; Gopee, 2001). Regardless of the

selected option, the peer review process must produce an auditable trail that demonstrates a

45

valid assessment of competence that would meet requirements of public accountability

(Australian Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000).

2.7.7 Performance appraisal – This generally refers to evaluation of an employee by an

employer / manager is generally undertaken to identify the on-going competence of

employees, to identify learning needs, promotion, and salary increments. Validity and

reliability of performance appraisal is dependent upon the assessment mechanism, tools and

criteria that are used. Used in conjunction with a formal ‘Peer review’ of the individual’s

performance, it may be used to demonstrate continuing competence in practice (Australian

Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000).

2.7.8 Objective Structured Competence Assessment or Evaluation (OSCE) – There is debate

in the literature as to the validity and reliability of simulated clinical skill assessments such as

OSCEs in assessing continuing competence (Canadian Nurses Association, 2000; Fitzgerald, et

al., 2001; Goodridge, 2007). In addition they are resource heavy and the expense of

administering OSCEs is high.

2.7.9 Examination and psychometric testing – In New Zealand and internationally,

examination is commonly used by regulatory authorities as a competence indicator for entry

to the register of nurses. The development of psychometrically sound and legally defensible

examination test banks has occurred over a number of years (Meretoja, et al., 2002;

Vandewater, 2004; Wilkinson, 2013). In the United States of America examination is also

commonly used by the organisations that administer and award nursing education credits.

However, there is no evidence based research to support that examination is an effective

indicator of continuing competence to practise (Fitzgerald, et al., 2001), although examination

does provide a standard form of assessment of, the knowledge and understanding of all

registrants (Vandewater, 2004; Wilkinson, 2013).

2.8 Summary of findings from the literature

2.8.1 Public protection

Within the literature there is general agreement that individual health professionals are

responsible for their continuing competence and that regulatory authorities are responsible

for managing this legislative responsibility within their jurisdiction (International Council of

46

Nurses, 2009; Secretary of State for Health (UK), 2007; Staunton & Chiarella, 2008; Swankin, et

al., 2006). That it is the responsibility of the profession and ultimately the regulatory authority

to determine and implement standards of competence, and codes of conduct and ethical

practice, in order to assure colleagues, employers and the general public that those health

professionals in practice are, and continue to be, competent (International Council of Nurses,

2006, 2009; Secretary of State for Health (UK), 2007).

Increased consumer awareness, technological advances, globalisation and the changing

healthcare environment have contributed to concern raised in relation to public safety,

geographic variations in qualifications, and poor patient outcomes (Health Workforce

Australia, 2012; Secretary of State for Health (UK), 2007; Taskforce on Health Care Workforce

Regulation, 1995).

2.8.2 Competence and continuing competence

The definitions of competence, competencies, and continuing competence have been

extensively debated internationally (Bryant, 2005; Chiarella, 2006; Chiarella, et al., 2008;

Cowan, et al., 2005; EdCaN, 2008; Hendry, et al., 2007; Pearson, Fitzgerald, Walsh, et al., 2002;

Vernon, et al., 2010). Despite clear and reasonably consistent definitions of competence

articulated by a number of nurse regulatory authorities, there is substantial variation in the

conceptualisation of continuing competence and in particular the distinction between core and

higher levels of competence, and the individual behaviours, attitudes and insight of

practitioners. It is acknowledged that there are distinctive differences between entry level

competence and continued competence which move beyond knowledge and skills, and should

take account of the complexities and context in which nursing practice is occurring (Benner,

1984; Chiarella, et al., 2008; Fitzgerald, et al., 2001; Hendry, et al., 2007; Pearson, Fitzgerald,

Walsh, et al., 2002; Vernon, et al., 2010). Given the multifaceted nature of nursing practice

and the diversity of practice settings it is evident that the context in which the nurse practises

is a critical consideration when defining and evaluating continuing competence (Vernon, et al.,

2010).

2.8.3 Continuing Competence Frameworks

The international literature is unequivocal about the importance of Continuing Competence

Frameworks (Australian Nursing and Midwifery Council, 2007; Bryant, 2005; Canadian Nurses

Association, 2000; Chiarella, 2006; EdCaN, 2008; Fitzgerald, et al., 2001; National Council of

47

State Boards of Nursing, 2009a). The registration requirements in the jurisdictions of most

countries contain an expectation that nurses will not only be competent to practise nursing on

registration, but will maintain that competence in respect of their chosen field or scope of

practice as they develop in their careers and renew their registration (Chiarella, et al., 2008;

International Council of Nurses, 2009). Importantly, Continuing Competence Frameworks

demonstrate to the public that the regulatory authority and nursing profession are cognisant

of, and have mechanisms to assess the continued competence of the profession to ensure

public safety. They are tools that have a clear purpose in terms of ‘public protection’, however

the literature suggests that if their purpose is also to promote ‘lifelong learning’ then this must

be clearly articulated (Australian Nursing & Midwifery Council, 2007; Campbell & MacKay,

2001; Goodridge, 2007) as this will influence the level of assessment required.

Competency standards have been developed in New Zealand and internationally as a way of

differentiating and standardising the variations in scopes and levels of practice within the

nursing profession (Chiarella, et al., 2008; International Council of Nurses, 2009; Vernon, et al.,

2010). It is noted that Continuing Competence Frameworks promote consistency of

‘continuing competence’ standards and assessment, and provide a mechanism for the

assessment of competence as a measure of public safety. It is also noted they should be

mandatory for all practising members of the profession, be flexible, have relevance and be

transferable to the differing levels of practice and settings in which nurses practise

(International Council of Nurses, 2007; National Council of State Boards of Nursing, 2009a;

Vernon, et al., 2010).

2.8.4 Communication

The need for clear communication, particularly in relation to the articulation of the purpose of

Continuing Competence Frameworks and competence standards, and how these items relate

to public protection or the relationship between public protection and lifelong learning, is a

common theme within the literature (Flanagan, et al., 2000; Vandewater, 2004). Development

of a common language and lexicon of terms related to continuing competence has been

identified as a communication strategy that assists in the successful implementation of

Continuing Competence Frameworks and understanding of the profession (Canadian Nurses

Association, 2000).

48

2.8.5 Indicators of competence

Self-assessment and self-declaration of competence, peer assessment, recency of practice and

continuing professional development /education are the most commonly used indicators of

continuing competence. Recency of practice and continuing professional development, are

quantifiable indicators (Canadian Nurses Association, 2000; National Council of State Boards of

Nursing, 2009b). However, when used independently they do not infer continuing

competence to practise (EdCaN, 2008; Pearson, et al., 1999; Vernon, et al., 2010). A

combination of competence indicators is recommended as no single indicator used

independently can infer continuing competence or safety to practise (Canadian Nurses

Association, 2000). Valid measurement of indicators which are subjective in nature is difficult.

However, inter-rater reliability is a critical component of this assessment process (EdCaN,

2008; Wilkinson, 2013).

2.8.6 Assessment methods

It is evident in the literature that a variety of assessment methods and tools should be

available, and that assessment tools should be ‘user friendly’ and able to related to the

individuals’ practice context (Australian Nursing and Midwifery Council, 2007; Canadian Nurses

Association, 2000). Tools and assessment criteria should relate directly to the relevant

standards of practice and to the associated requirements for continuing competence. Clear

communication and accessibility to guidelines for the assessment methods and tools is

identified as being critical to this process (EdCaN, 2008; National Nursing Research Unit, 2009).

2.8.7 Research

On-going evaluation of the impact of Continuing Competence Frameworks is essential and

should include outcomes for consumers, employers and nurses (EdCaN, 2008; Lazarus & Genell

Lee, 2006). The viability of existing Continuing Competence Frameworks and the validity of

associated competence indicators and assessment methods require further evaluation in order

to determine if, in fact, requiring and monitoring continuing competence is a strategy that is

effective in terms of assuring and ensuring public safety (Meretoja, et al., 2002; National

Council of State Boards of Nursing, 2009a; National Nursing Research Unit, 2009).

49

2.8.8 Who is responsible?

The literature identifies that confusion exists with regard to which entity is responsible for

ensuring, demonstrating and facilitating continuing competence – the individual, the

employing organisation, the professional body, or the regulatory authority? There is also

ongoing debate in relation to the responsibility and jurisdiction of the regulatory authority

with regard to the implementation of Continuing Competence Frameworks and their

responsibility in terms of assuring the public that they are safe (Secretary of State for Health

(UK), 2007; Swankin, 1995; Swankin, et al., 2006).


An extensive review of the national and international literature has indicated that while there

is significant interest in ensuring the continuing competence of health professionals in order to

ensure public safety, there is a paucity of research relating to the efficacy of continuing

competence requirements and frameworks once such measures are implemented. It is

generally acknowledged that Continuing Competence Frameworks have a role in assuring the

public that health practitioners, in this case nurse’s, continue to be competent. However,

there has been little work done on obtaining consensus as to what might constitute best

practice in demonstrating and assessing continuing competence.

Difficulties with regard to ensuring valid and reliable assessment of continuing competence in

nursing have been highlighted. A range of competence indicators and assessment tools are

identified, however, none of the articles or documents describe approaches that ensure the

validity and reliability of continuing competence assessment tools. No evaluations of existing

Continuing Competence Frameworks, implemented for nurses, have been undertaken and the

majority of the published studies are descriptive in nature, reporting predominantly qualitative

findings. Limitations of these studies include small sample sizes, voluntary participation,

qualitative descriptive methods and a focus on investigating individual competencies rather

than competence or continuing competence. The summary of findings from this literature

review mirror those of previous reviews and should be considered in the context of the on-

going international debate about the challenges of monitoring and ensuring the continued

competence of nurses in practice.

This chapter has presented a summary of the literature that underpins and supports the

significance of this research, and provides the context in which it is situated. Given the

50

legislative mandate in New Zealand and other international jurisdictions with regard to

protection of the public and ensuring the continuing competence of registered health

practitioners, and the current lack of empirical evidence in relation to the efficacy of

Continuing Competence Frameworks, this research has an opportunity to make a valuable

contribution to the national and international literature. Chapter Three will present, in detail,

the overarching theoretical framework, research approach, design and methods used to

undertake this research.

51

CHAPTER THREE - RESEARCH DESIGN AND METHOD

3.1 Introduction

This chapter commences by introducing the overarching research approach and discussing the

rationale for using evaluation research methodology. The scope of the research with regard to

the mixed method evaluation design is presented in two research stages. The individual

research methods and ethical considerations are discussed sequentially in association with

each stage. In conclusion the overarching ethical approval processes and relevant

documentation is presented.

Both nationally and internationally the literature reveals there is considerable interest in

existing models of continuing competence and their development. In particular extensive

work has been undertaken by nursing regulatory authorities in the following countries: New

Zealand, Australia, Canada, the United Kingdom, and the United States of America, to identify

valid and reliable mechanisms to monitor the continuing competence of nurses registered in

their jurisdictions. The Nursing and Midwifery Board of Ireland has also recently commenced a

project investigating models for assessment of continuing competence as a result of the

implementation of the Nurses and Midwives Act 2011 (Ireland).

The Nursing Council of New Zealand was the first of these regulatory jurisdictions to propose a

comprehensive evaluation of their Continuing Competence Framework for nurses, which was

in current operation. As discussed in Chapter One (1.2, p. 3), because part of my original

research was overtaken by the evaluation contracted by the Nursing Council of New Zealand

(Stage One) Evaluation of the Nursing Council of New Zealand Continuing Competence

Framework, I took the opportunity to extend my thesis to include a separate international

component that was consistent with, and relevant to my original research questions (Stage

Two) The International Consensus Model for the Assessment of Continuing Competence.

Findings from the evaluation of the Nursing Council of New Zealand Continuing Competence

Framework significantly contributed to the development of this second Stage, and assisted in

positioning it in terms of international relevance. It also provided a platform from which to

investigate the possibility of developing an International Consensus Model for the assessment

of continuing competence.

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3.2 Selection of the Research Approach

The overarching method chosen to investigate this topic was evaluation research. Evaluation

research is distinguished from other kinds of research by why it is undertaken rather than how

it is undertaken (Casswell, 1999). It is an approach to research that seeks to establish the

value and / or impact, to the recipients of the service, of an empirical topic such as a

programme, treatment, practice or policy (Carnwell, 1997; Davidson, 2005; Ovretveit, 2000)

and enables the researcher to determine the value of the topic through the use of inductive,

deductive or mixed method approaches (Clifford, 1997). Evaluation research is a methodology

that is concerned with seeking the views of stakeholders in order to appraise a program,

service provision, or enactment of policy, and to uncover the important factors latent in a

particular situation (Davidson, 2005; Parlett & Hamilton, 1972). Complementary mixed-

methods of data collection and analysis may be derived from the positivist and interpretive

paradigms (Davidson, 2005; Ovretveit, 2000). As such, the paradigm from which the

researcher views the research is reflected in the combination of methodological techniques

used to undertake the research at the process level of sampling, data collection and data

analysis (Sandelowski, 2000). A mixed methods design provides the ability to comprehensively

investigate the overarching research questions, whilst fulfilling the objectives of both of the

embedded studies because the strengths of combining qualitative and quantitative data

collection methods provided the researcher with more complete and more comprehensive

research results (Ovretveit, 2000; Sandelowski, 2000). The evaluation approach was both

interpretive and constructionist (Guba & Lincoln, 1989) with an underlying pluralistic approach

that facilitated the ability to take account of the wider contexts in order to describe, illuminate

and interpret, rather than purely measuring and predicting outcomes (Parlett & Hamilton,

1972). As noted by Tukey (1962, p.13) and cited by Thompson (2001, p. 256) “far better an

approximate answer to the right question, which is often vague, than an exact answer to the

wrong question, which can always be made precise”.

As identified in Chapter Two, a review of the contemporary literature suggests that reliability

and validation of competence frameworks continues to be subjective and problematic. A

sequential mixed-methods evaluation design was developed to ensure that the overarching

research questions were addressed (Table 2, p.5), whilst still complementing and addressing

the specific objectives of the two embedded studies: Stage One - the Evaluation of the Nursing

Council of New Zealand Continuing Competence Framework and Stage Two - the International

Consensus Model for the Assessment of Continuing Competence.

53

Overarching Research Questions

1. What are the relationships between current legislation, policy drivers and the statutory requirements to ensure registered nurses are competent and fit to practise?


3. What is the international consensus view of regulatory experts in relation to: a) best practice for nurses to demonstrate continuing competence; and b) best practice for regulatory authorities to assess continuing competence?

Research Questions - Stage One Research Questions – Stage Two




1. What is the consensus view of regulatory experts in relation to: a) best practice for nurses to demonstrate

continuing competence; and b) best practice for regulatory authorities to

assess continuing competence? 2. What, if any, differences are present between

the current regulatory requirements for the demonstration and assessment of continuing competence in six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America) and the best practice model developed through consensus?

3. What changes, if any, would be required to policy and regulation in these six countries to align their regulatory framework with best practice for demonstration and assessment of continuing competence?

Evaluation research utilising a sequential mixed-methods design is no different from any

other form of research, in that methodological deficits may exist and are not necessarily

obvious until the research is undertaken. However, reliability and validity of results is

dependent upon the rigorous nature in which sampling, data collection, data collation

and analysis is conducted. The sequential nature of the design adds strength to the

research in terms of the ability of the researcher to build on findings as they emerge

(Miller & Fredericks, 2006). Reliability is “the extent to which a data gathering method

will give the same results when repeated (i.e. consistency). It refers to the amount of

random or systematic error (bias) or variance in data which the method gives” (Ovretveit,

2000, p. 214). Validity is “the extent to which a measure or piece of data ‘reflects’ what it

is supposed to measure or give information about” (Ovretveit, 2000, p. 215). The aim is,

to reduce random errors through the use of a reliable measure, and to reduce additional

systematic error (bias) by using a valid measure. Ovretveit (2000) argues that the

importance of validity in evaluation research relates to whether the data collected are

54

relevant for judging the identified criterion for evaluation thus addressing the research

purpose, rather than solely focusing on whether the data gives a valid representation of

some aspect of the study.

The comprehensive nature of the sequential mixed-method design allows establishment of

value judgments based on evidence drawn from a variety of data collection methods,

incorporating inductive descriptive, exploratory and explanatory perspectives (Sandelowski,

2000). This approach was critical in this thesis, in order to elicit the variety of information

required to address the overarching research questions. In addition the internal logic of the

sequential mixed-methods design presented methodological strengths (methodological

triangulation) not evident in other designs (Miller & Fredericks, 2006; Sandelowski, 2000).

Methodological triangulation attempts to overcome the deficiencies inherent in choosing a

single method (Cowman, 2008) to interpret a complex phenomenon. The complementary

strengths of using qualitative and quantitative techniques in this way elicits more

comprehensive results through a process that is outcome orientated, and also exploratory and

confirmatory (Davidson, 2005; Miller & Fredericks, 2006; Neuman, 2000; Ovretveit, 2000;

Sandelowski, 2000). The collation of information from a variety of sources enhances construct

validity and robustness using triangulation, that reveals the convergence of evidence

(Cowman, 2008; Yin, 1994). Evaluation research is judged according to its internal and

external validity, objectivity and ability to be replicated (Parlett & Hamilton, 1972).

3.3 Research Design and Methods

The evaluation research design used for this study was informed by the work of Parlett and

Hamilton (1972), Guba and Lincoln (1989), and the later works of Ovretveit (2000), Davidson

(2005), and Miller and Fredericks (2006), all of whom advocate the importance of identifying

and seeking the views of key stakeholders (Carnwell, 1997), through the use of multiple data

collection strategies. Each phase of the research process detailed in this chapter incorporates

its own distinct sampling, data collection and analysis method which in turn has its own

measures of rigour, dependent upon the qualitative or quantitative perspective being

undertaken, for example, credibility and trustworthiness; or validity, reliability, inference and /

or transferability and ethical implications. The findings derived from each phase of the

research serve to inform the next phase in the research process, and as such, the careful

application of the sequential mixed methods design provides a consistent, rigorous, and

acceptable justification for the research approach (Miller & Fredericks, 2006; Sandelowski,

55

2000). Triangulation, the use of multiple methods to collect and interpret data, facilitates a

more accurate representation of reality (Polit & Hungler, 1995) through validation when one

set of results is confirmed by congruent results from another part of the study (Cowman,

2008).

3.3.1 Evaluation Research Process

The methods used to complete this research are presented below in diagrammatic form

(Figure 2) and further described in Stage One (3.3.2), Stage Two (3.3.3) and Methodological

Triangulation of Summary Data (3.3.4).

Figure 2 Evaluation Research Process

EVALUATON RESEARCH PROCESS

Met

hodo

logi

cal

Tria

ngul

atio

nIn

tern

atio

nal

Cons

ensu

s Mod

elNC

NZ C

ontin

uing

Co

mpe

tenc

e Fr

amew

ork

Literature Review

Stage One Phase 1

Document & Policy Review

Stage One Phase 2

Qualitative Interviews

Stage One Phase 3

QuantitativeE-survey

Data triangulation &

discussion

Stage TwoDelphi Round 1Stakeholder Interviews

(gpA)

Stage TwoDelphi Round 2

Qualitative E-survey (gpB)

Stage Two Delphi Round 3Quantitative

E-survey (gpB)

Stage Two Delphi Round 4

ConsensusE-survey

(gpA)

Discussion of findings

Summary Recommendations


Conclusion and Recommendations

Data triangulation & discussion of summary

findings fromStage One & Stage Two

56

3.3.2 Stage One – Evaluation of the Nursing Council of New Zealand Continuing Competence Framework

Stage One of my thesis is focused on the evaluation of the Nursing Council of New Zealand

Continuing Competence Framework. This aspect of my thesis commenced prior to the call for

tenders by the Nursing Council of New Zealand. However, as my supervisors and I successfully

tendered for the work, great care was taken to separate the work that was undertaken

collectively as the tender team, from work that I undertook independently as part of my thesis,

that was subject only to the level of scrutiny and input that doctoral supervisors would

provide. It was agreed that, should the supervisors feel the need to change my independent

work substantially, that work could not be identified as part of my thesis. However, this did

not occur and as previously noted in Chapter One, a matrix identifying both my individual

contributions that go to my thesis and also the collective contributions of the research team

members, in completing the contracted aspects of this work, is presented in Appendix I.

Table 4 presents the research questions posed in relation to Stage One of this thesis, alongside

the objectives stipulated by the Nursing Council of New Zealand for the evaluation of the

Continuing Competence Framework.

Table 4 Stage One research questions and the Nursing Council of New Zealand objectives

Stage One Research Questions Nursing Council of New Zealand Objectives




• Explore the validity of the stipulated hours of professional development and days/hours of practice over a three-year period, as indicators of competence.

• Provide information on the efficacy of undertaking a random audit of five percent of the nursing workforce to meet recertification requirements.

• Document and track the different forms of written evidence that are currently acceptable to the Nursing Council of New Zealand to demonstrate competence.

• Identify issues related to peer assessment of competence.

• Develop a framework to enable the Nursing Council of New Zealand to complete a further evaluation in five years’ time (Nursing Council of New Zealand, 2008).

57

The mixed methods approach used to complete Stage One; the evaluation of the Nursing

Council of New Zealand Continuing Competence Framework included three phases of inquiry

that were completed from 2009 – 2010, and are described in more detail below. The use of a

sequential design meant that the collated and analysed findings from each phase contributed

to the development of each subsequent phase culminating in the triangulation of all data sets

at the conclusion of Phase Three. As the development of this sequential design was contingent

upon a multi-staged approach it was critical to ensure that each phase of the research was well

planned, documented and executed in a coherent and logical manner in order to mitigate any

potential risk of error building upon error (Creswell, 2003; Sandelowski, 2000).

3.3.2.1 Phase One – Document Review

The purpose of Phase One was to explore and review the documents relating to the regulation

of nursing in New Zealand that led up to the implementation of the Health Practitioners

Competence Assurance Act 2003 (NZ) and the subsequent Nursing Council of New Zealand

Continuing Competence Framework. In order to complete Phase One three separate pieces of

work were undertaken: an historical review, a document and policy analysis, and a collation of

statistical data.

Historical review

A review was completed, and included historical documents relating to the legislation and

regulation of nursing in New Zealand, seminal events that impacted on the evolution of

nursing education and practice in New Zealand, relevant legislation, and Nursing Council of

New Zealand archived documents, policies, procedures, and guidelines. A descriptive analysis

was undertaken and the findings are presented in chronological order in Chapter Four (4.3).

Document and policy analysis

A comprehensive review of all documents relating to the development and implementation of

the Nursing Council of New Zealand Continuing Competence Framework was undertaken.

Documents relating to the twelve years leading up to, and including, the implementation of

the Continuing Competence Framework were examined, reviewed and catalogued. Thomas’s

(2003) general inductive approach to data analysis was used to undertake the critical

document analysis. The primary purpose of this inductive approach is to allow “findings to

emerge from frequent, dominant or significant themes inherent in raw data, without the

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restraints imposed by structured methodologies” (Thomas, 2003, p. 2). The process follows

five distinct steps:

1. Preparation of raw data files (“data cleaning”).

2. Close reading of text and identification of themes.

3. Creation of categories.

4. Overlapping coding and uncoded text.

5. Revision and refinement of the category system to reduce the data into the most

important thematic categories (Thomas, 2003, p. 3).

This logical and systematic approach to inductive analysis of data, provides a straightforward

structured method that allows the researcher to demonstrate the rigor and trustworthiness of

the data through the visible systematic approach that includes consistency checks.

Consistency checks are used for assessing the trustworthiness of the data analysis process

(Thomas, 2003). For the purpose of this study one of my doctoral supervisors reviewed the

category descriptions and the coding, allocation and interpretation of text to each category.

The overall findings are presented in Section Two, Chapter Four (4.4) in the form of a

descriptive summary related to the development and implementation process undertaken by

the Nursing Council of New Zealand.

Specific Nursing Council of New Zealand policy documents, procedures, and guidelines

associated with the implementation of the Continuing Competence Framework, including the

recertification process and audit requirements were analysed using a structured framework

informed by Musick’s (1998) Structured Approach to Policy Analysis. In general, policy analysis

is an analytical and descriptive process that attempts to define the purpose of the policy and

how it has been developed. Hence it is concerned with two distinct processes; the contents of

the policy, and the process by which it was developed (Musick, 1998).

Musick (1998) identified a systematic framework for policy analysis in medical education. The

framework proposes twelve essential “ingredients” (Musick, 1998, p. 4) to consider when

undertaking policy analysis: Conceptual; Normative; Theoretical; Empirical; Economic; Political;

Cultural; Ideological; Historical; Assumptive; Legal; and Logical. The value of each component

contributes equally to the overall process (Musick, 1998). The systematic utilisation of this

framework for analysis of the Nursing Council of New Zealand Continuing Competence

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Framework policy documents is presented in more detail in Section Two, Chapter Four (4.5)

and summarised in Table 5 (p. 97).

Collation of statistical data

Statistical information relating to recertification (Annual Practising Certificate applications),

recertification audits, and competence notifications were reviewed, and collated from the date

of implementation of the Continuing Competence Framework in 2004, and the recertification

audit process in 2005. These data are presented in Chapter Four (4.6).

In addition, 94 documents pertaining to the development and implementation of the Nursing

Council of New Zealand Continuing Competence Framework were reviewed and analysed.

The collated findings from Phase One of the evaluation (Chapter Four), provided a range of

information that contributed to the development of the semi-structured interview questions

implemented in Phase Two and the web-based e-survey implemented in Phase Three of the

evaluation. This process is consistent with the purpose of a sequential evaluation design

where the findings that emerge from each sequential phase, contribute to the development of

the subsequent phase in the research process (Miller & Fredericks, 2006).

3.3.2.2 Phase Two – Method; Semi-structured interviews with key stakeholders

The purpose of Phase Two was to determine from key nurse stakeholders their knowledge,

understanding and experience of the Nursing Council of New Zealand Continuing Competence

Framework and ultimately their satisfaction with, and confidence in, the Continuing

Competence Framework as a measure to ensure safe professional practice as a nurse in New

Zealand. These included aspects related to the Continuing Competence Framework processes

and procedures and associated professional, legal and ethical issues in relation to the

demonstration of continuing competence and safe practice.

Semi structured interviews with a purposive sample of 26 key nurse stakeholders were

completed. The semi-structured interview process provided a framework with which to pose a

range of open-ended questions related to the topic, and encouraged the participants to talk

freely about their views and experiences (Polit & Beck, 2010). The use of open-ended

questions encourages participants to respond in their own words, and enables richer and more

complex data to be collected (Whittemore & Grey, 2006).

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The purposive sample provided the researcher with the ability to choose participants with the

required specialised knowledge, experience, and status to contribute vital information to the

subject being researched (Whitehead & Annells, 2007). Participants were selected in order to

be representative of the following groups; nurse leaders from the following groups:

• Directors of nursing;

• Nurse managers from the public and private sector;

• Heads of schools of nursing;

• Nursing representatives from the Ministry of Health and professional nursing

organisations;

• Nurses who had been selected to participate in a recertification audit in the four years

since implementation of the Nursing Council of New Zealand Continuing Competence

Framework (2005 – 2009).

Twenty seven participants were selected to take part in the interview process. This was more

than sufficient as the literature identifies that, due to the potentially detailed and complex

data each participant may generate during the qualitative interview process (Polit & Beck,

2010; Whitehead & Annells, 2007), 10 - 15 participants is considered an adequate sample size

(Whitehead & Annells, 2007).

The twenty seven potential participants were contacted initially through an email invitation

that included a copy of the research information sheet and a written consent form (Appendix

II). Twenty six responded indicating that they were interested in participating in the research

and they were then contacted by telephone and the interview appointments were confirmed.

The semi-structured interviews were conducted as scheduled and included the following

elements:

• Understanding and experience of the Continuing Competence Framework including

the recertification audit processes

• Knowledge and understanding of the indicators of competence and evidential

requirements

• Confidence in the Continuing Competence Framework as a measure of safety to

practise

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• Contextual relevance in terms of their own experience, position, understandings and

opinions

• Knowledge and experience related to the professional development and recognition

process (PDRP).

Any additional information offered was noted and organised into themes. The interviews

ranged from 25 – 60 minutes in duration and each was digitally recorded and transcribed

verbatim. By recording the interviews the researcher is able to pay full attention to the

participant and to take note of non-verbal cues (Davies, 2007). It also facilitates the ability to

save a detailed account of the participant’s responses and a verbatim transcript for analysis

(Polit & Beck, 2010).

Data analysis

The transcribed interviews were collated and analysed by the researcher using Thomas’ (2003)

general inductive approach, the purpose being to allow “findings to emerge from frequent,

dominant or significant themes inherent in raw data, without the restraints imposed by

structured methodologies” (Thomas, 2003, p. 2). As previously noted this systematic approach

to inductive analysis provided a logical process for independent consistency checks, and

allowed the researcher to demonstrate the rigour and trustworthiness of the findings which

are reported in Chapter Five. The themes which emerged were then used to inform the

development of Phase Three, the web-based electronic survey (e-survey) reported in Chapter

Six.

Ethical considerations

Participation in the interview process was voluntary. Information about the study, its purpose,

the anticipated participant time commitment, and full contact details of the researcher, were

provided to each potential participant via an emailed information sheet accompanied by an

interview consent form. Informed consent was given prior to the interviews taking place and

all participants signed the consent form that was provided. No identifying information was

recorded and all data was coded, collated and de-identified during the analysis process.

3.3.2.3 Phase Three – Method; E-survey of New Zealand Nurses

A web-based quantitative e-survey was conducted with a representative sample of nurses

registered with the Nursing Council of New Zealand, and active in terms of mandatory

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participation in the Nursing Council of New Zealand Continuing Competence Framework

between the 1st and 16th December 2009. These nurses had all previously indicated to the

Nursing Council of New Zealand, by completing and signing a specific section on their annual

application for recertification, that they consented to their email addresses being made

available for Nursing Council of New Zealand approved surveys and research purposes. The

Nursing Council of New Zealand computer administrator uploaded a computer generated,

randomly selected sample of email addresses for 12% (n = 5,339) of nurses from this active

register. An invitation to participate in the research including a detailed information sheet that

explained the purpose of the research, what the findings would be used for, the anticipated

time it would take to complete the e-survey, the contact details of the researcher, and an

explanation of ‘implied consent and anonymity’ if the nurse chose to complete and submit the

e-survey, was sent via email to the potential participants. The uniform resource locator (URL)

link to the e-survey was embedded in the invitation and provided potential participants direct

web-based access to the E-survey. Copies of the research information sheet and e-survey are

appended (Appendix III).

For the purpose of this research ‘nurses’ were defined as Nurses Assistants (NA), Enrolled

Nurses (EN) and Registered Nurses (RN), who had applied to the Nursing Council of New

Zealand for recertification within the previous four years and who consented to participate in

web-based surveys. Nurse Practitioners were excluded from this research as they currently

have a different continuing competence process.

Research objectives

To determine the satisfaction of New Zealand nurses with, and confidence in, the Continuing

Competence Framework and to seek feedback from them with regard to:

• Their understanding of and / or ability to demonstrate the indicators of competence

required by the Continuing Competence Framework for safe professional practice;

o the self-declaration in terms of the professional, legal and ethical issues, and safe

practice;

o the required hours of clinical practice;

o the required professional development (continuing education) hours;

• Access to, and engagement with professional development and recognition

programmes;

63

• Satisfaction with the recertification audit process;

• Participation in a recertification audit, including:

o Understanding / satisfaction with the process, documentation and requirements in

terms of demonstrating competence

o Role of the peer assessor.

Survey Design

The web-based software platform ‘Zoomerang’ was used to develop and administer the

quantitative e-survey. The themes and questions were developed from the combined findings

of the literature review and the findings from the previous two research phases. In addition to

the demographic data, the questionnaire was based around four main themes, competence

(indicators, assessment, processes), annual practising certificate applications, recertification

audit processes, and professional development and recognition programmes.

The questionnaire was designed to capture a wide range of information through the use of

closed (yes / no) and attitudinal questions, resulting in categorical, nominal and ordinal data.

Nominal data were derived through categorisation of dichotomous data into two groupings,

for example questions with a response of yes or no. Attitudinal questions were measured

using a seven point Likert scale which comprised a list of positively and negatively worded

statements with which the participants were asked to indicate their strength of agreement or

disagreement.

The questionnaire was piloted electronically via ‘Zoomerang’ with a convenience sample of

fourteen nurses, prior to final implementation. This process enabled the questionnaire to be

tested and feedback provided. Following the initial pilot, adjustments were made to the

format, structure, and order of four questions. The questionnaire was then returned to the

pilot group. Anomalies in two questions were corrected, and the questionnaire was

confirmed. In order to reduce the possibility of multiple or unsolicited responses to the

questionnaire the web-link was specifically designed to allow only the original invited recipient

to respond. The questionnaire was designed to be incapable of being forwarded through

progressive email links.

The literature identifies that there are advantages and disadvantages when using e-surveys as

a method to conduct research (Duffy, 2002). However, the decision to use an electronic

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survey in both Stage One and Stage Two of this research was pragmatic, driven primarily by

the following factors:

• The ability to recruit participants from a geographically diverse sample group -

nationally and internationally;

• The ability to elicit asynchronous responses from multiple participants within a

defined time frame and across a variety of time zones;

• The ability to administer follow-up and reminder messages as necessary; the

ability to maintain anonymity within the sample group;

• The ability to manage and store potentially large data bases and to facilitate

electronic collation and coding of the data for analysis;

• The ability to manage costs within the financial constraints of a limited budget

(Duffy, 2002).

It was acknowledged that the use of an e-survey may result in the following disadvantages;

reduced response rates due to inconsistent technological literacy, internet access, or individual

preference of the potential sample group, the absence of the opportunity for discussion with

the participant, the absence of non-verbal cues, the opportunity to ignore or put aside an

electronic invitation, and the fear that their individual privacy and confidentiality of responses

may not be ensured (Duffy, 2002). These potential disadvantages were mitigated as much as

possible by ensuring potential participants were provided with direct access to all required

research information (the detailed research information sheet, researcher contact details,

details with regard to ethical considerations and the direct URL to the e-survey) within the one

email invitation. In addition the e-survey software provided the ability for the researcher to

identify and filter out the participant invitations that had been ‘hard bounced’ due to technical

issues, resulting in the original e-survey invitation not reaching the intended potential

participant.

Confidentiality

Participation in the e-survey was voluntary and anonymous. The electronic email address data

base was randomly generated by computer from the Nursing Council of New Zealand active

data base and uploaded directly by a Nursing Council of New Zealand administrator into the

‘Zoomerang’ web platform. No identifying information of potential participants was provided

to the researcher.

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Data Analysis

Participant responses were initially collated and analysed via ‘Zoomerang’ and then imported

using the software package Statistical Package for Social Sciences (SPSS) for Windows version

17.0, to enable more extensive statistical analysis. Preliminary analysis was completed with

the whole group using basic statistical frequencies, numbers, percentages, means and

distribution. The data were further analysed by cross-tabulating data and examining the

relationship between variables (scope of practice, employment area, and practice setting).

Analysis of variance (ANOVA) was used, when indicated, in order to provide a deeper

understanding of the data within, and between the groups. Detailed findings are presented in

Chapter Six.

3.3.2.4 Data triangulation, discussion and recommendations

A process of methodological triangulation was used to evaluate the Continuing Competence

Framework and to test the degree of convergence and validity of the research findings

(Carnwell, 1997; Davidson, 2005). Triangulation of the data from Phases One, Two and Three

added to the robustness (Ovretveit, 2000) of the research by eliciting a broader range of data

and perspectives, which in turn enhanced the construct validity. Validity and reliability of the

research findings can be directly affected by biases of the researcher (Ovretveit, 2000).

However, the use of mixed method sequential data collection and analysis, reduces the

possibility of this occurring (Sandelowski, 2000).

The triangulated findings of Stage One are presented and discussed in detail in Chapter Seven.

The recommendations specifically made to the Nursing Council of New Zealand following

completion of the evaluation of the Continuing Competence Framework are presented in Table

20 (p. 161).

3.3.3 Stage Two – The International Consensus Model for the Assessment of Continuing Competence

Findings from Stage One; the evaluation of the Nursing Council of New Zealand Continuing

Competence Framework have contributed to the development of Stage Two – the consensus

model for the assessment of continuing competence, and assisted in positioning it in terms of

international relevance by providing a platform from which to investigate the possibility of

66

developing an international consensus model for the assessment of continuing competence.

Stage Two was completed during 2011-2012.

In preparation for deciding on the most appropriate method with which to undertake Stage

Two of this study, the following research challenges were considered:

• The geographic spread and diversity of the expert group of potential participants;

• Differing cultural and political influences;

• Variation in regulatory structures, processes and authority;

• Variation in Nursing education standards and qualifications.

Of the research methods considered, the Delphi technique, which is “a method for structuring

a group communication process so that the process is effective in allowing a group of

individuals, as a whole, to deal with a complex problem” (Linstone & Turoff, 2002, p. 3), was

determined to be the most appropriate in order to achieve the research purpose. As

previously noted the research purpose was to determine the consensus view of international

regulatory experts in relation to best practice for nurses to demonstrate continuing

competence and for regulatory authorities to assess continuing competence. The following

research questions were posed:

1. What is the consensus view of regulatory experts in relation to:



2. What, if any, differences are present between the current regulatory requirements for

the demonstration and assessment of continuing competence in six countries and the

best practice model developed through consensus?

3. What changes, if any, would be required to policy and regulation in these six countries

to align their regulatory framework with best practice for demonstration and

assessment of continuing competence?

3.3.3.1 Method; the Delphi Technique

The Delphi technique offered a structured and logical approach that provided a platform to

engage with, and potentially achieve consensus from, a geographically diverse group of

regulatory experts, through a process of iteration. This process usually comprises four distinct

phases of data collection and analysis:

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• Exploration of the subject under discussion, where each individual is asked to

contribute the views they believe are pertinent to the issue.

• Reaching an understanding of how the whole group understands and views the issue.

For example where members of the expert panel agree or disagree about the issues

with respect to voting scales like importance, desirability, and/or feasibility.

• Exploration of disagreement in order to bring out the underlying reasons for the

differences in opinion, and to evaluate the reasons for them.

• Final evaluation that occurs when all previously gathered information has been initially

analysed and the evaluations have been fed back to the expert panel for consideration

(Linstone & Turoff, 2002).

The Delphi technique is a flexible and widely used method that is useful in achieving consensus

in an area where there is a lack of empirical evidence (Powell, 2003). It is has a structured

approach that is democratic and takes into account the combined knowledge and expertise of

its participants (du Plessis, 2007; Linstone & Turoff, 2002).

The ‘classic approach’ (Linstone & Turoff, 2002) to the Delphi technique was implemented to

undertake Stage Two of this research. This approach follows a prescribed set of procedures

that incorporate both behavioural and statistical elements and is characterised by five distinct

features; the anonymity of participants, iteration, controlled feedback, a statistical group

response, and stability in responses among an expert group of participants, derived from a

series of rounds of questionnaire surveys where summary information and results are fed back

to the expert panel members between each survey round (Linstone & Turoff, 2002; Stewart,

2001).

Typically, up to three rounds of questionnaires are sent to the expert panel (Linstone & Turoff,

2002), to elicit their responses and try to ascertain consensus. However, for the purpose of

this research four Delphi rounds were completed integrating the findings from the literature

review, and the evaluation of the Nursing Council of New Zealand Continuing Competence

Framework.

3.3.3.2 Expert panel

The success of the Delphi technique relies on the experiential knowledge, expertise and

credibility of the participants who make up the ‘expert panel’ (Linstone & Turoff, 2002).

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However, it does not require the expert panel to be a ‘representative sample’ for statistical

purposes (Linstone & Turoff, 2002). The quality of the panel is related to their willingness and

ability to make a valid contribution to the study being undertaken (Stewart, 2001). For the

purposes of this study the combined expertise of two expert panels were involved.

The first expert panel (Group A) was made up of a purposive sample of 14 international

regulatory and professional nursing representatives from the six countries (Australia, Canada,

Ireland, New Zealand, the United Kingdom and the United States of America) previously

identified as the focus for the development of the international consensus model for

assessment of continuing competence. Representatives from these countries were chosen as

they have similar standards of practice, regulatory structures for nursing and, as the literature

indicated, have previously commenced work investigating aspects of continuing competence.

Recruitment of this expert panel was by direct invitation, initially made by email and then

followed up by telephone. This panel was important in terms of initial stakeholder

engagement, consultation and confirmation of the specific legislative and regulatory context

within each country that had previously been identified in the international literature, and also

in providing clarity with regard to the complexity of the separate legislative and regulatory

jurisdictions within each country. It was also important to this work that the expert panel

(Group A), was specifically involved in responding to the summary findings presented to them

in round four that indicated a convergence of opinion and commonality of key principles.

The second panel (Group B) was a larger international group recruited specifically from within

the individual Regulatory Boards in each of the six countries and through the International

Council of Nurses Observatory on Licensure and Registration12. Recruitment was via an

electronic invitation sent directly to each individual Regulatory Board and to the International

Council of Nurses administration office. A snowball technique was used in association with the

recruitment of Group B participants. The snowball sampling technique is a non-probability

sampling technique that is useful to identify potential participants in research, where the

potential participants are unknown or difficult to access (Davies, 2007). This technique allows

12 The International Council of Nurses Observatory on Licensure and Registration consists of a small, invited, cross-sectional group established to provide ICN with advice on emerging and future trends in regulation, strategic initiatives to be undertaken and policy stances ICN should consider (International Council of Nurses, 2013).

69

existing research participants to recruit from among their acquaintances, thus growing the size

of the sample group. The electronic invitation clearly identified the purpose, structure and

ethical considerations of the research. It also stated the expertise required of the participants

in terms of their knowledge, understanding and experience relating to continuing competence

activities. The invitation requested that, if the recipient of the invitation did not feel they had

the relevant expertise to participate in the research, they could then forward the invitation to

an appropriate person within the Board or Council of nursing. Participation was voluntary and

anonymous. No identifying information was sought. The questionnaire rounds were

administered electronically in order to enable participants to access the questionnaire directly

through the web-based data platform Zoomerang.

3.3.3.3 Conduct of the Delphi Survey

Round one

Round one was conducted by completing individual interviews with the 14 members of expert

Group A. The interviews were unstructured and facilitated using open-ended questions. This

method was appropriate as the literature identifies that open ended questions are used to

increase the richness of data by allowing the participants to freely identify their views and

opinions (Schneider, Elliot, LoBiondi-Wood, & Haber, 2003). The following five questions were

posed:

1. Tell me about your experience with, and understanding of, continuing competence

frameworks/models.

2. In your view what is ‘best practice’ for the demonstration and assessment of

continuing competence?

3. What, if any, are the current regulatory requirements for the demonstration and

assessment of continuing competence in your country/jurisdiction?

4. What barriers and enablers exist in relation to the implementation of a

model/framework for assessment of continuing competence?

5. Do you believe it is possible to develop an international consensus model for the

assessment of continuing competence between the following six countries – Australia,

Canada, Ireland, New Zealand, the United Kingdom and the United States of America?

70

Each interview ranged from 40 – 75 minutes in length and was recorded and transcribed

verbatim. Detailed information with regard to the specific interview questions and emergent

themes are presented in Chapter Eight.

Round two

Round two was completed using an e-survey administered through the web-based data

platform Zoomerang. The aim of this second round was to seek an open response from the

larger expert panel (Group B). Predominantly open ended questions were used to elicit

feedback from the panel members in order to encourage them to respond without the

influence of the collated findings from round one. In addition the following two closed

questions were posed. The first to determine if the participant had prior knowledge and

expertise in the area of continuing competence, and the second to identify if the participant

considered development of an international consensus model was possible.

• Do you have knowledge and / or experience in the development or implementation of

continuing competence frameworks or models?

• Do you believe it is possible to develop an international consensus model for the

demonstration and assessment of continuing competence?

The participants were provided with the opportunity to add additional comments related to

both questions if they so wished. A copy of the Delphi round two e-survey is appended

(Appendix IV).

Round three

The development of questions for the Delphi round three drew heavily on the responses from

the previous two rounds. The e-survey was structured using themed statements developed

from the combined findings of rounds one and two. The participants were provided with the

summary of responses and asked to either, rate their level of agreement with the statements

on a five point Likert scale, or for some questions, to rank the statements in order of their

importance. This process sought to quantify the earlier findings from rounds one and two, and

determine any convergence and consensus of opinion. A copy of the Delphi round three e-

survey is appended (Appendix V).

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Round four

In round four the summary findings of the first three rounds of the Delphi study (the consensus

view) were presented to the expert panel (Group A) to consider the key principles and

components of an international consensus model for the assessment of continuing

competence. The members of Group A were invited to provide their views on the consensus

findings, the key principles, and the core components of a conceptual model for the

assessment of continuing competence. They were asked to consider the efficacy of the model

within each of their jurisdictions and to identify if any changes would be required to current

policy and / or legislation in order to bring their existing continuing competence processes into

line with the consensus framework. The participants were invited to respond to the

researcher by email or telephone within three weeks of receiving the summary findings.

Copies of the Delphi round four summary documentation and e-survey are provided in

Appendix VI and VII.

3.3.3.4 Data Analysis

The literature indicates that data analysis varies according to the purpose of the Delphi study,

the structure of the rounds, and the type of questions used to elicit information (Linstone &

Turoff, 2002). Content analysis was used to identify the themes generated from the

qualitative data derived from round one and round two. Content analysis is a widely used

qualitative research technique used to interpret meaning from the content of text data

(Schneider, et al., 2003; Shannon, 2005). It enables researchers to sift through large volumes

of data in a systematic fashion and is a technique that allows us to discover and describe the

focus of individual, or group in a logical and systematic way (Stemler, 2001). A summative

content analysis was then used to refine the Delphi round two data. This involved counting

and comparison, of keywords or key content areas, followed by the interpretation of the

underlying context (Schneider, et al., 2003).

Findings from these two data sets were further collated and major themes identified which

formed the basis of the structured e-survey implemented in round three. As the e-survey used

in round three was primarily structured using a rating scale, the data generated was

quantitative in nature and statistically analysed. The use of the five point Likert scale, on

which participants’ rated their level of agreement or disagreement (1 indicating Strongly Agree

and 5 indicating Strongly Disagree), provided the ability to determine percentage scores in

conjunction with the main statistical measures that included distribution of responses

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(standard deviation and interquartile range), and measures of central tendency (mean,

medium and mode) (Hsu & Sandford, 2007). Detailed discussion related to this process of

statistical analysis is presented in Chapter Eight (8.4). A convergence of opinion was evident at

completion of round three, however confirmation of the data by the expert panel (Group A)

was critical in order to validate the findings and relevance of this work to the six participant

countries and ultimately to confirm a best practice consensus view. In conclusion a collation

and discussion of these summary findings and the emergent consensus view is presented in

Chapter Nine in relation to the two overarching research questions (Table 2, p. 5).

Recommendations for a best practice international consensus model are made.

Determination of consensus

Interpretation of what constitutes consensus in a Delphi survey, is said to be based on the

arbitrary judgement of the researcher and is related to the types of questions and analysis that

have been used in each of the Delphi rounds (Linstone & Turoff, 2002). For the purpose of this

research the consensus view was determined throughout the iterative process by assessing the

stability of the participant responses to each Delphi round (Scheibe, Skutsch, & Schofer, 1975),

in conjunction with the analysis of percentage scores indicating the participants’ level of

agreement with the statements provided via the e-surveys. A percentage score of 90%

agreement or greater, with a mean score of less than two (based on the five point Likert scale),

was deemed as exhibiting a consensus view.

3.3.3.5 Ethical Considerations - Participation, Confidentiality and Rights

Participation in the Delphi e-survey was voluntary. All potential participants were initially

contacted by email and provided with an electronic invitation to participate in the Delphi e-

survey. An information sheet outlining the purpose, design, and possible outcomes of the

intended research, participant involvement, participant’s rights, and the full contact details of

the researcher (doctoral candidate) and doctoral supervisors was provided and is found at

Appendix VIII.

For the participants in Group A (Expert Panel), after the initial email invitation, an information

sheet relating specifically to the interview process and purpose, and the predicted time

commitment of the participant, accompanied by a consent form (Appendix IX) was sent to

each participant by email. Follow-up was then made by telephone and individual interview

times were arranged and scheduled. Whilst the participants in Group A were known to the

73

researcher, their responses were de-identified and their identities were not disclosed to other

members of Group A or Group B.

The participants for Group B were more difficult to access due to their broad geographic

spread internationally, and the lack of access to the specific contact details of individuals. As

previously stated, recruitment to this group was substantially through a second party access,

the International Council of Nurses Regulatory Observatory Committee and the email

addresses of individual nursing Regulatory Boards, in association with a snowball sampling

technique. Participation in the Delphi survey was voluntary and anonymous and, as such,

potential participants were able to opt out of the study by simply choosing not to respond to

the electronic invitation. The Delphi survey was administered through a web-based platform

that does not capture the email address of origin. In addition no identifying details were

required in order to complete the survey. As a result, the identity of participants in Group B is

not known to the researcher or the other participants in the study. Consent of the participants

was implied if they chose to complete and submit the e-survey.

Participation was not influenced by financial reward or duress. Participants in Group A were

able to withdraw from the study up until data had been collated and analysed. Participants in

Group B were unknown, therefore once they had submitted the e-survey it was unable to be

withdrawn however they could choose not to participate in the subsequent survey round. All

information was de-identified, coded, collated and analysed. Only summary data were

provided to participants as feedback. All data remain confidential to the researcher on a

password protected private computer in a locked office.

3.3.4 Methodological triangulation of overall summary data

As previously described (Section 3.2, p. 52), this research follows a sequential mixed methods

design that was completed in two stages. The analysis of findings and discussion relating to

Stage One and Stage Two are presented sequentially. Methodological triangulation of the

cumulative findings from Stages One and Two are discussed and presented in relation to the

three overarching research questions:



practise?


74




A conceptual model for the assessment of continuing competence is discussed.

Recommendations for future development of the best practice international consensus model

for assessment of continuing competence, the associated implications for key stakeholders,

and recommendations for policy change are made and presented in Section Four, Chapter Ten.

3.4 Management of researcher bias

Researcher bias is a well-documented phenomenon that has the potential to occur in any

research process. Biases introduced by the researchers can directly affect the validity and

reliability of research findings (Davidson, 2005; Schneider, et al., 2003). As previously

described this study has incorporated four distinct methods of data collection and analysis

culminating in methodological triangulation of the data to derive the summary findings of this

thesis. Whilst each method has the potential to allow the researcher to guide or mould

participant responses, measures have been put in place to eliminate and manage any potential

bias throughout the data collection, analysis or write up phases of this research.

In order to manage this potential risk, all data collection tools were developed and submitted

for ethical approval prior to implementation. In addition, all interview and e-survey questions

were piloted with selected small sample groups relevant to the intended participant groups,

prior to their administration. The author completed all aspects of the data collection and

analysis process ensuring a consistent and standardised approach throughout each phase.

Consistency and trustworthiness of the data were validated through a process of having my

doctoral supervisors independently review the raw data, the process of analysis, and

subsequent findings in terms of management of researcher bias, consistency, reliability and

validity. A table summarising the qualitative analysis process is provided as Appendix XI.

Methodological triangulation of the data provided the ability to elicit a broader understanding

of the data and information (Sandelowski, 2000).

3.5 Ethical approval

This research conforms with the guidelines prepared by the New Zealand Health Research

Council (2002) for the preparation and undertaking of research involving human subjects and

75

the Australian national statement on ethical conduct in research involving humans (National

Health and Medical Research Council, 2007).

Ethical approval was granted by the Health Research Council of New Zealand Health and

Disability Multi Region Ethics Committee, reference numbers: MEC/09/64/EXP and

MEC/11/EXP/010, the Eastern Institute of Technology, Hawke’s Bay Research Approvals

Committee, reference number Ref-27/09, and ratified by the University of Sydney, Human

Research Ethics Committee, reference number: Ref–12618. Copies of these ethical approval

documents are provided in Appendix X.

3.6 Limitations of the research

3.6.1 Research Design and methods

Evaluation research: As previously noted evaluation research utilising a sequential mixed-

methods design is no different from any other form of research in that methodological deficits

may exist, and are not necessarily obvious until the research is undertaken. However,

reliability and validity of results is dependent upon the rigorous nature in which sampling, data

collection, data collation and analysis is conducted. The sequential nature of the mixed

methods evaluation design and methodological triangulation of the data adds strength to the

design and the findings (Miller & Fredericks, 2006; Scheibe, et al., 1975).

Document review and policy analysis: The document review and policy analysis was extensive

and complex. Policy documents and statistical summaries were supplied by the Nursing

Council of New Zealand administrative staff on request. However, it is possible that some

historical documentation may have been missed, due to the absence of a chronologically

indexed archive of historical documents at the Nursing Council of New Zealand, and

subsequent difficulties associated with sourcing original documents.

Interviews: The face-to-face interviews conducted in Stage One and Stage Two of this

research were consistently administered using open ended or semi-structured questions.

Unfortunately it was not possible to interview all of the participants in Stage Two - Delphi

Round One, face-to-face due to the geographic distances and financial constraints. Hence,

three of the interviews were conducted by telephone. Whilst it is not thought that this was a

significant limitation, it is acknowledged that the interview rapport took slightly longer to

establish due to not being able to see the participant and relate to behavioural cues.

76

E-surveys: The web-based e-surveys were developed to elicit feedback from geographically

diverse participant groups and were used in both Stage One and Stage Two of the research.

Validity of the survey was examined following an initial pilot of each e-survey which indicated

consistency of participant responses and accuracy in interpretation of the questions. The e-

surveys provided the participants with a safe and anonymous means of expressing their views.

Issues relating to participant responses to e-surveys are acknowledged, and it is noted that the

perception of the participant was their perception on the day they completed the e-survey and

may alter over time; that the participant may have adopted what they perceive as a socially

acceptable position when responding to the e-surveys; or the e-surveys may have been

completed by someone other than the specified recipient (Duffy, 2002; Schneider, et al.,

2003). Whilst there is no formal evidence of any of these examples occurring, they are raised

and discussed in relation to the validity of the e-surveys.

Delphi study: Cultural bias of the expert panel participants may be viewed as a limitation, as it

is likely that many of the expert panel participants may have similar views (Linstone & Turoff,

2002). However, as this research is specifically related to nursing regulation and processes

with regard to continuing competence legislation, policy and processes, the criteria for

selection of the expert panels is considered appropriate. Whilst the potential for cultural bias

is acknowledged as a limitation, this issue was not overly apparent and is not considered to be

significant in terms of this research.

The Delphi e-survey Rounds two and three, were conducted via a web-link, in order to

maintain the confidentiality of the participants and to provide them all with consistent web-

access. By conducting the e-surveys in this way it is not possible to guarantee that the

participants in Delphi Round three (Group B) are the same Group B participants that

responded to Delphi Round two.

3.6.2 Language and terminology

The use of terminology related to the regulation of nurses varies across and between the

regulatory jurisdictions. The use of terms may hold a number of meanings and are often

culturally appropriate. It is acknowledged that different terms may, or may not, have the same

meaning in similar jurisdictions, therefore care has been taken to clarify the language and

terminology that has been used to undertake this research particularly when speaking or

corresponding with participants. Clarification was sought to confirm the meaning of any

77

jurisdiction specific terms used by participants, or that were found in the associated legislation

and documents.

3.6.3 Interpreting legislative requirements

The focus of this research is predominantly related to the continuing competence

requirements for nurses in the New Zealand regulatory environment. However, in order to

better understand and situate this research in the wider international regulatory environment

and particularly with regard to the six participant countries, it is necessary to have a broad

understanding of the international legislation and regulatory jurisdictions in which they are

situated. Every effort has been made to correctly interpret, analyse and describe these

documents.

3.6.4 Access to regulatory authorities and information

The geographic spread of the regulatory jurisdictions included in this research and

subsequently the participants, whilst a challenge at times was not insurmountable due to

consistent access to reliable telecommunications and internet services. However, ensuring

currency of data in a national and international regulatory environment that is constantly

changing may be considered a limitation. In this regard every attempt has been made to

confirm and ensure that the most up-to-date information in relation to legislation, policy and

associated regulatory requirements has been used.


This chapter has provided a detailed overview of the research design and methods. The

following section, Section Two; Chapters Four, Five, Six and Seven will present and discuss the

summary findings of Stage One, the evaluation of the Nursing Council of New Zealand

Continuing Competence Framework. Section Three; Chapters Eight and Nine will present and

discuss the findings related to Stage Two, the development of a consensus model for the

assessment of continuing competence and in conclusion Section Four, Chapter Ten presents

the summary findings of both studies in relation to current literature and the overarching

research questions.

78

SECTION TWO STAGE ONE: EVALUATION OF THE NURSING COUNCIL OF NEW ZEALAND CONTINUING COMPETENCE FRAMEWORK

Section Two presents Stage One of the research, the evaluation of the Nursing Council of New

Zealand Continuing Competence Framework. As previously noted aspects of Section Two of

this thesis was completed under contract to the Nursing Council of New Zealand to evaluate

the efficacy of the Continuing Competence Framework, which was implemented in 2004

following enactment of the Health Practitioners Competence Assurance Act 2003 (NZ).

Chapter Four presents the findings of Phase One of the study providing an overview of the

legislative history governing the regulation of the nursing profession in New Zealand, and the

findings derived from the document review and policy analysis of Nursing Council of New

Zealand documents leading up to and following implementation of the Health Practitioners

Competence Assurance Act (NZ) 2003.

Chapter Five presents the findings of Phase Two, the interviews with key nurse stakeholders.

Chapter Six presents the findings of Phase Three the e-survey of New Zealand nurses active on

the Nursing Council of New Zealand register.

Chapter Seven provides a triangulation of the cumulative data from Phases One, Two and

Three addressing the project outcomes identified by the Nursing Council of New Zealand and

providing a summary of key research findings to inform the second Stage of this research.

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CHAPTER FOUR - PHASE ONE FINDINGS: DOCUMENT REVIEW AND POLICY ANALYSIS

4.1 Introduction

Chapter Four presents the findings of Phase One of the evaluation of the Nursing Council of

New Zealand Continuing Competence Framework which included a comprehensive document

review and policy analysis.

The document review was completed in two parts. Firstly a focused review of historical

documents relating to the legislation and regulation of nursing in New Zealand leading up to

the implementation of the Health Practitioners Competence Assurance Act (NZ) 2003 was

undertaken. This was followed by a comprehensive review and analysis of Nursing Council of

New Zealand archived documents for the fourteen years preceding implementation of the

Continuing Competence Framework (2004). Whilst a complex and time consuming process,

this aspect of the evaluation was important in order to identify the documented processes by

which the Nursing Council of New Zealand had developed its Continuing Competence

Framework and associated policies and procedures.

Documents reviewed include:

• Papers and memoranda to the Nursing Council of New Zealand

• Nursing Council of New Zealand meeting minutes

• Published Council documents

NCN

Z Co

ntin

uing

Com

pete

nce

Fram

ewor

k

Stage One Phase 1


Stage One Phase 3


Data triangulation & discussion


Stage One Phase 2


80

4.2 Framework for the document review and analysis

4.2.1 Historical review

As previously stated, areas of exploration included historical data relating to legislation and

regulation of nurses in New Zealand; the development and implementation of the Nursing

Council of New Zealand Continuing Competence Framework; Nursing Council of New Zealand

projects, policies and procedures associated with the Continuing Competence Framework, and

stakeholder consultation and engagement. A simple descriptive review and analysis of these

documents was undertaken and a summary of events is presented in chronological order in

Chapter Four (4.3).

4.2.2 Policy analysis

Existing and current Nursing Council of New Zealand policies, procedures, and guidelines

associated with the Continuing Competence Framework, including recertification and audit

requirements were analysed using a framework informed by Musick’s (1998) structured

approach to policy analysis. Findings from these analyses are presented in Chapter Four (4.4).

4.3 The evolution of nursing regulation in New Zealand

The development of legislation and policy with regard to the regulation of nursing in New

Zealand has, and continues to be, shaped by a complex tapestry of social, political,

technological, scientific and multidisciplinary forces. Nursing is now the largest health

professional group in New Zealand, having developed from what was a small, largely

undefined and unregulated workforce in the mid-1800s (Gage & Hornblow, 2007; Gauld, 2001;

Sargison, 2001). By the late 1800s, economic growth, a rapidly increasing population,

increased social issues such as high maternal and infant mortality rates, and the arrival of

Nightingale trained nurses, heralded an era of increased political and professional control

(Jacobs, 2005). Local health services that had previously consisted of small cottage hospitals,

generally staffed by unqualified persons began to disappear (Rodgers, 1985). The introduction

of a government controlled public health system (New Zealand Department of Health, 1972)

and national licensure of the health professions followed soon after. It was during this time

that a number of health professions including nursing and midwifery, first became subordinate

to medicine. As noted by Papps (1997) the medical profession exerted power and control over

nursing and other health professions through the use of knowledge, social status and

exclusionary practices.

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4.3.1 Chronology of legislative change 1901 -1971

The Nurses Registration Act 1901 (NZ) was the first legislation that formally regulated the

nursing profession in New Zealand and the first legislation of its kind in the world. Entry

criteria were stipulated and a register of nurses was established. The register contained the

name, and address of each nurse, and details of where and when she trained (Rodgers, 1985;

Sargison, 2001). The Nurses Registration Act 1901 (NZ) stipulated that training programmes

were three years in duration, required that the nurse was 23 years of age, and had achieved a

pass in the state examination prior to entry to the register. The enactment of the Nurses

Registration Act 1901 (NZ) and the associated requirements introduced uniformity and

consistency of standards to the existing hospital based nurse training programmes. A

'grandmother' clause was introduced and those nurses already practising at the time the

Nurses Act 1901 (NZ) was passed, were entitled to go directly onto the register (Burgess, 2008;

Papps, 1997). The introduction of regulation and the subsequent formal education and

training of nurses, marked a considerable change in the status and social position of the nurse

(Papps, 2002). Gage and Hornblow (2007, p. 331) note that regulation of the health

professions also made “certain health-related practices illegal, through the Tohunga

Suppression Act 1907 (NZ)13 and the Quackery Prevention Act 1908 (NZ).”

In 1904, due to increasing public concern about the maternal and infant mortality rate,

legislation was passed for midwives, the Midwives Act 1904 (NZ). This was similar to the

previously enacted Nurses Registration Act 1901 and required standardised training for what

had been a predominantly untrained midwifery workforce. No midwifery training programmes

had been available in New Zealand until this time. The Midwives Act 1904 (NZ) established a

register, entry criteria of training, a state examination, and standards of practice similar to

those stipulated in the Nurses Registration Act 1901 (NZ). Training schools for midwives were

introduced with the establishment of St. Helen's hospitals, which were situated in a number of

regional areas in New Zealand (Papps & Olssen, 1997). The Nurses Registration Act 1901 (NZ)

and the Midwives Act 1904 (NZ) were implemented and administered by the then Department

of Health with the Inspector General of Hospitals being appointed as the Registrar for nurses

and midwives. However, within four years (1908) all legislation relating to nurses and

midwives was reviewed, the aim being to eliminate unnecessary and out of date clauses and

13 The Tohunga Suppression Act 1907 (NZ) was an Act of Parliament in New Zealand that aimed to replace tohunga (traditional Māori healers) with modern medicine.

82

requirements. This review was followed by the enactment of the Nurses Registration

Amendment Act 1920 (NZ) which, amongst other minor changes reduced the required age of

nurses at registration to 22 years (French, 1998; Papps, 2002).

During the 1920s nursing and midwifery legislation underwent a major review and the

previous two separate pieces of legislation, the Nurses Registration Act 1901 (NZ) and the

Midwives Act 1904 (NZ) were combined. This brought both professional groups under the

same statute, the Nurses and Midwives Registration Act 1925 (NZ). The enactment of the

Nurses and Midwives Registration Act 1925 (NZ) resulted in the creation of a six member

Nurses and Midwives Registration Board, and for the first time, stipulated that the Registrar

was the person who held office as the Director of the Division of Nursing in the Department of

Health. At this time the Nurses and Midwives Registration Board, was chaired by the Director

General of Health, who was appointed by statute. It is interesting to note that whilst the

Nurses and Midwives Registration Board included board members who were nurses, if the

Director General of Health was absent, any other Registered Medical Practitioner who was an

officer of the Department of Health was able to chair the Board, rather than one of the

Registered Nurse Board members (Papps & Kilpatrick, 2002). The Nurses and Midwives

Registration Act 1925 (NZ) also created a new category of nurse, the registered maternity

nurse. Less than a year after the implementation of the Nurses and Midwives Registration

Act 1925 (NZ), further changes were made and the Nurses and Midwives Registration

Amendment Act 1926 (NZ) was enacted, resulting in the age requirement for registration being

increased to 23 years again.

By the post-depression era of the 1930s nursing and the other main health professions, were

clearly defined in terms of their legislated title, role, and programmes of education, inter-

professional relationships and social status. However, the election of a Labour government in

1935 introduced the framework for a state funded comprehensive health system. This was to

have a substantial influence on funding, health care delivery and health work force

development for the next 50 years (French, 1998; Gage & Hornblow, 2007). State funding of

hospital based facilities was enacted, however payment for services in the primary sector was

retained and subsidised by the government. This resulted in the majority of nurses being

‘trained’ through apprenticeship programmes, employed in state sector hospitals, under

increasingly hierarchical structures, that included medical oversight of nursing practice. Those

nurses who registered and were employed in the primary sector, fulfilled a role primarily of

supporting the general practitioner (Gage & Hornblow, 2007).

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It is important to note that throughout the 1920s, nurses had debated a potential move of

nursing education to the University sector, and in 1928 the University of Otago established a

diploma programme. History indicates that the university programme was not sustainable due

to a variety of reasons, most notably a lack of political support as the apprenticeship model of

training nurses within the public health system provided a consistent supply of, what was a

relatively inexpensive, health workforce (Papps, 1997). This factor, in association with the

prevailing strong Nightingale ethos and insufficient funding, appears to have resulted in the

collapse of the university based nursing programme (Gage & Hornblow, 2007; Papps, 2002).

Throughout the 1930s the number of registered nurses continued to grow and further

amendments were made through the Nurses and Midwives Registration Amendment Act

(1926). The amendments provided the Nurses and Midwives Registration Board with the right

to approve private hospitals as nurse training institutions, and introduced the ability to limit

both public and private hospitals in terms of their structure and their demographic location

(French, 1998). In 1939 a further amendment to the Act instituted the requirement that all

nurses and midwives must hold an annual practising certificate. The power of the Nurses and

Midwives Registration Board was extended to allow it to impose fines for proven cases of

negligence and/or misconduct. The amendment also identified and approved Public Mental

Hospitals as nurse training schools (French, 1998), however it was not until the enactment of

the Nurses and Midwives Amendment Act 1944 (NZ) that the registration of psychiatric nurses

came under the control of the Nurses and Midwives Registration Board.

During the 1940s a number of amendments to the Act were made, many it would seem in

response to the increased demand for nurses as a result of New Zealand’s involvement in

World War II. The Nurses and Midwives Registration Amendment Act 1943 (NZ) introduced the

recognition of training undertaken by New Zealand nursing students overseas, in particular

those based in hospital ships during World War II, and again the age for general nurses at

registration was reduced, this time to 21 years. The enactment of the Nurses and Midwives

Registration Amendment Act 1944 (NZ) allowed for the creation of new training programmes,

including the registration of psychiatric nurses (introduced in 1944), and the registration of

male nurses (introduced in 1945). In 1945 new legislation, the Nurses and Midwives Act 1945

(NZ), revised and updated all previous revisions and amendments. The Nurses and Midwives

Act 1945 (NZ) remained in place, with amendments, until 1971 and allowed for an increase in

membership of the Registration Board, to nine members who were appointed for a three year

term. It also extended the Board’s disciplinary powers to include suspension of registration for

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up to a 12 month period (Papps, 2002). In the decades following World War II, the New

Zealand health sector was to become one of the largest areas of employment, and the most

expensive in terms of New Zealand government expenditure (Gage & Hornblow, 2007).

In 1957 a noteworthy change in the education of nurses took place as a result of the

implementation of the Nurses and Midwives Amendment Act 1957 (NZ). This legislation

introduced the registration category General and Obstetric Nurse, which in turn resulted in the

development of a new three year curriculum and training programme that combined the

previously separate, general and maternity nurse training programmes. Further amendments

to the legislation, curriculum and training in the 1960s introduced a register of Psychopaedic

Nurses (1961), and a register of Community Nurses (1965). The title ‘community nurse’ was

later changed to ‘enrolled nurse’ (Nurses Act (NZ), 1977). During the 1960s the need for

English language competence for nurses from overseas applying for registration in New

Zealand, was also specified. The clause “and is a fit and proper person to be registered”

(Nurses Act (NZ), 1977, s15) was introduced in association with applications for registration

(French, 1998; Papps, 2002).

4.3.2 Legislative and educative change

The Nurses Act 1971 (NZ) is an important piece of legislation in terms of the history of nursing

regulation in New Zealand. It established the Nursing Council of New Zealand to replace the

previous Nurses and Midwives Board. The Nursing Council of New Zealand was a ‘Body

Corporate’, thus separating the registration function of nursing and midwifery from the

Department of Health for the first time (Papps, 2002). The Nurses Act 1971 (NZ) clearly

stipulated the membership, functions of the chairman and deputy chairman, allowed for the

appointment of a Registrar of nurses, Deputy Registrars and other employees as necessary.

However, it was no longer enshrined in legislation that the position of Registrar be occupied by

a nurse and, as a result, a succession of lay persons were appointed to the position of Registrar

of the Nursing Council of New Zealand until 1989, when the first nurse/midwife was appointed

as the Registrar of the Nursing Council (Papps, 2002). The legislation specified the functions of

the Nursing Council of New Zealand including the authority to register, the authority over

schools of nursing, nursing programmes and experimental programmes, disciplinary and

disability powers, appeal procedures and annual practising certificate requirements (Burgess,

2008; Papps, 2002).

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The omission of the word ‘Midwives’ from the title of the Nurses Act 1971 (NZ), reflected the

position of midwives in the health sector at that time. As Papps (1997) noted, entry to

midwifery training in New Zealand was post nursing registration. The medicalisation of

childbirth and subsequent hospitalisation of women for childbirth, had occurred over a

number of years, and the majority of births at that time took place in maternity hospitals and

wards within general hospitals (Papps, 1997).

In 1971 the report An improved system of nursing education in New Zealand (Carpenter, 1971)

(subsequently referred to as ‘The Carpenter Report’), was released and recommended that

nursing education be moved from the hospital based training programmes, to occur in

educational institutions in cooperation with selected hospitals and health agencies (Carpenter,

1971). Dr Helen Carpenter14 had been contracted by the New Zealand Government to lead

this review of nursing education in New Zealand having previously contributed to the

development of nursing education programmes in Canada. The review was undertaken at a

time when student attrition rates were high and there was public concern that the traditional

apprenticeship scheme of hospital training was exploitative.

In response to the report recommendations, the Minister of Education established a

committee to consider ‘recommendation 1.6’ of The Carpenter Report (1971). The purpose of

the 1.6 Committee was to

…study the proposal for development of colleges of health sciences for the

preparation of nurses and other categories of personnel needed for the health

services; and that the committee make recommendations to the Government

concerning the most suitable educational setting for the development of these

colleges.

The committee, comprised 16 members, and did not include any representation from the

recently disestablished Nurses and Midwives Board nor the newly instituted Nursing Council of

New Zealand. Representatives were drawn from the Departments of Education and Health

(including the Assistant Director of Nursing Education in the Department of Health’s Division of

Nursing), the Vice Chancellors’ Committee of the University sector, the Technical Institutes

Association, the National Council of Women, the New Zealand Nurses Association, the New

14 Dr Helen Carpenter was the Director of the School of Nursing at the University of Toronto and a Consultant for the World Health Organisation. She had been involved in the redesign of nursing education programmes in Canada.

86

Zealand Student Nurses Association, the Medical Association of New Zealand and the Clinical

Dean of Otago University Medical School (Papps, 2002; Papps & Kilpatrick, 2002).

Whilst the 1.6 Committee did not reach consensus over the location of nursing education

programmes, the government agreed to establish two pilot programmes for a three year

comprehensive nursing diploma. Ultimately technical institutions were selected as the most

suitable location to educate student nurses and, as noted by Papps (2002), “the influence of

Helen Carpenter in this regard is apparent, since in Canada, nursing education programmes

were being transferred from hospital based training to community colleges” (p. 7).

Whilst there was acknowledgement that there was a need to review nursing education in New

Zealand, there was prevailing public resistance from hospital boards and many in the health

professions, including nurses, to the shift of nursing and midwifery education from the

traditional hospital based apprenticeship programmes to educational institutions. However,

despite this resistance the transition from hospital based nursing training to nursing education

programmes situated in polytechnics, commenced in March 1973. Two three-year

comprehensive nursing programmes were commenced in polytechnics, one situated in

Wellington and the other in Christchurch (Papps, 2002; Papps & Kilpatrick, 2002).

The enactment of the Nurses Act 1971 (NZ) provided for the registration of Comprehensive

Nurses from the programmes in technical institutions and removed age as a criterion for

registration, except for the enrolment of Enrolled Nurses. The Nurses Act 1977 (NZ) was the

final iteration of the Nurses Act, and for the next 26 years this was the legislation that

regulated nurses and midwives in New Zealand. During this time the Act and accompanying

regulations, were subject to numerous amendments. Most significantly in 1990, the Nurses

Amendment Act 1990 (NZ) restored autonomous practice to midwives and provided for direct

entry midwifery programmes, which meant that intending midwives were no longer required

to be registered as a nurse prior to entering a midwifery programme (Papps, 2002).

4.3.3 Evolving health services, nursing specialisation and health reforms

The 1980s marked the commencement of 20 years of turbulent health reforms and

restructuring within New Zealand. Rapid technological advances not only provided

opportunities for increased specialisation of nursing practice, but also increased the cost and

complexity of health care delivery. A change in government policy in the early 1990s

introduced the market driven business model to a publicly funded health service. Government

scrutiny of health services was intensified and considerable rationalisation and restructuring of

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services, including the health workforce, was commenced. The previous hierarchical systems

that had endured within the hospital sector for nearly one hundred years were dismantled,

resulting in the removal of many traditional nursing leadership roles. Whilst it cannot be

denied these changes had a major impact on the culture of the health workforce, for many

resulting in conflict, disillusionment and mistrust, the environment of constant change and

reform also presented opportunities, and nurses responded to the challenge evolving and

expanding their careers, education and practice (Bamford-Wade & Moss, 2010).

The changes to the health and educational sectors initiated wide ranging debate within nursing

leadership and culminated in the development of the discussion paper A Framework for

Nursing and Midwifery Education in New Zealand (Vision 2000 Committee, 1992), more

commonly referred to as The Vision 2000 document. This discussion paper proposed a

national framework for nursing and midwifery education and was the culmination of national

discussions with nursing leaders, educationalists, professional organisations, nurses and the

regulatory authority. Whilst the framework was never formally adopted, due to the lack of

overall consensus with regard to some recommendations, the Nursing Council of New Zealand

continued to progress and, as the legislation allowed, implemented several of the key issues.

As noted by Papps and Kilpatrick (2002, pp. 10-11) these issues included “entry to practice for

registered nurses by degree; standards and competencies; a post-registration framework, and

competence-based practising certificates”.

Eventually, although the business focused reforms of the 1990s failed, an increased awareness

of the need for a realignment of health service delivery, workforce planning, professional role

expansion and accountability to the public, remained (Bamford-Wade & Moss, 2010). During

the 1990s a new Nurses and Midwives Bill had been drafted but never passed. A major change

in this new legislation was to be a focus on ‘competence based practice’ with the requirement

that all nurses must demonstrate evidence of continuing competence, a requirement not

enshrined in the previous legislation. Initially, changes were expected by way of an

amendment to the Nurses Act 1977 (NZ), however, during the intervening years, a change in

government, the occurrence of a number of high profile medical incidents and subsequent

enquiries, all combined to result in a refocusing of legislative priorities (Kilpatrick, 2009; Papps,

2002). These events contributed to the government implementing a wider review of all

professional regulation, including nursing and as a result the proposed Nurses and Midwives

Bill was destined to never reach Parliament (Burgess, 2008).

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In 1994 as a direct result of the findings made in the Report of the Cervical Cancer Inquiry

198815, the Health and Disability Commissioner Act 1994 (NZ) was passed into law. The

purpose of this Act was to

promote and protect the rights of health consumers and disability services

consumers, and, to that end, to facilitate the fair, simple, speedy, and efficient

resolution of complaints relating to infringements of those rights (Health and

Disability Commissioner Act (NZ), 1994, s6).

This legislation was followed by the implementation of the Code of Health and Disability

Consumers’ Rights 1996 (NZ) which set out ten legally enforceable rights of consumers, and

the corresponding duties of health and disability service providers.

In 1998, the Nursing Council of New Zealand commenced the first major review of nursing

education since the Carpenter Report of 1971. In 2001 the Strategic Review of Undergraduate

Nursing Education: Report to Nursing Council of New Zealand, now commonly known as The

KPMG Report, was published. This report set the direction for nursing education for the next

ten years and introduced substantial developments in post-registration nursing education,

including the development of programme standards and competencies for the clinical Master

of Nursing for the preparation of Nurse Practitioners.

Finally in October 1999, the Nurses Act 1977 (NZ) was further amended, and hope of a new

Nurses Act was overtaken by the proposal for an omnibus type legislation which would

encompass the eleven existing occupational statutes governing 13 separate health professions

(Health Practitioners Competence Assurance Act (NZ), 2003). The policy framework originated

from an inter-departmental working party situated in the then Ministry of Commerce (now the

Ministry of Economic Development); the document was titled Policy Framework for

Occupational Regulation: A Guide for Government Agencies in Regulating Occupations

(Ministry of Commerce, 1999). The Government formally agreed to the policy framework in

August 1998 and, in a Ministry of Health discussion paper (2000), proposed new legislation,

the Health Professionals Competency Assurance Bill 2000 (NZ). Submissions on the various

proposals and options contained in the discussion document were lodged with the Ministry of

15 The Cartwright Report, named after the presiding judge, Judge Dame Silvia Cartwright, was the blueprint for patients' rights in New Zealand and arose after a Committee of Inquiry into unethical study involving women with major cervical abnormalities without definitively treating them undertaken at the country's premier women's hospital between 1966 -1987.

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Health in November 2000. Although there was optimism that the Health Professionals

Competency Assurance Bill 2000 (NZ) would be introduced into the house during 2001, it did

not occur until June 2002. A number of amendments were made to the Bill including a change

in the name of the Bill – the Health Practitioners Competence Assurance Bill 2002 (NZ). The

Health Practitioners Competence Assurance Bill 2002 (NZ) was received by the Select

Committee for submissions in October 2002, and the Select Committee reported back to the

House in May 2003. The legislation was finally passed through all stages of Parliament and

received Royal Assent on 18 September 2003 - the Health Practitioners Competence Assurance

Act 2003 (NZ).

The Health Practitioners Competence Assurance Act 2003 (NZ) came into force twelve months

later (18 September 2004), and in doing so repealed the existing 11 individual occupational

statutes. At the time of enactment the Health Practitioners Competence Assurance Act 2003

(NZ) applied to 15 registration authorities including nursing, however Section 115 of the Act

allows the Minister of Health to make a recommendation to the Governor-General “that the

Act be extended to include a new health profession if they meet the criteria in Section 116 of

the Act”. In summary Section 116 of the Health Practitioners Competence Assurance Act 2003

(NZ) allows that, should the Minister be satisfied, after consulting with the interested

organisation, that the new profession either “poses a risk of harm to the public” or “it is

otherwise in the public interest to regulate” he may deem the criteria to be met (Health

Practitioners Competence Assurance Act (NZ), 2003). However, neither the term “risk of harm”

nor “public interest” is defined in the Act. These are left to the discretion of the individual

regulatory authority to determine.

It is also important to note that not all health professional groups in New Zealand are

regulated under the Health Practitioners Competence Assurance Act 2003 (NZ), either because

they work under the direct supervision of a regulated health professional, or because they are

deemed to pose little risk to the public. These professional groups are regulated in a variety of

non-statutory ways through their employers or in some instances self-regulated by the

profession (Ministry of Health, 2010). The Health Practitioners Competence Assurance Act

2003 (NZ) does not prevent unregulated or untrained people from operating in the health

sector provided they do not “hold themselves to be a registered health professional” (Ministry

of Health, 2010). Under the Act, the Minister of Health is also responsible for a single shared

Disciplinary Board the Health Practitioners Disciplinary Tribunal, which is administered for all

health professions specified in the Act. This tribunal hears and determines cases against health

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practitioners, although the regulatory authorities, via professional conduct committees, can

also investigate individual practitioner’s competence and conduct.

4.3.4 Legislation and the New Zealand health system

As previously indicated, the health sector in New Zealand is comprised of a complex system of

legislation, organisations and people. Each has a role in the provision of health and disability

services, the aim being “to achieve better health outcomes for the New Zealand public”

(Ministry of Health, 2011a). The health and disability system’s statutory framework is now

comprised of over 20 separate pieces of legislation. Whilst the most important in terms of this

research is the Health Practitioners Competence Assurance Act 2003 (NZ), it does not function

in isolation and intersects with a number of other Acts, for example the Health Act 1956 (NZ),

the Health and Disability Commissioner Act 2004 (NZ), the New Zealand Public Health and

Disability Act 2000 (NZ) and the Crown Entities Act 2004 (NZ). All of these statutes have an

impact in terms of determining the social and political context in which health professionals

practise.

The Health Act 1956 (NZ) specifies the roles and responsibilities of incumbents to safeguard

the public’s health, including the Minister of Health, the Director of Public Health, and

designated officers for public health. It contains the provisions for environmental health,

infectious diseases, health emergencies and the national cervical screening programme.

As previously noted the Health and Disability Commissioner Act 1994 (NZ) was enacted as a

direct consequence of the findings of the Report of the Cervical Cancer Inquiry (Cartwright,

1988). The New Zealand Public Health and Disability Act 2000 (NZ) establishes the structure of

underlying public sector funding and the organisation of health and disability services. It

establishes District Health Boards (DHBs) and sets out the duties and role of key participants,

including the Minister of Health, Ministerial committees, and health sector provider

organisations. The New Zealand Public Health and Disability (NZPHD) Act 2000 (NZ) sets the

strategic direction and goals for health and disability services in New Zealand. These include

“to improve the health and disability outcomes for all New Zealanders, to reduce disparities by

improving the health of Maori and other population groups, to provide a community voice in

personal health, public health, and disability support services and to facilitate access to, and

the dissemination of information for the delivery of health and disability services in New

Zealand” (Ministry of Health, 2011b).

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A large number of health service provider organisations in New Zealand are owned by the

Crown (from the Commonwealth term Crown), and are termed Crown Entities16. The Crown

Entities Act 2004 (NZ) provides the fundamental statutory framework for the establishment,

governance, and operating of Crown Entities. It clarifies lines of accountability, relationships,

and reporting requirements between Crown Entities, their Board members, the relevant

responsible Ministers, and the House of Representatives.

4.3.5 Review of the Health Practitioners Competence Assurance Act 2003 (NZ)

In 2009 the Psychotherapy Board of New Zealand, which was established in 2007, became the

16th health profession to be regulated under the Health Practitioners Competence Assurance

Act 2003 (NZ). In the same year, concerns had been raised in government, relating to the high

costs associated with the establishment of separate authorities and a perceived ‘proliferation

of registration authorities’ (Ministry of Health, 2010). The Director-General of Health directed

the Ministry of Health to review the operation of the Health Practitioners Competence

Assurance Act 2003 (NZ). A discussion document was released for public consultation. Its

purpose was to:

• outline the policy principles that are relevant to regulating health professions,

• discuss the Ministry’s criteria for regulation and those used in similar jurisdictions,

• propose revised criteria to assist the Ministry in advising the Minister whether a

profession ‘poses a risk of harm’ or ‘it is otherwise in the public interest’ to regulate

that profession (New Zealand Ministry of Health, 2010).

The findings of the review determined that no operational changes were required in terms of

the Health Practitioners Competence Assurance Act 2003 (NZ). However, the criteria for

recommending registration of a profession and any new registration authorities were

amended. The aim was to monitor and reduce future potential for further increases in the

number of registration authorities.

A Ministerial review was commenced in 2011 to investigate the efficacy of the ‘administrative

functions of the sixteen regulatory authorities’. The purpose of this review was primarily

focused on reducing the financial costs related to the administration of separate independent

regulatory authorities, with the proposal that grouping the administrative functions of the

16 A Crown entity is an organization that forms part of New Zealand's state sector established under the Crown Entities Act 2004, a unique umbrella governance and accountability statute.

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regulatory authorities would reduce costs by several million dollars per annum17. However, to

date, this review has not been completed as no agreement has been achieved between the

individual regulatory authorities and the Ministry of Health.

In August 2012, the National Government of the day initiated a third review of the Health

Practitioners Competence Assurance Act 2003 (NZ). The document Review of the Health

Practitioners Competence Assurance Act 2003: A Discussion Document (Ministry of Health (NZ),

2012a) was released for public consultation on 31 August 2012 and states that it combines the

previous two reviews. Four areas for review are highlighted - Future focus, Consumer focus,

Safety focus, and Cost effectiveness focus. However, a large portion of the document focuses

on the authority and functions of the independent regulatory authorities, and provisions in

relation to the Ministry of Health and health workforce issues. Whilst a public consultation

was undertaken, to date, no outcomes are publicly available.

4.4 Review of Nursing Council of New Zealand documents

Chronologically, there is a well-documented trail mapping the development of the Nursing

Council of New Zealand Continuing Competence Framework over ten years. The Nursing

Council of New Zealand initially signalled this work in its inaugural Strategic Plan 1 April 1994 –

31 March 1997 (Nursing Council of New Zealand, 1994). The four stage project plan identified

a number of critical strategic issues associated with the development of the Continuing

Competence Framework. The implementation of competency based practising certificates,

was identified as a strategic priority. This was closely associated with the requirement to

develop criteria for performance-based annual practising certificates and recertification

processes, development of “registration / enrolment competencies” and the development of

post-registration competencies and standards (Chappell, 1995; Nursing Council of New

Zealand, 1994).

In August 1996, a discussion paper The Development of Performance-based Practising

Certificates, was released by the Nursing Council of New Zealand for consultation. The focus of

this paper was stated as being a “means to ensure public confidence in the continuing

competence of nurses and midwives” (Nursing Council of New Zealand, 1996, p. 1). The

17 The health regulatory authorities in New Zealand are independent of the Ministry of Health and as such the annual fees paid by the health professionals so regulated fund the functions of the individual regulatory authorities.

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subsequent analysis of submissions relating to this consultation was presented to the Nursing

Council of New Zealand at its meeting on 28-29 April 1997 and as a result the first document

outlining the draft Competency-based Practising Certificate Framework was developed for

consultation in 1997 (Nursing Council of New Zealand, 1997). A working group on

competency-based practising certificates was established in 1997, with representation from a

range of nurses and nursing organisations, including consultation with Maori Nurse

Representatives. In September 1998, draft guidelines for Competency-based Practising

Certificates were developed for wide consultation, and on 1 April 1999 Guidelines for the

Continuing Competence Framework was published (Nursing Council of New Zealand, 1999).

In March 2001, following extensive consultation the Nursing Council of New Zealand published

the document Towards a Competency Framework for Nursing (Nursing Council of New

Zealand, 2001b). Essentially this document described the process and components of the

proposed Continuing Competence Framework, developed in anticipation of the impending

enabling legislation. In November 2001 the Nursing Council of New Zealand went on to

publish Guidelines for Competence Based Practising Certificates for Registered Nurses (Nursing

Council of New Zealand, 2001a). This document aimed to provide nurses with information

about the proposed process for renewal of Annual Practising Certificates (recertification), once

the new legislation was in place. In December 2002 a report to the Nursing Council of New

Zealand proposed a new strategic project to further develop the Competency Assurance

Framework18.

The Nursing Council of New Zealand minutes of 1 July 2003, record discussion related to the

proposed Competency Assurance Framework, and the anticipated impact of the legislative

changes outlined in the Health Practitioners Competence Assurance Bill 2002 (NZ) (Health

Practitioners Competence Assurance Bill (NZ), 2002). It was noted in these minutes that there

was also discussion with regard to the role of the Nursing Council of New Zealand. The

minutes indicate that some Council members perceived that there was confusion and

misunderstanding amongst nurses, with regard to the role and functions of the Council in

relation to continuing competence. A suggestion was made that a video be produced,

outlining the key functions of the Council. However, there is no record that this initiative was

undertaken.

18 It is noted that during this time there were frequent changes in the terminology used in Nursing Council of New Zealand documents, to describe the framework and processes that are now formally named the Continuing Competence Framework.

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A memo to the Council (January 2004) recommended approval of the draft consultation

document Review of the Guidelines for Competence-based Practising Certificates (Nursing

Council of New Zealand, 2004c). The consultation document proposed the level of assessment

required for continuing competence purposes; issues related to the validity of using portfolios

for assessment in this context; the resource implications of a random audit of portfolios; and

the time and effort required by nurses to meet the competence requirements. It was noted

that the Health Practitioners Competence Assurance Act 2003 (NZ) does not define

competence, but does define the required standard of competence in relation to a health

practitioner as “the standard of competence reasonably to be expected of a health practitioner

practising within that health practitioner’s scope of practice” (Health Practitioners Competence

Assurance Act (NZ), 2003, 5) and that this definition suggests more than entry level practice

(Nursing Council of New Zealand, 2004c). However, the memo to the Council included a

recommendation that the assessment of continuing competence should be at ‘low level‘,

although what this terminology means is not specified.

Consultation on the Review of the Guidelines for Competence Based Practising Certificates

(2004c), commenced in March 2004 and submissions were closed on 31 May 2004. The

consultation document was circulated to a wide range of individuals and groups, and included

a number of important appendices: 1: The current guidelines for competence based practising

certificates. 2: Continuing competence requirements of other nursing authorities. 3: Continuing

competency requirements of other professions. 4: Continuing practice competencies for the

renewal of practising certificates.

An in-depth analysis of the submissions derived from the Review of the Guidelines for

Competence Based Practising Certificates (2004) was completed and presented to the Nursing

Council of New Zealand on 1 August 2004, in association with the document Continuing

Competence Framework (Nursing Council of New Zealand, 2004a). This appears to be the final

document outlining the Nursing Council of New Zealand Continuing Competence Framework

requirements prior to implementation.

It is clear that extensive consultation occurred over a number of years during the development

and led to various iterations of the Continuing Competence Framework between 1997 and

2003. However, it is important to note that the Continuing Competence Framework could not

be implemented until the change in the legislation occurred, with the enactment of the Health

Practitioners Competence Assurance Act 2003 (NZ). The following section (4.5) presents the

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review of Nursing Council of New Zealand policy documents related to the Continuing

Competence Framework and associated recertification processes.

4.5 Analysis of Continuing Competence Framework and Recertification policies

This section (4.5) provides a critique of the clarity and consistency of the Nursing Council of

New Zealand policy documentation associated with the Continuing Competence Framework.

Two policy documents have been developed in association with the implementation of the

Nursing Council of New Zealand Continuing Competence Framework. They are The Continuing

Competence Framework, and The Recertification Audit Process Policy.

The Continuing Competence Framework is a publicly available document on the Nursing

Council of New Zealand website. However, whilst it is called a ‘policy’, it is written in the form

of a guideline. It does not provide any indication of the date on which it came into effect, or a

date when it will be reviewed. In association with the Continuing Competence Framework is a

subordinate in-house procedural guide that is not publicly available. It outlines the in-house

operational and procedural processes and requirements of the Continuing Competence

Framework. This document is written in the form of a Memorandum (dated August 2004).

The Recertification Audit Process Policy (Guideline Policy 05.3) (August 2006; May 2008) is also

an in-house document and not publicly available. This ‘policy’ is also written in the form of a

guideline or procedure document. It does not include a purpose statement or any linkage with

the Continuing Competence Framework. The document focuses solely on the procedural

aspects of the Recertification Audit process. The criteria for exemption from audit, and the

‘evidential requirements’ associated with the Recertification Audit Process are publicly

available on the Nursing Council of New Zealand website. However, there is no purpose

statement or information linking the Recertification Audit to the Nursing Council of New

Zealand Continuing Competence Framework. In addition no information is available to nurses

with regard to the recertification process timelines and document tracking once the audit

process has been commenced.

At the time this document review was undertaken, all aspects of the Continuing Competence

Framework process; the Application for Recertification (Annual Practising Certificate) and the

Recertification Audit Process, were administered in a hard copy format. A package of the

relevant documentation was posted annually to each individual nurse, to either apply for

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Recertification (renewal of the Annual Practising Certificate), or selection for participation in

the Recertification Audit process.

The documentation provided to the nurses applying for Recertification is a package that

includes all of the required documents and the required timeframes for completion. However,

the nurses who are selected for Recertification Audit receive a package that includes:

• A template letter explaining the requirements of the Recertification Audit

• A participant information sheet – why have I been selected for a recertification audit?

• An Audit Checklist

For all other required documents, such as: the Standards of Practice; the Domains and

Competencies of Practice; the assessment criteria and associated assessment forms, the

nurses are directed to source them directly from the Nursing Council of New Zealand website.

At the time that Stage One of this research was completed the Nursing Council of New Zealand

recertification audit documents were available in PDF format as read only, and required the

nurse to download and/or print them. Subsequently, the Nursing Council of New Zealand has

implemented the recommendations of this evaluation and the recertification audit

documentation is now able to be completed electronically.

As noted in Chapter Three section 3.3.2.1, the structured approach to policy analysis proposed

by Musick (1998), provided a useful framework to inform the analysis of the two key Nursing

Council of New Zealand policy documents associated with the Continuing Competence

Framework - The Continuing Competence Framework and The Recertification Audit Process.

According to Musick (1998), policy analysis is concerned with two distinct but related

processes – the contents of the policy and the process by which it was developed. Musick

(1998) notes that often policy initiatives are advocated or described, without an examination

of the process by which they were developed, or who was involved. Table 5 presents the

summarised analysis of the Nursing Council of New Zealand policy documents associated with

the Continuing Competence Framework: Continuing Competence Framework, and

Recertification Audit Process Policy.

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Table 5 Analysis of key Nursing Council of New Zealand policy documents Components of framework The Continuing Competence Framework The Audit Process (Recertification Audit Policy) Conceptual: What are the core concepts under discussion? How are they defined? What are their measurable outcomes?

Competence Continuing competence

Competence Continuing competence Recertification

Normative: What "ought to be" true in regard to the policy? Do current views of key people or groups differ?

Policy developed from an extensive range of submissions from internal and external stakeholders

Policy developed from a range of submissions from stakeholders

Theoretical: Within what theoretical framework(s) does the policy fit?

Legal/regulatory Legal/regulatory

Empirical: Are there research studies in the literature which could be helpful in illuminating the issues? What important facts can be gleaned from these studies?

Literature from other nursing regulatory authorities (United Kingdom Nursing and Midwifery Council, Canadian Nurses Association, Nursing and Midwifery Council of Australia) informed the development of the Continuing Competence Framework. Limited empirical research was evident in the background to the development of the policy. To date it appears no other regulatory authorities internationally have undertaken research into the efficacy of the Continuing Competence Frameworks or associated policies.

Literature from other nursing regulatory authorities i.e. United Kingdom Nursing and Midwifery Council, Canadian Nurses Association, Nursing and Midwifery Council of Australia, and the National Council of State Boards of Nursing, has informed this process. A small body of published empirical research was evident in the background to the development of the policy. However it appears a pragmatic approach was used in determining required criteria.

Economic: What impact would the adoption of the policy have on budgetary resources? What economic structures would need to be in place in order to implement the policy?

Recommendation in 1998 that the Nursing Council of New Zealand documents a full cost-benefit of the introduction of competence based practising certificates.

Significant impact on budget resources noted if the Nursing Council of New Zealand was required to audit all nurses – mitigated to some extent by the development of a framework for the approval of Professional Development and Recognition Programmes (PDRP)

Cultural: How are different organizational, racial, gender and/or professional cultures affected by the policy?

Working party to develop cultural competencies included Maori representation.

Not identified

Ideological: How are the ideological and informational aspects of the policy interwoven? Do various parties participating in the policy development process bring strong ideological frameworks into the discussions?

Decisions from submissions to consultation documents generally went with the majority view.

Decisions from submissions to consultation documents generally went with the majority view.

Framework informed by Musick (1998). Policy analysis in medical education: A structured approach.

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4.6 Nursing Council of New Zealand statistics

Section 4.6 presents the collation and analysis of a selection of statistical data provided by the

Nursing Council of New Zealand since the implementation of the Continuing Competence

Framework in 2004. Of particular interest are the numbers of Annual Practising Certificates

that have been issued, and the comparison between Recertification Audit completions and

Competence Notifications.

Figure 3 depicts the number of practising certificates issued by the Nursing Council of New

Zealand for the years from implementation of the Continuing Competence Framework (2004)

until data collection was undertaken in early 2010. These figures are inclusive of all nursing

scopes of practice, new graduate registrations and registration of internationally qualified

nurses.

Figure 3 Practising Certificates issued

As depicted there was a significant reduction in the number of practising certificates issued

between the 2004/2005 and 2006/2007 years. From 18 September 2004 the Nursing Council

of New Zealand implemented the Continuing Competence Framework and issued interim

practising certificates for periods of three, six, nine or twelve months on a quarterly basis to

correspond with the applicants’ birth date. The numbers for 2004/2005 year reflect this initial

process.

42,00043,00044,00045,00046,00047,00048,00049,00050,00051,00052,000

2004/2005 2005/2006 2006/2007 2007/2008 2008/2009

51,189

48,240

45,774 45,691

48,683

Practising Certificates issued

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In December 2005 the Nursing Council of New Zealand implemented the recertification audit

process. Nurses who did not meet the Nursing Council of New Zealand requirements for

ensuring continuing competence were issued with interim practising certificates under Section

31 of the Health Practitioners Competence Assurance Act 2003 (NZ). These were replaced with

full practising certificates as the nurses met the required conditions. As the numbers fall quite

steeply it appears that a number of nurses who were no longer practising, or who no longer

met the continuing competence requirements elected not to reapply for a practising certificate

during this initial two year period.

Of the 421 nurses selected for audit in the 2005/2006 year, 50 nurses chose not participate in

the Recertification Audit or renew their practising certificates. From 2006 to 2008 issue of

practising certificates remained relatively stable but in the 2008/2009 year there was a

significant increase of 12% recorded. This appears to be due to an increase in registration of

new graduates (6%), and of internationally qualified nurses (12%), and may be the attributed

to the international recruitment strategies employed by several large District Health Boards

(Nursing Council of New Zealand, 2010a).

Figure 4 depicts the recertification audit and competence notification trends over the period

since implementation of the Continuing Competence Framework. Nurses who are levelled on

Nursing Council of New Zealand approved Professional Development and Recognition

Programmes are exempt from the recertification audit process.

Figure 4 Recertification audit trends and competence notifications

2005/2006 2006/2007 2007/2008 2008/2009

421

1,288

1,083 1,075

289

1,129

768 768

82 159

315 307

43 50 40 105

Recertifcation audit Met requirements

Did not meet requirements Competence notifications

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Under the Health Practitioners Competence Assurance Act 2003 (NZ), Section 34, the Nursing

Council of New Zealand may review the competence of a nurse if she/he has not maintained

the required standard of competence; if there is evidence to suggest the nurse’s practice poses

a risk of harm to the public; or at any other time. Notifications are made through the following

mechanisms; by an employer when a nurse has resigned or been dismissed for reasons relating

to competence; by the Health and Disability Commissioner or the Director of Proceedings if he

or she believes that a nurse poses a risk of harm by practising below the required standard of

competence; and by any health professional who believes there is a competence issue.

Whilst this is a process independent of the Continuing Competence Framework, it was

important to review the competence notification trends in association with the Continuing

Competence Framework recertification audit data, as nurses who are reviewed under

competence notification are exempt from the recertification audit process.

4.7 Summary of findings from the document review and policy analysis

This section (4.7) summarises and highlights the findings from the document review, policy

analysis and statistical trends with regard to practising certificate renewal and competence

notifications. These findings will be discussed in more detail in Chapter Seven where the

results are triangulated.

4.7.1 Development of Continuing Competence Framework

There is significant evidence that the development and implementation of the Continuing

Competence Framework was well researched and detailed. It included extensive stakeholder

involvement, consultation, and feedback over an eight year period. However, the historical

documents relating to this project and the associated stakeholder contributions urgently

require professional indexing and archiving.

The selection of the continuing competence indicators – self-declaration, practise hours and

continuing professional development hours was based on the best international evidence at

the time of development and implementation. However, the decision to stipulate recency of

practice and continuing professional development in association with a specified minimum

number of hours required in a three year period appears to have been a pragmatic one, based

on what was considered fair and reasonable at the time.

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The inclusion of the Recertification Audit process in the Continuing Competence Framework

was a decision based on wide consultation and discussion at the time of implementation and

was considered to be an important measure of the reliability and validity of the Framework.

The subsequent decision to select five percent of the nursing population per year to

participate in the Recertification Audit appears to have been pragmatic. However, whilst there

is no documentation that suggests the selection of five percent was based on empirical

evidence the statistical comparison of Recertification Audit outcomes indicate that the process

is working effectively.

4.7.2 Policy documents

The policy documents associated with the Nursing Council of New Zealand Continuing

Competence Framework - Continuing Competence Framework Policy and Recertification Audit

Policy are substantially in-house procedural guidelines rather than overarching policy

documents and as such require review and amendment.

4.7.3 Recertification Audit

It is evident that the Continuing Competence Framework Recertification Audit process is

effective in terms of the statistical outcomes that have been demonstrated. However, a

number of quality improvement initiatives related to the nurses’ experience of the process

were identified during the document and policy review and will be further investigated in the

subsequent Stage One research phases.

Currently there is no facility for online application for Recertification or for submission and

tracking of Recertification Audit documentation. In addition there is not a clear and

transparent process in relation to the submission, assessment, tracking and management of

Recertification evidentiary documentation. Internal moderation of these items is ad hoc and

requires urgent revision in order to assure inter-rater reliability and transparency of audit

processes.


The Health Practitioners Competence Assurance Act 2003 (NZ) was enacted on 18 September

2003. As noted earlier, it was not until the enactment of this legislation that the regulatory

authorities, including the Nursing Council of New Zealand, had a legal mandate to provide a

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mechanism to ensure the competence of nurses. However, the various iterations of guidelines

for competence based practising certificates and other consultative processes clearly

demonstrate that the Nursing Council of New Zealand had prepared the ground well leading

up to enactment of the new legislation, and had developed an extremely comprehensive

evidence based Continuing Competence Framework. The findings of this document and policy

review indicate some areas for attention and these will be further discussed in Chapter Seven

in association with the findings from Phase Two (qualitative interviews) and Phase Three

(quantitative questionnaire) of the research.

The following chapter (Chapter Five) will present the findings derived from the qualitative

interviews undertaken with key nurse stakeholders.

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CHAPTER FIVE - PHASE TWO FINDINGS: INTERVIEW DATA

5.1 Introduction

This chapter will present the findings derived from the qualitative interviews completed with

key nurse stakeholders in relation to the Nursing Council of New Zealand Continuing

Competence Framework and associated recertification processes.

As previously discussed, 26 interviews were undertaken, with a purposive sample of key

stakeholders representative of the following groups: registered nurses who had participated in

a recertification audit; nurse managers and directors of nursing from District Health Boards;

primary and private sector organisations including non-government organisations, elder health

and disability services, Ministry of Health, professional organisations and schools of nursing.

Previous Chairs of the Nursing Council of New Zealand, previous and current Council staff were

also interviewed in order to provide additional data in relation to the historical, developmental

and operational aspects of the Continuing Competence Framework and to provide consistency

and validation of the findings from the document review and policy analysis completed in

Phase One.

Each interview ranged from 25 – 60 minutes in duration and was recorded, coded and then

transcribed. The transcribed data were analysed using Thomas’ (2003) general indicative

approach for qualitative data analysis. This method was used in order to condense the

extensive and varied raw data into a brief summary format, to establish clear links between

the research objectives and the summary findings derived from the raw data, and to allow the

researcher to identify categories and themes evident in the raw data. The general inductive

approach provided an efficient and systematic model for data analysis. Consistency of data

NCN

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Stage One Phase 1


Stage One Phase 3


Stage One Data triangulation &

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Stage One Phase 2


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theming was independently checked by one of my doctoral supervisors following the initial

thematic categorisation, and again by all of my doctoral supervisors following summary

analysis and generation of the sub-themes. The data findings from the interviews are

presented in this chapter and were used to inform the development of the web-based e-

survey. Triangulation of overall findings is presented in Chapter Seven.

It is important to note that the overwhelming response by the participants indicated a positive

commitment to the Continuing Competence Framework process. Further, they reported a

comprehensive understanding of the intention of the Continuing Competence Framework and

the purpose and intentions behind the process were considered imperative and valuable. In

particular, the participants endorsed the importance of the Continuing Competence

Framework process in meeting the Nursing Council of New Zealand agenda of public safety,

and emphasised the value of the Continuing Competence Framework process in addressing the

responsibility of individual nurses to engage with the process and maintain competence. The

three thematic categories and eleven sub themes that emerged from the data are listed in

Table 6 and presented in the subsequent chapter sections.

Table 6 Thematic categories and sub-themes

Thematic category Sub-themes

Competence • Lack of clarity and understanding • Purpose of the Continuing Competence

Framework • Continuing competence indicators • Education and continuing competence

The role of the Nursing Council of New Zealand

• Legal status of framework (indicators, self-declarations)

• Responsibility and accountabilities (role of bodies, people)

• Communication and consultation

The recertification audit process • Peer assessment • Audit requirements (documentation,

timeframes, guidelines and templates) • Transparency of the audit process • Communication and processes • Professional Development and

Recognition Programmes

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5.2 Competence

Competence was a major and underlying theme that emerged from all of the interviews.

Whilst it was generally acknowledged that the Nursing Council of New Zealand has defined

‘competence’ and set standards of ‘practice’, some felt there was a lack of clarity amongst

some nurses that resulted in a level of confusion, particularly with regard to the purpose of the

Continuing Competence Framework; interpretation and enactment of the competencies for

continuing competence; and / or understanding of how to interpret and provide evidence in

relation to the indicators of competence. Issues of validity and consistency were also raised in

relation to the indicators of competence and their relationship with continuing competence.

5.2.1 Lack of clarity and understanding

This theme emerged from a variety of comments made in relation to a general confusion of

nurses with regard to the concepts of ‘competence’ and ‘continuing competence’

I think many nurses perceive competence in terms of clinical tasks and competencies, not the whole picture. The current competencies seem quite repetitive and the language is complicated so this doesn’t help. I don’t think the competencies make it clear that nurses should be assessing their on-going competence – where they are now in terms of practice, rather than just being competent, which could be perceived as a minimum level.

There was a general view that clear guidelines are needed for nurses to help clarify the

concepts of competence and continuing competence, particularly in terms of ensuring that

nurses can accurately complete a self-assessment and the self-declaration for the renewal of

their annual practising certificate. The following quotes reflect some of the comments

Well I know myself the first time I had to fill out that form of course I was going to tick that I’m competent. ‘Cos I think I’m competent. But interestingly if you’re not knowledgeable about what the competencies are then how do you know. So maybe there should be something on the form that shows you what they are.

You know, ticking to say you’re competent actually doesn’t mean ‘Well I think I am competent’. Maybe it should be worded, ‘Can you provide evidence that you [continue] to meet the competencies?’ and ‘as you may be audited’.

5.2.2 Purpose of the Continuing Competence Framework

The opening question for each interview was “Tell me about your understanding of the

Continuing Competence Framework”. Generally the interview participants demonstrated they

clearly understood the purpose and importance of the Continuing Competence Framework in

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terms of requirements of the Health Practitioners Competence Assurance Act 2003 (NZ) and

the role of the Nursing Council of New Zealand as the regulatory authority. However, some

participants raised the issue of confusion regarding the purpose of the Continuing Competence

Framework suggesting that, while the Nursing Council of New Zealand has a role in “ensuring

some degree of competence”, there is a “general misunderstanding on behalf of nurses of

what the Council’s role is in this regard”.

Several participants indicated that the Nursing Council of New Zealand should be concerned

with the ‘minimum standard’ of competence and that it is the employers’ role is to drive a

performance development culture

I know that there is a set of competencies which are essentially minimum competencies for each of the scopes of practice NP, RN and EN or NA. That those are required by law under the HPCA Act and that Council has a - various processes for those three groups in terms of determining that members of the profession meet those [minimum] competencies. That, for the RN scope in DHBs, that process is significantly [related] to the PDRP programme and where there’s an established PDRP 19 programme Council audits the PDRP programme or authorises the PDRP programme as a proxy for Council’s own auditing process for RNs. RNs ‘levelled’ in a PDRP are required to meet higher levels of competency.

Another participant commented

It is how a nurse retains competence on an on-going basis [this is the point]. Nurses who have achieved a level on a PDRP are excluded from random audit because they have demonstrated they have achieved the required Council competence plus whatever additional ones are required for their level on the PDRP.

For others the framework was seen as a positive and necessary process about setting and

maintaining standards and the notion of capturing practice ‘development’

The Continuing Competence Framework is a process whereby Nursing Council has set some standards for the amount of professional development that nurses have to undertake in order to maintain their APC20. Also, the amount of time that they need to be in actual practice in order to maintain their APC, so it’s a way of

19 As noted in section 1.9 (p. 15) PDRPs are programmes offered by health provider organisations to their nursing staff. They are not under the control of the Nursing Council of New Zealand. However, if the PDRP is approved by the Nursing Council of New Zealand as meeting a prescribed set of competence standards, nurses who are members of the PDRP may be exempt from the Nursing Council of New Zealand recertification audit process. 20 Annual Practising Certificate (APC).

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creating a standard which replaces the previous system of having no standard of what people were engaged in.

Another participant expressed the view that “while no system can totally ensure competence it

is important to have some system to review competence”. The notion that the Council’s current

Continuing Competence Framework is just an ‘indicator’ of competence was also expressed by

this participant

...an audit done by a regulatory body in no way can say ... ‘Oh you’re competent to practise’. A PDRP process I think can because it goes into much more depth. But anything a regulatory authority does can only be an indicator really.

Nursing Council should actually clarify the purpose of the process … Because it has, it’s got confused with PDRP, without a shadow of a doubt. The idea of it being minimal and they’ve - and it’s a - just an absolute focus on safety. Public safety as opposed to professional development!

Another participant suggested that

Perhaps the Nursing Council of New Zealand needs to make it really clear what they want from the framework, do they want to monitor competence to ensure public safety or do they want to monitor competence, ensure public safety and promote professional career development. I think many nurses are confused because they think the Nursing Council of New Zealand owns the PDRP process and it all gets tied up with the competence framework – they don’t understand PDRP belongs to the employers and NZNO.

The issue of indicators of competence was also raised as an area that might be better clarified

within the competence assessment process.

5.2.3 Continuing competence indicators – do they infer competence?

Generally the indicators of continuing competence (Self-assessment, hours of practice and

hours of professional development) were thought to be adequate. However, the notion of

hours worked or hours engaged in professional development, as a reflection of competence

was not without some criticism. Issues identified included the actual number of hours in

comparison to other health professions, the determination of the number of hours, and

elements that one might capture in a portfolio to indicate competence relating to hours. The

idea that indicators might actually be a measure of competence was less clear as one

participant reported

The larger question is, are the competencies valid and reliable really? Because that’s the thing that you’re measuring them against. So that’s - if they’re not valid and reliable then actually the process is less important. And whilst they are

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the competencies that we have, there is quite a bit of literature and research around are they - you know are they actually the measures of what makes someone competent? How do we know that? Have we proven that those are the things that we look for?

One participant reported that portfolios are only useful if you can know what should go in

them stating that

You know everyone’s decided that the thing we need to do is create evidence for competence...they’re not quite sure what evidence and so they dump everything into a portfolio of evidence ‘cos they don’t have the ability or energy all the time to discern what is actually needed.

Whilst many participants debated aspects about hours and recency of practice as a valid

representation of practice the overall sentiment is captured in the following quote

Yes but even so just because somebody has met all of those requirements - the 60 hours etcetera I’m not sure you could still stand with your hand on your heart and say that’s a guarantee that somebody’s competent.

It was suggested by a number of the participants that nurses as health professionals need to

engage more in the process – that self-assessment should be a valid and reliable indicator of

competence if undertaken in an honest and thorough manner. The following issue was raised

With self-assessment you rely on the honesty and insight of the nurse, who is a health professional, and in most cases that is fine however there is always a very small group who will fall outside what is acceptable ... so the trick is how to validate a self-assessment...

The question of what constituted education for continuing competence was reported as a

central concern for a number of participants. There was a general feeling that many nurses did

not understand either what constitutes continuing professional development or how it

translates to evidence of competence. This element will be further discussed under the theme

‘Education and continuing competence’.

5.2.4 Education and continuing competence

Generally, participants indicated that the requirement for continuing professional

development/education was an appropriate indicator and expectation for continuing

competence. However, participants cited that there was a range of activities necessary to

maintain clinical skills but raised issues about their direct relevance to competence or public

safety. For example, intravenous accreditation or testing, manual handling, fire drills,

cardiopulmonary resuscitation and infection control updates might all be considered as

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‘continuing education’, and questions arose as to which of these activities were simply

refreshing existing skills, which led to new knowledge and which played any role at all in

assuring that a nurse was competent?

There appears to be several schools of thought around the professional development. And one school of thought is professional development needs to be new knowledge and building new knowledge to show that you’re continuing to build knowledge base. There’s another school of thought that any course could be perceived as professional development.

I think nurses understand how CPR, IV and all those task based clinical updates contribute to professional development; it’s the other stuff that isn’t so clear. The problem really is that people are gathering certificates for this and that purely as evidence, but really it’s more about what did you get out of it – how did .... enhance your practice. That’s what is generally not done well, it requires you to think about your practice and that has to be a good thing.

Several participants commented that consistent guidelines around expectations of what

constitutes continued professional development activities for continuing competence would

be beneficial to a number of nurses.

The only comment that I would make is that I think that there needs to be a line drawn in what constitutes continuing competence ...I know nurses for example who will go to the Nursing Council forum because they know that they will get a lot of hours for the Nursing Council forum. And while that’s professional update it’s not clinical update.

I guess that’s one of the things that isn’t captured very well by Nursing Council is the fact that their professional development contributes to their practice.

One participant was able to differentiate the confusion around educational activities and

competence suggesting that the

...requirement is that people are able to reflect on how a professional development activity enhances their ability to do their job, or enhances their registered nurse role.

Another participant reported that if you take the perspective that educational activities are

those which enhance the effective practitioner, then activities such as volunteering and non-

health related education might be used to “Describe that [activity] in terms in augmenting

their ability to be an effective practitioner”.

Participants broadly reported anxiety amongst nurses about the educational activities that

might count in continuing competence, the framework and indicators. They identified that the

portfolio and the role of portfolios for recording competence also caused some confusion.

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I think there’s a lot of confusion there. People don’t really know what they should be sort of measuring themselves against and what they shouldn’t, I don’t think it’s a straightforward process for them at all and in fact I think what’s happening is they’re tending to find someone else who’s been audited before and seeing how they can match.

They don’t seem to understand that you don’t need a whole portfolio of certificates and exemplars what you need is be able to provide concise evidence that you are competent to practice in the role you are in, so you actually need to focus on the actual competencies and how you meet them....

Both the effort to engage with the process and the lack of clarity around competence

requirements was reported as possibly impacting on an individual nurse’s willingness to

remain in the profession. This issue was also related to the requirements of the recertification

audit process. As two participants commented

I also think that we’ve lost - I mean, with the HPCA we’ve lost health professionals... they’ve said “Oh I can’t”, you know, “this is far too hard”.... There’s been a reaction to that and we have lost some good people as a result of it.

I mean having your competence questioned and going through a formal process is extremely stressful. I know the legislation wants to be helpful and supportive and that’s Council’s policy too but it is extremely stressful. I do think that the Nursing Council of New Zealand in its notification to the nurse that a competence question has been raised with the nurse - and I know it’s probably not the Council’s job to do this but the most difficult thing is if the nurse is so upset and then resigns her position because then they can’t find another place generally speaking to meet the practice requirement conditions Council puts on them.

No evidentiary detail was provided to substantiate this assertion around resigning from the

profession, but the perception of the amount of effort required to maintain a record of

competence was often mentioned. One participant, however, commented

I thought I would leave if I was ever audited. But I’m a good nurse, so I thought ‘why should I leave’ ... that was my motivator.

The other frequently mentioned element was the concern about the effort, the anxiety

invoked by the process and the lack of clarity around responsibility for maintaining

competence

They don’t realise that it’s their individual responsibility. And if you work with nurses who have got issues around competence or issues … or even being audited. They don’t understand that it’s their responsibility. They think it’s the employers or they think “Well you haven’t done this for me.

This issue is further reported in the consideration around accountabilities and responsibilities.

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5.3 The role of the Nursing Council of New Zealand

The role of the Nursing Council of New Zealand in terms of ensuring public safety was

discussed by most participants. Issues with regard to nurses’ general understanding of the

Council’s role, jurisdiction and discretion were raised in relation to the Continuing Competence

Framework.

5.3.1 Legal status of framework (indicators, self-declarations)

The Application for Practising Certificate form requires that nurses make a self-declaration that

they meet the requirements stipulated by Council. Participants identified that there is an

apparent lack of understanding of some nurses with regard to the status of the self-declaration

or that the application for practising certificates had in fact changed as a result of the

Continuing Competence Framework and was now competence based. One commented

I [suspect] many nurses just get the form tick the boxes, pay the money and hope they will never be audited. I don’t think they actually stop and think about am I competent or what they’re signing. That probably only happens if they get called for audit.

Another commented

Actually ... have had the odd case where nurses tick all the boxes and know they haven’t done the number of required hours.

Other comments reported the reaction of nurses to receiving the “package” from the Nursing

Council of New Zealand advising that they were being audited.

But surprisingly even people who should have an understanding of what it all means often get hooked into the providing evidence. And I wonder if that’s a response to the anxiety about ... they think I’m incompetent, so I need to show them everything I’ve got that proves that I have a shred of competence.

5.3.2 Responsibility and Accountabilities (role of bodies, people)

This sub theme identified a view that nurses may not have a clear understanding about the

role of the Nursing Council of New Zealand and their personal responsibility for their own

competence. There was a recurrent theme that nurses did not understand that this was a part

of their professional responsibility and only worried about it if they were audited. One

participant expressed the view that the audit process provided “a good wake-up call for these

nurses.” Other participants commented variously

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...that reflects a general misunderstanding on behalf of nurses of what Nursing Council’s role is. Like Nursing Council couldn’t give a toss if a registered nurse is competent or expert. What they need to know is they’re safe.

If you are a registered nurse in my view you have obviously the obligation as a professional to increase your body of knowledge, be able to demonstrate that you’re competent at all times.

The Nursing Council as a regulatory authority has a responsibility to set the standards, to be clear about the process. But then the health professional has a responsibility to be aware of those standards and to try and meet them.

They don’t realise that it’s their individual responsibility. And if you work with nurses who have got issues around competence or issues, you know that - or even being audited. They don’t understand that it’s their responsibility. They think it’s the employers or they think ... well you haven’t done this for me.

5.3.3 Communication and consultation

This lack of awareness of a nurse’s individual responsibilities for maintaining competence was

linked to the need for the Nursing Council of New Zealand to have good communication and

consultation mechanisms in place. A number of participants commented on the extensive

consultation with the profession, undertaken by the Nursing Council of New Zealand during the

development and implementation of the Continuing Competence Framework, and the

communication with the nursing sector following implementation, through Nursing Council

Forums, web-site information and newsletters to individual nurses. Despite these

communications, it was generally felt that a number of nurses still did not have a clear

understanding of the role and function of the Nursing Council of New Zealand, the Continuing

Competence Framework process or the responsibilities inherent in being registered as a nurse.

The complexity of the Nursing Council of New Zealand form for application and renewal of

practising certificates (Application for Practising Certificate) was commented on by several

participants as being difficult to follow and cluttered. One participant reported

It’s an unmitigated disaster – it’s very cluttered and it doesn’t flow very well. It is difficult to find information about competence until you get to the back page.

Another participant indicated they did not know the Scopes of Practice and associated

competencies were on the form at all.

One of the difficulties is there isn’t any information about the competencies so how do you know how to assess them.

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5.4 Recertification audit process

This theme was specifically related to discussion on the recertification audit process.

However, as will be noted, comments made by some participants also overlapped with other

categories and themes.

5.4.1 Peer assessment

In relation to peer assessment for validation of competence to practise, there was a range of

issues reported as indicated in the following quotes. The question of who should be a peer

assessor was raised on a number of occasions. This included opposing views that on the one

hand the peer assessment must always be undertaken by a nurse and on the other that in

some situations it may be appropriate that another health practitioner who works closely with

a nurse, could undertake peer assessment. In both situations it was agreed that there needed

to be clear and explicit assessment criteria.

I think it has to be a nurse. And I just think it’s all a part of the development of a professional attitude and recognition of your particular skills and knowledge ... so if I’m the nurse being audited and I go down the road to meet someone at an iwi21 provider and say ‘...can I talk to you about how I meet my competencies ... and then of course the Nursing Council of New Zealand need to know about the person that’s signing you off.

I can’t see any reason why a health practitioner who works closely with the nurse cannot be a peer assessor, so long as they have the right criteria and tool to assess the person against. Let’s be realistic nurse’s work in a wide range of settings and sometimes the team they work with doesn’t include another nurse. I might be an OT or doctor or some other health professional... that person probably knows more about the nurse’s practice ... is better able to comment than someone they don’t work with. I know it’s about being a nurse but surely if the criteria are clear, I suppose I mean the competencies, it should be fine.

The validity of the peer assessment process was also discussed at length particularly the issue

of who should be a peer assessor, and importantly, the criteria for their selection. The

following comments were made

I do know that some registered nurses don’t engage formally in a – through the formal processes in a DHB and rely very heavily on peer review to support their practice. And that’s the friends’ thing.

21 In New Zealand society, ‘iwi’ (Māori pronunciation: [iwi]) means peoples or nations (Ballara, 1998).

http://en.wikipedia.org/wiki/New_Zealand

http://en.wikipedia.org/wiki/Wikipedia:IPA_for_M%C4%81ori

http://en.wikipedia.org/wiki/Nations

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I don’t think the process is adequate because it is about peer. And it’s about choice. And that’s why I come back to saying let’s get real about this and have a process which is visible, which is mandatory. So we can say to the public that all our nurses that are engaged in registered nursing duties for the public have met a competency framework that is visible.

...Well it’s hard to know if they’re valid because people will interpret what evidence is required for them the best way they can. I think there could be more guidelines. Peer assessments I think that - that in itself lends it a whole new perspective on people who might sign off that somebody else is competent because they are - they need the staff. And they also - I mean I suppose I could say I know of some cases where people have signed off people as being competent with a peer review, or validated stuff when it’s been thrust under their nose.

We rely on the nurse to choose a peer assessor, we rely on the peer assessor to be honest and base their assessment on evidence – in an ideal world this is fine, but we know there will always be outliers and somehow we need to be sure that the peer assessment is valid – based on evidence – this is about public safety. It’s good… it’s a reasonable expectation to use peer assessment but surely we can tighten up the loop.

5.4.2 Audit requirements (documentation, timeframes, guides and templates)

The audit process itself raised a number of concerns and misunderstandings. While

participants indicated generally that they understood that there were several requirements to

be met in relation to the audit process, what was of most concern was the limited access to

the appropriate forms. Participants reported that they were not supplied with hard copy

forms but were directed to the Nursing Council of New Zealand website to print off forms.

Several participants commented they found this process “frustrating”, and in addition

There was no hard copy of the competence forms – I got one off the website, but couldn’t type into it.


You know again I think things are complicated ... I’m talking generally, not just with the form. I think there‘s an awful lot of surveillance with nurses that’s unnecessary and just over-reactive...

In terms of timeframes and tracking of documents after the audit documentation is submitted, concern was expressed by two participants. One commented

It [submitted audit documents] just went into a deep hole ... I rang the Nursing Council of New Zealand to say I didn’t have a practising certificate yet, and was told not to worry. But I did worry. My employer worried about liability.

And another two participants commented

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I got my documents in within the timeframe, but I have no idea what had happened to them after that. I heard nothing until my APC arrived in the mail about ten weeks later.

I have conversations with nurses who have been in audit. Some of them are really positive. Feeling that they’ve actually been made to stand back and think about their practice and get peer reviews, and some of them of course are stressed out.

‘Not having clear guidelines’ was reported by a number of participants. This issue appeared to be specifically in relation to completion of the self-assessment and peer assessment documents. Two participants commented that

So rather than ‘you’re competent and we’re not expecting anything else’ it’s more of a feeling that ‘I’m incompetent and I need to prove that I am competent”, which creates anxiety for people. And as they go through the process I think the - as the years have gone by there’s been a streamlining of the evidence that’s required and also I think nurses have got a bit better at understanding what a portfolio of evidence is, rather than the shopping trolley.

I know there was information on who to contact if I needed guidance but don’t you think if the competencies were written in clear language and less repetitive that people wouldn’t need to ask for guidance. It’s OK for people who write this stuff all the time but I’m a practitioner and really I just want to know what evidence they want for each criterion and then I know what to provide. I suppose what I sent must have been OK because I got a practising certificate … I didn’t get any feedback about my documents but I did get a letter to tell me in future to make sure my peer assessor wrote more comments….I thought that was a bit punitive.

Several participants commented on the recertification audit information and documentation

they received. The participant comment below is most representative of the wider discussion

I got the package from Nursing Council and thought oh ….. then I thought well get on with it. But it didn’t have any forms or anything just told me to get them from the website, initially they weren’t all available – I think… the competency form wasn’t there, anyway I got one from someone else who had been through it, but you couldn’t type straight on you had to hand write. I don’t really have a problem with the process [being audited] because I felt good afterwards – I had evidence and proved I was competent, but I felt the documentation you receive should be complete, that would have made the process a lot easier and less stressful…

Elements expressed in this sub-theme overlap with elements which emerged in the following

two sub-themes.

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5.4.3 Transparency of the audit process

Concerns were raised by participants about the transparency of the audit process in terms of

who would be assessing the material provided and against what criteria would the material

provided be assessed. Confidentiality was another concern. One participant commented

There was no indication of how it would be assessed or who would assess it ...[it] really concerned me that I had no idea of who was going to be viewing this information ... So I did worry about the notion of confidentiality.

One participant was concerned about being identifiable, and reported

It wasn’t an objective - well it wasn’t an assessment that was … any nurse making application, it was because I was identifiable. The comments were specific because they knew who I - what my role was.

5.4.4 Communication and processes

Participants commented on a number of issues in relation to communication and processes

associated with submission of evidence for recertification. Other comments related to tracking

the audit process and feedback with regard to the appropriateness and acceptability of the

evidence submitted.

I just received the Annual Practising Certificate... we only hear back from Nursing Council when there’s an issue with a nurse’s submission – and that has happened on two occasions with nurses who have had to resubmit because it has been deemed that they haven’t provided enough evidence for particular criteria. It seems the only feedback that you do get is by way of ... the nurse being rubber stamped with their practising certificate.

I would have liked some feedback, because you put a lot of effort in and in my situation I was working blind, no-one else had been audited – it just seemed to go into a dark hole and I heard nothing then one day my practising certificate turned up in the mail. I presume everything was OK.

The public safety focus was the focus of my audit information which was my - about my clinical practice. And I provided not only a verified list of education but also copies of the certificates that were relevant to my clinical practice. And in my appraisal from the senior nurse it was clearly identified that I had completed a post graduate cert in … and participated in the compulsory education within the workplace. I also had my education verified by another senior nurse …. And yet that was questioned. Now three different pieces of evidence around my professional development which well exceeded the hours required and I was asked to provide more information.

In addition the need for electronic submission and access was also raised.

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We live in an electronic age so why isn’t everything available to be done on line. It would be a lot easier to fill in the forms and to send them to your assessors, rather than printing everything off – providing it’s actually available of course.

We can look up nurses’ current registration online, so surely something could be set up for tracking our audit documents. It might take away the mystery and anxiety if you knew where your documents were and you could say to your employer well I submitted them and at this stage…

Generally, there was a feeling that the recertification process was reasonable. However,

improvements in the availability and access to guidelines, required assessment forms, and

tracking of audit documentation could be improved. Communication in terms of feedback

from the recertification audit was raised as an important area for consideration by some

participants; but others posed the view that feedback is not the role of the regulatory

authority, which should only be concerned with ensuring public safety and administering

associated monitoring processes.

5.4.5 Professional Development and Recognition Programmes (PDRPs)

PDRPs were identified as a sub theme in relation to recertification and audit requirements

because a number of participants referred to confusion about the role of the Nursing Council

of New Zealand and PDRPs. There was a sense that the Nursing Council of New Zealand had

“muddied the waters” by setting the criteria for, and approving PDRPs.

I think people think that the PDRP programme is the work of the Council. When in fact, it is about professional development and career development not competence. That’s why I don’t think the Nursing Council of New Zealand should be involved in approving them. Other than - the competence levels – fine.

So they should only be interested in the programme in the terms of if you have a professional development programme and it meets the minimum competence for continuing competence as per the Nursing Council Framework then your staff that are engaged in that programme can be excluded from audit.

I think part of the confusion is because the Nursing Council of New Zealand has got guidelines for PDRP programmes but it also approves them...I think the Nursing Council of New Zealand dabbled in something that it really shouldn’t have been doing in terms of those PDRP programmes approval when the focus was not on whether the people - the expert and proficient levels - but that clearly the competence - the competent level was the key point.

I had to keep saying to them, no under the Act you do not actually have to be part of a PDRP process because the Act and Council did not require that. The employers could choose to make that a mandatory part of their employment but actually legally under the Act it was not a mandatory part of the process. [What is] ... wanted is evidence. And so I used to say to the staff as long as you can

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provide evidence and you can actually address those competencies and how you meet them. And you can be really clear that your evidence meets them then there’s no reason why you won’t gain registration.

However, not all participants considered the use of PDRPs as a means of providing evidence of

continuing competence to be problematic, as can be seen by the quotes below.

So it’s kind of been two fold I guess. On one hand I know that where the responsibility for the Nursing Council competencies comes in and we have an employer driven PDRP programme. But the two of them actually, I think, are linking in really nicely now and giving clarity about what the expectations are in one and the other. They’re being - if - when - now that they’re keeping their PDRPs up to date it’s not nearly so difficult to translate when they are audited now you know, how those standards are met - how they’re meeting those standards, what - you know, what evidence they can give because they’re starting to build that up within their PDRPs.

What I’m saying about the PDRP thing I think that’s raised the whole profile because they know they’re not going to get audited and so therefore if they talk to their colleagues.

Issues were raised with regard to transferability between programme providers even though

the programmes are all approved by the Nursing Council of New Zealand. Some were of the

view that the Nursing Council of New Zealand should take a more proactive role in the

administration of PDRPs to ensure standardisation and transferability.

I think that even though the Nursing Council approves PDRP to a common standard it’s ... It’s pretty obvious that there’s an inconsistency in what the PDRPs actually relate to. Particularly, in terms of their transferability from one employer to another...I think there needs to be more standardisation of the PDRP...we do need a stronger steer from Council in terms of standardising - towards a national PDRP process.

There were also mixed views expressed about whether PDRPs should be mandatory or

voluntary. Some felt that PDRPs were such a good idea that there was no reason why they

should not be mandatory, and that there would be an underlying reason for anyone who did

not wish to belong.

And I can’t see why ... why being on a PDRP programme is something that you wouldn’t want to do. So the notion of it being voluntary or not voluntary is the case. But really, I would think that nurses who don’t want to be on a PDRP programme should be asking why that is. You know, why would I not want to be engaging with my colleagues. In terms of helping me determine my competence and my fitness to practice and my career progression. If I was thinking that, I would be quite concerned.

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I react to compulsory anything. But I can see that if I was a leader of a DHB that I would want as many as possible in that process. To show them ‘well I know that my workforce is working to a certain standard’. And I would really be concerned with those that aren’t in the process. Especially as usually ... it’s the good people that are going on these processes and it’s the people that are out – the outliers that are actually quite often the trouble, not function quite as well ... sort of people that stay as outliers form it. So yeah, I wouldn’t support compulsory, but I would say strongly encourage people to be on it.

5.5 Summary of findings from the interviews

A summary of the findings from the interviews is presented below. These findings will be

discussed in more detail in Chapter Seven where the results are triangulated.

5.5.1 Competence

It was the consensus view of the interview participants that the Nursing Council of New

Zealand Continuing Competence Framework is an important process for ensuring the

continuing competence of nurses and assuring public safety. However, the participants

identified that there was a general lack of clarity and understanding amongst nurses with

regard to the concepts of competence, and continuing competence. In addition, the

participants indicated that there was also a level of confusion in relation to the assessment of

continuing competence, and the notion of a minimum standard of assessment.

There was general agreement that the Nursing Council of New Zealand indicators of continuing

competence are appropriate. However, the suitability of stipulating a minimum number of

hours of practice and professional development was questioned in terms of its ability to

provide a valid inference of continuing competence. In addition the participants noted that

there was confusion over what constitutes continuing professional (educational) development

activities for continuing competence. The participants identified the need for the

development of clear guidelines as to what constitutes evidence of continuing competence.

5.5.2 Role of the Nursing Council of New Zealand

The interview participants indicated that there had been extensive consultation with the

nursing profession over the development and implementation of the Nursing Council of New

Zealand Continuing Competence Framework. However, they also noted that there was a small

group of nurses for whom there was still a level of confusion in relation to the purpose of the

Continuing Competence Framework and the role of the Nursing Council of New Zealand in

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ensuring the continuing competence of nurses and the safety of the public. They also

perceived a lack of clarity amongst some nurses, with regard to the responsibility and

accountability of the Nursing Council of New Zealand as opposed to the responsibility and

accountability of the employer and the individual nurse. Whilst the PDRP was not the focus of

this research, the interview participants raised it as a confusing issue for nurses in relation to

who is responsible and accountable for the PDRP process.

The legal status of the self-declaration (a section of the Application for a Practising Certificate

form), was questioned by a number of the interview participants as it was noted that there

was no explanation included on the Nursing Council of New Zealand Application for a

Practising Certificate form, that would inform the applicant as to status of the declaration they

were being asked to sign. The participants questioned the veracity of the self-declaration

made on the Application for a Practising Certificate form, which they considered to be

‘cluttered’ and difficult to follow.

5.5.3 Recertification Audit

The Nursing Council of New Zealand recertification audit process was considered by the

interview participants as a useful tool for the promotion of professional responsibility and

accountability amongst nurses and as validation of the Continuing Competence Framework.

However, issues were raised in relation to the validity and reliability of the associated self-

assessment and peer assessment processes.

In addition the participants noted that there was repetition and complex language used on the

competence assessment forms and no guidelines in relation to what constitutes the evidential

requirements for demonstrating continuing competence to practise and continuing

professional development. The interview participants reported difficulties in accessing

recertification audit forms - particularly the peer assessment forms and criteria. It was also

noted that none of the forms were able to be completed online and submitted electronically

and this was perceived by the participants as a barrier. The suggestion was made that, as a

minimum a full hard copy set of recertification audit documentation should be provided to

each recertification audit participant and that the Nursing Council of New Zealand should

investigate and implement a system for electronic submission and management of the

recertification audit process and documentation.

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This chapter has summarised and presented the themes and sub-themes that emerged from

the interviews with key stakeholder participants. The findings include process and delivery

issues and concerns regarding clarity and use of the applications, recognition of competence

activities and the need to validate some indicators of continuing competence. Overall the

participants reported strong support for the Continuing Competence Framework as a

mechanism to ensure continuing competence and were supportive of the influence of the

Continuing Competence Framework to improve individual nurse accountability.

The reported confusion regarding the expression of competence is consistent with a

contextual and subjective stance toward understanding the concept. These findings informed

the development of the e-survey, the results of which are presented in Chapter Six and

contribute to the data triangulation and discussion presented in Chapter Seven.

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CHAPTER SIX - PHASE THREE FINDINGS: E-SURVEY DATA

6.1 Introduction

As described in Chapter Three; Stage One, Phase Three of this research focused on collection

of data from New Zealand nurses via a web-based (Zoomerang) e-survey.

Essentially, the questionnaire was designed to elicit demographic data in addition to

information on four key themes (Competence and fitness to practise, Peer Assessment,

Recertification Audit, PDRPs) which were drawn from the findings of the previous research

phases.

The data were coded and collated independently via the Zoomerang software and server then

further analysed using the Statistical Package for Social Sciences (SPSS) for Windows version

17.0. Any errors or inconsistencies in data were carefully screened out by evaluating the range

of values generated by running the descriptive frequencies. Statistical results are presented in

this chapter in the following sections under the headings of: Demographic data; Competence

and fitness to practise; Recertification Audit; and Professional Development and Recognition

Programmes.

6.2 Demographic data

6.2.1 Distribution and return of the research questionnaire

An email invitation to participate including the URL link to the web-based research

questionnaire was distributed to approximately 12% (n = 5339) nurses registered with the

Nursing Council of New Zealand and active in terms of the Continuing Competence Framework

since 2005. Of the 5339 emailed invitations to participate, 1764 were not viewed or

NCN

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uing

Com

pete

nce

Fram

ewor

k

Stage One Phase 1


Stage One Phase 3


Data triangulation &

discussion


Stage One Phase 2


123

responded to, 800 invitations were hard bounced - marked as undeliverable, and 461 invitees

elected not to complete the questionnaire by submitting an opt-out response. Two thousand

three hundred and fourteen (n = 2314) potential participants viewed the questionnaire and

1157 submitted completed questionnaires. The questionnaire link was active for a two week

period from 2 – 16 December 2009, during which time access was only available to the

invitees. Data relating to participation and response rates (completed questionnaires) is

presented in Table 7.

Table 7 Participation rates and sample size

Sample size Participation rate

Population size

Margin of error

Confidence level

Response distribution

1157 50% 45,000 2.85% 95% 50%

The data were collated by the overall response, and further analysed using the variables,

scope of practice and practice area.

6.2.2 Scope of Practice

Of the total participant group (n = 1157), 0.6% (n = 7) identified their scope of practice as

Nurse Assistant, 3.9% (n = 45) as Enrolled Nurse, and 95.5% (n = 1105) as Registered Nurse. As

reflected in Figure 5, the participant sample is representative of the overall population of

nurses who held current practising certificates as at 31 December 2009.

Figure 5 Representation of questionnaire participants

0.6% 3.9%

95.5%

0.4% 6.6%

93.0%

Nurse Assistant

Enrolled Nurse

Registered Nurse

Outer circle - Nurses with Practising Certificates n = 44,497 on 31/12/2009 Inner circle - Questionnaire participant group n = 1157

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A cross tabulation of the overall group response to the question “What is your highest

qualification?” by the variable ‘scope of practice’ is presented in Table 8.

Table 8 Cross tabulation highest qualification by scope of practice

Total

What is your scope of practice? Nurse

Assistant Enrolled

Nurse Registered

Nurse 1157 7 45 1105

Hospital Certificate 177 1 30 146 15.3% 14.3% 66.7% 13.2%

Graduate Certificate 34 2 8 24 2.9% 28.6% 17.8% 2.2%

Graduate Diploma 168 0 0 168 14.5% 0.0% 0.0% 15.2%

Bachelor’s Degree 387 1 2 384

33.4% 14.3% 4.4% 34.8%

Postgraduate Certificate 158 1 0 157

13.7% 14.3% 0.0% 14.2%

Postgraduate Diploma 106 0 0 106

9.2% 0.0% 0.0% 9.6%

Master’s Degree 74 0 0 74

6.4% 0.0% 0.0% 6.7%

PhD 11 0 0 11

1.0% 0.0% 0.0% 1.0%

Other, please specify 42 2 5 35

3.6% 28.6% 11.1% 3.2%

A compilation of the overall group response is depicted in Figure 6.

Figure 6 Highest qualification - Overall group response

15%

3%

15%

33%

14%

9%

6% 1% 4%

Hospital CertificateGraduate CertificateGraduate DiplomaBachelors DegreePostgraduate CertificatePostgraduate DiplomaMasters DegreePhDOther, please specify

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Of the overall participant group, 2 participants identified they did not hold a current practising

certificate and 72 participants (6%) were not currently employed as a nurse.

6.2.3 Employment setting and practice area

A collation of current employment settings of the overall participant group (n = 157) is

depicted in Figure 7, and reflects the diversity and range of employment settings across the

overall group. Whilst the greater percentage of participants 58% (n = 671) indicated they

were employed by District Health Boards (DHBs), 42% (n = 486) indicated they worked in a

variety of private, government, and non-government agencies.

Figure 7 Current employment setting - overall group response

A cross tabulation of participants’ current employment setting by their scope of practice is

presented in Table 9 and indicates the diverse demographic spread of the overall participant

group. A proportion of 56% indicated they were employed by District Health Boards (DHB)

and 44% indicated they were employed across the range of private, NGO, PHO, Maori Health,

rural health, education, management, elder health, government and other agencies.

40%

9% 7%

7%

7%

2%

9%

1% 1%

1% 1% 1% 3%

2% 9%

DHB (Acute)

DHB (Primary Health/Community)

DHB (Other)

Private Hospital

Primary health (NGO / PHO)

PHO

Aged Care Sector (Rest home / Residential Care)

Nursing Agency

Self Employed

Maori Health Service Provider

Rural

Health Management

Educational Institution

Government Agency (MOH, ACC, CorrectionsService, Defense Forces)Other please specify

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Table 9 Cross tabulation of current employment settings by scope of practice

Total

What is your scope of practice? Nurse

Assistant Enrolled

Nurse Registered

Nurse 1145 6 44 1095

DHB (Acute) 460 2 6 452

40.2% 33.3% 13.6% 41.3%

DHB (Primary Health/Community) 98 0 6 92

8.6% 0.0% 13.6% 8.4%

DHB (Other) 84 0 6 78

7.3% 0.0% 13.6% 7.1%

Private Hospital 86 0 2 84

7.5% 0.0% 4.5% 7.7%

Primary health (NGO / PHO) 81 0 2 79

7.1% 0.0% 4.5% 7.2%

PHO 22 0 0 22

1.9% 0.0% 0.00% 2.0% Aged Care Sector (Rest home / Residential Care)

101 3 14 84 8.8% 50.0% 31.8% 7.7%

Nursing Agency 14 0 0 14

1.2% 0.0% 0.0% 1.3%

Self Employed 13 0 0 13

1.1% 0.0% 0.0% 1.2%

Maori Health Service Provider 9 0 0 9

0.8% 0.0% 0.0% 0.8%

Rural 8 0 0 8 0.7% 0.0% 0.0% 0.7%

Health Management 15 0 0 15 1.3% 0.0% 0.0% 1.4%

Educational Institution 29 0 1 28 2.5% 0.0% 2.3% 2.6%

Government Agency (MOH, ACC, Corrections Service, Defence Forces)

18 0 0 18 1.6% 0.0% 0.0% 1.6%

Other please specify 107 1 7 99

9.3% 16.7% 15.9% 9.0% * Total n = 1145, 12 participants did not respond to this question

Figure 8 depicts the current practice areas represented by the overall participant group. The

demographic distribution of participants by ‘current nursing practice area’ was extensive with

28 practice areas being identified. By far the largest group of participants were those who

identified as practising in medical (n = 138) and surgical (n = 151) services, with peri-operative

care (operating theatre, n = 89) and continuing care (elder health, n = 82) being the next

largest participant groups. However, overall there was equal representation from both the

primary health and acute service sectors.

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Figure 8 Current nursing practice area – overall participant group

A cross tabulation current area of nursing practice by scope of practice is presented in Table

10 and demonstrates the demographic distribution of participants by number and percentage

distribution.

60

58

89

151

138

25

16

40

3

6

6

33

58

9

54

13

82

47

42

38

3

7

62

46

18

11

13

9

20

0 20 40 60 80 100 120 140 160

Emergency and Trauma

Intensive Care/Cardiac Care

Peri Operative Care (Operating Theatre)

Surgical

Medical

Palliative Care

Obstetrics/Maternity

Child Health, including Neonatology

School Health

Youth Health

Family Planning/Sexual Health

District Nursing

Practice Nursing

Occupational Health

Primary Health Care

Public Health

Continuing Care (Elderly)

Assessment and Rehabilitation

Mental Health (inpatient)

Mental Health (community)

Addiction Services

Intellectually Disabled

Nursing Administration and Management

Nursing Education

Nursing Professional Advice/Policy Development

Nursing Research

Non-nursing health related management or administration

Other non-nursing paid employment

Not in paid employment

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Table 10 Cross tabulation current area of nursing practice by scope of practice

Total

Nurse Assistant

Enrolled Nurse

Registered Nurse

1157 7 45 1105

Emergency and Trauma 60 0 0 60 5.2% 0.0% 0.0% 5.4%

Intensive Care/Cardiac Care 58 0 0 58 5.0% 0.0% 0.0% 5.2%

Peri-operative Care (Operating Theatre) 89 0 1 88 7.7% 0.0% 2.2% 8.0%

Surgical 151 0 3 148 13.1% 0.0% 6.7% 13.4%

Medical 138 1 4 133 11.9% 14.3% 8.9% 12.0%

Palliative Care 25 0 2 23 2.2% 0.0% 4.4% 2.1%

Obstetrics/Maternity 16 0 1 15 1.4% 0.0% 2.2% 1.4%

Child Health, including Neonatology 40 0 1 39 3.5% 0.0% 2.2% 3.5%

School Health 3 0 1 2 0.3% 0.0% 2.2% 0.2%

Youth Health 6 0 0 6 0.5% 0.0% 0.0% 0.5%

Family Planning/Sexual Health 6 0 0 6 0.5% 0.0% 0.0% 0.5%

District Nursing 33 0 0 33 2.9% 0.0% 0.0% 3.0%

Practice Nursing 58 0 3 55 5.0% 0.0% 6.7% 5.0%

Occupational Health 9 0 0 9 0.8% 0.0% 0.0% 0.8%

Primary Health Care 54 0 1 53 4.7% 0.0% 2.2% 4.8%

Public Health 13 0 0 13 1.1% 0.0% 0.0% 1.2%

Continuing Care (Elderly) 82 3 14 65 7.1% 42.9% 31.1% 5.9%

Assessment and Rehabilitation 47 1 8 38 4.1% 14.3% 17.8% 3.4%

Mental Health (Inpatient) 42 1 0 41 3.6% 14.3% 0.0% 3.7%

Mental Health (Community) 38 0 2 36 3.3% 0.0% 4.4% 3.3%

Addiction Services 3 0 0 3 0.3% 0.0% 0.0% 0.3%

Intellectually Disabled 7 0 2 5 0.6% 0.0% 4.4% 0.5%

Nursing Administration and Management 62 0 1 61 5.4% 0.0% 2.2% 5.5%

Nursing Education 46 0 0 46 4.0% 0.0% 0.0% 4.2%

Nursing Professional Advice/Policy Development 18 0 0 18 1.6% 0.0% 0.0% 1.6%

Nursing Research 11 0 0 11 1.0% 0.0% 0.0% 1.0%

Non-nursing health related management or administration 13 0 0 13 1.1% 0.0% 0.0% 1.2%

Other non-nursing paid employment 9 0 0 9 0.8% 0.0% 0.0% 0.8%

Not in paid employment 20 1 1 18 1.7% 14.3% 2.2% 1.6%

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6.3 Competence and fitness to practise

The Nursing Council of New Zealand Continuing Competence Framework includes three

indicators of competence:

A. Self-declaration of competence to practise (based on self-appraisal using the Nursing

Council of New Zealand competencies for the relevant scope of practice);

B. Verification of practice hours (minimum of 450 hours / 60 days in past three years);

C. Verification of professional development (minimum of 60 hours in past three years).

Seven combinations of the indicators were presented to participants who were asked to rank

from 1 (Best) to 7 (Worst), which they believed provided the best evidence of continuing

competence to practise. Of the overall participant group 52% (n = 470) ranked the

combination of the self-declaration (A), evidence of practice hours (B) and evidence of on-

going professional development (C), as the best indicator of continuing competence, and 40%

(n = 311) identified the self-declaration when used independently as the worst indicator of

continuing competence to practise. Overall participant rankings are depicted in Figure 9.

Figure 9 Indicators that provide the best evidence of competence to practise

1 = Best 2 3 4 5 6 7 = WorstA, B & C 52% 15% 9% 9% 5% 4% 6%A & B 9% 24% 28% 16% 12% 10% 2%A & C 5% 14% 25% 27% 17% 11% 2%B & C 25% 24% 12% 22% 9% 5% 3%A only 8% 5% 7% 7% 19% 13% 40%B only 10% 11% 11% 10% 21% 27% 10%C only 7% 11% 12% 7% 14% 23% 26%

0%

10%

20%

30%

40%

50%

60%

130

Participants were then asked to rank the same indicators from 1 (Best) to 7 (Worst) to indicate

which they believed provided the best evidence of continuing professional development. The

overall participant responses were similar with 48% (n = 402) ranking the combination of the

self-declaration (A), evidence of practice hours (B) and evidence of on-going professional

development (C), as the best indicator of professional development. The least popular

indicator of competence to practise was (A) self-declaration only, which represented a

response from 43% (n = 322) of the total participant group. Overall participant rankings are

depicted in Figure 10.

Figure 10 Indicators that provide the best evidence of continuing professional development

It is interesting to note that for both questions, participants ranked a combination of the three

indicators (A, B & C) as providing the best evidence of competence to practise and on-going

professional development. However, it is of note that the participants ranked the self-

declaration of competence (based on self-appraisal of their ‘competence’ using the Nursing

Council of New Zealand competencies for their scope of practice) as the ‘worst’ indicator for

providing evidence of competence to practise when used independently.

1 = Best 2 3 4 5 6 7 = WorstA, B & C 48% 14% 11% 10% 5% 4% 7%A & B 5% 17% 18% 22% 20% 14% 3%A & C 8% 18% 31% 19% 13% 8% 2%B & C 24% 26% 15% 22% 7% 5% 2%A only 6% 5% 6% 7% 18% 16% 43%B only 8% 11% 9% 7% 12% 35% 18%C only 21% 13% 12% 9% 17% 12% 16%

0%

10%

20%

30%

40%

50%

60%

131

Figure 11 A mechanism to ensure nurses are competent and fit to practise

In response to the question “Do you think that the current Nursing Council of New Zealand

Continuing Competence Framework and processes for renewing practising certificates,

provides the mechanism to ensure that nurses are competent and fit to practise?” 76% (n =

876) of participants responded ‘yes’ and 24% (n = 281) responded ‘no’ (Figure 11). This

response is representative of the nursing population with a margin of error of 2.85% and

confidence level of 95%.

Responsibility for maintaining continuing competence to practise was a recurring theme

throughout the Phase Two – interviews. Questionnaire participants were asked to rate their

level of agreement with four statements (Figure 12).

Figure 12 Responsibility for maintaining continuing competence to practise

76%

24%

Yes

No

0

200

400

600

800

1000

1200

1 2 3 4 5 6 7

Num

ber

Strongly Agree Strongly Disagree

As a health professional I amresponsible for maintaining my owncompetence to practise

My employer is responsible formaintaining my competence topractise.

The Nursing Council of New Zealandis responsible for maintaining mycompetence to practise

When completing my NCNZapplication to renew my practisingcertificate I understand that I amsigning a legal declaration

132

Participants indicated on a seven point Likert scale (the score of 1 indicated that they strongly

agreed and the score of 7 indicated that they strongly disagreed with the statement). An

independent t-test was used to collate the responses to the four statements. Table 11 depicts

the collation of responses.

Table 11 Responsibility for maintaining continuing competence to practise 1 2 3 4 5 6 7 Overall

Participant Group Strongly

agree Strongly

disagree Mean Standard

Deviation

1. As a health professional I am responsible for maintaining my own competence to practise.

n 812 226 74 20 10 5 10 1.48 .965

% 70% 20% 6% 2% 1% 0% 1% 2. My employer is responsible for

maintaining my competence to practise.

n 187 267 252 174 109 85 83 3.29 1.769

% 16% 23% 22% 15% 9% 7% 7% 3. The Nursing Council of New

Zealand is responsible for maintaining my competence to practise.

n 145 151 174 203 133 158 193 4.10 1.989

% 13% 13% 15% 18% 11% 14% 17%

4. When completing my NCNZ application to renew my practising certificate I understand that I am signing a legal declaration.

n 1016 89 23 6 7 3 13 1.20 .845

% 88% 8% 2% 1% 1% 0% 1%

*Total participants n = 1157, 95% Confidence Interval

Descriptive statistics were used to calculate the mean (M) scores and standard deviation (SD)

for each of the four items. There was no significant variation in responses between the three

scopes of practice (NA, EN, RN) or employment setting. The overall participant group mean

scores for items 1 and 4 indicated that there was strong agreement that the individual nurse is

responsible for maintaining their own competence to practise (M = 1.48) and understanding

that when signing the self-declaration, they are signing a ‘legal declaration’ (M = 1.20).

However, for items 2 (employer is responsible) and 3 (Nursing Council of New Zealand is

responsible) the mean scores were (M = 3.29; SD = 1.769) and (M = 4.10; SD = 1.989)

respectively, indicating some ambivalence within the overall participant group. The standard

deviation for items 2 and 3 demonstrates the broad distribution of responses across the seven

point continuum (strongly agree – strongly disagree).

When items 2 and 3 were cross-tabulated by employment area, findings indicated that nurses

employed in Health Management (n = 15) and Educational Institutions (n = 29) scored the

highest mean scores for both items. Item 2, “my employer is responsible for maintaining my

competence to practise” (Health Management, M = 4.87, SD = 2.200; Educational Institution,

133

M = 4.07, SD = 1.624) and item 3, “The Nursing Council of New Zealand is responsible for

maintaining my competence to practise” (Health Management, M = 5.33, SD = 1.952;

Educational Institution, M = 5.48, SD = 1.661).

During Stage One, Phase One (policy review) and Phase Two (stakeholder interviews),

misinterpretation of the intent/meaning of the ‘self-declaration questions’ listed on the

Nursing Council of New Zealand ‘Application for Practising Certificate’ form was introduced as

a possible issue in terms of the following: nurses not completing the documentation

accurately; increased numbers of contacts and queries and administrative time for Nursing

Council of New Zealand staff responding to, and following up, information in relation to

incomplete documentation. In response to the identification of these issues, questionnaire

participants were asked to rate their level of understanding with each of the five Nursing

Council of New Zealand questions. Participants indicated on a seven point Likert scale (the

score of 1 indicated excellent understanding and the score of 7 indicated very poor

understanding). Responses are presented in Table 12.

Table 12 Nursing Council of New Zealand recertification application questions 1 2 3 4 5 6 7 Overall Participant

Group Rate your understanding with the following questions…

Excellent understanding

Very poor understanding

Mean Standard Deviation

Have you completed a minimum of 450 hours of nursing practice in New Zealand within the past three years?

n 1051 57 18 12 2 6 11 1.20 .815

% 91% 5% 2% 1% 0% 1% 1% Have you undertaken the minimum number of required professional development hours (i.e. 60 hours) within the past three years?

n 1029 83 22 9 6 2 6 1.19 .703

% 89% 7% 2% 1% 1% 0% 1%

Do you meet the Nursing Council of New Zealand's competencies for your scope of practice?

n 941 122 59 20 6 7 2 1.32 8.12

% 81% 11% 5% 2% 1% 1% 0% Do you have a mental or physical condition that means you are unable to perform the functions required for the practice of nursing?

n 826 92 31 14 9 8 177 2.15 2.185

% 71% 8% 3% 1% 1% 1% 15%

Have you been the subject of an investigation, disciplinary or criminal proceedings or a disciplinary order in New Zealand or any other country since you last applied for a practising certificate?

n 883 58 14 9 3 4 186

2.09 2.214 % 76% 5% 1% 1% 0% 0% 16%

*Total participants n = 1157, 95% Confidence Level, Margin of Error 2.85%

The majority of participants indicated an excellent understanding of the five questions (M =

1.19 – 2.09). However, it is of note that for two questions “Do you have a mental or physical

134

condition that means you are unable to perform the functions required for the practice of

nursing?” and “Have you been the subject of an investigation, disciplinary or criminal

proceedings or a disciplinary order in New Zealand or any other country since you last applied

for a practising certificate?” 18% (n = 208) and 17% (n = 202) of participants respectively

indicated that they had a limited to very poor understanding of the meaning/intent of the

questions.

6.4 Recertification audit

In Phases One and Two of the research the issue of the role and function of the peer assessor

was raised. In order to capture those issues the following questions were included in the

questionnaire. In response to the question “Have you ever been asked to be a Peer Assessor

for a colleague who was being audited?” (Table 13), 22% (n = 252) responded yes, and 78% (n

= 905) responded no. Of the participants who indicated they had been a Peer Assessor, five

identified as Enrolled Nurse and 247 as Registered Nurse. No Nurse Assistants were

represented in the Peer Assessor group.

Table 13 Participation as a Peer Assessor

Total

Scope of Practice

Nurse Assistant

Enrolled Nurse

Registered Nurse

1157 7 45 1105

Yes 252 0 5 247 22% 0% 11% 22%

No 905 7 40 858 78% 100% 89% 78%

Participants were asked six questions in relation to being a Peer Assessor. Twenty five percent

of participants (n = 67) indicated that they were not provided with information about the

recertification audit process, and 18% (n = 48) indicated they were not provided with

documentation about the relevant scope of practice and competencies. Ten percent (n = 27)

were not provided with a competence assessment form. When asked if the assessment was

based on evidence 6% (n = 15) participants indicated it was not. Fourteen percent (n = 37) did

not discuss their assessment with their colleague. Detailed results are depicted in Figure 13.

135

Figure 13 Peer Assessor

Of the overall participant group 90% (n = 1037) indicated they had not been selected for

recertification audit. Ten percent of the overall participant group (n = 120) indicated they had

been audited between the years 2005 and 2009 inclusive. Figure 14 depicts the audit

distribution of participants by audit year.

Of the 120 participants who indicated they had been audited, 111 identified as Registered

Nurse and 9 identified as Enrolled nurse. No Nurse Assistants had been audited.

Figure 14 Recertification audit distribution of participants by audit year

0% 50% 100%

Did you understand you were completing andsigning a legal document?

Did you discuss your assessment with yourcolleague?

Was your assessment based on evidence?

Where you provided with a competenceassessment form?

Were you provided with documentation about therelevant scope of practice and competencies?

Were you provided with information about therecertification audit process?

91%

86%

94%

90%

82%

75%

9%

14%

6%

10%

18%

25%

No

Yes

Yes, 2005 (n = 11)

Yes, 2006 (n = 20)

Yes, 2007 (n = 29)

Yes, 2008 (n = 30)

Yes, 2009 (n = 30)

No (n = 1037)

136

Participants were asked to respond to six questions with regard to the written information

they received from the Nursing Council of New Zealand prior to their recertification audit. It is

interesting to note that whilst 120 participants indicated that they had been audited,

additional participants chose to also respond to these questions. Table 14 presents the results.

Table 14 Recertification audit information n = count of participants selecting the option % is percent of the total participants electing the option

When you were audited did you receive written information about…

Total Yes No

1 …the recertification audit process? 127 n 116 11 % 91% 9%

2 …the recertification audit time frame? 125 n 116 9 % 93% 7%

3 …the domains of practice and competencies for your scope of practice? 124 n 114 10

% 92% 8% 4 …the evidence you would need to provide for the

recertification audit? 125 n 113 12 % 90% 10%

5 …where you could obtain clarification if necessary? 124 n 102 22 % 82% 18%

6 …the process after submission of your documentation? 123 n 96 27 % 78% 22%

Table 15 presents a cross-tabulation of responses by audit year. In response to question 3

“When you were audited did you receive written information about: The domains of practice

and competencies for your scope of practice?” the results improved significantly with 100% of

participants indicating they received the information in 2009. There was no significant

variation in the responses received with regard to the other five questions across the five year

period.

137

Table 15 Recertification audit information – comparison by audit year When you were audited did you receive written information about…

2005 2006 2007 2008 2009

1 …the recertification audit processes? Yes 100% 95% 100% 93% 93% No 0% 5% 0% 7% 7%

2 …the recertification audit time frame? Yes 100% 100% 97% 97% 93% No 0% 0% 3% 3% 7%

3 …the relevant domains of practice and competencies for your practice?

Yes 100% 90% 86% 90% 100% No 0% 11% 14% 10% 0%

4 …the evidence you would need to provide for the recertification audit?

Yes 100% 90% 93% 90% 93% No 0% 11% 7% 10% 7%

5 …where you could obtain clarification if necessary?

Yes 73% 90% 79% 83% 90% No 27% 11% 21% 17% 10%

6 …the process after submission of your documentation?

Yes 70% 84% 72% 87% 79% No 30% 16% 28% 13% 21%

Based on the documentation they had received from the Nursing Council of New Zealand

participants were asked to rate their understanding of how to provide evidence for four items:

practice hours; professional development hours; self-assessment of competencies for their

scope of practice, and peer assessment of competencies for their scope of practice.

Responses to the four items are collated in Table 16.

Table 16 Understanding of evidence required for the Recertification Audit

1 2 3 4 5 6 7

Mean Standard

Deviation

Based on information received rate your understanding of how to provide

Excellent understanding

Very poor understanding

Evidence of practice hours. n 129 16 10 5 5 0 0

1.43 .958 % 78% 10% 6% 3% 3% 0% 0%

Evidence of professional development hours.

n 119 22 10 5 5 0 3 1.58 1.213

% 73% 13% 6% 3% 3% 0% 2% Self-assessment of your competencies for your scope of practice.

n 86 30 16 13 7 6 6 2.19 1.675

% 52% 18% 10% 8% 4% 4% 4%

Peer assessment of your competencies for your scope of practice.

n 84 25 17 14 10 7 6 2.30 1.737

% 52% 15% 10% 9% 6% 4% 4%

138

Participants indicated on a seven point Likert scale (the score of 1 indicated that they had an

excellent understanding and the score of 7 indicated that they had a very poor understanding).

The item “Evidence of practice hours” achieved a mean score of (M = 1.43) with a standard

deviation of (SD = .958) indicating that the overall participant group had an excellent

understanding of the documentation relating to how to provide evidence of practice hours.

The other three items all achieved means scores ranging from 1.58 – 2.30 indicating good to

excellent understanding of the documentation by the majority of participants, however, as

depicted the standard deviation ranged between (1.213 – 1.737) reflecting a greater

distribution of scores across the seven point rating scale.

Based on a list of three options (A., B., & C.) participants were asked to select which option

best reflected the communication or documentation they received from the Nursing Council of

New Zealand following submission of their audit material. Findings are presented in Table 17.

Table 17 Submission of audit documentation

A. No further correspondence 93 66% B. Single correspondence requesting further information 32 23%

C. Multiple correspondence 16 11% Total 141 100%

Of the overall participant group 141, 66% (n = 93) indicated that they received no further

correspondence. Twenty-three percent (n = 32) received a single correspondence requesting

further information and 11% (n = 16) indicated they received multiple correspondence.

Participants were asked to rate their level of agreement with four satisfaction statements in

relation to the recertification audit documentation, communication and process. Ratings were

scored on a seven point Likert scale (the score of 1 indicated they strongly agreed and the

score of 7 indicated they strongly disagreed). Findings are presented Table 18.

139

Table 18 Satisfaction with audit documentation, communication and processes

1 2 3 4 5 6 7 Mean Standard

Deviation Strongly agree

Strongly disagree

The specified time frames were acceptable.

n 60 29 20 11 5 3 9 2.39 1.759

% 44% 21% 15% 8% 4% 2% 7%

The request for information and correspondence from the Nursing Council of New Zealand was clear.

n 62 29 19 12 5 5 6 2.33 1.684

% 45% 21% 14% 9% 4% 4% 4%

The style of correspondence from the Nursing Council of New Zealand was appropriate.

n 62 24 17 17 6 8 2 2.36 1.636

% 46% 18% 12% 12% 4% 6% 1%

I was satisfied with the process. n 57 22 18 13 11 2 14

2.72 1.989 % 42% 16% 13% 9% 8% 1% 10%

Generally, there was a high level of agreement with the four statements producing a range of

means scores from (M = 2.33 – 2.72). However there was a distribution of scores across the

seven point rating scale (SD = 1.636 – 1.989), with a small proportion of participants indicating

they strongly disagreed with each statement.

6.5 Professional Development and Recognition Programmes

Three questions were included in the questionnaire with regard to Professional Development

and Recognition Programmes (PDRPs). Whilst PDRPs are not the focus of this research, there

was significant comment raised throughout the interview process (Phase Two) with regard to

perceived advantages and disadvantages with regard to PDRPs and the perceived overlap / link

with the Continuing Competence Framework. On several occasions the comment was made

that PDRPs should be compulsory for all nurses. However this was not a consistently held

opinion.

Participants were asked if they believed that PDRPs should be compulsory. Eleven hundred

and thirty six participants responded to this question. Figure 15 presents the overall group

response. Forty-nine percent (n = 557) responded ‘yes’ PDRPs should be compulsory and 51%

(n = 579) responded ‘no’ they should not. This response is representative of the nursing

population with a margin of error of 2.87% and 95% confidence level.

140

Figure 15 Should Professional Development and Recognition Programmes be Compulsory?

Table 19 presents a cross-tabulation of responses by employment setting. It is interesting to

note that, of the participants employed by District Health Boards (DHBs), an employment

setting in which participants generally have access to PDRPs, 48% (n = 309) responded yes

PDRPs should be compulsory and 52% (n = 330) responded no they should not.

Table 19 Cross-tabulation of Employment setting by “Should PDRPs be compulsory?”

DHB

(Acu

te)

DHB

(Prim

ary

Heal

th/C

omm

unity

)

DHB

(Oth

er)

Priv

ate

Hosp

ital

Prim

ary

heal

th (N

GO /

PHO

)

PHO

Aged

Car

e Se

ctor

(Res

t hom

e /

Resid

entia

l Car

e)

Nur

sing

Agen

cy

Self

Empl

oyed

Mao

ri He

alth

Ser

vice

Pro

vide

r

Rura

l

Heal

th M

anag

emen

t

Educ

atio

nal I

nstit

utio

n

Gove

rnm

ent A

genc

y (M

OH,

ACC

, Co

rrec

tions

Ser

vice

, Def

ence

For

ces)

Oth

er p

leas

e sp

ecify

1124 458 97 84 84 78 21 96 14 13 9 7 15 29 15 104

Yes 553 228 43 38 38 36 10 56 8 5 5 3 9 11 11 52

49% 50% 44% 45% 45% 46% 48% 58% 57% 39% 56% 43% 60% 38% 73% 50%

No 571 230 54 46 46 42 11 40 6 8 4 4 6 18 4 52

51% 50% 56% 55% 55% 54% 52% 42% 43% 62% 44% 57% 40% 62% 27% 50%

*Total participants n = 1124, 95% Confidence Level, Margin of Error 2.89%

Participants were asked to indicate if they were levelled on a PDRP and if they had access to a

PDRP. Eleven hundred and seventeen participants participated in this question. Fifty-six

49% 51%

Yes

No

141

percent (n = 626) indicated that they were levelled on a PDRP and 44% (n= 491) indicated that

they were not. Figure 16 displays the results.

Figure 16 Professional Development and Recognition Programmes

In response to the question “Do you have access to a PDRP?” 1129 participants participated,

76% (n = 863) responded that they had access to a PDRP and 24% (n = 266) responded that

they did not have access. Twenty percent of the participants who have access to a PDRP have

chosen not to be levelled.

6.6 Summary of findings from the e-survey

This section (6.6) summarises and highlights the findings from the questionnaire. These data

will be discussed in more detail in the Chapter Seven where the overall results are

triangulated.

6.6.1 Demographic data

The e-survey participant sample is representative of the overall population of nurses who hold

current practising certificates in New Zealand (n = 44497), with a 2.85% margin of error and

95% confidence level. The overall participant group represents a diverse demographic sample

in terms of their identified employment setting and practice area.

0 500 1000

Are you levelled on a PDRP, 2.90% Margin ofError, 95% Confidence Level

Do you have access to a PDRP, 2.88% Margin ofError, 95% Confidence Level

Yes 626

Yes 863

No 491

No 266

No Yes

142

6.6.2 Competence and fitness to practise

The majority of participants (76%, n = 876) believe the Nursing Council of New Zealand

Continuing Competence Framework and processes for renewing practising certificates provide

the mechanism to ensure nurses are competent and fit to practise. The combination of three

continuing competence indicators (self-declaration, practice hours, and continuing

professional development) was ranked as providing the best evidence of continuing

competence to practise and on-going professional development. The self-declaration, if used

independently, was ranked by the e-survey participants as the worst indicator of competence.

Seventy percent (n = 812) of the e-survey participants strongly agreed that individual nurses

are responsible for maintaining their own competence to practise, and 16% (n = 187) strongly

agreed that their employer was responsible for maintaining their competence to practise. A

further 13% (n = 145) believed that the Nursing Council of New Zealand was responsible for

maintaining their competence to practise.

The majority of the e-survey participants indicated they understood the statements used on

the Nursing Council of New Zealand application for renewal of practising certificates, with the

exception of “Do you have a mental or physical condition that means you are unable to

perform the functions required for the practice of nursing?” and “Have you been the subject of

an investigation, disciplinary or criminal proceedings or a disciplinary order in New Zealand or

any other country since you last applied for a practising certificate?” Eighteen percent (n =

208) and 17% (n = 202) respectively indicated they had a poor understanding of the meaning

of these questions. Ninety-eight percent (n = 1128) of the nurses who participated indicated

they understood that the self-declaration is a legal document.

6.6.3 Recertification audit

Twenty-two percent (n = 252) of the overall participant group indicated they had been a peer

assessor. Of the peer assessor group 25% (n = 67) indicated they were not provided with

information about the process, 18% (n = 8) indicated they were not provided with

documentation about the scope of practice, 10% (n = 27) indicated they were not provided

with assessment forms, 6% (n = 15) indicated their peer assessment was not based on current

evidence, and 14% (n = 37) indicated that they did not discuss the peer assessment with the

colleague that they had assessed.

143

Ten percent (n = 120) of the overall participant group indicated that they had been audited

from 2005 - 2009. The majority of the audit participants (93%, n = 116) indicated that they had

received written information with regard to the recertification audit process, the required

timeframes, the required competencies and evidential documentation, instructions where

they could obtain further information and / or clarification, and the process following

submission of their documentation. A small number of participants (7%, n = 9) indicated they

did not receive any information.

The majority of participants (78%, n = 129) indicated that they had a good understanding of

what evidence to provide for the recertification audit, based on the information they received

directly from the Nursing Council of New Zealand. However, 34% (n = 48) of the participants

indicated that they had received requests for additional information from the Nursing Council

of New Zealand, following submission of their recertification audit documentation. Overall the

e-survey participants indicated that they were generally satisfied with the recertification audit

documentation, Nursing Council of New Zealand communications and the recertification audit

process.

Seventy-six percent (n = 863) of the e-survey participants indicated that they had access to a

PDRP and 56% (n = 626) of these participants identified that they were members of a PDRP. Of

the overall participant group 49% (n = 557) indicated that PDRPs should be compulsory and

51% (n = 579) indicated that they should not.


This chapter has presented the Stage One, Phase Three e-survey findings. A number of the

findings provided confirmation of the views expressed by the interview participants. Chapter

Seven will present the triangulation and discussion of the summary findings from each

previous phase of the research, in relation to the research questions. Recommendations are

made for on-going development and quality improvement of the Nursing Council of New

Zealand Continuing Competence Framework.

144

CHAPTER SEVEN - DISCUSSION, CONCLUSION AND RECOMMENDATIONS

7.1 Introduction

This chapter presents the triangulation and analysis of the findings from the previous three

research phases and situates these findings in relation to the Stage One research questions:

1. What are the relationships between current legislation, policy drivers and

statutory requirements to ensure registered nurses in New Zealand are

competent and fit to practise?


3. What is the efficacy of the current Continuing Competence Framework for

nurses in New Zealand and does it reflect best practice?

The discussion will respond to these research questions in association with the objectives that

were specified by the Nursing Council of New Zealand (Table 4, p. 54) for the evaluation of the

Nursing Council of New Zealand Continuing Competence Framework.

The chapter will conclude by summarising the Stage One – Evaluation of the Nursing Council of

New Zealand Continuing Competence Framework findings, listing recommendations for the

Nursing council of New Zealand and introducing Stage Two - The international consensus

model for the assessment of continuing competence.

7.2 Data triangulation and discussion

The overwhelming view of key stakeholder participants was that the Continuing Competence

Framework is a critical and important mechanism to ensure nurses are fit and competent to

NCN

Z Co

ntin

uing

Com

pete

nce

Fram

ewor

k

Stage One Phase 1


Stage One Phase 3


Stage One Data triangulation &

discussion


Stage One Phase 2


145

practise. Seventy-six percent of e-survey participants believe that the Nursing Council of New

Zealand’s Continuing Competence Framework and processes for renewing practising

certificates, provides the mechanism to ensure nurses are competent and fit to practise. This

response is representative of the nursing population with a margin of error of 2.85% and

confidence level of 95%.

A number of items for clarification and / or quality improvement have been highlighted in the

data and will be further analysed and discussed in this chapter. The report touches briefly on

the confusion that the interview data seem to indicate exists between; the evidential

requirements of the PDRPs, the evidential requirements of the Continuing Competence

Framework recertification audit, the notion of mandatory versus voluntary participation in

PDRPs, and role confusion between the responsibility and accountability of the Nursing

Council, employers and the individual nurse.

7.2.1 Purpose, roles and responsibilities

The international literature is unequivocal about the importance of Continuing Competence

Frameworks (Australian Nursing and Midwifery Council, 2007; Bryant, 2005; Canadian Nurses

Association, 2000; Chiarella, 2006; EdCaN, 2008; Fitzgerald, et al., 2001). Importantly, they

demonstrate to the public that the regulatory authority and nursing profession are cognisant

of, and have mechanisms, to assess the continuing competence of the profession and ensure

public safety. Continuing Competence Frameworks also promote consistency of continuing

competence standards and assessment, and provide a mechanism for the assessment of

competence as a measure of public safety (Swankin, et al., 2006; Vandewater, 2004). Further,

framework standards and assessment options should be flexible, have relevance and be

transferable to the differing levels of practice and settings in which nurses practise, and

assessment should be mandatory for all members of the profession (Vernon, Chiarella, et al.,

2011).

Interview participants clearly supported the Nursing Council of New Zealand’s

Continuing Competence Framework as a mechanism of setting standards and the notion

of capturing practice development. One participant commented

The Continuing Competence Framework is a process whereby Nursing Council has set some standards for the amount of professional development that nurses have to undertake in order to maintain their APC. Also, the amount of time that they need to be in actual practice in order to maintain their APC. So it’s a way of

146

creating a standard which replaces the previous system of having no standard of what people were engaged in.

However, participants raised the issue of confusion regarding the purpose of the Continuing

Competence Framework and the roles and responsibilities inherent in the process, suggesting

that while the Nursing Council of New Zealand has a role in ensuring some degree of

competence, there is a general misunderstanding by nurses as to the nature of the Nursing

Council of New Zealand’s role.

7.2.2 The nature of a protective jurisdiction and the role of the regulatory authority

As discussed in Chapter One and identified by interview participants, the role of the Nursing

Council of New Zealand, the regulatory authority established to administer the legislation in

relation to nurses in New Zealand, is often misunderstood by nurses and indeed other health

professionals. The role of the legislation (Health Practitioners Competence Assurance Act (NZ),

2003) is protective, and therefore the institutions, roles and committees created by it, all exist

to protect the public from the risk of harm, rather than to protect the interests of the

professions so regulated (Vernon, et al., 2010). The functions and powers of the Nursing

Council of New Zealand are defined in the legislation and establish a form of regulatory regime

known as a protective jurisdiction (Staunton & Chiarella, 2008). Hence, the role of the Nursing

Council of New Zealand, amongst other things is to establish and maintain standards of

practice. This particular role includes setting the standards for monitoring the competence

and continuing competence of the profession in order to ensure public safety. Hence

compliance of individual nurses with the requirements of the Continuing Competence

Framework is mandatory. Any health practitioner who is concerned about another health

practitioner’s practice and who considers the standard of practice “may pose a risk of harm to

the public” must notify the Registrar of the relevant authority (Health Practitioners

Competence Assurance Act (NZ), 2003, s34). There are also provisions for both the public and

specified health providers to notify the Registrar about health concerns that may affect a

health practitioner’s ability to practise (Health Practitioners Competence Assurance Act (NZ),

2003, s45).

Clearly if such concerns are raised, even though regulated health professional groups enjoy a

respected public profile, an important aspect of that regulation is that health professionals

who are part of a regulated professional group can be brought to account for their practice

and, if their registration is cancelled, lose their right to practise. In New Zealand, nurses are

held accountable for their practice under the Health Practitioners Competence Assurance Act

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2003 (NZ) and are expected to maintain appropriate standards of professional conduct. Were

these standards to be breached, then a complaint may be lodged against that nurse. However,

having recognisable standards of practice that are upheld by the professional disciplinary

bodies also provides guidance for the profession and assists in setting boundaries for

professional practice.

It is also important to understand where this area of law is situated within the legal system, as

the protective jurisdiction is an area that is often misunderstood and can cause confusion

(Secretary of State for Health (UK), 2007). This is particularly the case when other areas of the

legal system, such as the criminal jurisdiction, coronial jurisdiction or the civil law area of

negligence are also involved in the matter (Adrian & Chiarella, 2010). A protective jurisdiction

forms part of a body of law known as administrative law, a branch of law which deals with the

administrative processes of governments and formal decision making bodies. It has very

different functions and processes from the criminal law which exist “to punish offenders and to

deter potential offenders” (Adrian & Chiarella, 2010; Bates, 1989). In a New South Wales

(NSW) (Australia) Supreme Court decision Health Care Complaints Commission (HCCC) v Bruce

Litchfield, (1997, 41 NSWLR 630) the Court explained that

Disciplinary proceedings against members of a profession are intended to

maintain proper ethical and professional standards, primarily for the protection

of the public, but also for the protection of the profession (Ibid, 635).

The New South Wales Supreme Court in HCCC v Litchfield went on to say that it accepted that

the toll of disciplinary proceedings might be high in terms of “money and emotional stress”

(Adrian & Chiarella, 2010, p. 7), but took pains to explain that this was not the intention of a

protective jurisdiction “These matters would be highly relevant if the purpose of these

proceedings were punitive, but their purpose is entirely protective” (Adrian & Chiarella, 2010, p.

7).

In Condon, (NMT230206JHC) a New South Wales Nurses Tribunal case, the Tribunal explained

the nature of a protective jurisdiction, “To protect the public, maintain the standards of the

nursing profession and maintain public confidence in the profession, guided the decision of the

Tribunal in relation to the protective orders that were made” (Adrian & Chiarella, 2010, p. 7).

The Tribunal went on to explain that protective orders are concerned with maintaining

standards within the nursing profession, maintaining public confidence in the nursing

profession, and providing a general deterrence to make it clear that the type of behaviour in

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which the nurse engaged, is not acceptable behaviour for a registered nurse (Adrian &

Chiarella, 2010).

It is hoped that this discussion assists in developing an understanding of the nature of a

protective jurisdiction. The aim is not to punish the transgressing nurse, although it might be

argued that suspension or de-registration certainly does. However, this is a by-product of the

legislation in a protective jurisdiction, not its primary intent (Secretary of State for Health (UK),

2007). This is an important issue for future discussion in this thesis, as there is significant

misunderstanding about the role of the Nursing Council of New Zealand, with several

comments suggesting that it exercises a punitive jurisdiction over the nursing profession,

rather than a protective jurisdiction for the public.

7.2.3 What is meant by the requirement for continuing competence?

Within any discussion about the requirement for continuing competence, it is important to

differentiate between the original requirement for competence on initial registration, and the

requirements of the Continuing Competence Framework. It is clear from the interview data

(see Chapter Five) that there is a lack of clarity about the nature of the required standard of

continuing competence. Several participants indicated that the Nursing Council of New

Zealand should only be concerned with the minimum standard of competence and that the

employer’s role is to drive a performance development culture. Some of the interview

participants insisted that the standard to be met was “the minimum standard”, and one

participant suggested that they only had to meet the same standard as they met on

registration. This does not correspond to the requirement of “reasonableness” set out in s5(1)

of the Health Practitioners Competence Assurance Act 2003 (NZ). The requirement concerns

the need to demonstrate that nurses continue to be competent to a standard reasonably

expected in their scope of practice. How nurses live out this scope of practice would have to

be dependent upon the roles in which they work – otherwise no-one could ever be held to

account, nor would there be any need to differentiate between nurses working in

management, research, education, policy or other roles that contribute to nursing practice. It

is not enough for a Director of Nursing to demonstrate that [s]he has met the competencies on

review in 2010 in the same way as [s]he met them on graduation in 1990. Her/his competence

today is about the ability to fulfil a management role. Similarly, if someone were a manager

and a clinician, or a manager and an educator, the evidence that they would submit to

demonstrate continuing competence would not be that they attended cardiopulmonary

resuscitation training and an intravenous venous accreditation, although arguably both of

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those would be valuable for the new graduate working in an emergency department. But the

requirement for the manager / educator / researcher would be work experience and

continuing professional development relevant to the context and role in which they practise.

In a protective jurisdiction, “that which is reasonable must always correlate to that which

keeps the public safe” (Bates, 1989).

Discussion with the participants about the assessment of continuing competence

demonstrated a general lack of consensus about what should be assessed and the level of

assessment that is required. As previously noted “health professionals are expected to

maintain appropriate standards of professional conduct”, this does not equate with the notion

of a minimum standard. There was also some confusion identified with regard to who is

responsible for maintaining competence to practise. In response to the e-survey, 70% of

participants strongly agreed that individual nurses are responsible for maintaining their own

competence to practise. However, 16% strongly believed that their employer is responsible

for maintaining their competence to practise, and a further 13% strongly believe the Nursing

Council of New Zealand is responsible for maintaining their competence to practise. Cross-

tabulation of the data by employment area indicated that nurses employed in Health

Management (n = 15) and Educational Institutions (n = 29) scored the highest mean scores for

the item “my employer is responsible for maintaining my competence to practise” and item

“the Nursing Council is responsible for maintaining my competence to practise”. Whilst this

response does not appear to be unique to the New Zealand context (Australian Nursing and

Midwifery Council, 2007; Campbell & MacKay, 2001; Canadian Nurses Association, 2000;

Chiarella, et al., 2008; Fitzgerald, et al., 2001; Goodridge, 2007), it does highlight the need for

the Nursing Council of New Zealand to be explicit and overt in terms of the purpose of the

Continuing Competence Framework, the role and responsibility of the Nursing Council of New

Zealand and the responsibility of the individual Health Professional (nurse), the employer and

the profession in this regard.

The findings of Phase Two and Phase Three of the research indicate some misinterpretation of

the intent/meaning of the self-declaration questions listed on the Nursing Council of New

Zealand’s Application for Practising Certificate Form. This item was introduced as a possible

issue in terms of nurses not interpreting the questions correctly and, as a result, not

completing the documentation accurately. It was felt that this aspect called into question the

veracity and validity of the self- declaration and resulted in increased contact with the Nursing

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Council of New Zealand administrative staff, and an increase in administrative time spent

following up information in relation to incomplete, and inaccurate documentation.

Ninety-eight percent of participants indicated they understood that the self-declaration is a

legal document and yet in response to the question relating to indicators of competence, self-

declaration was scored as the worst indicator of competence. Arguably if a health professional

completes an honest and subjective self-assessment, as required when completing the current

Application for Practising Certificate form, then signs the declaration indicating their

competence and fitness to practise, it should be a valid and verifiable indication of their

competence and hence, safety to practise. However, a number of interview participants

questioned the validity of the declaration made by nurses when completing the Application for

Practising Certificate. They suggested that “its status and significance” is not apparent to

some nurses and “the form is seen purely as a tick box” unless the nurse is actually selected for

recertification audit and required to provide validated evidence.

7.2.4 Communication and consultation

In terms of communication and consultation, the literature identifies that clear articulation of

the purpose of the Continuing Competence Framework is required (public protection or public

protection and lifelong learning). There must also be clear articulation of continuing

competence standards, documentation related to the Continuing Competence Framework

must be accessible and processes transparent, and web-based options should be available

(Australian Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000; Chiarella,

2006; Chiarella, et al., 2008; Goodridge, 2007; McGrath, et al., 2006). Involvement of all levels

of the profession is also noted as essential for Continuing Competence Frameworks (Australian

Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000; National Council of

State Boards of Nursing, 2009a).

It is clear that there has been considerable consultation with the profession and other key

stakeholders over a number of years, and that various iterations of the Continuing

Competence Framework were developed and implemented. Nurses have been kept well

informed. The Nursing Council of New Zealand’s requirements for renewal of Practising

Certificates was provided individually to all nurses in the form of a Nursing Council of New

Zealand News Update, dated 1 November 2004. This newsletter contained a summary of the

Health Practitioners Competence Assurance Act 2003 (NZ), the Nursing Council of New Zealand

definition of practising, the scopes of practice, process for annual practising certificate

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renewal, the competence and fitness to practise requirements for renewal of Practising

Certificates, and an overview of the Continuing Competence Framework.

7.2.5 Indicators of continuing competence

As identified in the literature (Australian Nursing and Midwifery Council, 2007; Bryant, 2005;

Canadian Nurses Association, 2000; National Council of State Boards of Nursing, 2009a),

competence frameworks are tools that have a role in regulating and guiding the profession by

setting the standards for competence assessment and ensuring consistency in the monitoring,

and on-going assessment of competence (Pearson, Fitzgerald, Walsh, et al., 2002). They have

a clear purpose in terms of ‘public protection’, however literature suggests that if their

purpose is also to promote ‘lifelong learning’ then this must be clearly articulated (Australian

Nursing and Midwifery Council, 2007; Campbell & MacKay, 2001; Goodridge, 2007) as it will

influence the level of assessment required.

The international literature identifies that the most commonly used indicators of competence

are self-assessment, peer assessment, recency of practice and continuing professional

development / education. A combination of indicators is recommended - no single indicator

used independently can measure ‘competence’. Valid measurements of indicators which are

subjective in nature, is difficult (Pearson, Fitzgerald, Walsh, et al., 2002; Vandewater, 2004).

Inter-rater reliability is a critical component of the assessment process (EdCaN, 2008;

Wilkinson, 2013). Recency of practice, and practice tasks are quantifiable indicators, however

they should not be used in isolation (Australian Nursing and Midwifery Council, 2007; Campbell

& MacKay, 2001; Fitzgerald, et al., 2001). It is also of note that, despite clear and reasonably

consistent definitions of competence articulated by a number of nurse regulatory authorities,

a level of confusion about the conceptualisation of competence and the distinction between

core and higher levels of competence, behaviours and insight is still apparent (Australian

Nursing and Midwifery Council, 2007; Campbell & MacKay, 2001; Canadian Nurses Association,

2000; Goodridge, 2007; Nursing and Midwifery Council, 2008).

Following a number of consultative processes, the Nursing Council of New Zealand made a

decision in March 2004 with regard to the indicators of competence. The Continuing

Competence Framework includes three indicators of competence: A. Self-declaration of

competence to practise (based on self-appraisal using the Nursing Council of New Zealand

competencies for the relevant scope of practise); B. Verification of practice hours (minimum of

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450 hours / 60 days in past three years); C. Verification of professional development (minimum

of 60 hours in past three years).

Qualitative data revealed that there was some criticism of the notion of the unit of hours as a

reflection of competence. Issues identified ranged from the actual number of hours in

comparison to other health professions, the determination of the hours, and elements that

might be captured in a portfolio to indicate competence. The idea that indicators might

actually represent competence was much less clear, with some comment about validity and

reliability. There was also a range of comments about what constituted professional

development and the role and accountability of peer assessors.

In the e-survey, participants were asked to rank the indicators from 1 (Best) to 7 (Worst) to

indicate which they believed provided the best evidence of continuing competence to practise.

The indicator of competence to practise ranked ‘best’ by participants was the combination of

the self-declaration (A), evidence of practice hours (B) and evidence of on-going professional

development (C), which represented 52% (n = 470) of the total overall responses. The least

popular indicator of competence to practise was (A) self-declaration only, which represented a

response from 40% (n = 311) of the total participant group.

Participants ranked a combination of the three indicators (A, B & C) as providing the best

evidence of competence to practise and on-going professional development. However, it is of

note, that the participants ranked the self-declaration of competence (based on self-appraisal

of their ‘competence’ using the Nursing Council of New Zealand competencies for their scope

of practice) as the ‘worst’ indicator for providing evidence of competence to practise when

used independently. Data from interviews and the survey indicate that there is a general

satisfaction with the stipulated hours for professional development and for clinical practice.

However, it is clear that in terms of competence, these stipulated hours are indicators rather

than guarantees.

Peer assessment is included in the recertification audit process and is used in association with

self-assessment, as a way to validate the continuing competence of individual nurses. The

decision by the Nursing Council of New Zealand to use peer assessment as a measure of

continuing competence, was based on the previously implemented Nursing and Midwifery

Council (UK) Prep Model (2011), which uses peer assessment as a means of validation for self-

assessment.

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In relation to the use of peer assessment for validation, a range of issues was reported in the

qualitative data. The majority of participants indicated that the peer assessor should be a

nurse. However, there was also comment, that in some situations it may be appropriate that

another health practitioner who works closely with a nurse, could undertake peer assessment

– but with the proviso that there needed to be clear and explicit assessment criteria

...well it’s hard to know if they’re valid because people will interpret what evidence is required for them the best way they can. I think there could be more guidelines. … Peer assessments I think that - that in itself lends it a whole new perspective on people who might sign off that somebody else is competent because they are - they need the staff. And they also - I mean I suppose I could say I know of some cases where people have signed off people as being competent with a peer review, or validated stuff when it’s been thrust under their nose.

Concerns were also evident in the participant e-survey findings. In response to a question

about whether participants had ever been asked to be a peer assessor, 21% (n = 242) of the

overall participant group indicated they had previously been a peer assessor. A further

question sought information about a number of issues identified in the interviews: provision of

information; provision of documentation about the relevant scope of practice and

competencies; provision of a competence assessment form and criteria; if the assessment was

based on evidence; if the assessment was discussed with the colleague; and understanding

that which was being competed and signed was a legal document.

Of the peer assessor group, 25% (n = 60) indicated they were not provided with information

about process, 18% (n = 45) were not provided with documentation about the scope of

practice, 10% (n = 24) were not provided with assessment forms, 6% (n = 14) indicated their

assessment was not based on evidence, and 14% (n = 34) did not discuss the assessment with

the colleague they assessed.

7.2.6 The recertification audit

In December 2005, as part of the Continuing Competence Framework, the Nursing Council of

New Zealand initiated the recertification audit process of individual nurses. Five percent of

nurses renewing their practising certificates annually are randomly selected for individual

recertification audit. The decision by the Nursing Council of New Zealand to select 5% of

nurses for audit annually appears to have been based on available international literature and

‘best practice’ at the time. This figure is pragmatic, as no single piece of evidence exists to

prove it is a valid representation of the New Zealand nursing workforce; however statistical

findings from the recertification audits and competence notifications conducted over the past

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five years suggest that the 5% measure is appropriate and effective. In addition the

recertification audit process has provided the Nursing Council of New Zealand with feedback

on the annual recertification processes and validation that nurses are complying with the

Continuing Competence Framework requirements.

Five of the interview participants indicated that they had previously been audited as part of

their recertification process. Concerns were raised about the transparency of the audit

process, such as who would be assessing the material provided. One participant’s comment

below reflects the discussion

There was no indication of how it would be assessed or who would assess it ...[it] really concerned me that I had no idea of who was going to be viewing this information ... So I did worry about the notion of confidentiality.

Another participant was concerned that evidence submitted for recertification was personally

identifiable, and commented

It wasn’t an objective - well it wasn’t an assessment that was … any nurse making application, it was because I was identifiable. The comments were specific because they knew who I - what my role was.

There was also concern expressed about the lack of feedback about the audit process. Inter-

rater reliability and moderation processes in relation to the assessment of evidence are not

apparent in the documents reviewed. The need for processes that ensure inter-rater reliability

is supported by the international literature (McGrath, et al., 2006).

Data from the e-survey indicated that 10% (n = 120) of the overall participant group had been

audited during the previous four years, from December 2005 – December 2009 inclusive. The

majority (90%) of audit participants indicated they received written information with regard to

the audit process, timeframes, competencies, evidence, where to obtain clarification and the

process after submission of documentation. A small percentage (10%) indicated they did not.

Whilst the percentage is small in terms of the overall nursing population, it should be noted

that it still represents a significant cost in terms of Nursing Council of New Zealand

administrative resources responding to and processing additional queries, requests and

documentation.

The majority of participants (88%) indicated that they had a good understanding of what

evidence to provide for the recertification audit based on the information they received from

the Nursing Council of New Zealand. Thirty four percent of participants indicated they received

requests for further information following submission of their audit documentation. This is

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another area that represents a significant cost in terms of the Nursing Council’s administrative

resources.

Overall, participants indicated that they were generally satisfied with the recertification audit

documentation, communication and process. Additionally, in response to the question “when

you were audited did you receive written information about the domains of practice and

competencies for your scope of practice?” there was significant improvement in 2009 from

previous years with 100% of participants indicating they received the information.

Nurses who participate in a Nursing Council of New Zealand approved PDRP process are

exempt from the recertification audit process. Nursing Council of New Zealand documentation

relating to the implementation of the Continuing Competence Framework and recertification

audit process signals that recertification audit numbers were expected to drop significantly

over the initial five year period, due to increased participation of nurses in PDRPs. Whilst,

there has been a slight incremental reduction in recertification audit numbers (n = 1288, 2006-

2007; n = 1075, 2008 – 2009) this has not been significant and may be due to voluntary

participation in PDRPs and relatively low participation nationally.

7.2.7 Continuing Competence Framework policies and documentation

The Nursing Council of New Zealand has three policy documents associated with the

Continuing Competence Framework; these are the Continuing Competency Policy (GPO02.10)

(August 2004, March 2007), the Continuing Competence Policy (RP05.03) (August 2004, June

2009), and the Recertification Audit Process Policy (GPO 05.3) (August 2006; May 2008), all of

which are in-house documents. The Continuing Competency Policy (GPO02.10) is a governance

document, whilst the Continuing Competence Policy (RP05.03) and the Recertification Audit

Process Policy (GPO 05.3) outline the procedural requirements of the Nursing Council of New

Zealand’s Continuing Competence Framework, and the associated recertification audit process.

The policies are written in the format of a guideline or procedure, rather than that of a formal

policy and they are not publicly available. Whilst the policies include a ‘policy statement’ they

do not include a ‘purpose statement’ and they focus solely on procedural aspects of the

Continuing Competence Framework and recertification audit processes.

However, a clear explanation of the criteria for the Continuing Competence Framework;

exemption from the recertification audit; and the recertification audit ‘evidential

requirements’, is available to the public on the Nursing Council of New Zealand website. Again

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there is no ‘purpose statement’ linking the Continuing Competence Framework to the Nursing

Council of New Zealand requirements that are mandated by the Health Practitioners

Competence Assurance Act 2003 (NZ). In addition, there is no information available to nurses

with regard to the recertification process or timelines once their documentation has been

submitted to the Nursing Council of New Zealand for assessment. This is an area of concern

which was raised by the interview participants and confirmed by the e-survey participants.

As noted in Chapter Four, a number of iterations of different forms of written evidence to

demonstrate competence were developed by the Nursing Council of New Zealand. One early

option was for nurses to maintain a personal professional portfolio of evidence which may be

called on for audit. It appears that the later decision not to audit portfolios was pragmatic, and

largely based on administrative and financial considerations. This decision is supported by the

international literature which suggests that a portfolio is not an adequate indicator of

continuing competence or safety to practise. Portfolios are noted as being time-consuming,

difficult to assess and lacking inter-rater reliability, due to their subjectivity (EdCaN, 2008).

They are tools best used to recording practice and developing an individual’s reflective

thinking (Australian Nursing and Midwifery Council, 2007; Canadian Nurses Association, 2000;

EdCaN, 2008; Fitzgerald, et al., 2001; Vandewater, 2004).

Currently a package of hard copy documentation is posted to individual nurses selected for

recertification audit. This package includes:

• A form / template letter – recertification audit

• Information sheet – why have I been selected for a recertification audit?

• Nurse audit checklist

Nurses are directed to the Nursing Council of New Zealand website to download and print the

relevant template documents, for example, competencies for the scope of practice and

competence assessment forms. These documents are not included as hard copy in the

recertification audit package and are only available as a PDF template from the Nursing Council

of New Zealand website. Hence nurses are required to source the relevant documentation

and enter their evidential data by hand rather than providing the opportunity to download and

enter their data electronically – or copy the form into a MS-Word document so that

information can be typed in.

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The notion that the Nursing Council of New Zealand’s current process for assessment of

continuing competence is just an ‘indicator’ of competence was expressed by one participant

...an audit done by a regulatory body in no way can say ... ‘Oh you’re competent to practise’. A PDRP process I think can because it goes into much more depth. But anything a regulatory authority does can only be an indicator really.

Additionally, there is confusion with the Nursing Council of New Zealand’s role in

recertification and Professional Development and Recognition Programmes (PDRPs) which are

approved by the Nursing Council of New Zealand. This confusion was highlighted in the

following quote

Nursing Council should actually clarify the purpose of the process … because it has, it’s got confused with PDRP, without a shadow of a doubt. The idea of it being minimal and they’ve - and it’s a - just an absolute focus on safety. Public safety as opposed to professional development. There needs to be some clarification. Who is responsible and what is the purpose?

As demonstrated, the requirements and processes for assessment of continuing competence,

the Nursing Council of New Zealand Continuing Competence Framework and the PDRPs have

become enmeshed, and subsequently have created confusion.

7.3 Key research findings

7.3.1 Legislation, policy and statutory requirements to ensure registered nurses are competent and fit to practise in New Zealand

As previously noted the primary purpose of the Health Practitioners Competence Assurance

Act 2003 (NZ) “is to protect the health and safety of members of the public by providing for

mechanisms to ensure that health practitioners are competent and fit to practise their

professions” (Health Practitioners Competence Assurance Act (NZ), 2003). The Health

Practitioners Competence Assurance Act 2003 (NZ) clearly sets out the conditions and

requirements that health professionals must meet in order to practise under the Act (Health

Practitioners Competence Assurance Act (NZ), 2003, s3(2)), including the mechanisms to

ensure that these practitioners are competent and fit to practise their professions for the

duration of their professional careers. Establishment of these mechanisms is the responsibility

of the regulatory authority (Health Practitioners Competence Assurance Act (NZ), 2003, s11).

Hence, the establishment of the Nursing Council of New Zealand Continuing Competence

Framework in 2004, as the statutory mechanism to ensure and monitor the continuing

competence of nurses for the purpose of public safety (Nursing Council of New Zealand,

2004a).

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7.3.2 The role of the Nursing Council of New Zealand

It was evident from the participant (nurse’s) responses that there was a lack of clarity and

some confusion amongst some nurses with regard to the role, responsibility and

accountabilities of the Nursing Council of New Zealand, in terms monitoring and ensuring

nurses’ continuing competence to practise and public safety. It was also evident that some

participants were unsure of their own responsibility and accountability with regard continuing

competence and safety to practise.

Confusion existed between the evidential requirements of the Nursing Council of New Zealand

Continuing Competence Framework recertification audit processes, and the requirements and

purpose of the union and employer owned Professional Development and Recognition

Programmes (PDRPs). Participant responses indicate that this confusion between the purpose

and ownership of these two separate processes has had a negative impact on the Nursing

Council of New Zealand by introducing a heightened level of anxiety amongst nurses.

7.3.3 Continuing Competence Framework

There was general agreement that the Continuing Competence Framework is a critical and

important mechanism to ensure nurses are competent and fit to practise. It is a mechanism

that the participants believe promotes professional responsibility and accountability. Seventy-

six percent of the e-survey participants identified that the Continuing Competence Framework

and processes for recertification (renewal of Annual Practising Certificates), provide the

mechanism to ensure that nurses are continuing to be competent.

There is historical evidence that the initial development of the Nursing Council of New Zealand

Continuing Competence Framework was well researched, detailed, and included extensive

stakeholder involvement and consultation. However, the historical documents associated with

the development and implementation of the Continuing Competence Framework, require

professional indexing and archiving.

The interview and e-survey participants indicated that there was a lack of clarity and some

confusion with regard to the required standard for the assessment of continuing competence.

Is it a minimum standard of competence that is being assessed, or is it continuing competence

that takes into account required standards and competencies of practice in association with

the nurse’s role and context of practice? In addition, the participants identified that there was

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a lack of clarity and guidelines with regard to what constitutes continuing professional

development and evidence of continuing professional development.

7.3.3.1 Indicators of continuing competence

The indicators of continuing competence (self-assessment, practice hours/recency and

continuing professional development hours) are all considered to be appropriate indicators of

competence, that when used together can imply continuing competence and therefore may

imply safety to practise. However, they do not guarantee that a nurse is safe to practise on

any given day. In addition, the stipulation of a minimum number of practice, and continuing

professional development hours, when used independently, was not considered by the

participants to be a valid measure of competence.

7.3.3.2 Application for recertification (Annual Practising Certificate)

Issues were identified with regard to the verification and legal status of the self-declaration

and the validity and reliability of the self-assessment (Application for Practising Certificate

form). In addition, the e-survey participants indicated that the Application for Practising

Certificate (recertification) form is difficult to read and not user-friendly.

7.3.3.3 Recertification Audit

The recertification audit process is generally considered by the participants as being an

important quality indicator that provides a measure of validity and reliability to the Continuing

Competence Framework. Statistical findings from the recertification audits and competence

notification trends conducted over the past five years (2005 - 2009), suggest that the 5%

measure for audit per annum is appropriate and effective.

As previously noted, issues were identified with regard to the validity and reliability of the self-

declaration and self-assessment documentation. Peer-assessment and the inter-rater

reliability of the Nursing Council of New Zealand recertification audit and assessment

processes were also identified as areas requiring process improvement. In addition, a number

of quality improvement areas were identified with regard to the Nursing Council of New

Zealand recertification audit process. These operational aspects included: improved access to

recertification audit documentation; development of recertification audit process guidelines;

application and document tracking processes, and moderation of assessment materials.

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The findings from Stage One of this research demonstrate that the Nursing Council of New

Zealand Continuing Competence Framework is considered to be an important, valuable and

relevant process. The Continuing Competence Framework promotes consistency of practice

standards and provides a mechanism for the annual assessment of continuing competence as

a measure of public safety. Importantly, the Continuing Competence Framework

demonstrates to the public that the regulatory authority and nursing profession are cognisant

of, and has mechanisms to, assess and monitor the continuing competence of the profession.


The overarching purpose of this thesis is to determine the relationships between current

legislation, policy and statutory requirements to ensure that registered nurses are competent

and fit to practise in New Zealand. Evaluation research using a sequential mixed-methods

design has been used to complete Stage One – The evaluation of the Nursing Council of New

Zealand Continuing Competence Framework. Each sequential phase of data collection and

analysis has focused on a particular evaluand grouping which has served to inform the basis for

the next phase of data collection and analysis.

Chapter Seven has presented the triangulation of the Stage One summary findings in relation

to the research questions, previously identified in Table 2 (p. 5), in association with the

national and international literature. Although Stage One of this research has demonstrated

overarching endorsement of the Nursing Council of New Zealand Continuing Competence

Framework, a number of areas for improvement were identified specifically in relation to

Nursing Council of New Zealand operational processes, documentation, accountabilities and

responsibilities. A list of the operational recommendations made to the Nursing Council of

New Zealand is presented in Table 20.

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Table 20 Summary of recommendations made to the Nursing Council of New Zealand

Recommendation One - Communicate the Nursing Council of New Zealand Role and Responsibilities 1(a) Improve and make overt the ‘public nursing’ profile of the Nursing Council of New Zealand with

regard to its role and responsibility as the regulatory authority for nurses in New Zealand 1(b) Differentiate and communicate the Nursing Council of New Zealand’s expectations with regard to

the responsibility of individual nurses, employers and the profession in terms of the requirements of the Continuing Competence Framework and the Health Practitioners Competence Assurance Act 2003 (NZ).

1(c) Articulate and communicate the Nursing Council of New Zealand’s role and responsibilities with regard to PDRPs.

Recommendation Two - Revise Continuing Competence Framework Documentation 2(a) Revise the Continuing Competence Framework and Recertification Audit policy documentation to

include a clear purpose statement and policy framework principles. 2(b) Provide on all Continuing Competence Framework related documentation (including the Nursing

Council of New Zealand website), a clear and consistent definition of what constitutes ‘continuing competence’ with explicit criteria in relation to how continuing competence may be assessed.

2(c) Revise Continuing Competence Framework documentation available to nurses and provide more explicit and detailed guidelines with regard to Continuing Competence Framework evidentiary requirements, assessment processes, recertification audit process including recertification assessment and timelines.

Recommendation Three - Revise Application for Practising Certificate form 3(a) Provide a clear and more comprehensive definition of the status of the self-declaration on the

‘Application for Practising Certificate’ form. In this regard the Nursing Council of New Zealand should consider taking advice on the inclusion of a statutory declaration.

3(b) Reformat the ‘Application for Practising Certificate’ form to make more explicit and obvious, the crucial information with regard to the self-declaration. For example, the information in relation to the scopes of practice and associated competencies; and the guidelines with regard to questions nine (Do you have a mental.....for the practice of nursing?) and ten (Have you been the subject of an investigation.....since last applied for a practising certificate?). Move demographic information and guidelines and codes to the back of the application.

3(c) Clearly articulate the penalties for providing false and misleading information on all documentation related to the Continuing Competence Framework.

Recommendation Four - Review Recertification Audit Documentation and Procedures 4(a) Provide recertification audit material and guidelines in both hard copy and electronic formats,

with the provision for participants to enter data directly onto electronic forms. 4(b) Move to a system of electronic submission of recertification audit data. 4(c) Move to a system of electronic tracking of recertification audit documents, accessible to nurses

who are participants in the audit process. 4(d) Revise and provide clear criteria and guidelines for the selection of peer assessors. 4(e) Provide peer assessors with guidelines for the ‘peer assessment’ process, in addition to clear and

explicit assessment criteria. Provide documentation options in hard copy or electronic formats. 4(f) Instigate clear internal moderation processes to improve inter-rater reliability and transparency

of audit assessment processes.

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The report prepared for the Nursing Council of New Zealand, specifically addressing the project

objectives stipulated by the Nursing Council of New Zealand (Table 1, p. 3), has been published

Evaluation of the Continuing Competence Framework (Vernon, et al., 2010), and is publicly

available from http://nursingcouncil.org.nz/Publications/Reports.

The findings from Stage One, Evaluation of the Nursing Council of New Zealand Continuing

Competence Framework, in association with the international literature, form the basis for the

development of Stage Two of this thesis. Stage Two – The International Consensus Model for

the Assessment of Continuing Competence, continues to investigate the relationships between

current legislation, policy drivers and statutory requirements to ensure registered nurses are

competent and fit to practise, by evaluating the possibility of developing an international

consensus model for the demonstration of continuing competence. The following section,

Section Three: Chapters Eight and Nine will present and discuss the findings derived from the

Stage Two Delphi Study.

http://nursingcouncil.org.nz/Publications/Reports

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SECTION THREE STAGE TWO: THE INTERNATIONAL CONSENSUS MODEL FOR THE ASSESSMENT OF CONTINUING COMPETENCE

Section three presents the international component of this research and draws heavily on the

findings of Stage One, and in particular the evaluation of the Nursing Council of New Zealand

Continuing Competence Framework. Findings from the evaluation of the Nursing Council of

New Zealand Continuing Competence Framework have assisted to position this research in

terms of its international relevance and transferability, and provided a platform from which to

evaluate the possibility of developing an international consensus model for the assessment of


Chapter Eight provides an overview of the Delphi process that was undertaken and

presents the analysis of the findings that emerged from the first three Delphi rounds. A

summary of the consensus views and the key principles derived from the Delphi rounds

(one-three) are presented.

Chapter Nine presents and discusses the analysis of the Delphi Round Four participant

responses and provides a summary of the overall consensus views in relation to the

three research questions, and in association with the contemporary literature.

Recommendations for the development of a best practice international consensus

model for the assessment of continuing competence are proposed.

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CHAPTER EIGHT - STAGE TWO: FINDINGS OF THE DELPHI STUDY

8.1 Introduction

This chapter presents the findings from Stage Two of this research, the international consensus

model for the assessment of continuing competence. As previously described in Chapter

Three (3.3.3), this second Stage of the research was undertaken using the Delphi technique.

It is clearly identified in the literature (Chapter Two) that, internationally there is considerable

interest in models of continuing competence and the development of Continuing Competence

Frameworks. In particular, over the past 14 years considerable work has been undertaken by

nursing regulatory authorities in the following countries, New Zealand, Australia, Canada, the

United Kingdom, and the United States of America to identify valid and reliable mechanisms to

monitor the continuing competence of nurses registered in their jurisdictions. Findings from

Stage One, the evaluation of the Nursing Council of New Zealand Continuing Competence

Framework, provided a platform from which to investigate whether the development of an

international consensus model for the assessment of continuing competence was possible.

Determining the consensus view of these six specified countries (Australia, Canada, New

Zealand, Ireland, the United Kingdom and the United States of America) was the main focus of

the Delphi study. As previously noted in Chapter One (1.2), in order to determine whether

development of an international consensus model for the assessment of continuing

competence was possible, the following overarching questions were posed

1. What is the consensus view of regulatory experts in relation to:



Inte

rnat

iona

lCo

nsen

sus M

odel Stage Two

Delphi Round 1Stakeholder Interviews

(gpA)


Qualitative E-survey

(gpB)


E-survey (gpB)


ConsensusE-survey

(gpA)



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the demonstration and assessment of continuing competence in six countries

(Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of

America) and the best practice model developed through consensus?




In May 2011, soon after the commencement of Stage Two of this research a Memorandum of

Understanding and Cooperation was signed between the key nursing regulatory authorities in

seven countries Australia, Canada, New Zealand, Ireland, the United Kingdom, the United

States of America and Singapore. The purpose of this memorandum is to

confirm closer links between the organisations in order to develop standards for

the regulation of nurses and nursing practice and to facilitate the free exchange

of professional knowledge that contribute to the development of standards.

The memorandum goes on to state that the organisations recognise that there are potential

benefits to be gained from a closer collaborative relationship to better protect the public

health, safety and welfare22.

8.2 Delphi Round One - Interviews

As previously noted in Chapter Three, the overarching Method chapter (3.3.3.2 Expert Panel

and 3.3.3.3 Conduct of the Delphi Survey), round one of the Delphi study was completed by

interviewing a purposive sample of 14 nurse regulatory experts (Group A) who were recruited

from the six countries identified as the focus for the development of the international

22 Following notification that the Memorandum of Understanding and Cooperation had been signed, the Chief Executive of the Singapore Nursing Board (SNB), the regulatory authority for nurses and midwives in Singapore, was contacted and was invited to nominate a designate to participate in this research as a member of the expert panel (Group A). This was because the other six countries had already been identified to be the reference group and, given Singapore’s inclusion in the Memorandum of Understanding and Cooperation it seemed appropriate to extend an invitation to participate in the research. The invitation was declined, as at that time the Singapore Nursing Board did not require nurses to meet any specific continuing competence requirements. However, the Chief Executive of the Singapore Nursing Board requested that they receive a copy of the final research report and that an invitation be issued to be involved in any subsequent research.

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consensus model (Australia, Canada, Ireland, New Zealand, the United Kingdom and the

United States of America), and from the International Council of Nurses (ICN). The interviews

were largely unstructured and posed the following five semi-structured, open ended questions

as prompts:

1. Tell me about your experience with and understanding of Continuing

Competence Frameworks / models.

2. Describe what you believe is ‘best practice’ for the demonstration and

assessment of continuing competence.

3. What, if any, are the current regulatory requirements for the demonstration and

assessment of continuing competence in your country/jurisdiction?

4. Describe any barriers or enablers that exist in relation to the implementation of

a model/framework for assessment of continuing competence.

5. Do you believe it is possible to develop an international consensus model for the

assessment of continuing competence between the following six countries –

Australia, Canada, Ireland, New Zealand, the United Kingdom and the United

States of America?

Each interview ranged from 40 – 75 minutes in length and was recorded and transcribed

verbatim. The data produced was rich and descriptive in nature. In each case the opening

question “Tell me about your experience with and understanding, of Continuing Competence

Frameworks/models,” was used to set the scene for the interview process, providing the

interviewer with a baseline understanding of each participant’s knowledge and expertise in

relation to the international legislative context in which they practised.

As previously described in Chapter Three (3.3.3.4 Data Analysis), a process of summative

content analysis was used to identify themes and interpret the text data. Consistency of the

initial data analysis, thematic categorisation and generation of sub-themes was independently

checked and verified by a doctoral supervisor. The themes and sub-themes identified in the

data are presented in Table 21 and described in the following sections of Chapter Eight.

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Table 21 Thematic categories and sub-themes - Delphi Round One

Thematic category Sub-themes

Continuing Competence Frameworks - Consistency of purpose and understandings

• Competence and continuing[ed] competence • Purpose of a Continuing Competence

Framework • Public safety

Variation in legislation and policy

• Permissive legislation • Right-touch regulation

Best Practice

• Legal status of framework • A common language • Assessment of continuing competence-

competence indicators • Validity and reliability of competence

indicators • Responsibility and accountability

Barriers and Enablers

• Continuing competence - legislative requirement or career development

• Variation in terminology and language • Consistency in roles and education standards • Administrative and financial viability

8.2.1 Continuing Competence Frameworks - Consistency of purpose and understandings

All of the interview participants identified a common purpose in terms of the role and

responsibility of a regulatory authority and continuing competence requirements, particularly

in relation to protection of the public. It was the unanimous view of the participants that


competence between the six countries was possible. Four participants identified that an

important starting point for this process would be achieving consensus in terms of “common

beliefs, values and core principles”. A number of subthemes emerged within this category and

are described below.

8.2.1.1 Competence and continuing competence

Each interview participant articulated clear understandings of what they believed constituted

and defined competence and continuing competence. The definitions and explanations

provided were consistent in terms of their elements and purpose. Whilst the use of language

varied in some instances, all participants identified that they believed competence was

measured by achieving a predetermined standard of knowledge and skills, attitudes and

behaviours relevant to the approved education and practice standards and a code of

conduct/ethics.

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Whilst the definition of what constituted continuing competence was similar in every case, an

additional element of “competence relevant to the role / context in which the nurse practised”

was also discussed by 11 of the 14 participants. One participant commented

From a continuing competence perspective - obviously we all have competency standards for initial registration or initial endorsement relevant to the registered role for example competency standards for registration as a registered nurse, midwife and enrolled nurse. And those standards are used as a - as a minimum standard. But if you’re talking about defining continuing competence it can’t be based solely on a minimum standard, it needs to be competence relevant to the role the person holds and the context in which they practise. There is a distinct difference from initial competence at registration.

Another participant stated

Continuing competence occurs on a continuum. It is about how we continue to learn and evolve throughout our career. It is not about remaining static and meeting a minimum standard. It is about continuing to be safe to practise and it has to be contextualised.

8.2.1.2 Purpose of a Continuing Competence Framework

The purpose of a Continuing Competence Framework in terms of its value as a tool for

monitoring the continuing competence of the profession was voiced by all participants. One

participant commented

Basically the purpose is to provide the public with some assurance that practitioners continue to be competent and safe in their practice. Nurses need to understand that continuing competence is not about seeing if you’re a good nurse or a great nurse. It’s about the regulator’s role - that is to make sure you’re competent, that you’re not a safety risk. And employers should be working with the nurse to advance their skills and do all of those things, but this continuing competence process is about establishing safety to practise.


Continuing competence is one of the more challenging pieces to do with nursing: regulation. I think just about anything else we – we can come up with good systems that can measure and do ensure competence, or at least as much as you can…when it comes to continuing competence, it’s not a one-off, it’s on-going and it’s important. Its massive numbers and it’s hard to measure in a cost-effective way… to me comes back to that question: are we looking at trying to have a certain level of competence in every nurse, or are we trying to make sure to take out the, you know, the bad apples, the ones that are the problems. So, if we’re trying to make sure of this certain level of competence in every nurse, that’s – it’s hard to do. But I do think it’s important, and I think we have to keep working at it, until we come out with the best system possible that is – is cost-

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effective as much as possible, and time-efficient as possible. Because both of those are issues, I mean, if you don’t have enough nurses in the workforce, if you’re using resources and time in this piece of work, are you ultimately serving the patient’s needs as well, you should be because after all that’s what the purpose is. So, it’s about all the bits of the framework that have to come together to make it – give you the best result possible.

In addition to discussing the regulatory / monitoring purpose of a Continuing Competence

Framework, four participants also talked about its use as a career development tool. One

participant made the following statement

The notion of Continuing Competence Frameworks has gained momentum. Continuing competence is now a requirement of our legislation, rather than just a presumption that a nurse remains competent purely by virtue of their registration. Another aspect of this is the public expectation and actually right to be assured that the nurse who is treating them is competent. We [regulators] are now required to ensure and monitor the continuing competence of nurses in practice. Obviously a continuing competence model incorporates the policies and tools we use to do that. Basically it can be used as a regulatory tool and also as a career development tool.


It goes without saying that a Continuing Competence Framework is a mechanism with which regulators can provide the public with some assurance that they do actually monitor the competence of the profession and in some cases this may be linked with a career development plan. The tension arises when some nurses perceive the purpose of the framework is all about them. I mean - they miss the point and perceive it as surveillance or punitive.

8.2.1.3 Public safety

The notion of ‘public safety’ was raised by all participants and was identified as being integral

to the purpose of regulation and the role of the regulator. It was also linked with discussion

about associated responsibilities and public expectations. One participant commented

I guess the bottom line is that the model gives the public some assurance that the people, who are caring for them or, you know, engaging with them as regulated health professionals, in this case nurses, are competent to practise. It is mainly about public assurance, really.

Another participant who noted the purpose of Continuing Competence Frameworks (8.2.1.2)

went on to discuss it in terms of the relationship between the employer, the nurse and safety

to practise.

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Nurses need to understand that continuing competence is not about seeing if you’re a good nurse or a great nurse. It’s about the regulator’s role that is to make sure you’re competent, that you’re not a safety risk. And employers should be working with the nurse to advance their skills and do all of those things, but this is about establishing safety to practise.

Public safety was also strongly linked with the concept of professional responsibility - who is

responsible? One of the participants stated

…actually continuing competence is about public safety. It is a professional responsibility and whilst regulators may be delegated the responsibility [from government] to ensure competence and monitor continuing competence the individual health professional is ultimately responsible.


Continuing competence… one would hope that in the future nurses will just - you know accept that this is what I do. And do it not with that kind of grumble, grumble but you know “of course I’m a professional this is what I do”.

A further participant stated

We should be encouraging people to take more responsibility for being mature professionals. I’m interested in people stepping up to the plate and feeling positive about this additional thing they can do to enhance their - their role. It is their responsibility after all. I wonder if we’re under-utilising the employer in this in some way, after all they have a responsibility as well.

8.2.2 Variation in legislation and policy

Variation in legislation and policy between and within countries was cited by eight participants

as a possible challenge, but not a barrier in terms of reaching consensus on the development

of an international model for continuing competence. One participant commented

Well I think that now we’re trying to develop a regulatory community. I think these are some of the things that we can certainly put on the table. And try and develop some research projects around and develop new trusts with each other related to - to some consistency of the systems. I think it’s one of our biggest difficulties understanding each other’s systems… in this particular group [six countries] … there’s a level of consistency already in how we approach nursing regulation and actually our legislation isn’t so different, it’s the policies that flow out of it. Continuing competence is a complex process so there is benefit in having consistency.

Another participant suggested that the development of a common Code of Ethics and

Standards of Practice may be a starting point for this process.

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One of the things around continuing competence is that different countries are at different stages. The legislative requirements are different and so some, have very well-developed models and others are – are just starting to look at it. So I think sometimes it’s harder to come to consensus where you’ve got so many at different stages. Whereas, you have the standards for practice for example, or a code of ethics for example, which is much more – I mean, a code of ethics is a code of ethics, right? And, you know, I could envision something like it, a code of ethics that could be agreed on, probably more easily than something like a continuing or competence programme, but I don’t think that’s impossible it’s probably just and easier place to start.

8.2.2.1 Permissive legislation

The importance of “permissive legislation” was a term that was frequently used during the

interviews when participants were describing the context of their current regulatory

environment. However, there was significant variation with regard to the permissiveness of

the legislation and legislative requirements and delegation of responsibility. In some cases

participants described the legislation as prescriptive in terms of what was “required” or

“allowed”, whilst in others the legislation was “high level” and clearly delegated the

responsibility for policy development, implementation and monitoring to the regulatory

authority. One participant commented

The legislation is definitely an enabler – it requires a continuing competence process to be put in place, but it allows the regulator to determine and implement the policy and processes. So the legislation is reasonably permissive in terms of how it is enacted and applied by the regulator. The advantage is the continuing competence process can be mandated, and then basically it becomes a compliance model.

It was apparent that in some cases the physical situation/context and structure of the

regulatory authority, (for example if the regulatory authority was an independent entity or

situated within a Ministry of Health or Health Department) had a significant influence on

powers of the authority in terms of financing, implementing and monitoring new processes.

One of the participants commented

You know, we are here by virtue of the legislation that, you know, government authorises us to act as the regulator, but we are not within the government. We sit independently, however many of the State Boards are within the department of health and they sometimes have a very narrow function. This isn’t a barrier necessarily but it can be a challenge when trying to implement new policy and processes particularly if there are conflicting priorities.

In contrast another commented

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We are fortunate because we are an independent body and are funded by the fees our nurses pay. The legislation is reasonably permissive so we have control over how and what we implement as long as we can demonstrate we are putting in place policy processes that meet the legislative requirements of the ACT.

8.2.2.2 Right-touch regulation

The term right-touch regulation23 was raised in nine of the 14 interviews particularly related to

the enactment of legislative requirements with regard to continuing competence and

implementation of regulatory processes. Seven participants noted that requirements relating

to “continuing competence” were noted in the governing legislation. However, whilst there

was variation in terms of the legislative requirements between jurisdictions, in most cases

development, implementation and monitoring of Continuing Competence Frameworks and

policy was at the discretion of the regulatory authority.

Our legislation requires we monitor the continuing competence of the profession. We work from a basis of trust, you know, that we trust professionals. And we also work from a basis of believing that if the professional has accountability and responsibility for their own behaviour, then light-touch24 [right-touch] regulation is all that’s required. So we shouldn’t be heavy handed in our approach.

Right-touch regulation was mentioned in the context of the financial implications and

managing large nursing work force numbers. In particular, the balance between economics

and continuing competence models that may be perceived as focusing on compliance and

surveillance was discussed. One participant stated

It’s important to come from a pragmatic economical point of view, apart from anything else because all of these things cost a fortune and unfortunately there isn’t an economy in scale. The legislation requires it and I think it is important to have requirements in place in relation to continuing competence but the difficulty is balancing the requirements and assessment of them. Secondly I’m not sure it’s really a proportional response to - to kind of police you know professional people. Because we want to encourage, we want professional behaviour and more autonomous and more self-directed practice. And over regulating, surveillance, this counters to that really, if we’re saying we don’t really believe any of you and we want to check up on you all the time that not really right-touch, do you know what I mean?

23 Right-touch regulation is the minimum regulatory force required to achieve the desired result (Council for Healthcare Regulatory Excellence, 2010, p. 4). 24 Light-touch and right-touch regulation are terms that some research participants used interchangeably.

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Four participants noted an emerging tension between the legislative requirement to ensure

public safety and future workforce implications. One participant stated

probably one of the biggest issues … is the objects and the principles that underpin the legislation so that while public protection is a primary interest for the regulator everything must be right-touch and be balanced against workforce implications. So that’s something that regulators have not in the past had to consider as equally as they would consider public protection. So it is judging and assessing against those two. So it’s changed the - the way in which we do business.

8.2.3 Best Practice

A high level of willingness to work together to achieve agreement in relation to international

best practice principles was apparent when undertaking these interviews. The statement of

one participant reflects a number of the other comments made.

Well I think that now we’re trying to develop a regulatory community. I think these are sort of things that we can certainly put on the table. And try and develop sort of some of the research projects around and -develop new trusts and understandings with each other - and related to - to some consistency of the systems and process. I think it’s one of our biggest difficulties is we are all duplicating … You know in this particular group that we have here [Australia, Canada, Ireland, New Zealand, Singapore, United Sates of America, United Kingdom] there’s a level of consistency in how we have approached regulation and a willingness to work together.


I think this is exciting – that someone is looking at what is happening internationally. Because of the magnitude of this work, it would be great if we could have some commonality and be able to do some research that informs state of the art regulatory processes. So I think it’s great that this discussion is happening prompted by your research.

A number of subthemes emerged within this category, some of which were identified as

enablers in the development and implementation of existing continuing competence models.

8.2.3.1 Legal status of the framework

The legal status of the Continuing Competence Framework was identified as a component of

best practice that was directly related to the comments previously made in (8.2.2.1)

permissive legislation and the later thematic category (8.2.4) barriers and enablers.

Participants identified strongly that where the particular nursing or health professional

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legislation included statements related to competence, continuing competence and public

safety, then the ability of the regulatory authority to develop, resource and implement policy

and associated frameworks, was significantly enabled as was their ability to ensure the

compliance of the profession.

8.2.3.2 A common language

Development of a common language was highlighted as a critical component of a best practice

model. Differences in the use and meaning of some words, definitions and terminology were

highlighted as a challenge for the development and implementation of a consensus

framework. One of the participants stated

I think what would be really good is to get consensus on the terminology – language that we use. That would be a good start. We seem to have very similar definitions but sometimes the words we use mean something entirely different in another country.

The identification of the need for a common language linked strongly with the following subtheme.

8.2.3.3 Assessment / demonstration of continuing competence - competence indicators

There was general agreement that monitoring the continuing competence of the profession

was a priority for most jurisdictions. Various models and frameworks for the assessment of

continuing competence have been developed and implemented in Australia, Canada, the

United Kingdom, New Zealand and some States in the United States of America. A number of

similarities exist between these frameworks particularly in terms of the philosophy, policy and

combination of competence indicators. When discussing the challenges in developing and

implementing a best practice model, one participant highlighted the following

One of the critical aspects is to put a model together that provides a holistic view of the persons continuing competence, it’s not about surveillance. If we work on the understanding that the person has already met competence for registration, then the continuum we are concerned about starts from that point. The indicators that we choose should reflect that after all these are registered health professionals and as such deserve a level of trust – so are we saying demonstrate to us that you continue to be competent or are we saying prove you’re not incompetent. Those are two totally different standpoints - the model needs to be very clear.

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This item related directly back to the fundamental purpose of the model and the use and

understanding of the language and raises the question; are competence indicators tools for

the assessment of continuing competence or tools that provide the nurse with a mechanism to

demonstrate continuing competence? Another participant stated

Because, in essence, what you want is to create a culture of competence, so that people don’t just prepare for a test or recertification, but continuing competence - it becomes a mind-set, something that you just do as a professional.

The need for the model to be multifaceted in terms of elements that contribute to continuing

competence was indicated by twelve of the participants. One participant stated

I think for me mine are sort of more generic rather than nursing specific principles but for me it’s about - it [Continuing Competence Framework] needs to be multi-faceted. So it needs to have a whole lot of different elements to it. And it needs to have a mix of compliance things like our standards. But also things that are about that kind of sense of professionalism.

It was generally identified by the participants that a combination of competence indicators

should be incorporated into the model in order to provide the opportunity to draw on

information from more than one source, thus enhancing the validity of the overarching

assessment.

The competence indicators most commonly associated with existing continuing competence

models were identified by the participants as: self-assessment; practice hours; continuing

education / continuing education credits; peer or manager observed assessments; observed

structured clinical assessment (OSCE); portfolio assessment and career development plans.

Examination was an indicator proposed by two of the participants as a possible assessment

tool to consider in the future, however it was not an indicator currently embedded in any of

the existing Continuing Competence Frameworks.

The adequacy of the competence indicators related to attitudinal and behavioural

characteristics, for example a ‘person’s insight’ or ability to self-assess was posed as a

challenge in terms of implementing adequate assessment strategies. One participant

commented

It’s the people who come up as competence notifications and we know in nursing, often when you go back to what is the primary issue; it is around communication and lack of insight. And so because they lack insight, they don’t make the right decisions along the way. But, in fact, that may never change, that lack of insight. So it’s those very subjective things that are often the issue,

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not the fact that they can do the task really well, but actually how they decide whether they will or won’t or how they’re going to do it, or are they capable and is it actually within their role. I’m not sure this is a changeable behaviour.

Self-assessment was identified by twelve of the participants as one of the most preferred

indicators of competence when used in combination with other indicators. However, issues

related to the subjectivity of this indicator were also highlighted by all participants as a

potential risk. In particular “lack of insight” was raised by three participants as an issue in

relation to self-assessment of continuing competence. This item linked strongly with the next

subtheme related to the validity and reliability of the competence indicators.

8.2.3.4 Validity and reliability of competence indicators

The validity and reliability of the indicators selected to assess continuing competence was

identified by all participants as a challenge that required attention when developing a best

practice framework. One participant commented

We know we’re not the only discipline that has this struggle about determining competence in an on-going manner. Certainly there’s got to be – we look for a model that is administratively feasible, that is legally sound, that’s acceptable to the profession where the bottom line is definitive in saying “yes, you do this and you’re competent”. I look at the research, you know, for us shows that there is no evidence to show that a certain number of practice hours or CE hours is what does it.


Validity is an issue. You know, the literature shows, and we knew it intuitively, that self-assessment is not a very robust approach to continuing competence, but we needed to do something and it is cost effective, plus it makes nurses think about what they are actually doing. So if you use it in association with some other measures you start to get a broader picture.

Whilst all participants discussed the importance of being able to demonstrate that the

framework is valid and reliable, issues related to the limitations of individual indicators were

discussed at length. Five of the participants identified that in their experience, a pragmatic

approach to selection of appropriate indicators was required as no single indicator was able to

provide valid reliable information related to continuing competence. In addition the

participants strongly indicated that the benefits also needed to be related to the cost of

administering the framework, the purpose for which it is implemented and the responsibility

of health professionals for maintaining their continuing competence.

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8.2.3.5 Responsibility and accountability

Responsibility and accountability for continuing competence was raised by all interview

participants. “A collective responsibility” for this process was identified as being critical in

terms of providing a more comprehensive and reliable assessment of competence. One

participant commented

I think it’s a multi-pronged approach for sure and multi-level champion role, I think that’s why it is a collective responsibility for the nurse, the employers, the educators, the regulators/government but mostly individual nurses.

Another participant said

So if you have a mechanism/model in place that takes advantage of the individual and the employer, to me that’s a win-win. If you’ve got the employer engaged, you’ve got the professional organisation engaged, you’ve got the nurse engaged, you’ve got the regulatory body engaged by establishing what it needs which is to say they’re competent, then I feel as a regulator my responsibility is met and that is a best practice model.

In all instances, the interview participants highlighted the final responsibility and accountability

for an individual’s continuing competence was with that individual. Below are several quotes

that reflect these responses.

I think that – that we are – we have earned the right to be called professionals, and with that comes some rights and some responsibilities, and in the list of things that I think comes as a responsibility is that if you are a professional, you take responsibility for maintaining your own knowledge and skills and that you certainly are accountable for whether or not you maintain those. And I think we should never forget that, that in the end, it is every individual’s responsibility. Employers have some responsibility but that does not abdicate the responsibility from the individual, because that is accountability and responsibility are inherent in the definition of being a professional as far as I’m concerned.

For me, it starts from the individual professional. I mean, they’re self-regulating professionals. Individual nurses do have a responsibility in terms of trying to demonstrate their commitment to continuing competency, to lifelong learning, reflective practice, and to nursing practice, you know. Certainly ensuring that their competencies are relevant and up-to-date on a continuing basis relative to their practice is important. I think the quality of care starts with the individual professional.

Issues in relation nurses’ understanding or lack of understanding in relation to their

responsibilities as a registered health professional were identified as possible challenges to

development of a model for best practice. This item also overlapped with nurses’

understanding of their responsibilities in terms of public safety. One participant commented

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We have the same issues with regard to who is responsible; some nurses don’t understand their responsibility as a health professional, that actually continuing competence is about public safety. Sometimes nurses confuse the regulator with the union and the professional organisation – often it is about a lack of understanding.

8.2.4 Barriers and Enablers

A number of the participants identified factors that were perceived to be both barriers and

enablers, and this appeared to be dependent upon the context in which they occurred. A

number of the items that emerge in this category also related directly to the development of a

best practice framework.

8.2.4.1 Continuing Competence – legislative requirement or career development

Legislation was raised again within this thematic category particularly in relation to nurses’

understanding of, and participation in, a continuing competence process. Ten participants

perceived the legislation to be a significant enabler in this process. One participant stated

The biggest enabler has probably been the legislation, prescribing it [continuing competence] essentially.


I think possibly one of the biggest enablers is clear communication, and in our case it was the permissive legislation that gave us the jurisdiction to require compliance of the profession. However legislation may also be a barrier in terms of a consensus model, but I’m not familiar enough with the legislation in the other countries to know.

In contrast another participant made the comment

Until now we have been constrained by the legislation. Well perhaps not constrained, but we have different levels of legislation. Basically if the legislation is silent and there is nothing to require nurses to participate then of course many won’t. Hence implementation and uptake is inconsistent across…

This theme was expanded by another participant who stated

You know, the barriers – the challenges are that the programme that we currently use which is, you know, self-assessment, peer feedback, learning plan, evaluation is not compulsory in terms of the legislation. So, the barrier is nurses’ willingness to participate in the programme and to participate in the way that they are intended to. Some nurses engage really well with the programme, which are usually the ones actually who don’t need it.

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In conclusion one participant stated

Continuing competence requirements will probably separate into what is the regulatory - regulators responsibility, the legislated mandate, and how the profession and professional organisations will support that.

8.2.4.2 Variation in terminology and language

Variation in the terminology and language used within and between countries was raised by

three participants as an issue that had the potential to be a barrier in some jurisdictions. This

was evident from the following two statements

Even in our own country, there are different definitions for what certification means. Variation in language and terminology – use of terms is something that needs to be addressed – a common language, common terminology so everyone has the same understanding, otherwise there are issues.

I’m not sure that we all have the same understandings for the same terms, for example ‘scope of practise’ in some jurisdictions it means the area of practise you work in, and in others it is the registration that the nurse holds. To move forward we need to agree on the language and accepted meanings.

8.2.4.3 Consistency in role definition and education standards

Reaching agreement and common understandings with regard to role definitions and

education standards was identified as a significant enabler in terms of development of a best

practice consensus model. This was linked with the need to reach common understandings on

a code of conduct in order to address the attitudinal and behavioural expectations of a

continuing competence model.

Mobility of the nursing workforce featured within this subtheme in relation to facilitating

movement of nurses between regulatory jurisdictions both within countries and between

countries. This item was identified as challenge that was specifically attributed to the issue of

“trust” and lack of common understandings of consistent role definition, educational

qualifications and practice standards.

8.2.4.4 Administrative and financial viability

The importance of the administrative and financial viability of the continuing competence

model was raised by all participants, particularly in relation to the large number of nurses

within some of the jurisdictions. Aspects such as monitoring the compliance of participants

through audit processes were identified as challenges due to the large numbers of nurses and

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associated administrative costs. Three participants discussed the use of a risk matrix approach

as a strategy that provided a more targeted approach, utilising resources in areas or with

individuals where a potential of identified competence issue had occurred. One of the

participants stated

Logistically with large nurse numbers a risk based approach is manageable. Auditing a percentage would be prohibitive but identifying those individuals or groups that are a potential risk – risk matrix - targets the limited resources to where they are most appropriate.

The second participant stated

Let’s face it the majority of nurses are competent and continue to be competent so the cost comes with those who are not. There comes a point with error where you’re seeing that there’s the scale of the error or the number of errors triggers a response. That’s the model that we are looking at, risk management - not the indicators of competence necessarily, but the indicators that somebody may not be competent and then auditing them. I mean I think you’ve got to look at things like red flags, they’d be two flags, could be with an individual or an area of practice. With large number of nurses in practise we need to develop a model that achieve our goals but is administratively feasible.


We know how to do a psychometrically sound, a legally defensible and administratively feasible test – we use them for entry to the register. But I’m convinced nurses just don’t want to sit an exam on an on-going basis and do they really need to? Shouldn’t we be targeting our resources where we know there may be an issue? So, you know, then that puts us back to Square One. There’s a lot of money and a lot of resources put into these programmes and I want to make sure we’re not just doing it for the sake of saying we’ve met a legislative requirement.

8.2.5 Summary - Delphi Round One

In summary, it was the unanimous view of the interview participants that development of an

international consensus model for the assessment of continuing competence, between the six

countries identified as the focus of this study is an important initiative, and that such a

consensus is possible. It was felt that the new relationship between these countries in terms

of the recently signed memorandum of understanding would facilitate this on-going work.

Limited knowledge and understanding of the legislative, regulatory and educational

requirements for nurses between countries, was identified as a contributor to the perceived

difficulty for nurses wishing to move between regulatory jurisdictions, within and between

countries. Four participants noted that having a greater understanding of the legislative,

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education and qualification frameworks in each of the six countries was a critical factor in

facilitating greater ease of mobility for nurses both within and between the countries. Another

participant stated that “by working more closely together a greater level of trust would be

developed between regulatory jurisdictions”.

The establishment of common values, beliefs and guiding principles contributing to an

internationally agreed code of conduct, education and practice standards was also identified

by seven participants in relation to the development of a consensus model. The variation in

understandings related to the specific indicators that were embedded in the Continuing

Competence Framework were not considered to be a critical issue provided that ultimately the

model allowed flexibility in terms of its implementation requirements, was administratively

feasible, financially viable and defensible in terms of providing some assurance of public

safety.

Whilst the collated findings from round one (Group A) were not provided to the participants in

round two (Group B), they did form the basis for the development of the semi structured

questions posed in the Delphi round two e-survey.

8.3 Delphi Round Two – E-survey

The aim of round two was to seek an open response from the larger, anonymous international

cohort of expert participants (Group B), and to test the stability of the findings derived from

the round one, face-to-face interviews completed with members of Group A. The design of

the round two e-surveys was predominantly semi-structured with open-ended questions that

were formulated using the findings of round one (Group A). A criterion for participant

inclusion in the e-survey (expert Group B), was knowledge and expertise with regard to

Continuing Competence Frameworks and or / nursing regulation. The questions posed were:

1. Do you have knowledge and or experience in the development or

implementation of Continuing Competence Frameworks?

2. Describe the ways you believe it is possible and appropriate for nurses to

demonstrate continuing competence.

3. Describe how you believe continuing competence should be assessed.

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4. In your experience please describe the barriers and /or enablers that may

exist when implementing a model for the demonstration and assessment of


5. Do you believe it is possible to develop an international consensus model for

the demonstration and assessment of continuing competence?

The participants were also provided with the opportunity to add any further comments. As

previously noted a copy of the e-survey is attached (Appendix IV).

8.3.1 Distribution and return of the Delphi round two e-survey

As previously noted in Chapter Three (3.3.3.2 Expert panel), an email invitation to participate

including the detailed research information sheet and the URL link to the web-based e-survey,

was sent to the nursing regulatory authorities and professional nursing organisations in

Australia, Canada, Ireland, New Zealand, the United Kingdom, the United States of America,

and to the International Council of Nurses (ICN) for distribution to the ICN Regulatory

Observatory Group.

Summative content analysis, previously described in Chapter Three (3.3.3.4), was used to

interpret the qualitative text data and identify the emergent themes. This logical and

systematic interpretive process involved counting and comparison of keywords and content

areas. Summary data from this process of analysis are presented in relation to each of the five

survey questions. Because of the snowballing technique used to recruit Group B participants,

and the deliberate intent to ensure that participant responses remained anonymous,

participation statistics will not be reported by geographic region.

Fifty-one participants responded to the invitation to take part in the Delphi round two e-

survey, all of whom completed and submitted responses to the e-survey (Table 22).

Table 22 Knowledge and / or experience of Continuing Competence Frameworks?

Sample size Yes No Total n % n % N %

51 67.7 34 33.3 17 100

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Of the 51, participants 33.3% (n = 17) indicated that they did not have experience in the

development or implementation of Continuing Competence Frameworks. The responses from

these 17 participants have been included in the round two data analysis and have also been

used as a sub group for cross tabulation when analysing the data.

8.3.2 Demonstration and assessment of continuing competence

All participants (n = 51) submitted responses to question two “Describe the ways you believe it

is possible and appropriate for nurses to demonstrate continuing competence” and question

three “Describe how you believe continuing competence should be assessed.” Whilst the

majority of the text responses were consistent with the responses from round one, it was

evident that the difference in the terminology used between and within countries, related

directly to how continuing competence was described. The collated responses with regard to

the ways it is possible and appropriate for nurses to demonstrate continuing competence are

presented in Table 23.

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Table 23 The ways it is possible and appropriate to demonstrate continuing competence Responses Response Count Certification/relicensure25 12 Mandatory continuing competence program requirements26 6 Multisource feedback27 8 Multi-pronged approach28 2 360 degree multi source29 14 Continuing education / education credits 15 Professional development hours 3 Approved continuing education programs 1 Mandatory continuing education 2 Evidence of successful educational outcomes 1 Recency of practice 4 Satisfactory and consistent practice at same or higher level/ongoing practice 7 Hours of practice 7 Practice reviews / audit of practice 2 Documentation of current clinical and safe practice 1 Professional portfolios 8 Reflective practice / self-reflection / self-assessment 7 Self-assessment 6 Self-declaration of competence 2 Peer / colleague feedback 5 Peer assessment / review 1 3rd party assessment 2 Employee evaluations indicating competency 3 OSCE 3 Observation/assessment of practice 4 Objective competency evaluation 1 Return demonstration, simulation 4 Skills demonstration 3 Written examination 3 Random audit 2

However, as depicted in Table 24 when they were asked to identify how continuing

competence should be assessed there was significant variation across a number of items.

25 Variation in terminology and associated legislative requirements between countries e.g. New Zealand nurses apply for recertification annually. United States of America nurses apply for relicensure annually. 26 Requirement, based on standards of practice, self-assessment plus ability to draw on tool box of indicators if comprehensive assessment required. 27 Reflection, multi-source feedback, learning plans, chart review, practice visits, multi-source feedback, case studies/chart stimulated recall, OSCE's, written/oral exams, practice interviews. 28 Combination of practice hours, Continuing Education (CE), some other sort of assessment/evaluation. 29 Comprehensive assessment - competencies appropriate to the practice role and approved standards. Senior peer / employer assessment. Examination of actual practice. Evidence of involvement in current nursing education relevant to practice.

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Table 24 How should continuing competence be assessed? Response Response Count Certification / relicensure 6 Self-assessment 10 Self-declaration / assessment of competence 4 Reflective practice / self-reflection / self-assessment 8 Mandatory continuing competence program requirements – combination of indicators30

10

Multisource feedback31 9 Multi-pronged approach32 2 360 degree multi source33 13 In current / recent practice 15 Satisfactory and consistent practice at same or higher level/ongoing practice 8 Hours of practice 6 3rd party assessment 3 Peer / colleague feedback 4 Peer assessment / review 3 Senior nurse assessment 1 Continuing education / education credits 16 Professional development hours 5 Approved continuing education programs 3 Professional review e.g. work based assessment or credentialing education program

8

Evidence of successful educational outcomes 2

Written examination 2 Practice reviews/audit of practice 2 Observation/assessment of practice 4 OSCE 2 Skills demonstration 2 Professional portfolios 12 Random audit 4 Employee evaluations indicating competency 3 Quality monitoring and improvement program 1 Not sure - an objective, external mechanism 1 Toss her in the lake to see if she floats 1

Sixty-seven percent (n = 34) of the participants who responded to this question identified that

a form of multi-source feedback is required for assessment of continuing competence. Whilst

30 Legislative requirement, based on standards of practice, self-assessment plus ability to draw on tool box of indicators if comprehensive assessment required. 31 Reflecting on the feedback and developing, implementing and evaluating a learning plan, chart review, practice visits, multi-source feedback, case studies/chart stimulated recall, OSCE's, written/oral exams, practice interviews. 32 Combination of practice hours, CE, some other sort of assessment/evaluation. 33 Comprehensive assessment - competencies appropriate to the practice role and approved standards. Senior peer / employer assessment. Examination of actual practice. Evidence of involvement in current nursing education relevant to practice. Combination of practice hours, CE, some other sort of assessment/evaluation.

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the participants identified a range of indicators of continuing competence the most frequently

identified items were: current practice / practice hours; continuing education; self-assessment;

peer assessment; and professional portfolios.

8.3.3 Barriers and Enablers when implementing a model for demonstration and assessment of continuing competence

Fifty participants responded to question four, “In your experience please describe the barriers

and / or enablers that may exist when implementing a model for the demonstration and

assessment of continuing competence.” As depicted in Table 25, many of the barriers and

enablers identified by participants in the Delphi round two are consistent with those

previously identified by Delphi round one participants, particularly: 8.2.4.1 Continuing

competence - legislative requirement; 8.2.4.2 Variation in terminology and language; and

8.2.4.4 Administrative and financial viability. Each of these themes again featured as both

barriers and enablers to implementation of a Continuing Competence Framework.

Administrative and financial viability was rated as the most significant barrier to the

development and implementation of a framework, whilst legislation was identified as the most

significant enabler. Validity and reliability of competence indicators (8.2.3.4) was another

theme that again featured strongly in relation to barriers to the implementation of a

Continuing Competence Framework. Participants identified a number of issues previously

noted in Delphi round one, related to the validity and reliability of continuing competence

indicators and their associated assessment processes. This item was also strongly linked to the

items, ‘insufficient evidence based research’ and ‘evidence based best-practice’.

Consistent communication, terminology and understandings was identified by six participants

as a barrier, however it was identified as a significant enabler with regard to best practice and

implementation of a Continuing Competence Framework, and in relation to facilitating

mobility of nurses within and between countries.

It was interesting to note that “Resistance from external agencies” was an item not previously

identified as a barrier. Cross tabulation of the participant responses related to this item,

indicated that all participants who identified this item as a barrier were situated within the

United States of America and Canada.

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Table 25 Barriers and enablers to implementing a model for assessment of continuing competence

Barriers Response Count

Enablers Response Count

1. Financial efficacy and viability 25 1. Legislation 26 • Development, implementation and

ongoing administrative costs 15 • Required to demonstrate to public

attention to public safety 8

• Cost related to large nursing population

7 • Legislative mandate authority of the Regulatory Board

12

• Technology and resources 3 • Consistent policy, processes, understandings

6

2. Insufficient evidence based research

23 2. Consistent communication, terminology and understandings

16

• Validity and reliability of competence indicators

12 • Standardised terminology, definitions, understandings

10

• Efficacy, validity and reliability of models

5 • Clear communication of requirements, processes

6

• Quality of continuing education 2 • Inter-rater reliability of assessment

processes 4

3. Acceptance and buy-in of the profession - nurses

18

3. Evidence based practice – register of competent workforce

15

• Trust / mistrust / fear 6 • Sound statistical data and researched models

3

• Lack of understanding of responsibility

4 • Agreement, consistent processes, practices, languages within and between countries

5

• Cost and time involvement 5 • Statistical data related to improved patient outcomes

2

• Resistance to change 3 • Financial efficacy and viability 5

4. Legislation 17 4. Committed professional champions

10

• Not mandated in the legislation 4 • Culture of high performers 2 • Limited powers of the regulatory

authority 3 • Support and buy-in of professional

organisations 5

• Inconsistent legislation, policy and process

10 • Increased professional awareness 3

5. Resistance from external agencies 12 5. Nurses’ access to resources 8 • Employers 4 • Access to online systems 3 • Professional organisations 1 • Access to continuing education 3 • Unions • Education providers

6 1

• Reasonably priced continuing education opportunities

2

6. Nurses access to resources 8 6. Employer support 3

7. Inconsistent communication, terminology, and understanding

6

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8.3.4 Do you believe it is possible to develop an international consensus model for the demonstration and assessment of continuing competence?

As depicted in Figure 17, in response to the question five “Do you believe it is possible to

develop an international consensus model for the demonstration and assessment of continuing

competence?”, of the overall participant group 88% (n = 45) indicated they believed it was

possible to develop a consensus model and 12% (n = 6) indicated they did not.

Figure 17 Possible to develop a consensus model for the demonstration and assessment of continuing competence?

Thirty six of the 45 participants, who believed development of an international consensus

model is possible, provided additional comments. One participant made the following

statement

Yes I believe it is possible but it’s not going to be easy. Margret Mead said “Never doubt that a small group of committed people can change the world. Indeed it is the only thing that ever has.” This is something that we need to do.

Of the 12% (n = 6) of participants who indicated development of an international consensus

model was not possible, of the original total, 4% (n = 2) of the participants identified that they

had experience in the development / implementation of Continuing Competence Frameworks.

Both participant responses reflected the previously identified theme (Table 20) inconsistent

legislation, policy and process which were perceived as significant barriers. One participant

commented

It would be desirable to have this but individual states laws are not consistent.

And the other commented

Yes 88%

No 12%

Yes

No

189

Maybe, not in my lifetime – there are many roadblocks that must be addressed. Continued competence will not become international until, or unless all the countries standardise the core requirements and curriculum for nurses. This current variance in educational requirements for entry to practice is the primary barrier to any international implementation.

Of the original total, the remaining 8% (n = 4) were all participants who stated they had no

experience in the development / implementation of Continuing Competence Frameworks.

One participant from this group provided the following comment that was consistent with the

larger group response.

Probably not possible, unless we can get consensus within our own country.

8.3.5 Summary – Delphi Round Two E-survey

Summary data from round two of the Delphi e-survey reflected stability with the findings of

Delphi round one e-survey. This was particularly evident with regard to the purpose of

Continuing Competence Frameworks, the definition of continuing competence and the

selection of appropriate competence indicators. The data indicated that legislative

frameworks, particularly the jurisdiction of the individual regulatory authority and associated

policy requirements, had a significant impact upon the ability to implement a Continuing

Competence Framework. This item featured significantly as both a barrier and an enabler.

The following items were highlighted for further investigation in the Delphi round three e-

survey:

• The definition of ‘competence’ and ‘continuing competence’.

• An understanding of what constitutes ‘professional responsibility’ and ‘nursing

practice’.

• Responsibility and accountability.

• The purpose and core requirements of a Continuing Competence Framework including

the indicators of continuing competence.

• Implementing a Continuing Competence Framework – barriers and enablers.

8.4 Delphi Round Three – E-survey

Questionnaire development for the Delphi round three e-survey drew heavily on the responses

from the previous two rounds. The e-survey was structured using statements drawn from the

findings of the previous two Delphi rounds, incorporating summary findings from the Delphi

190

round two e-survey. The underlying design of the e-survey (Appendix V, Delphi round three e-

survey) was based on a five point Likert (rating) Scale to elicit the participant’s level of

agreement or disagreement with the statement items. The score of one indicated strong

agreement and the score of five indicated strong disagreement. This process sought to

quantify the earlier findings from Delphi rounds one and two and determine any convergence

and consensus of opinion. Participants were provided with a three week timeframe in which

to complete and submit the e-survey. The summary data were coded and collated

independently via the Zoomerang software platform, and then exported to the Statistical

Package for Social Sciences (SPSS) for Windows version 20, for further analysis. Any errors or

inconsistencies in data were carefully screened out by evaluating the range of values

generated by running the descriptive frequencies.

8.4.1 Distribution and return of the Delphi round three e-survey

The Delphi round three e-survey was distributed via the web-based software platform

Zoomerang. As participation in the Delphi rounds two and three e-surveys was anonymous

and administered through the Zoomerang web-based portal it was not possible to determine if

the same participants responded to both e-surveys. However, distribution of the web-based

invitation was administered through the same address data base for both Delphi rounds.

The web-based invitation to participate in the Delphi round three e-survey, including the URL

link to the Delphi round three e-survey, was distributed to 52 prospective participants. Of the

52 web-based invitations six were not viewed or responded to, five were marked as

undeliverable, and two participants elected not to complete the Delphi round three e-survey

by submitting an opt-out response. Thirty-nine participants completed and submitted the

Delphi round three e-survey. Data relating to participation and response rate is presented in

Table 26.

Table 26 Participation rate and sample size

Sample size Participation sample Participation rate

52 39 75%

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8.4.2 Definition of competence and continuing competence

Variation in the definition and interpretation of the terms ‘competence’ and ‘continuing

competence’, particularly in relation to nursing regulation and practice, was identified by

Delphi round two participants as an item for further investigation and agreement. Despite this

belief the published definitions of competence and continuing competence, in the six countries


America) appear to be similar. Each definition of competence includes the requirement to

meet a prescribed standard of knowledge, skills and decision making for safe practice. In

addition to these items, the definitions of continuing competence all include items such as, the

on-going ability of the nurse to continue to integrate up-to-date knowledge, skills, judgement

and decision making appropriately in the context / role in which they practise. However, it is

noted that variation does exist in terms of the ‘local’ legislation, policy, and procedures and in

some cases where a Continuing Competence Framework exists, implementation and

ownership.

Delphi round three e-survey participants were asked to rate their level of agreement or

disagreement with a definition of competence and continuing competence derived from the

existing published definitions. Table 27 presents a summary of participant results.

Table 27 Definitions of competence and continuing competence

Strongly Agree

Agree Undecided Disagree Strongly Disagree

Response Count

Competence is the combination of skills, knowledge, attitudes, values and abilities that underpin the effective performance as a nurse.

45% (n=17)

55% (n=21) 0% 0% 0% 38

Continuing Competence is the on-going ability to keep up-to-date the skills, knowledge, values, attitudes, and abilities required to practice effectively and safely in the context / role in which they practise.

45% (n=17)

55% (n=21) 0% 0% 0% 38

Thirty-eight (100%) of the participants who responded to both of the statements indicated

they agreed or strongly agreed with the definitions provided.

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8.4.3 Definition of nursing practice

Inconsistencies in the definition of what constitutes ‘nursing practice’ is an item that was

identified in Delphi round one and round two e-surveys, as a potential barrier to the

implementation of a consensus model for continuing competence. The majority of

participants indicated that the definition should be inclusive of all nursing roles that contribute

to nursing as a profession, for example; nursing education, nursing management, governance

and policy, nursing regulation, nursing research and clinical nursing practice. Thirty-eight

participants responded to this question, all of whom strongly agreed or agreed with the

inclusive definition provided. Figure 18 presents the results.

Figure 18 Definition of nursing practice

The standard deviation and variance for this item (SD = .504; V = .254) demonstrates the close

distribution of participant responses across only two points of the five point continuum

(strongly agree – agree) and is reflected in the mean score of (M = 1.45).

8.4.3 Continuing competence of registered health practitioners – who is responsible?

8.4.3.1 The responsibility of a Registered Nurse

Lack of a common understanding related to what nurses believe constitutes their professional

responsibility with regard to their continuing competence, was identified in the previous two

rounds as being a significant barrier to the development and implementation of a Continuing

Competence Framework. In order to investigate this area more fully, the participants were

asked to rate their level of agreement with five statements. The participant statements are

collated and the findings presented in Table 28.

0% 20% 40% 60% 80% 100%

The definition of nursing practice should beinclusive and encompass: Nursing Management;

Nursing Education; Nursing Research; NursingPolicy; Nursing Regulation; Nursing Governance;

and Clinical Nursing Practice.

21 17

Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

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Table 28 As a registered health professional individual nurses are responsible for

Strongly Agree

Agree Undecided Disagree Strongly Disagree

Rating Mean

Response Count

Demonstrating a commitment to continuing competence throughout their professional careers.

74% (n=28)

26% (n=10) 0% 0% 0% 1.24 *38

Ensuring that they continue to meet the relevant standards and competencies required for their scope of practice and relevant to the role and context in which they practise.

78% (n=29)

22% (n=8) 0% 0% 0% 1.19 **37

Actively participating in and meeting the requirements specified by their regulatory authority.

81% (n=30)

19% (n=7) 0% 0% 0% 1.16 **37

Participating in on-going educational activities relevant to their scope of practice.

76% (n=28)

24% (n=9) 0% 0% 0% 1.22 **37

Providing an appropriate, safe, ethical and competent standard of nursing practice.

82% (n=31)

18% (n=7) 0% 0% 0% 1.16 *38

*1 participant failed to respond to 2 items, **2 participants failed to respond to 3 items

Descriptive statistics were used to calculate the mean (M) scores and standard deviation (SD)

for each of the five statements. As depicted in Figure 19, 100% of the participants indicated

they strongly agreed or agreed with each of the five statements. The mean scores ranging

from (M = 1.16 – 1.24), standard deviation of (SD = .370 - .431) and variance of (V = 1.37 -

1.86).

The participant group mean score for each statement indicated that overall there was strong

agreement that the individual nurse is responsible for maintaining their own continuing

competence. The standard deviation and variance for each item demonstrated the tight

distribution of participant responses across only two points of the five point continuum

(strongly agree – agree).

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Figure 19 Individual nurses are responsible for their own continuing competence

8.4.3.2 Responsibility and accountability

Clarification with regard to who else has responsibility for the continuing competence of

registered nurses, was highlighted as an important consideration when implementing a

Continuing Competence Framework. This item was raised by participants in Delphi round one

and two e-surveys, particularly in relation to the role of the employer, the professional

organisation and the regulatory body. Whilst it was unanimously agreed that ultimately the

registered nurse is responsible and accountable throughout their career for their own

continuing competence, the accountability and / or responsibility of associated stakeholders

was identified as being either a significant barrier or enabler to the implementation of a

continuing competence process. Round three participants were asked to rate their level of

agreement or disagreement with five statements in relation to this item. Table 29 presents a

collation of the findings.

0% 20% 40% 60% 80% 100%

Demonstrating a commitment to continuing competencethroughout their professional careers.

Ensuring they continue to meet the standards andcompetencies required for their practice relevant to the

role and context in which they practise.

Actively participating in and meeting the requirementsspecified by their regulatory authority.

Participating in ongoing educational activities relevant totheir scope of practice.

Providing an appropriate, safe, ethical and competentstandard of nursing practice.

28

29

30

28

31

10

8

7

9

7

StronglyAgree

Agree

Undecided

Disagree

StronglyDisagree

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Table 29 Continuing competence of registered nurses – who is responsible?

Strongly

Agree Agree Undecided Disagree Strongly

Disagree Rating Mean

Response Count

Governments are responsible for passing legislation, and ensuring its enactment.

31% (n=12)

69% (n=27) 0% 0% 0% 1.72 39

Regulatory authorities are responsible for protecting the safety of the public by setting the standards of nursing practice and monitoring the competence of the profession.

39% (n=15)

61% (n=24) 0% 0% 0% 1.62 39

Professional organisations are responsible for facilitating/guiding the development of the nursing profession.

26% (n=10)

71% (n=27) 0% 3%

(n=1) 0% 1.79 *38

Employers are responsible for maintaining quality practice environments that support and facilitate continuing competence opportunities for nurses and monitoring their continuing competence.

40% (n=15)

60% (n=23) 0% 0% 0% 1.61 *38

Nursing education organisations are responsible for providing high quality programmes that prepare competent nurses and provide relevant continuing education opportunities.

31% (n=12)

69% (n=27) 0% 0% 0% 1.69 39

*n = 1 participant failed to respond to 2 items

The majority of participant responses indicated ‘agreement’ with each of the five statements.

However, in response to the statement ‘Professional organisations are responsible for

facilitating / guiding the development of the nursing profession’ one participant indicated they

disagreed. As shown in Figure 20 there was no notable difference in mean scores (M = 1.61 –

1.79) or the distribution of participant responses.

196

Figure 20 Responsibility and accountability

8.4.4 Core requirements of a Continuing Competence Framework

8.4.4.1 Operational requirements

Models and understandings of what constitute a Continuing Competence Framework or model

vary internationally. Delphi round three e-survey participants were asked to indicate their

level of agreement with four statements relating to the operational requirements for a

consensus model.

As depicted in Table 30 the majority of participants strongly agreed with each of the

statements with mean scores ranging from (M = 1.11 – 1.39). In particular 90% of participants

strongly agreed with the first statement ‘CCFs must be financially viable’ and this response is

reflected in the standard deviation and variance score (SD = .311; V = .097).

0% 20% 40% 60% 80% 100%

Governments are responsible for passinglegislation, and ensuring its enactment.

Regulatory authorities are responsible forprotecting the safety of the public by setting thestandards of nursing practice and monitoring the

competence of the profession.

Professional organisations are responsible forfacilitating the development of the nursing

profession.

Employers are responsible for maintaining qualitypractice environments that support and facilitatecontinuing competence opportunities for nurses

and monitoring their continuing competence.

Nursing education organisations are responsiblefor providing high quality programmes that

prepare competent nurses and provide relevantcontinuing education opportunities.

12

15

10

15

12

27

24

27

23

27

1

StronglyAgreeAgree

Undecided

Disagree

StronglyDisagree

197

Table 30 Continuing competence consensus model requirements

Strongly



Response Count

CCFs must be financially viable, flexible, applicable to a variety of settings, provide options for demonstrating competence and be clearly communicated to all stakeholders.

90% (n=34)

10% (n=4) 0% 0% 0% 1.11 *38

CCFs are tools that are used to monitor the continuing competence of the profession and individual practitioners.

73% (n=27)

27% (n=10) 0% 0% 0% 1.27 **37

Competence indicators are measures that assess competence against specified standards.

68% (n=28)

32% (n=9) 0% 0% 0% 1.32 **37

Competence indicators may imply competence but cannot ensure the continuing competence of an individual.

63% (n=24)

34% (n=13)

3% (n=1) 0% 0% 1.39 *38

*n = 1 participant failed to respond to all items, **n = 2 participants failed to respond to 2 items

8.4.4.2 Assessment of continuing competence

Extensive research exists with regard to individual measures of competence and competence

indicators. However, the assessment of the continuing competence of nurses continues to be

a phenomenon that is proving difficult to validate. Current research suggests that no

‘individual measure assures competence or public safety. However, evidence drawn from a

variety of measures provides a strong indication of competence and may be used to imply

continuing competence. Thirty-four (67%) of the Delphi round two e-survey participants

identified that ‘multisource’ or ‘360 degree’ feedback is critical when assessing the continuing

competence of nurses. In addition, responses to the Delphi round two e-surveys highlighted a

general view that the measurement of continuing competence requires contextualising in

terms of the requirements of the practice environment and the individual’s role. Four

statements were posed in relation to the composition and components of a Continuing

Competence Framework and participants were asked to rate their level of agreement with

each item. Figure 21 presents the participant responses.

198

Figure 21 Assessment of continuing competence

Eighty-four percent (n = 32) of the participants strongly agreed with the statement

‘competence indicators must be flexible and relevant to the scope in which the nurse is

practising’ and 78% (n = 29) strongly agreed that ‘assessment of continuing competence

requires the integration of multi-source assessment i.e. a variety of competence indicators’.

However, in response to the statements ‘on its own continuing competence or professional

education is not an adequate measure of continuing competence’ and ‘hours of practice is not

an adequate measure of continuing competence’, the participant responses were divided

between strongly agreed and agreed with four participants indicating they were undecided.

Table 31 presents the collated responses.

Table 31 Assessment of continuing competence

Strongly



Response Count

Assessment of continuing competence requires the integration of multi-source assessment i.e. a variety of competence indicators.

42% (n=16)

47% (n=18)

8% (n=3)

3% (n=1) 0% 1.68 38

Hours of practice are not an adequate measure of continuing competence.

47% (n=18)

50% (n=19)

3% (n=1) 0% 0% 1.55 38

0% 20% 40% 60% 80% 100%

Competence indicators must be flexible and relevantto the scope in which the nurse is practising.

Assessment of continuing competence requires theintegration of multi-source assessment i.e. a variety

of competence indicators.

On its own continuing professional development(CPD) or professional education is not an adequate

measure of continuing competence.

Hours of practice are not an adequate measure ofcontinuing competence.

32

29

16

18

6

6

18

19

2

3

1

1

StronglyAgreeAgree

Undecided

Disagree

StronglyDisagree

199

8.4.4.3 Indicators of continuing competence

In Delphi round two e-survey, five indicators of continuing competence were identified that

received the highest response count in terms of their importance for inclusion in a consensus

model for the assessment of continuing competence. Delphi round three e-survey participants

were asked to rate their level of agreement or disagreement with the inclusion of the five

indicators listed in Figure 22.

Figure 22 Indicators of continuing competence

As depicted in Figure 22, 100% (n = 39) of participants strongly agreed or agreed that

‘continuing professional development’ and ‘hours in current / recent practice’, should be

included as indicators of continuing competence in the consensus framework. Ninety percent

(n = 34) of the participants agree or strongly agreed that ‘self-assessment / self-declaration’

should be included and 10% (n = 4) were undecided.

While 45% (n = 17) of the participants agreed ‘peer assessment’ should be included, 47% (n =

18) were undecided and 8% (n = 3) believed it should not be included. Seventy-one percent (n

= 27) of the participants disagreed or strongly disagreed with the inclusion of ‘professional

portfolio’ as an indicator of competence, 24% (n = 9) indicated that they were undecided, and

5% (n = 2) believed it should be included.

0% 20% 40% 60% 80% 100%

Practice hours i.e. participation/recency of nursing practice

Self assessment/self declaration

Peer assessment

Continuing professional development

Professional portfolio

27

22

6

28

1

12

12

11

11

1

4

18

9

2

13

1

14

Practice hours i.e.participation/recency of

nursing practice

Self assessment/selfdeclaration Peer assessment Continuing professional

development Professional portfolio

Strongly Agree 27 22 6 28 1Agree 12 12 11 11 1Undecided 0 4 18 0 9Disagree 0 0 2 0 13Strongly Disagree 0 0 1 0 14

200

Descriptive statistics were used to calculate the mean (M) scores, standard deviation (SD) and

variance (V) for each of the five competence indicators in order to assist in determining their

inclusion in the consensus framework. Findings are presented in Table 32.

Table 32 Competence indicators

Strongly

Agree Agree Undecided Rating

Mean Standard

Deviation Variance Response

Count

Self-assessment / self-declaration 58% (n=22)

32% (n=12)

10% (n=4) 1.53 .687 .472 *38

Practice hours i.e. current/recent nursing practice

69% (n=27)

31% (n=12) 0% 1.31 .468 .219 39

Continuing professional development

72% (n=28)

28% (n=11) 0% 1.33 .530 .281 39

Peer assessment 16% (n=6)

29% (n=11)

47% (n=18) 2.42 .948 .899 *38

Professional portfolio 2.6% (n=1)

2.6% (n=1) 0% 3.89 1.110 1.232 *38

*n = 1 participant failed to respond to three items

Three indicators of competence; examination, objective structured clinical examination (OSCE)

and audit of practice were also included by a small number of participants who responded to

the Delphi rounds one and two e-surveys. Delphi round three e-survey participants were

asked if these indicators should, or should not, be included in the consensus framework. The

participant responses are collated and depicted in Figure 23.

Figure 23 Outlying competence indicators

0% 20% 40% 60% 80% 100%

Examination

Objective Structured ClinicalExamination (OSCE)

Audit of Practice

1

7

5

2

9

32

36

23

ExaminationObjective StructuredClinical Examination

(OSCE)Audit of Practice

Yes Should be included 1 0 7Undecided 5 2 9No Should not be included 32 36 23

201

Eighty-four percent (n = 32) of the participants indicated that ‘examination’ should not be

included as an indicator of continuing competence, and 95% (n = 36) indicated that ‘OSCE’

should not be included. In contrast 59% (n = 23) of the participants believed ‘audit of practice’

should not be included, however a further 23% (n = 9) were undecided and 18% (n = 7)

believed it should be included as one of the indicators of continuing competence.

8.4.5 Implementing a Continuing Competence Framework – barriers and enablers

Delphi round three e-survey participants were provided with a list of barriers and enablers

identified in round two, and asked to rate those on a five point Likert scale from significant

barrier to significant enabler. Figure 24 provides a summary of the participant responses.

Figure 24 Barriers and enablers

As depicted in Table 33, two items were agreed to be significant enablers by the majority of

the participants; ‘authority of the regulatory body’ (92%, M = 1.77) and ‘communication with

key stakeholders’ (93%, M = 1.62). ‘Legislation’ was also identified as an enabler (85%, M =

2.00), and although ‘differing qualifications’ had previously been identified as a barrier, 80%

(n= 31) of the participants in round three identified ‘differing qualifications’ as not applicable.

‘Number of nurses on the register’ had also previously been identified as a barrier, however

while 27% (n = 10) of the participants again identified it as a barrier, 58% (n = 22) identified it

as not applicable. It is interesting to note that with regard to the item ‘political interests’, 54%

(n = 20) of the participants were undecided.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Communication with key stakeholders

Legislation

Authority of the Regulatory Body

Professional Nursing Organisations

Financial viability

Political Interests

Differing qualification requirements

Expectations of the Public

Number of nurses on the register

19

10

16

1

4

1

17

23

20

24

12

4

4

3

3

3

11

9

20

5

11

6

3

3

13

10

3

1

9

1

1

3

31

22

22

Significant Enabler Enabler Undecided Barrier Significant Barrier N/A

202

Table 33 Barriers and enablers

Significant

Enabler Enabler Undecided Barrier Significant

Barrier N/A Rating Mean

Std. Error

Response Count

Number of nurses on the register 0% 0% 16%

(n=6) 24%

(n=9) 3%

(n=1) 58%

(n=22) 4.92 .211 *38

Expectations of the public

3% (n=1)

10% (n=4)

28% (n=11)

3% (n=1) 0% 57%

(n=22) 4.62 .281 39

Differing qualifications requirements 0% 0% 13%

(n=5) 8%

(n=3) 0% 80% (n=31) 5.36 .196 39

Political interests 0% 11% (n=4)

54% (n=20)

27% (n=10) 0% 8%

(n=3) 3.46 .180 **37

Financial viability 10% (n=4)

31% (n=12)

23% (n =9)

33% (n=13)

3% (n=1) 0% 2.92 .166 39

Professional nursing organisations / unions

3% (n=1)

62% (n=24)

28% (n=11)

8% (n=3) 0% 0% 2.38 .108 39

Authority of the regulatory body

41% (n=16)

51% (n=20)

8% (n=3) 0% 0% 0% 1.77 .100 39

Legislation 26% (n=10)

59% (n=23)

8% ( =3)

8% (n=3) 0% 0% 2.00 .127 39

Communication with Key stakeholders

49% (n=19)

44% (n=17)

8% (n=3) 0% 0% 0% 1.62 .101 39

*n = 1 participant failed to respond to two items, **n = 1 failed to respond to one item

8.4.6 Consensus Model

Eighty-eight percent (n = 31) of round two participants indicated that they believed it was

possible to develop an international consensus model between the six identified countries

(Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States of

America), for the demonstration and assessment of continuing competence. However, the

comments provided by these participants also indicated that whilst they believed this to be

possible, there was a need to gain consensus on the core foundation principles in relation to

common understandings and the transportability and efficacy of the framework. In order to

test the round two responses, participants in round three were asked to rate their level of

agreement or disagreement with the following three statements:

1. It is possible to develop a consensus model for the assessment of continuing

competence.

2. It is possible to develop key principles for the assessment of continuing competence.

3. The consensus model must be flexible and adaptable.

Thirty-nine participants responded to these questions. Table 34 presents the collation of

responses.

203

Table 34 Continuing competence consensus model requirements

Strongly



Response Count

It is possible to develop a consensus model for the assessment of continuing competence.

20% (n=8)

67% (n=26)

8% (n=3)

5% (n=2) 0% 1.95 39

It is possible to develop key principles for the assessment of continuing competence.

46% (n=18)

54% (n=21) 0% 0% 0% 1.56 39

The consensus model must be flexible and adaptable.

67% (n=26)

33% (n=13) 0% 0% 0% 1.31 39

All of the participants agreed or strongly agreed with statements 2 and 3. However, in

response to statement 1 ‘It is possible to develop a consensus model for the assessment of

continuing competence’, 87% (n = 34) of the participants agreed and 13% (n = 5) of the

participants were undecided or disagreed. This response is reflected in the mean score of (M =

1.95) and standard deviation and variance (SD = .724; V = .524).

Figure 25 Consensus model

Figure 25 depicts the comparison of responses. The participant comments reflected those of

round one and two participants, particularly in terms of a willingness to work collaboratively to

facilitate the development of an international consensus framework.

0% 20% 40% 60% 80% 100%

It is possible to develop a consensus model forthe assessment of continuing competence

It is possible to develop key principles for theassessment of continuing competence

The consensus model must be flexible andadaptable

8

18

26

26

21

13

3 2

Strongly Agree

Agree

Undecided

Disagree

Strongly Disagree

204

8.5 Summary of findings from the Delphi rounds (one – three)

8.5.1 The consensus model

The view of the majority of the Delphi participants is that the development of an international

consensus model for the assessment of continuing competence, between the six identified

countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United states

of America) is an important initiative that is possible (Agreement = 87%, M = 1.95, SD = .724, V

= .524).

The consensus view of the participants is that there is initial work required to in order to

determine a common foundation prior to development of the consensus model. It was the

consensus view of the participants that initially the development of key principles for the

assessment of continuing competence be agreed (Agreement = 100%, M = 1.56, SD = .502, V =

.252).

The most commonly expressed requirement identified by the participants is that the

consensus model must be flexible and adaptable (Agreement 100%, M = 1.31, SD = .468,

V.219).

8.5.2 Definitions

It was the consensus view of the participants that the inclusive definitions of ‘competence -

the combination of skills, knowledge, attitudes, values and abilities that underpin the effective

performance as a nurse’ and ‘continuing competence - the on-going ability to keep up-to-

date the skills, knowledge, values, attitudes, and abilities required to practise effectively and

safely in the context/role in which they practise’ were appropriate. Both definitions achieved

the same agreement rating (Agreement 100%, M = 1.55, SD = .504, V = .254).

The inclusive definition of what constitutes nursing practice was agreed to include all ‘nursing

roles’ that contribute to the nursing profession i.e. nursing regulation; nursing governance;

nursing policy; nursing management; nursing education; nursing research; and clinical nursing

practice (Agreement 100%, M= 1.45, SD = .504, V = .254).

8.5.3 Responsibility and accountability

Responsibility and accountability for continuing competence were items that attracted wide

ranging comment. A consensus view was achieved in terms of the understanding of what

205

constitutes the individual registered nurse’s responsibilities for their continuing competence.

There was consensus with regard to the overarching responsibility of the key stakeholder

groups, particularly the employer with 40% (n = 15) of participants indicating they strongly

agreed and 60% (n = 23) that they agreed employers are responsible for maintaining quality

practice environments that support and facilitate continuing competence opportunities for

nurses, and for monitoring their continuing competence.

8.5.4 Continuing Competence Framework

Ninety percent (n = 35) of the participants strongly agreed and 10% (n = 4) agreed (M = 1.11),

that it is important that the continuing competence model must be administratively feasible,

financially viable and defensible in terms of providing some assurance of public safety.

Flexibility in terms of the implementation and utilisation of embedded indicators of continuing

competence was identified as a requirement. It is the consensus view (100%, M = 1.32) that

competence indicators are measures that assess competence against specified standards. In

addition the relevance of these indicators to the scope/context in which the nurse is practising

is agreed to be important by 97% of the participants (M = 1.16).

8.6.5 Indicators or continuing competence

It is the consensus view that the following three indicators of continuing competence, used

together, should be included in the international consensus framework: self-assessment / self-

declaration (Agreement 90%, M = 1.53, SD = .687, V = .472); practice hours /recent nursing

practice (Agreement 100%, M = 131, SD = .468, V = .219); and continuing professional

development (Agreement 100%, M = 1.33, SD = .530, V = .281). Whilst other indicators of

competence were identified, such as portfolio and examination, none achieved a consensus

rating. However, the ability to incorporate a ‘tool box’ of additional optional indicators was

identified as beneficial by 67% (n = 34) Delphi round two participants.

8.5.6 Barriers and enablers agreed

A number of barriers and enablers were initially identified in relation to the development of a

consensus model, however, only two of the identified enablers were rated by the majority of

the participants in round three: authority of the regulatory body (Agreement 92%, M = 1.77,

SD = .627, V = .393); and communication with key stakeholders (Agreement 93%, M = 1.62, SD

= .633, V = .401). Legislation had been identified as a significant enabler and barrier in round

206

two however in round three it was rated an enabler by 85% of participants and a barrier by

only 8% of the participants. A further 8% were undecided. A number of the barriers

previously identified by the participants for example, financial viability, political interests and

the number of nurses on the register, were again rated as barriers. However, none of these

items achieved a consensus rating. Eighty percent (n = 31) of the participants indicated that

‘differing qualifications’ was no longer applicable as a barrier and 56% (n = 22) and 58% (n =

23) respectively indicated that ‘expectations of the public’ and number of nurses on the

register’ were no longer considered to be barriers.

8.6 Key principles and core components underpinning the development of an international consensus model

8.6.1 Key Principles underpinning the consensus model

The following list of key principles have been derived from the findings of the Delphi rounds

(one-three), and have been identified and agreed by the participants as underpinning the


competence between Australia, Canada, Ireland, New Zealand, the United Kingdom and the

United States of America.

• The purpose of nursing regulation is protection of the public.

• The public has the right to expect that Registered Nurses, who are in practice, are and

continue to be, competent.

• Revalidation, recertification, re-registration should occur annually and be associated

with the requirement to declare and/or demonstrate the ability to meet required

standards of continuing competence.

• Education and practice standards for Registered Nurses are similar between the six

participant countries and imply the same expectations.

• Definitions of competence, continuing competence and nursing practice between and

within the six participant countries are similar and imply the same meaning.

• Development of an international model for the assessment of Continuing Competence

Framework requires agreement on a common language - lexicon of terminology in

relation to Continuing Competence.

• Whilst a ‘legislative mandate’ is a significant enabler in terms of implementation and

compliance with Continuing Competence Frameworks, it is not an essential component

for the implementation of a Continuing Competence Framework.

207

• Registered Nurses are registered health professionals who are responsible,

accountable, ethical, competent and committed to life-long learning and nursing

practice.

• Registered Nurses are responsible and accountable for ensuring their own individual

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.

• The Continuing Competence Framework must have a clear and transparent purpose

and processes that are credible and understandable to the public and the nursing

profession.

• Continuing Competence Frameworks are tools that facilitate the assessment and

monitoring of the continuing competence of the profession, and as such they have a

role in assuring and ensuring public safety.

• Assessment of Continuing Competence requires triangulation of data from a selection

of sources.

• No single indicator of competence can measure or appropriately assess ‘continuing

competence’ or ensure valid, reliable and consistent measurement of ‘continuing

competence’.

• The Continuing Competence Framework must be flexible and adaptable,

administratively feasible, financially viable, and publicly defensible.

8.6.2 Core components of the consensus model

The Delphi participants (rounds one - three) identified and agreed that a best practice

consensus model for the assessment of continuing competence requires the development and

inclusion of the following core components:

• An internationally agreed and clearly communicated purpose statement that identifies

the expectations of the Continuing Competence Framework and its functions in terms

of the monitoring and assessment of the continuing competence of nurses and

protection of the public.

• An internationally agreed lexicon of terminology that includes, but is not limited to,

agreed definitions of the terms ‘Competence’, ‘Continuing Competence’ and ‘nursing

practice’.

208

• Development of criterion based assessment guidelines.

• Development of a tool box of indicators for the assessment of continuing competence

including but not limited to the following:

Core indicators Optional indicators

• Self-assessment / Self-declaration • Practice Hours (current and recent

practice) (specified number) • Continuing professional development

/ education hours (specified number)

• Peer Assessment • Professional Portfolio • Observed Structured Clinical

Examination (OSCE) • Examination


This chapter has presented and summarised the findings that have emerged from the first

three Delphi rounds. Whilst a number of the findings provided confirmation of the views

expressed by Group A participants during round one, alternative views have also been

introduced. A summary of the key principles derived from these findings have been

presented.

Chapter Nine will present a discussion of the replies received from the Delphi round four

expert panel (Group A) participants, in response to the consensus views and key principles that

emerged from the previous Delphi rounds (one – three). The overall consensus views will be

presented and discussed in relation to the contemporary literature, and recommendations for

the development of a best practice international consensus model for the assessment of

continuing competence will be proposed.

209

CHAPTER NINE – THE CONSENSUS VIEW; DISCUSSION, CONCLUSION AND RECOMMENDATIONS

9.1 Introduction

Chapter Nine presents a discussion of the replies received from the Delphi round four expert

panel (Group A) participants, in response to the consensus views and key principles that had

emerged from the previous Delphi rounds (one – three). The overall consensus views of

participants are presented and discussed in relation to the contemporary literature and in

response to the three research questions identified earlier and repeated below.

1. What is the consensus view of regulatory experts in relation to best practice for nurses

to demonstrate continuing competence and for regulatory authorities to assess



the demonstration and assessment of continuing competence in six countries


America) and the best practice model developed through consensus?




Recommendations for the development of a best practice international consensus model for

the assessment of continuing competence are proposed in association with recommendations

for future research.

Inte

rnat

iona

lCo

nsen

sus M

odel Stage Two

Delphi Round 1Stakeholder Interviews

(gpA)


Qualitative E-survey (gpB)


E-survey (gpB)


ConsensusE-survey

(gpA)



210

9.2 Delphi Round Four – The consensus view

As described in Chapter Three (3.3.3.3) the expert panel (Group A) participants (n = 12) were

provided with summary findings and consensus views derived from the previous three Delphi

rounds, and invited to consider these findings in terms of their applicability in relation to the

participants’ own regulatory jurisdictions (Australia, Canada, Ireland, New Zealand, the United

Kingdom and the United States of America). The following two questions were posed:

1. What, if any, differences are present between your current regulatory requirements

for the demonstration and assessment of continuing competence and the best

practice model proposed through consensus?

2. What changes, if any, would be required to policy and regulation to align your

regulatory framework with best practice for demonstration and assessment of


In addition, the expert panel participants were also asked to consider the list of key principles

and core components identified and agreed by the Delphi (round three) participants, for

inclusion in an international best practice consensus model for the assessment of continuing

competence (Appendix VI). The expert panel (Group A) participants were asked to indicate

their agreement or disagreement with these items either by email or by completing a short

web-based e-survey (Delphi round four – E-survey, Appendix VII). Participants were also

provided with the opportunity to provide additional comment in relation to each of the items.

9.2.1 Distribution and return of the Delphi Round Four e-survey

The content that was emailed directly to each of the 12 expert panel (Group A) participants

comprised the summary findings from the Delphi (round three) including the summarised

consensus views, the list of key principles and the list of the core components identified and

agreed for inclusion in the international best practice consensus model. The email invitation

provided the participants with the option of replying directly to the researcher by email or by

responding to the web-based e-survey through the URL link that was provided. The

participants were requested to provide their responses within three weeks of receiving the

email invitation. As presented in Table 35, nine of the expert panel (Group A) participants

completed and submitted responses to the Delphi round four e-survey.

211

Table 35 Participation rate and sample size

Sample size Participation sample Participation rate

*12 9 75% * Excludes representation from the Nursing and Midwifery Council (UK)

Due to restructuring within the Nursing and Midwifery Council (UK) and subsequent changes

to the Council and Administrative Staff, the original Nursing and Midwifery Council (UK)

representative on the Delphi Expert Panel (Group A), was not available to participate in the

Delphi round four. It was decided not to introduce any new participants to the expert panel in

this final stage of the Delphi process.

9.2.2 Expert panel responses (Delphi round four)

As noted in 9.2 the expert panel participants were asked to consider the list of key principles

and core components identified and agreed by the Delphi round three participants, for

inclusion in the best practice model for the assessment of continuing competence. The

collation of these responses indicating the expert agreement or disagreement are presented

and further discussed in the following sections.

Table 36 presents the findings relating to the list of key principles that underpin the

development of the best practice consensus model for the assessment of continuing

competence.

Table 36 Key principles underpinning the best practice consensus model

Agree Disagree Undecided Rating Average

Rating Count

The purpose of nursing regulation is protection of the public.

100.0% (9) 0.0% (0) 0.0% (0) 1.00 9

The public has the right to expect that RNs, who are in practice, are and continue to be, competent.

100.0% (9) 0.0% (0) 0.0% (0) 1.00 9

Revalidation/recertification/relicensure should occur annually, associated with requirements to declare and/or demonstrate ability to meet required standards of continuing competence.

62.5% (5) 25.0% (2) 12.5% (1) 1.50 *8

212

Education and practice standards for RNs are similar between the six participant countries and imply the same expectations.

44.4% (4) 0.0% (0) 55.6% (5) 2.11 9

Definitions of competence, continuing competence and nursing practice between and within the six participant countries are similar and imply the same meaning.

77.8% (7) 0.0% (0) 22.2% (2) 1.44 9

Development of an international model for the assessment of continuing competence requires agreement on a common language – lexicon of terminology.

100.0% (9) 0.0% (0) 0.0% (0) 1.00 9

A legislative mandate is considered an enabler in terms of implementation and compliance with continuing competence requirements. It is not considered essential for implementation of a Continuing Competence Framework.

50.0% (4) 25.0% (2) 25.0% (2) 1.75 *8

RNs are registered health professionals who are responsible, accountable, ethical, competent and committed to life-long learning and nursing practice.

88.9% (8) 11.1% (1) 0.0% (0) 1.11 9

RNs are responsible for ensuring their own individual continuing competence, relevant to the required practice standards, code of conduct, and practice setting.

88.9% (8) 11.1% (1) 0.0% (0) 1.11 9

Employers and employment settings have a responsibility and role in facilitating and ensuring that their RN workforce is, and continues to be, competent.

88.9% (8) 11.1% (1) 0.0% (0) 1.11 9

The Continuing Competence Framework must have a clear and transparent purpose and processes that are credible and understandable to the public and the nursing profession.

100.0% (9) 0.0% (0) 0.0% (0) 1.00 9

Continuing Competence Frameworks are tools that facilitate the assessment and monitoring of the continuing competence of the profession, and as such they have a role in assuring and ensuring public safety.

100.0% (8) 0.0% (0) 0.0% (0) 1.00 *8

Assessment of continuing competence requires triangulation of multi-source data.

88.9% (8) 0.0% (0) 11.1% (1) 1.22 9

No single indicator of competence can measure or appropriately assess ‘continuing competence’ or ensure valid reliable and consistent measurement of ‘continuing competence’

77.8% (7) 11.1% (1) 11.1% (1) 1.33 9

The Continuing Competence Framework must be flexible and adaptable, administratively feasible, financially viable, and publicly defensible.

100.0% (9) 0.0% (0) 0.0% (0) 1.00 9

* One expert panel participant did not respond to three of the items

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As depicted in Table 36 consensus was achieved across 10 of the 15 listed key principles.

However, for the item “annual revalidation/recertification/relicensure, associated with

requirements to declare and/or demonstrate the ability to meet required standards of

continuing competence”, only five of the eight expert panel participants (62.5%) who

responded to this question, agreed with the requirement for annual assessment. Two

participants indicated they did not agree with annual assessment, and a third participant

indicated they were undecided. One participant commented

Agree that continuing competence requirements should be associated with registration/licensing renewal. Is annual appropriate? What is the evidence on a safe and effective renewal period?

Five of the nine expert panel participants (55.6%), indicated that they were undecided with

regard to similarities between the “Education and Practice Standards across the six focus

countries. One participant stated

Based on practice analysis we know this to be true for Canada and the US. Not aware of evidence to show practice similarities between all six countries.

This response indicates that further discussion and analysis of the education and practice

standards between the six countries is required before any agreement related to reciprocity of

qualifications and practice can occur.

Of the eight participants who responded to the item “A legislative mandate is considered an

enabler in terms of implementation and compliance with continuing competence

requirements. It is not considered essential for implementation of a Continuing Competence

Framework”, four participants (50%) indicated that they agreed, two (25%) indicated that they

disagreed and two (25%) indicated they were undecided. One of the participants who

indicated they disagreed provided the following comment “If the focus is public safety then it

has to be mandated”. This response was consistent with the responses from the previous

Delphi rounds and supported the view that the legislative mandate of regulatory authorities

and the ability to enforce compliance with continuing competence requirements was

considered a significant enabler.

In response to the items “RNs are registered health professionals who are responsible,

accountable, ethical, competent and committed to life-long learning and nursing practice”;

“RNs are responsible for ensuring their own individual continuing competence, relevant to the

required practice standards, code of conduct, and practice setting”; and “Employers and

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employment settings have a responsibility and role in facilitating and ensuring that their RN

workforce is, and continues to be, competent”, eight of the nine participants (88.9%),

indicated they agreed with each statement. One participant identified that they disagreed

with each of the three statements and commented

The responsibility and accountability of employers needs to be clarified particularly with regard to the provision of safe practice environments and ensuring the staff they employ are competent.

The item “No single indicator of competence can measure or appropriately assess continuing

competence, or ensure a valid reliable and consistent measurement of continuing

competence”, received an agreement score of 77.8% (n=7). One participant (11.1%) indicated

that they disagreed with the item and stated “A psychometrically sound and legally defensible

competence assessment is a valid and reliable measure of competence”. One participant

indicated that they were undecided with regard to this question, however no additional

comments were provided. Each of the items that have been identified in Table 36 will be

discussed in more detail in section (9.3).

The findings of the Delphi round three, identified that an international best practice consensus

model for the assessment of continuing competence should include the three core

components listed in Table 37. The expert panel participants were asked to consider and

indicate their agreement or disagreement with the inclusion of these items. As depicted in

Table 37 it was the consensus view of the expert panel that each of these items was “critical to

the successful development and implementation of the best practice framework”. One

participant indicated that they were undecided in relation to the item ‘Criterion based

assessment guidelines’ commenting “Need to be more clear with what is meant in this

statement”.

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Table 37 Core components of the best practice consensus model


Rating Count

An internationally agreed and clearly communicated purpose statement that identifies the expectations of the Continuing Competence Framework and its functions in terms of: a) protection of the public; and b) the monitoring and assessment of the continuing competence of nurses.

100.0% (9) 0.0% (0) 0.0% (0) 1.00 9

An internationally agreed lexicon of terminology that includes agreed definitions of the terms ‘Competence’, ‘Continuing Competence’ and ‘Nursing Practice’.

100.0% (9) 0.0% (0) 0.0% (0) 1.00 9

Criterion based assessment guidelines. 88.9% (8) 0.0% (0) 11.1% (1) 1.22 9

Development of a tool box of indicators for multi-source assessment of continuing

competence was previously identified as a component of the best practice consensus model.

Three indicators were identified as being essential for inclusion in this tool box. Table 38

presents the collation of the participant responses, indicating consistently that seven of the

participants agreed with the components, one participant consistently disagreed and one

participant was undecided. The participants who identified that they were undecided or

disagreed both commented that they required further evidence that the components listed in

Table 38 would assure continuing competence.

Table 38 Essential components for tool box of continuing competence indicators


Rating Count

Self-assessment / Self-declaration 77.8% (7) 11.1% (1) 11.1% (1) 1.33 9

Practice Hours (current and recent practice) - specified

77.8% (7) 11.1% (1) 11.1% (1) 1.33 9

Continuing professional development / education hours - specified

77.8% (7) 11.1% (1) 11.1% (1) 1.33 9

Four optional indicators of continuing competence were identified in the previous Delphi

rounds for consideration in the best practice consensus model. Table 39 represents the

collation of the expert panel responses. Of these items only ‘Peer Assessment’ was

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consistently identified for inclusion in the tool box of indicators. The following comment was

made “What is the evidence that supports inclusion of these indicators as measures of

continuing competence?”

Table 39 Optional components for tool box of continuing competence indicators


Rating Count

Peer Assessment 88.9% (8) 11.1% (1) 0.0% (0) 1.11 9

Professional Portfolio 44.4% (4) 44.4% (4) 11.1% (1) 1.67 9

Observed Structured Clinical Examination (OSCE)

33.3% (3) 44.4% (4) 22.2% (2) 1.89 9

Examination 12.5% (1) 62.5% (5) 25.0% (2) 2.13 8

9.3 What is the consensus view of regulatory experts?

The consensus view of the Delphi participants was that the development of an international

best practice consensus model for the assessment of continuing competence, between

Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America

is an important initiative that is possible to achieve. In addition there was agreement with

regard to many of the key principles (8.6.1) and the list of core components (8.6.2) identified

for inclusion in a best practice consensus model. As previously noted, it was also agreed by the

Delphi participants that there is preliminary work required in terms of developing closer

national and international relationships, and refining the common understandings between

regulatory jurisdictions, which build on the key principles identified by the Delphi participants.

Discussion related to the overall Delphi findings in relation to the key principles and proposed

components of the conceptual consensus framework is presented in the following sections.

9.3.1 Common values, beliefs and guiding principles

The notion of ‘building trust’ was raised by some participants in the Delphi rounds one and

two, in relation to preconceived ideas and / or limited understanding of the nursing education

and practice standards required in other regulatory jurisdictions. Following further analysis

the notions of “dispelling preconceived ideas” and “building trust among the participant

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regulatory authorities” were identified as items critical to the successful development of an

international consensus model.

It is the consensus view of the Delphi participants (Agreement = 100%, M = 1.56) that by

building on the list of key principles previously identified, a set of ‘common values, beliefs and

guiding principles’ for Continuing Competence Frameworks can be developed and agreed

internationally. The commonality of, and agreement on, aspects such as role definitions,

education and practice standards, and the codes of conduct/behaviour required of a nurse, are

items that have been identified by the participants as critical to the development of the

consensus model.

The most commonly expressed requirements identified by the Delphi participants are the

requirements that the best practice consensus model must be flexible and adaptable

(Agreement 100%, M = 1.31), and administratively feasible, financially viable and defensible in

terms of providing some assurance of public safety (Agreement 100%, M = 1.11). Issues

relating to the requirement that Continuing Competence Frameworks must be ‘defensible’, are

frequently identified in the literature (National Council of State Boards of Nursing, 1996,

2009a; Vandewater, 2004), particularly in association with the responsibilities of regulators

with regard to ‘public protection’ (Secretary of State for Health (UK), 2007; Swankin, et al.,

2006). This discussion appears to be strongly linked with the notion of measurement, validity

and reliability. It is evident in the literature (EdCaN, 2008; Vandewater, 2004; Wilkinson,

2013), and is also demonstrated in Stage One and Stage Two of this research that a focus on

measurement, rather than assessment, can inhibit the development of Continuing

Competence Frameworks and constrain assessment processes.

9.3.2 Consistency of purpose

It was the consensus view of the Delphi participants that the development and integration of

commonly agreed principles and approaches to continuing competence (Agreement 100%, M

= 1.56), between the six focus countries was possible, and is a strategy that “would enhance

stakeholder engagement and buy-in”. Whilst there is a commonality of understanding with

regard to the overarching purpose of Continuing Competence Frameworks in nursing

regulation, it is apparent from this research that internationally there is not a consistent

approach to the development, implementation and use of these frameworks.

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The contemporary literature highlights a variety of competence assessment tools, many

associated with measuring competence against specified education standards for entry to

practice and issues related to the validity and reliability of these tools in terms of determining

competence (EdCaN, 2008; Flanagan, et al., 2000; Vandewater, 2004; Vernon, et al., 2010).

However, very little emphasis has been given to actually defining the phenomenon that is

continuing competence, or evaluating the existing models / frameworks for the assessment of


It is apparent that, whilst a number of jurisdictions have implemented similar Continuing

Competence Frameworks, implementation across the overall sample group is inconsistent, and

is reported by the Delphi participants and in the literature, as being impeded by local

legislation, local policy and / or financial and resourcing constraints (EdCaN, 2008;

International Council of Nurses, 2009; National Council of State Boards of Nursing, 2005,

2009b; Vandewater, 2004). In addition, whilst there was general consensus with regard to the

purpose of Continuing Competence Frameworks as tools that ensure the continuing

competence of nurses and ensure public safety, there is still variation with regard to the

overarching intent of the indicators of competence embedded in the Continuing Competence

Framework. This item is related to a fundamental philosophical question underpinning the

Continuing Competence Framework – Is continuing competence being measured or assessed?

By definition the two words ‘measured’ and ‘assessed’ lend themselves to two different

conceptual approaches to evaluation. To ‘measure’ is “to ascertain the size, amount, or

degree of (something) by using an instrument or device marked in standard units, or by

comparing it with an object of known size: judge someone or something by comparison with (a

certain standard)” (Oxford University Press, 2013). However, to ‘assess’ is “to evaluate or

estimate the nature, ability, or quality of someone or something” (Oxford University Press,

2013).

This variation in terminology may be merely an anomaly, caused by differences in the use of

language and interpretation across and between countries as it is apparent that in some cases

the words ‘measure’ and ‘assess’ are being used synonymously. However, regardless of the

reason, this item highlights the need to clearly define and articulate the different connotations

of these words (measurement and assessment) prior to the development of the Continuing

Competence Framework, as their use will have implications for the selection of the indicators

of continuing competence that are incorporated.

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9.3.3 A common language

It is commonly accepted that words can mean different things to different people, and the

context in which a word or a sentence is used can change the significance or value of the

intended meaning (Canadian Nurses Association, 2000; International Council of Nurses, 2009;

Wilkinson, 2013). The contemporary literature identifies the importance of developing and

clearly defining a common lexicon of terms that specifically pertains to the concept of

‘continuing competence’ (Bryant, 2005; Canadian Nurses Association, 2000). Variation in use

of language and inconsistencies in the interpretation of words was identified as a potential

barrier to the development and implementation of an international consensus model. This

was found to relate particularly to the understanding of the terminology used when describing

continuing competence, within and between countries. Although this item did not meet the

statistical threshold that was set in terms of ‘achieving a consensus view’, it is an item that was

considered to be fundamental in terms of developing and successfully implementing an

international consensus framework. In addition, the significant variation in participant

understanding and the differing use of terminology, within and between countries, was

evident in the written and verbal responses made during each of the Delphi rounds, further

highlighting the requirement to develop an internationally agreed lexicon of terminology.

9.3.4 Definitions

Initially the perceived variations in the definition and interpretation of the terms ‘competence’

and ‘continuing competence’, in relation to nursing regulation and practice, were identified by

the Delphi participants as items for further investigation and agreement. However, despite

this belief, findings from this research indicate that the existing definitions and interpretations

of what constitutes competence and continuing competence, in five of the six focus countries

are very similar. These countries are Australia, Canada, New Zealand, the United Kingdom and

the United States of America (Australian Nursing and Midwifery Council, 2009; Campbell &

MacKay, 2001; Canadian Nurses Association & Canadian Association of Schools of Nursing,

2004; National Council of State Boards of Nursing, 1996; Nursing Care Quality Assurance

Commission, 2009; Nursing Council of New Zealand, 2010b, 2010c). Ireland does not currently

have published definitions of competence and continuing competence. As previously noted,

each of the published definitions of competence currently specifies the requirement for: a

prescribed standard of knowledge; skills; and decision making for safe practice.

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In addition to these items, the definitions of continuing competence all include items such as

the on-going ability of the nurse to continue to integrate up-to-date knowledge, skills,

judgement and decision making appropriately in the context / role in which they practise. The

contextualisation of an individual’s practice is an item that was considered by the Delphi

participants as “essential to the assessment of continuing competence”. It was the consensus

view of the Delphi participants (Agreement 100%, M = 1.55) that the inclusive definitions of

competence and continuing competence were appropriate.

Variation in what is considered to be ‘nursing practice’ also emerged as an item for further

investigation during Delphi rounds one and two. However, the consensus view of the Delphi

round three participants was that the internationally agreed definition of nursing practice

should be inclusive and encompass all nursing roles that contribute to the nursing profession

(Agreement 100%, M = 1.45). This item achieved general agreement from the Delphi round

four participants, with the proviso that further work was required in terms of clearly

articulating what is considered ‘practice’. One participant commented

There is a disconnect between the definition of nursing practice and regulatory accountability for public safety – this is controversial but we need to tackle the historical conviction that nurses who are not in direct practice are still practising nursing!

9.3.5 Professional responsibility and accountability

As previously noted, responsibility and accountability for the continuing competence of nurses

was an item that was identified by participants in response to the Delphi rounds one and two

as being an item that required further clarification, particularly with regard to stakeholder

responsibilities. However, after completion of the Delphi rounds three and four the

participants’ consensus views were confirmed and are discussed below.

Ultimately the individual registered nurse is responsible and accountable throughout their

career for ensuring and maintaining their own continuing competence relative to the required

standards of practice and the relevance to the role that they perform (Agreement 100%, M =

1.19). The individual nurse is also responsible and accountable for providing an appropriate,

safe, ethical and competent standard of nursing practice at all times (Agreement 100%, M =

1.16) and, as a registered health professional, is responsible for actively participating in

ongoing education and other activities required by their regulatory authority, relevant to their

nursing practice (Agreement 100%, M = 1.16).

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With regard to the responsibility and accountability of key stakeholder groups in relation to

continuing competence, the consensus view of the Delphi participants was that employers

have a responsibility to maintain quality practice environments that support and facilitate

continuing competence opportunities for nurses, and for monitoring the continuing

competence and practice of the nurses in their employ (Agreement 100%, M = 1.61). This is an

area of current debate in the international literature, particularly in relation to the

proliferation of specialty and advanced practice roles, expanded nursing practice, privatisation

of the health sector and changing workforce requirements (Donovan, Diers, & Carryer, 2012;

Holloway, 2011), all of which have a significant impact on the continuing competence of

nurses.

It was the consensus view of the Delphi participants (Agreement 100%, M = 1.62) that the

regulatory authority is responsible for protecting the safety of the public by setting the

standards of nursing practice and monitoring the competence of the profession. However, it

was also noted by the participants that, as nurses are registered health professionals, there is

an inherent level of trust afforded to them. As such, an annual self-assessment by the nurse

against their required standards for practice and professional development is a commonly

used and economically viable indicator that implies the nurse is continuing to be competent.

It was considered that professional nursing organisations (Agreement 97%, M = 1.79) also have

a role in facilitating and guiding the career development of the profession. It was further

identified by the participants that career development initiatives are more appropriately

situated with the professional nursing organisations, rather than with the regulatory authority.

The consensus view of the Delphi participants was that the role of government in relation to

responsibility for the continuing competence of nurses was to pass appropriate legislation and

ensure its enactment (Agreement 100%, M = 1.72). However, it was acknowledged that public

safety is also the purview of government, as is the provision of healthcare and health

workforce requirements, all of which intersect with the regulation of health professionals

(Chiarella & White, 2013).

9.3.6 Agreed barriers and enablers

As noted in Chapter Eight, a range of barriers and enablers were initially identified related to

the development and implementation of an international consensus model. However, final

analysis of all Delphi participant responses confirms that it is the consensus view that only two

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items: namely, ‘authority of the Regulatory Body’ (Agreement 92%, M = 1.77, SD = .627, V =

.393); and ‘communication with key stakeholders’ (Agreement 93%, M = 1.62, SD = .633, V =

.401) are considered to be significant in terms of enabling the efficacious implementation of a

Continuing Competence Framework. Both items are highlighted in the international literature

as being critical in terms of ensuring stakeholder engagement (Canadian Nurses Association,

2000; International Council of Nurses, 2009; Vernon, et al., 2010), compliance with Continuing

Competence Framework requirements (Vernon, et al., 2013), and assuring public safety

(International Council of Nurses, 2009; Secretary of State for Health (UK), 2007; Swankin, et al.,

2006).

The following items: number of nurses on the register; expectations of the public; differing

qualifications; political interests; financial viability; and professional organisations / unions,

were initially identified as being potential barriers to the development and implementation of

Continuing Competence Frameworks. These views were consistent with themes previously

identified in the literature (National Council of State Boards of Nursing, 2009a). However, in

the final analysis, the consensus view was that these items were no longer considered to be

applicable as barriers, with the exception of ‘political interests’. Fifty four percent (n = 20) of

the Delphi participants indicated they were undecided as to the status of this item ‘political

interests’ and 27% (n = 10) rated it as a barrier. It was interesting to note that ‘political

interests’ was rated as an enabler by only 11% (n = 4) of the participants. This finding is

consistent with the views expressed in the international literature in relation to the jurisdiction

and positioning of some regulatory authorities, particularly those situated within Departments

of Health (Cutcliffe, 2010; International Council of Nurses, 2009; Taskforce on Health Care

Workforce Regulation, 1995).

9.3.6.1 Authority of the Regulatory Body

It was evident from the participant responses that a significant enabler, in terms of the

participation of nurses in existing Continuing Competence Frameworks, related directly to the

legislative authority of the regulatory authority. To-date, it appears that internationally, the

successful implementation of Continuing Competence Frameworks has occurred mostly in the

jurisdictions where the regulatory authority has the mandate to require the compliance of

nurses in continuing competence activities (Australian Nursing and Midwifery Council, 2009;

International Council of Nurses, 2009; Nursing Council of New Zealand, 2006b). Most

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commonly this has been done by linking the continuing competence requirements with the

annual recertification, revalidation or registration requirements for the individual nurse.

The Delphi participants (Delphi Rounds one, two and four) reinforced the views expressed in

the international literature (International Council of Nurses, 2009; Vandewater, 2004; Vernon,

et al., 2013) indicating that Continuing Competence Frameworks that are implemented solely

for the purpose of ‘career development’ and/or as ‘quality improvement initiatives’, and do

not require mandatory compliance, are often focused solely on educational criteria and

ultimately have more limited engagement from nurses.

9.3.6.2 Legislative mandate

A legislative mandate was identified by 85% (n = 33, M = 2.00) of the Delphi round three

participants as being an enabling factor in the development and implementation of Continuing

Competence Frameworks, and a barrier by only 8% (n = 3). The international literature

(International Council of Nurses, 2009; Swankin, 1995; Swankin, et al., 2006) indicates that the

legislative status of ‘continuing competence requirements’ in relation to public protection, has

a strong influence on the successful implementation, compliance with, and viability of

Continuing Competence Frameworks (Swankin, et al., 2006; Vandewater, 2004). The literature

indicates that, in jurisdictions where the legislation and subordinate regulations are silent,

successful implementation of continuing competence requirements is less likely to occur or to

be implemented successfully (International Council of Nurses, 2009).

9.3.6.3 Communication with key stakeholders

Communication and consultation with key stakeholders is identified in the literature (Canadian

Nurses Association, 2000) and was evident during Stage One of this research, as being a

critical factor in terms of ensuring the active engagement of stakeholders in the development

and implementation of the Continuing Competence Frameworks (Vernon, et al., 2013; Vernon,

et al., 2010). This item was also strongly linked with the items: common values, beliefs and

guiding principles (9.3.1), the development of a common language (9.3.3), and common

understandings in terms of the definitions of competence, continuing competence and nursing

practice (9.3.4), previously discussed in this Chapter.

9.3.7 Assessment of Continuing Competence

Extensive literature exists with regard to individual measures of competence and competence

indicators (Canadian Nurses Association, 2000; EdCaN, 2008; National Nursing Research Unit,

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2009; Vandewater, 2004; Wendt & Alexander, 2007). However, the assessment of the

continuing competence of nurses continues to be a phenomenon that is proving difficult to

validate (National Council of State Boards of Nursing, 2009a). Current research into

international opinion on this matter suggests that no individual measure ensures competence

or public safety (Vernon, et al., 2013; Vernon, et al., 2012). However, evidence drawn from a

variety of measures is considered to provide a strong indication of competence and may be

used to imply continuing competence. The consensus view of the Delphi participants was that

multisource feedback about the nurse, and the context in which the nurse practises, is critical

when making an assessment of continuing competence.

9.3.8 Indicators of continuing competence

It was the overall consensus view of the Delphi participants, that the three indicators of

competence identified in Chapter Eight (8.6.5) and further discussed below, should be included

in the international consensus framework for the assessment of continuing competence: Self-

assessment, in association with a self-declaration (Agreement 90%, M = 1.53, SD = .687);

practice hours (Agreement 100%, M = 131, SD = .468, V = .219); and demonstrated continuing

professional development activities (Agreement 100%, M = 1.33, SD = .530, V = .281) all had

strong indicators of agreement. Peer assessment was identified as a useful, valid and reliable

indicator of continuing competence when used in association with self-assessment, and was

identified as being an indicator that should be used at the discretion of the individual

regulatory authority.

It was agreed by the Delphi participants that, when used together, in association with the

context in which practice is occurring, these indicators of competence are able to suggest

continuing competence (Agreement 97%, M = 1.16). Additionally, the Delphi participants

noted that the best practice consensus framework should include provision for regulatory

authorities to retain flexibility in terms of the inclusion of additional indicators of competence

(a tool box), when deemed necessary.

9.3.9 Mitigating known risk

Throughout this research, mitigating known risk and promoting patient safety have been

clearly identified as fundamental to the development of a best practice Continuing

Competence Framework. It has been agreed that the purpose of a Continuing Competence

Framework is to provide a mechanism for Registered Nurses to demonstrate that they are

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indeed continuing to be competent, and for regulatory authorities to assess and monitor the

continuing competence of nurses in practice. The Delphi participants have agreed that the

regulatory purpose of a Continuing Competence Framework is to assure public safety and, as

such, it is not a process for the management of competence notifications or practice

breakdown, nor is it a process for career development. Clearly competence notifications and

recognition of system breakdown are also important issues, as a Continuing Competence

Framework alone cannot ensure public safety. However, these items require separate

processes in order to achieve their purpose and to maintain the integrity and transparency of

the Continuing Competence Framework. Examples were provided by some of the expert panel

participants of processes that have been implemented in some jurisdictions to address issues

of practice breakdown (Benner, Malloch, & Sheets, 2010), competence notifications (Nursing

Council of New Zealand, 2013a) and career development initiatives (Nursing Council of New

Zealand, 2004b). These processes have been implemented separately but in association with

continuing competence requirements.

The right of the nursing regulatory authority to initiate an audit of individual nurses was

identified as a common risk management strategy (Nursing Council of New Zealand, 2013a),

and this has commonly been used when an individual nurse or practice area has been

identified as being at high risk of practice error (Nursing and Midwifery Council (UK), 2011,

2012). Whilst this method of risk management is identified as administratively feasible,

particularly in relation to monitoring the continuing competence of large nursing populations,

it is reliant on the determination of what is considered to be ‘high risk’. In addition, there is an

inherent implication that nurses who work in an area that is considered to be a high risk area

are more likely to pose a risk to public safety than those nurses who are employed in what are

considered moderate or low risk areas. Examples of this method of monitoring continuing

competence, commonly used in the United Kingdom, demonstrate that this risk management

approach alone is not an adequate method to monitor the continuing competence of nurses in

practice (Council for Healthcare Regulatory Excellence, 2012b). However, when used in

association with mandatory annual continuing competence requirements and random audit of

a number or percentage of a jurisdiction’s nursing population, it can provide further insight

into potential problem areas.

Random audit of a percentage of the nursing population is a method used for monitoring

compliance with continuing competence requirements, particularly in association with self-

assessment (Canadian Nurses Association, 2000), and is evident within a number of the

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Continuing Competence Frameworks currently in operation (Table 3, pp. 35-36). As noted in

the literature, implementation of a random audit system requires administrative resourcing in

terms of the process and associated policy development (Canadian Nurses Association, 2000;

EdCaN, 2008). However, when used in association with continuing competence requirements,

mandatory random audit of a percentage of the nursing population in practice can provide the

following benefits: for the individual nurse, validation that they are indeed continuing to be

competent; for the regulatory authority, verification and validation that continuing

competence requirements and processes are appropriate and being met; and again for the

regulators, in some cases identification of individuals who require remedial action with regard

to demonstrating continuing competence to practise and / or safety to practise (Vernon, et al.,

2010).

9.4 The best-practice international consensus model for the assessment of Continuing Competence

The consensus view of the Delphi participants was that the best practice model should include

an internationally agreed and clearly communicated purpose statement that identifies the

expectations of the Continuing Competence Framework. The functions of the Continuing

Competence Framework in terms of the monitoring and assessment of continuing competence

and protection of the public should be clearly articulated. And an internationally agreed

lexicon of terminology that includes, but is not limited to, agreed definitions of the terms

‘Competence’, ‘Continuing Competence’ and ‘Nursing Practice’ should be developed and

agreed. The development of agreed, criterion-based Standards of Practice and assessment

guidelines were considered to be important, particularly in relation to facilitating mutual

recognition and any future consideration of reciprocity of qualifications and registration

between the regulatory jurisdictions.

The consensus view of the Delphi participants was that development and agreement on a list

of key principles that would underpin the development of the best practice model was critical.

However, not all of the key principles listed in Table 36 (p. 211) achieved consensus from the

expert panel (Delphi round four) participants. As previously noted, one expert panel

participant consistently disagreed with the statements associated with mandatory compliance,

responsibility and accountabilities. However there was overall agreement that risk

management and the defensibility of the Continuing Competence Framework were priorities.

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Therefore, it is proposed that the consensus model includes mandatory audit of a percentage

of the practising population of nurses within each jurisdiction.

Confirmation of consensus was achieved in relation to the core components of the best

practice international consensus model and the inclusion of four indicators of continuing

competence. These four indicators are self-assessment, stipulated practice hours, stipulated

professional development hours and peer assessment. No agreement was achieved with

regard to the inclusion of the following items: observed structured clinical examination (OSCE),

professional portfolio, and examination, as indicators of continuing competence.

Table 40 represents a collation of the components identified by consensus for inclusion in the

proposed best practice international model for the assessment of continuing competence.

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Table 40 Components of the best practice international consensus model

Component Advantages Disadvantages Considerations

Guiding principles • Facilitate the development of a mutually agreed, standardised and consistent framework

• Promote the reciprocity of qualifications and facilitate mobility of nurses between jurisdictions

• Complexity of the consensus process

• Requires a commitment to work together

Common language – Lexicon of terminology

• Consistent interpretation and understanding of concepts, definitions, and assessment measures within and between countries

• Requires extensive consultation and agreement

Best practice Continuing Competence Framework

• Principle function is as a quality assurance mechanism • Mechanism for the assessment of competence as a

potential measure of public safety • Demonstrates to public that the nursing profession is

cognisant of, and has mechanisms to assess the continuing competence of the profession and thereby ensure competence and assure public safety

• Promotes consistency of continuing competence standards and assessment processes

• Large nursing population numbers • Difficulty in identifying valid and

reliable indicators to assess continuing competence

• Regulatory authorities are accountable for ensuring health practitioners safety to practise and assuring public safety

• Framework needs to be administratively feasible, financially viable and legally defensible

Mandatory assessment linked to annual recertification /revalidation / relicensure

• Ensures mandatory compliance • Facilitates the regulatory purpose of public protection • Encourages professional responsibility and

accountability of the nurses as a registered health professional

• May necessitate changes to existing legislation, regulations, policy

• May meet resistance from the profession or professional organisations

• Consultation with key stakeholder groups essential

• Increased cost associated with nursing numbers and assessment requirements

• May necessitate changes to existing legislation, regulations, policy

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Indicators of continuing competence Self-Assessment

• Is completed by the individual • Promotes professional responsibility in terms of being

responsible and accountable for their competence and continuing competence

• Actively involves the nurse • Enhances nurse’s awareness of Standards of Practice

and Ethical Conduct in relation to their role/context of practice

• Issues of validity and reliability • Reliant on the nurse’s judgement,

insight, and ability to reflect on their own practice in relation to the required standards, role and context in which they practise.

• Appropriate for assessing large nursing populations

• Administratively feasible • Economically viable • Should be used in association with

method of validation i.e. audit or peer assessment

Mandatory Practice Hours (specified number/timeframe)

• Quantifiable measurement of practise hours • Implies currency of practice

• Assures but does not ensure continuing competence


• Administratively feasible • Economically viable

Mandatory Professional Development hours (specified number/timeframe)

• Quantifiable measurement of professional development hours

• Demonstrates engagement in learning activities • Implies continuing professional development /

learning

• Assures but does not ensure continuing competence

• Access to professional development opportunities


• Administratively feasible • Economically viable

Peer Assessment • Can be completed in the work place/practice environment

• Promotes a facility for constructive feedback based on the Standards of Practice

• Requires access to a peer or colleague to perform the assessment

• Requires understanding of the specific criteria (Standards of Practice) and understanding of the requirements of the practice context and role

• Clear guidelines and criteria for peer assessment process

• Criteria for selection of ‘peer’ and assessment responsibilities

Audit of a percentage of practising population of nurses annually

• Provides verification and validation that continuing competence requirements are being met and that the regulatory authority is ensuring and monitoring the competence of the profession

• Used to validate the competence of an individual and may infer the continuing competence of profession

• Provides information with regard to the continuing competence of a sample of the overall nursing population

• Cannot guarantee competence of the profession or individuals

• Requires administrative resourcing and development of clear and transparent policy and processes

• Consideration of economic viability when determining sample size in relation to size of nursing population

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9.5 Changes required to align international regulatory requirements with best practice for the assessment of continuing competence

The Delphi round four participants were asked to consider the summary findings from the

previous three Delphi rounds and identify if differences existed between their current

regulatory requirements for the demonstration and assessment of continuing competence and

the best practice model proposed through consensus. The expert panel responses indicated

there was agreement with the philosophy and definitions proposed in the best practice model.

One of the participants made the following comment

I am aware that whilst differences still exist across the country with regards to the demonstration and measurement of continuing competence. In fact there is a range of self-reporting, peer review, and random testing. That being said, I believe the definitions and understandings are consistent.


Minimal differences - we use a variable approach to continuing competence that includes the elements identified in the Delphi rounds as well as additional alternatives.

One participant noted that the current variations in regulatory terminology and the

subsequent understandings of these terms required clarification, particularly in relation to

legislative requirements. This response highlighted again the need to develop a common

lexicon of terminology and understandings.

Annual re-registration, re-validation is NOT part of our continuing competence model - there is an annual requirement to meet continuing competence requirements - this may reflect different use of language in different jurisdictions and needs clarification.

The expert panel was asked to identify if any changes would be required in order to align their

current regulatory processes with the proposed best practice framework for the

demonstration and assessment of continuing competence. Whilst no significant changes were

identified by the participants, it was noted that in some jurisdictions there would need to be

amendments made to some subordinate areas of regulatory policy and / or process, in order

to align them with the suggested best practice framework. One participant commented

No changes would be required to existing policy or regulation frameworks. Current legislation provides flexibility around policy and indicators. Changes can be made to sub-ordinate policy without requiring a regulation change.

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We would need to alter option details in our state regulations.

It was pleasing to note that, whilst some jurisdictions may not currently have an existing

Continuing Competence Framework, there was significant interest in the findings of this

research in terms of informing future consultation and development processes.

Our model is not yet decided. The framework is still being developed and will need consultation at a national level. It is anticipated to have a framework in place by 2014. We will utilise the findings of the study, to inform the process of our own consultation document.

The purpose of the best practice Continuing Competence Framework with regard to public

safety was raised by one participant in response to this question.

One of the key considerations that is missing is the notion of risk - if the purpose of continuing competence is public safety, we should be developing a model that is based on mitigating known risk.

This participant’s comment relates directly to the underlying philosophy of the Continuing

Competence Framework and the need to articulate clearly both the focus and purpose of the

best practice framework and its association / relationship with separate identified strategies

for the management of practice breakdown and competence notifications.

9.6 Recommendations for further development of the international consensus model

As previously noted in section 9.3, there is a consensus view that the development of a best

practice international consensus model for the assessment of continuing competence,

between Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States

of America is an important initiative that will be possible to achieve. It was also identified by

the expert panel participants (Delphi round four), that the Memorandum of Understanding

and Cooperation that was agreed between the key regulatory authorities identified in this

research, may provide an appropriate forum to facilitate future development of the best

practice international consensus model. The following areas for further development have

been identified as:

1. Further refinement of the key principles identified as underpinning the international

best practice consensus model for the assessment of continuing competence, and

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agreement of the regulatory representatives for each of the six identified countries

(Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States

of America) on each of the key principles.

2. Development of the agreed international lexicon of terminology related to nursing

regulation and the assessment of continuing competence.

3. Development of the best practice Continuing Competence Framework, including:

assessment guidelines; assessment criteria (relevant to each of the indicators of

continuing competence); and a rubric for triangulation of continuing competence

assessment data.


Chapter Nine has presented a summary of the findings from the Delphi study and proposed

the beginning conceptual framework for the international consensus model for the assessment

of continuing competence. It has been identified in this research that the international best

practice framework, if adopted, must contribute to the core regulatory purpose in each

regulatory jurisdiction. In the six countries that were the focus of this research (Australia,

Canada, Ireland, New Zealand, the United Kingdom and the United States of America), the core

regulatory purpose is public protection.

The framework must therefore be based on strong research evidence and relate to the

potential risk to public safety presented by nurses who do not continue to be competent

throughout their careers. The best practice framework proposed in this thesis is based on the

consensus view of the Delphi participants and aims to deliver a proportionate, consistent and

affordable system for the assessment of continuing competence that will provide assurance to

the public that nurses in practice are competent.

The following Section (Section Four, Chapter Ten) will discuss the overall findings of this thesis

in terms of the New Zealand and international nursing regulatory environments, and the

overarching research questions. The relevance of this thesis in terms of its contribution to

nursing regulation and practice will be discussed and recommendations for further research

will be made.

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SECTION FOUR CONTINUING COMPETENCE AND PUBLIC SAFETY A RELATIONSHIP BETWEEN LEGISLATION, POLICY AND PRACTICE

Section Four presents the conclusion to this thesis and positions the thesis in terms of the New

Zealand and international nursing regulatory environment.

Chapter Ten presents the triangulation of the cumulative findings from Stages One and Two of

this research in relation to the three overarching research questions:



practise?





A discussion of the findings and the limitations of this thesis are presented, including

recommendations for future development of the best practice consensus model for

assessment of continuing competence, the associated implications for key stakeholders, and

recommendations for future research.

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CHAPTER TEN - DISCUSSION, CONCLUSION AND RECOMMENDATIONS

10.1 Introduction

This Chapter presents a descriptive triangulation of the cumulative findings from Stage One

(Evaluation of the Nursing Council of New Zealand Continuing Competence Framework) and

Stage Two (The International Consensus Model for the Assessment of Continuing

Competence), of this research in relation to the three overarching research questions:


statutory requirements to ensure registered nurses are competent and fit to practise?





The discussion of the summary findings is situated in terms of the national and international

regulatory context for nursing and is presented in association with the national and

international literature. The thesis will conclude by identifying its contribution to the

contemporary nursing environment and by presenting recommendations for future research

and further development of the best practice international consensus model for assessment of


Met

hodo

logi

cal

Tria

ngul

atio

n

Conclusion and Recommendations

Data triangulation & discussion of summary

findings fromStage One & Stage Two

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10.2 Relationships between legislation, policy drivers and statutory requirements to ensure registered nurses are competent and fit to practise

There has been increasing public and political scrutiny of medical, nursing and allied health

errors over the past 25 years. Assuring and ensuring public safety has become a regulatory

imperative in New Zealand and in other jurisdictions (Ministry of Health (NZ), 2012a; Secretary

of State for Health (UK), 2007; Swankin, 1995). International trends with regard to the

regulation of health professions signal that there is a greater focus on consumer protection,

standardisation of legislation and the concomitant responsibility and accountability of health

professionals (Ministry of Health (NZ), 2012a; Secretary of State for Health (UK), 2007). In New

Zealand and internationally, there is also growing scrutiny of the performance of regulatory

authorities and health service organisations in terms of their roles in protecting the health and

safety of the public; individual, team and organisation accountabilities; and workforce

flexibility and value for money (Council for Healthcare Regulatory Excellence, 2012a, 2012b;

Secretary of State for Health (UK), 2007).

As previously noted in sections 1.6 and 2.3.1, the principal purpose of the Heath Practitioners

Competence Assurance Act 2003 (NZ) is to protect the health and safety of the public of New

Zealand (Health Practitioners Competence Assurance Act (NZ), 2003). One of the key

underpinning values of this legislation is the accountability of individual health practitioners for

their own safety to practise and the application of professional judgement in their clinical

practice (Ministry of Health (NZ), 2012a; Nursing Council of New Zealand, 2013b). Until the

Health Practitioners Competence Assurance Act 2003 (NZ) came into force, there was a

presumption that nurses and other health professionals in New Zealand continued to be

competent throughout their careers. However, there was no requirement that they provide

any assurance or demonstrate their continuing competence in any way. The only exception

was an individual who was found to be incompetent as the result of a complaint or the

notification of a practice error, and was therefore subject to separate legislative and regulatory

processes (Forrester, Davies, & Houston, 2013; Health and Disability Commissioner Act (NZ),

1994; Nursing Council of New Zealand, 2013a).

Nursing is a profession that combines the application of substantial knowledge, skills and

abilities in order to provide ethical and safe nursing practice (Chiarella & White, 2013). It is

clearly identified that the unsafe and unethical practice of nurses may result in harm to the

public unless there is a high level of accountability (Secretary of State for Health (UK), 2007;

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Swankin, 1995). Therefore, the complex nature of nursing practice relies on the ethical,

knowledge-based and skilful practice of nurses who are able to use clinical judgement

(decision making), that is appropriate to their role/scope of practice and relevant to the

particular clinical situation at any given time (International Council of Nurses, 2007; National

Council of State Boards of Nursing, 1996; Vandewater, 2004). It was unanimously

acknowledged by the participants in this research that, as regulated health professionals,

nurses are responsible and accountable for their own professional practice. As such, they have

a public and civic responsibility to uphold their standards of practice and to practise in such a

way as to ensure their ongoing competence to practise (Vernon, et al., 2013).

It is the legislated responsibility of the nursing regulatory authorities in all of the six countries

that were the focus of Stage Two of this research (Australia, Canada, Ireland, New Zealand, the

United Kingdom and the United States of America), to hold nurses professionally accountable

for their practice. However, the requirement that the regulatory authority monitors or

ensures the continuing competence of these nurses throughout their careers is not a legislated

requirement in all of these jurisdictions34 (International Council of Nurses, 2009). This research

has demonstrated that, whilst a specific legislative mandate is certainly considered by the

research participants to be beneficial in terms of ensuring the compliance of nurses with

continuing competence requirements, it was not considered to be an essential requirement in

terms of implementing a Continuing Competence Framework. As ‘protection of the public’ is

deemed a primary function of a regulatory authority, the research participants considered that

implementation of regulatory processes, policy or frameworks associated with protection of

the public, such as a Continuing Competence Framework, were functions already within their

mandate and therefore at the discretion of each individual regulatory authority.

There is a strong link between a nurse’s continuing competence and their workplace

environment. It is acknowledged that the health care environment has become increasingly

complex and, as the pace of technological and scientific developments accelerate increasing

demands are made on limited health funding resources, resulting in changes to the provision

of health services, health workforce skill mix, nurse-patient staffing ratios and ultimately the

continuing competence requirements of nurses. These demands, in association with the

increased complexity of care, higher patient acuity, and shorter hospital stays cannot be

34 Predominantly the differences exist in the United States of America, due to the fact that it is a federated system. The legislation and requirements for registration varies significantly from State to State in terms of the presence or absence of a mandate to monitor continuing competence.

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underestimated in terms of the impact they have on the context in which the nurse practises

(Health Workforce Australia, 2012; Ministry of Health (NZ), 2012a; Swankin, et al., 2006; Tabari

Khomeiran & Kiger, 2006). It is well documented that suboptimal practice environments can

impede safe practice and therefore jeopardise patient safety (Benner, et al., 2010; Secretary of

State for Health (UK), 2007). Keeping pace with the speed of these changes is challenging for

many nurses and may have a substantial influence in terms of enabling or impeding their

continuing competence and therefore their safety to practise (Aiken et al., 2001; Finlayson,

Aiken, & Nakarada-Kordic, 2007). The challenge for nursing regulatory authorities is to ensure

that appropriate and efficacious mechanisms for the demonstration, assessment and

monitoring of the continuing competence of individual nurses and the profession are available

and defensible.

As noted in section 4.3.4, the New Zealand health sector is a complex system of legislation,

organisations and people. The statutory framework that governs the health sector and the

provision of health services is comprised of over 20 separate pieces of legislation (Ministry of

Health, 2011b), that together work to protect the safety of the public and in doing so,

determine the social, fiscal and political context in which health professionals practise. Public

scrutiny and political agendas have both played roles in driving the development of legislation

and associated regulations and policy. This has been demonstrated by the New Zealand

Government’s response to various sentinel events, one example being the Cervical Cancer

Inquiry (Cartwright, 1988), which instigated the introduction of the Health and Disability

Commissioner Act 1994 (NZ), followed by the New Zealand Public Health and Disability Act

2000 (NZ) and the Health Practitioners Competence Assurance 2003 (NZ).

The independent structure and authority of the Nursing Council of New Zealand under the

provisions of the Health Practitioners Competence Assurance Act 2003 (NZ) facilitates their

focus on their core business, which is protecting the public and ensuring the safety of nurses to

practise. This model of regulation is considered to be permissive (International Council of

Nurses, 2009), in that the legislation (Health Practitioners Competence Assurance Act (NZ),

2003) allows the Nursing Council of New Zealand significant powers in terms of the

development and implementation of its regulatory policies, processes and operational

functions, without the conflicting priorities that result from increasing constraints on health

funding, health system error/failure, workforce shortages and political interference.

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Figure 27 depicts the New Zealand healthcare environment and the relationships between

legislation, regulatory authorities, health care organisations, health care professionals and the

public as consumers of healthcare services. The diagram sets out to show how relationships

exist between the legislation, policy drivers and the regulatory requirements with regard to

the competence and continuing competence of health professionals in New Zealand.

Figure 26 Healthcare Environment (New Zealand)

As noted in section 4.3.5, during the past four years (2009 – 2012) in New Zealand, three

Ministerial reviews of different aspects of the Health Practitioners Competence Assurance Act

2003 (NZ) have been undertaken. The first two reviews focused on operational aspects of the

Act, including the role and function of the regulator. The third consultation document 2012

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Review of the Health Practitioners Competence Assurance Act 2003: A Discussion Document

(Ministry of Health (NZ), 2012a) purports to combine the previous two reviews and introduces

four areas of focus for the 2012 review: future focus, consumer focus, safety focus, and cost

effectiveness focus. An underlying theme throughout the discussion documents appears to be

the intent to review the independent structure, authority and functions of the regulatory

authorities seeking to remove what are perceived as being ‘regulatory barriers’ in terms of

future workforce requirements and attaining financial efficiencies. It is acknowledged that the

Government has a legitimate interest in the registration and regulation of health professionals

(Chiarella & White, 2013), and indeed ensuring access to, and provision of affordable health

services. However, ensuring public safety is the function and purpose of the regulatory

authority (Health Practitioners Competence Assurance Act (NZ), 2003). Cost cutting, political

agendas and health workforce needs should not become the primary drivers for the

development of registration standards and the regulation of the health professions (Chiarella

& White, 2013; Duffield et al., 2007), and these aspects should be carefully balanced in terms

of their potential impact on public safety.

A report on the public consultation has not yet been published, nor has any evidence that the

existing regulatory requirements for nurses in New Zealand do not meet the needs of

“complex clinical environments” (Ministry of Health (NZ), 2012a, p. 4), or indeed the four areas

of focus identified in the discussion document: future focus, consumer focus, safety focus, and

cost effectiveness focus (Ministry of Health (NZ), 2012b). In addition, in 2012 the Nursing

Council of New Zealand sought an independent external review of its performance as a

regulatory authority. The Review conducted for the Nursing Council of New Zealand (Council

for Healthcare Regulatory Excellence, 2012a), by the British Council for Healthcare Regulatory

Excellence (CHRE) determined that the Nursing Council of New Zealand has effective processes

for handling conduct, competence and health related cases and thereby fulfils its role of

protecting the public by ensuring that the individual nurses they regulate are fit to practise

(Council for Healthcare Regulatory Excellence, 2012a).

Stage One of this research has evaluated the Nursing Council of New Zealand Continuing

Competence Framework (Vernon, et al., 2010) as the statutory mechanism to ensure and

monitor the continuing competence of nurses for the purpose of public safety (Nursing Council

of New Zealand, 2004a). It has been identified that the Continuing Competence Framework is

a cost effective mechanism that is fulfilling its regulatory purpose in terms of increasing the

understanding and compliance of nurses with the required Standards of Practice and

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associated continuing competence requirements, monitoring the continuing competence of

nurses in practice, and thereby providing an assurance of public safety.

10.3 Is it competence that is being assessed / measured, or safety to practise?

As previously noted, the safety of health professionals to practise has gained increasing public

attention over recent years, particularly in relation to public safety (Secretary of State for

Health (UK), 2007). Assuring the public that robust processes exist to ensure and monitor the

continuing competence and safety of nurses to practise has become a priority for nursing

regulatory authorities (Ministry of Health (NZ), 2012a). However, in some jurisdictions, the

requirement to provide a quantifiable and defensible ‘measurement’ of continuing

competence appears to be driven more by the public and political scrutiny and/or the litigious

nature of the society, rather than the notion of public protection and safety to practise.

Registered Nurses must meet a minimum standard of competence for initial registration.

However, continuing competence is a concept that, as implied by the terminology, occurs on a

continuum from the time of initial registration throughout the nurse’s professional career. It is

therefore associated with, and influenced by, a number of internal and external factors, for

example: individual behavioural traits such as insight, judgement and decision making; and

environmental factors such as the context of practice, access to resources, and patient acuity

(Adrian & Chiarella, 2010). All of these traits and environmental factors have the potential to

significantly influence the safety of an individual to practise at any given time and in any given

situation.

It is evident from the literature and the findings of this research that, whilst there are many

common philosophies and processes related to measuring and / or assessing continuing

competence, up until this research was undertaken, no consensus had been agreed

internationally with regard to the most appropriate and efficacious model for regulatory

authorities to assess and monitor this complex phenomenon. In addition, there is a

presumption that the measurement and / or assessment of the competence and continuing

competence of nurses, assures and ensures their safety to practise. Whilst it is argued that it is

the professional responsibility of all practising nurses to maintain their competence to

practise, and that well developed and comprehensive Continuing Competence Frameworks

provide assurance to the regulator and the public that the nurse is indeed continuing to be

competent to practise, no independent indicator of competence has been identified that can

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ensure the continuing competence of a nurse. The assessment of a nurse’s competence at any

time during their career is a predictor that demonstrates their continuing competence, or not,

and therefore implies their safety to practise, or not. However, it cannot ensure the safety of

the individual nurse to practise at any given time.

The words ‘measured’ and ‘assessed’ are used synonymously when describing the assessment

of competencies, competence and continuing competence. However, the variation in meaning

implied by these terms arguably goes to the heart of this debate. “To measure” is “to

ascertain the size, amount, or degree of (something) by using an instrument or device marked

in standard units or to judge someone or something by comparison with (a certain standard)”

(Oxford University Press, 2013), and “to assess” is “to evaluate or estimate the nature, ability,

or quality of someone or something” (Oxford University Press, 2013). Frequently there is a

singular approach by the regulatory authorities to the quantitative ‘measurement’ of

competence, rather than a more qualitative approach to the ‘assessment and monitoring’ of

continuing competence (National Nursing Research Unit, 2009). The reductionist approach

associated with the perceived need to ‘measure’ and quantify continuing competence has

resulted in stalling the development and implementation of Continuing Competence

Frameworks in some jurisdictions, moving the focus to what the nurse can do as opposed to

what they know (Manley & Garbett, 2000; Watson, et al., 2002), and how they translate that

knowledge into safe nursing practice (National Nursing Research Unit, 2009).

Translation of knowledge into safe nursing practice requires the nurse to have the ability to

make clinical judgements, based on sound knowledge, skills, and assessment of potential risk

(Dolan, 2003; Gibson & Soanes, 2000; National Nursing Research Unit, 2009; Pearson,

Fitzgerald, Walsh, et al., 2002). A lack of self-awareness or personal insight has been identified

as a key contributor to unsafe practice (Adrian & Chiarella, 2010). Nurses who lack personal

insight are less likely to reflect on, or assess their own practice, to seek continuing professional

development opportunities or, to recognise when their practice is unsafe (Chiarella & White,

2013; Pearson, Fitzgerald, Walsh, et al., 2002). However, in the absence of a quantifiable and

defensible mechanism for the assessment of continuing competence, many jurisdictions have

implemented models of continuing competence assurance that are comprised of an amalgam

of competence indicators.

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The indicators of continuing competence (self-assessment, practice hours/recency and

continuing professional development hours) are all considered to be appropriate indicators of

competence, that when used together can predict continuing competence and therefore may

imply safety to practise (EdCaN, 2008; Vandewater, 2004). However, they cannot guarantee

that a nurse is safe to practise on any given day (Vernon, et al., 2013; Vernon, et al., 2010). In

addition, the stipulation of a minimum number of practice, and continuing professional

development hours, when used independently, are pragmatic and / or arbitrary requirements

and not considered to be a valid measure of competence, continuing competence or safety to

practise. However, evidence of recency of practice and active engagement in professional

development / education opportunities arguably provides a more robust indication that the

nurse’s knowledge and skills are continuing to be current, and that the nurse might be aware

of what they do not know or what skills and knowledge they lack. The assessment of

competence therefore can be used as the yardstick that will predict continuing competence

and imply safety to practise.

10.4 The consensus view of regulatory experts in relation to best practice for nurses to demonstrate continuing competence; and best practice for regulatory authorities to assess continuing competence

The consensus view of the regulatory experts was that the international consensus model for

the assessment of continuing competence set out in Chapter Nine, was a framework that

provides a mechanism for nurses to demonstrate continuing competence and for regulatory

authorities to assess and monitor the continuing competence of nurses in practice. It is a

mechanism that provides information about a nurse’s continuing competence at a given time,

but it does not ensure the safety of nurses in every practice situation (Kohn, Corrigan, &

Donaldson, 2000). This is a view that is consistent with the international literature, which

identifies that implementation of Continuing Competence Frameworks should contribute to

the core regulatory purpose, that is, public protection (Bryant, 2005; Secretary of State for

Health (UK), 2007; Swankin, 1995).

Chapters Eight and Nine have presented the consensus views of regulatory experts with regard

to the development of a best practice international consensus model for nurses to

demonstrate continuing competence and for regulatory authorities to assess and monitor the

continuing competence of the profession. A conceptual framework for the assessment of

continuing competence has been proposed. Table 40 (pp. 228-229) lists the components

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identified for inclusion in this framework, in association with the perceived advantages and

disadvantages and points for consideration by the regulatory authorities. The framework aims

to encourage the professional accountability and reflexivity of the nurse and provides for the

combination of multi-source data. However it is developmental and requires further

agreement, particularly in relation to the underlying guiding principles and existing

recertification / relicensure / revalidation or registration requirements within the regulatory

jurisdictions.

It is agreed that any best practice framework must be based on sound evidence and address

the issues of assuring and ensuring the ‘continuing competence’ and ‘continuing safety to

practise’ of nurses. However, whilst the terms continuing competence and continuing safety

to practise are often used synonymously, the implementation of a Continuing Competence

Framework cannot guarantee public protection, nor can it ensure the continuing safety to

practise of nurses in every circumstance. In the current context of health care delivery and in

the face of the public scrutiny of health system error, the continuing competence of individual

nurses is only one component of ensuring patient safety. Patient safety initiatives must also

focus on, and address system error, system redesign and improvement (Benner, et al., 2010;

Secretary of State for Health (UK), 2007). This includes the acknowledgement that health

service providers who employ nurses and other health professionals, also have a joint

responsibility and accountability for providing safe and supportive practice environments and

for ensuring patient safety (Callender, Hastings, Hemsley, Morris, & Peregrine, 2007; Duffield,

et al., 2007; National Council of State Boards of Nursing, 2005).

The best practice Continuing Competence Framework must therefore assure the public that

nurses who are in practice continue to be competent to practise, whilst mitigating the

potential risk to public safety that is presented by nurses who do not continue to be

competent throughout their careers (Adrian & Chiarella, 2010; Citizen Advocacy Center, 2004;

Swankin, et al., 2006). In addition, the consensus framework must be appropriate for

implementation across extremely large nursing populations and provide a mechanism that is

accessible, proportionate, consistent, defensible and affordable (National Council of State

Boards of Nursing, 2009a; Nursing and Midwifery Council (UK), 2012).

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10.5 Contribution to the national and international research environment

This thesis makes a contribution to the national and international research environment, in

particular the relatively small body of literature relating to nursing regulation, continuing

competence and public safety. Whilst there has been considerable international interest in

the concept of continuing competence, up until this research was undertaken there was

limited research-based evidence to support a particular competence assessment process. No

research had evaluated the acceptability of an existing Continuing Competence Framework for

nurses, or sought to determine the consensus view of international nursing regulatory experts

with regard to the concept of continuing competence. This research has sought to understand

the relationships between legislation, policy drivers and the continuing competence

requirements for nurses in New Zealand, in association with determining an international best

practice consensus model for the assessment of continuing competence.

Stage One of the research focused on the relationship between legislation, policy and the

continuing competence requirements for nurses in New Zealand since the enactment of the

Health Practitioners Competence Assurance Act 2003 (NZ), and the subsequent

implementation of the Nursing Council of New Zealand Continuing Competence Framework in

2004. The evaluation of the efficacy of the Nursing Council of New Zealand Continuing

Competence Framework was completed in 2010 and contributes to Stage One of this thesis.

All of the recommendations that were made to the Nursing Council of New Zealand at that

time (Table 20, p. 161), have now been acted upon, resulting in revisions to the Nursing

Council of New Zealand website, policies, procedures and processes. In addition the full

evaluation report Evaluation of the Continuing Competence Framework (Vernon, et al., 2010)

was published by the Nursing Council of New Zealand in October 2010.

The findings from Stage One of the research were used as the foundation from which to launch

the second stage of the research, which commenced in 2011 and focused on determining the

consensus view of international regulatory experts from six countries: Australia, Canada,

Ireland, New Zealand, the United Kingdom and the United States of America, with regard to a

best practice international consensus model for the assessment of Continuing Competence.

Overall the research has demonstrated that the Nursing Council of New Zealand Continuing

Competence Framework is a well-accepted and recognised regulatory tool for the assessment

and monitoring of continuing competence, providing an acknowledged level of functionality in

terms of ensuring public safety. In addition, this research has determined (where evidence

245

existed) the consensus view of international nurse regulatory experts with regard to the

concept of continuing competence and the development of a best practice consensus model

for the assessment of continuing competence. Preliminary data and recommendations for

future development of the international consensus model have been collated, confirmed and

distributed to the expert panel (Group A) participants. The subsequent international

publications and presentations resulting from the research presented in this thesis are listed

on pages xiii-xv.

10.6 Recommendations for future research

It is clear that further research is needed to investigate and evaluate the phenomenon of

continuing competence, particularly as it relates to health professionals and their safety to

practise. In addition, there is a growing public expectation, and in many regulatory

jurisdictions, legislative requirements, that health professionals demonstrate that they are,

and continue to be, competent throughout their careers. However, to date a legally

defensible, administratively feasible and financially viable model for the assessment of

continuing competence remains elusive.

As identified in Chapter Two, the literature indicates that limited research has been

undertaken that has evaluated and critiqued the various models proposed for the assessment

of continuing competence. To date, it appears that only one study has been published

(Vernon, et al., 2010), that has comprehensively evaluated an existing Continuing Competence

Framework implemented by a regulatory authority for the purpose of public protection.

Despite the acknowledged limitations of this evaluation research, there is potential to replicate

either stage of this mixed methods evaluation. Sufficient methodological description has been

provided in the body of this thesis to make transparent the research design and process and

thereby to enable replication.

It is acknowledged that the understandings of continuing competence, associated assessment

frameworks and indeed evaluation research are evolving. Future researchers may wish to

benchmark with similar international Continuing Competence Frameworks. It would be

possible to collect and undertake a comparative analysis of the baseline data between

regulatory jurisdictions as more regulatory authorities develop and implement frameworks for

evaluation of their continuing competence standards. Urgent research is required in this area

246

in order to ensure that the continuing competence strategies that are implemented are

effective and evidence based.

This research has demonstrated that, whilst a large body of research exists in relation to the

independent indicators of competence and their applicability to the assessment of continuing

competence, many of the suggested assessment approaches are based on subjective and

comparative data. It is therefore proposed that another area of research that would

significantly contribute to the audit process, would be the development of a criterion

referenced assessment rubric for the triangulation of qualitative and quantitative data derived

through the combination of competence indicators. Development of such a tool would have

the benefit of introducing a greater degree of consistency, validity and reliability to the

assessment process, thereby providing an element of defensibility to the Continuing

Competence Framework.

10.7 Conclusion

Chapter Ten has discussed and presented the summary findings of this thesis in relation to the

overarching research questions and the New Zealand and international regulatory

environments. Recommendations for policy change and future research have been proposed.

The relationships between legislation, policy and continuing competence requirements of

registered nurses in New Zealand have been investigated, presented and discussed in

conjunction with:

a) A comprehensive evaluation of the Nursing Council of New Zealand Continuing

Competence Framework; and

b) the development of a conceptual best practice model for assessment of

continuing competence based on the consensus views of international nurse

regulatory experts.

It has been identified throughout this research that the adoption and implementation of

Continuing Competence Frameworks by regulatory authorities contributes to their primary

regulatory purpose, which is public protection. Therefore, development of the best practice

international consensus model for the assessment of continuing competence must be based

on research evidence, and related to, the potential risk to public safety presented by nurses

who do not continue to be competent throughout their careers. The aim of the best practice

247

Continuing Competence Framework that has been proposed in this research is to provide a

publicly credible, transparent, proportionate, consistent and affordable process for the

assessment of continuing competence, which provides assurance to the public that nurses in

practice are, and continue to be, competent.

248

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261

APPENDICES

APPENDIX I Evaluation Matrix ......................................................................................... 262

APPENDIX II Stage One – Phase Two (Interviews): Research Information Sheet and Interview Consent Form ............................................................................... 263

APPENDIX III Stage One – Phase Three (E-survey): Research Information Sheet and E-survey ........................................................................................................ 264

APPENDIX IV Stage Two – Delphi (Round Two): E-survey .................................................. 265

APPENDIX V Stage Two – Delphi (Round Three): E-survey ............................................... 266

APPENDIX VI Stage Two – Delphi (Round Four): Summary Documentation ...................... 267

APPENDIX VII Stage Two – Delphi (Round Four): E-survey ................................................. 268

APPENDIX VIII Stage Two – Delphi E-survey: Research Information Sheet ......................... 269

APPENDIX IX Stage Two – Delphi Group A (Expert Panel Interviews): Research Information Sheet and Consent Form .......................................................... 270

APPENDIX X Ethics Approval Documentation ................................................................... 271

APPENDIX XI Process of Qualitative Analysis ..................................................................... 271

262

APPENDIX I Evaluation Matrix

EVALUATION MATRIX Evaluation of the Nursing Council of New Zealand Continuing Competence Framework

Research Phases Distribution of research activities

Phase One – Document /Review and Policy Analysis

Data Collection: Data collection, review and descriptive analysis of NCNZ CCF documents

• Data collection, review, descriptive analysis – Rachael Vernon

• Oversight of process and confirmation of descriptive findings - Dr Elaine Papps

Data Collection: Review of NCNZ CCF policy documents and analysis of data

• Policy analysis and categorisation - Rachael Vernon • Review and confirmation Dr Elaine Papps

Statistical data Collation: Comparative analysis of NCNZ statistical data

• Rachael Vernon

Compilation and write-up of findings • Write up - Rachael Vernon. Confirmation/validation of findings and suggested revisions Dr Elaine Papps

Phase Two – Qualitative Interviews

Development of interview questions • Rachael Vernon – Reviewed by Prof. Mary Chiarella and Dr Elaine Papps

Data Collection: Select participants, organise, and conduct interviews

• Rachael Vernon

Thematic analysis • Initial categorisation and theming - Rachael Vernon • Review and confirmation of categorisation and

suggestions for refinement of themes - Prof. Mary Chiarella, Dr Elaine Papps and Dr Denise Dignam

Compilation and write-up of qualitative interview findings

• Initial write-up of findings - Rachael Vernon • Review, confirm and edit findings - Prof. Mary

Chiarella, Dr Elaine Papps

Phase Three – Quantitative E-survey

E-survey development • Development and implementation of E-Survey -Rachael Vernon

• Confirmation of E-questions - Dr Elaine Papps and Dr Denise Dignam

Data Collection: E-Survey implementation; collation and statistical analysis; write-up of quantitative statistical findings

• Rachael Vernon

Phase Four – Compilation and Write-up of NCNZ Report

Triangulation of data (phases 1, 2, 3) • Rachael Vernon. Review and suggestions for editing and refinement Prof. Mary Chiarella, Dr Elaine Papps

Compilation of NCNZ report • Rachael Vernon – write-up of first draft. • Review and edits of NCNZ report, review,

confirmation, validation of legislative data interpretation – Prof. Mary Chiarella and Dr Elaine Papps

• Suggestions on final edits – Prof. Mary Chiarella and Dr Denise Dignam

263

APPENDIX II Stage One – Phase Two (Interviews): Research Information Sheet and

Interview Consent Form

05/08/09 1

Evaluation of the Nursing Council of New Zealand Continuing Competence Framework

Information Sheet – Interview Questions

Introduction

We invite you to participate in the evaluation of the Nursing Council of New Zealand “Continuing Competence Framework.” In doing so, you will have the opportunity to express your point of view and to have a role in influencing the framework in the future.

Why are we doing this research?

The continuing competence framework established by the Nursing Council of New Zealand was implemented in 2004. Five years on it is now timely for its effectiveness to be evaluated. The purpose of this research is to explore, evaluate and determine if the Nursing Council of New Zealand Continuing Competence Framework provides the mechanisms to ensure that nurses are competent and fit to practise their profession as stipulated in section 1 of the HPCA Act 2003 (NZ).

To explore the model on which the ‘Continuing Competence Framework’ is based

To explore the validity of the stipulated hours of professional development and day/hours of clinical practice over a three year period, as indicators of competence

To provide information on the efficacy of undertaking a random audit of five percent of the nursing workforce to meet recertification requirements.

To document and track the different forms of written evidence that is currently acceptable to the Council to demonstrate competence.

To identify any issues related to peer assessment of competence.

To develop recommendations for the ‘Continuing Competence Framework’ to enable the Council to complete a further evaluation in five years time.

The research is being undertaken using a sequential mixed-method evaluation research design, and will be completed in four phases. Ethical approval has been granted by the New Zealand Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP and lodged with the University of Sydney Human Research Ethics Committee, and the Eastern Institute of Technology Research Approvals Committee.

Participation, Confidentiality and Rights

We invite you to participate in a short confidential interview. We anticipate the interview will take approximately 30-40 minutes of your time and is comprised of questions relating to your experiences and understanding of the “Continuing Competence Framework.”

The interview will be recorded and then transcribed. All responses will be treated in confidence by the researcher and all data will have any identifying information removed. You may request to see your interview transcripts if you wish; decline to answer any questions; withdraw from the study at any time; ask any questions about the study at any time during participation; provide information on the understanding that your name will not be used unless you give permission to the researcher.

05/08/09 2

This evaluation research is being carried out under contract to the Nursing Council of New Zealand. The information collected will de-identified and will be coded, collated and analyzed. It will remain confidential to the researcher on a password protected computer in a locked office. The de-identified data will contribute to the final written report submitted to the Nursing Council of New Zealand. Aspects of the research may also contribute to Rachael Vernon’s Doctoral thesis through the University of Sydney, Australia.

Members of the research team are listed below. If you have any questions in relation to this study please contact Rachael Vernon (Lead Researcher).

Research Team

Rachael Vernon (Lead Researcher) Head of School Nursing Faculty of Health & Sport Science, EIT Hawke’s Bay Private Bag 1201 Taradale New Zealand [email protected]

Telephone (06) 974 8000

Professor Elaine Papps Professor of Nursing EIT Hawke’s Bay & Director of Nursing, HBDHB Faculty of Health & Sport Science, EIT Hawke’s Bay Private Bag 1201 Taradale New Zealand

Professor Mary Chiarella Professor of Nursing & Chair Australian Nursing and Midwifery Council Faculty of Nursing & Midwifery University of Sydney New South Wales Australia

Professor Denise Dignam Associate Dean (External Engagement) Faculty of Nursing, Midwifery & Health University of Technology Sydney New South Wales Australia

Thank you for considering participating in this research. If you agree to participate please complete the consent form included with this information sheet and return it to Rachael Vernon.

mailto:[email protected]

New Zealand Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP



I have read the Information Sheet and have had the details of the study explained to me. My questions have been answered to my satisfaction, and I understand that I may ask further questions at any time.

I understand I have the right to withdraw from the study at any time and to decline to answer any particular questions.

I agree to provide information to the researcher on the understanding that my name will not be used without my permission.

I understand that the information will be used for this research (Evaluation of the Continuing Competence Framework), that it may also contribute to Rachael Vernon’s Doctoral thesis, and publications arising from both research projects.

I agree / do not agree to the interview being audio taped.

I also understand that I have the right to ask for the audio tape to be turned off at any time during the interview.

I agree to participate in this research under the conditions set out in the Information Sheet.

Signed: ...................................................................................... Name: ...................................................................................... Date: ......................................................................................

264

APPENDIX III

Stage One – Phase Three (E-survey): Research Information Sheet and E-survey


Information Sheet

We invite you to participate in the evaluation of the Nursing Council of New Zealand “Continuing Competence Framework.” In doing so, you will have the opportunity to express your point of view and to have a role in influencing the framework in the future.

Why are we doing this research? The continuing competence framework established by the Nursing Council of New Zealand was implemented in 2004. Five years on it is now timely for its effectiveness to be evaluated. The purpose of this research is to explore, evaluate and determine if the Nursing Council of New Zealand Continuing Competence Framework provides the mechanisms to ensure that nurses are competent and fit to practise their profession as stipulated in section 1 of the HPCA Act 2003 (NZ).

To explore the validity of the stipulated hours of professional development (60 hours) and hours of clinical practice (450 hours/60 days) over a three year period, as indicators of competence.

To provide information on the efficacy of undertaking a random audit of five percent of the nursing workforce to meet recertification requirements.

To document and track the different forms of written evidence that is currently acceptable to the Council to demonstrate competence.

To identify any issues related to peer assessment of competence.

To develop recommendations for the ‘Continuing Competence Framework’ to enable the Council to complete a further evaluation in five years time.

The research is being undertaken using a sequential mixed-method evaluation research design, and will be completed in four phases. Ethical approval has been granted by the New Zealand Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP and lodged with the University of Sydney Human Research Ethics Committee, and the Eastern Institute of Technology Research Approvals Committee.

Participation, Confidentiality and Rights In order to participate, all you need to do is to fill in and return the attached anonymous questionnaire. We anticipate the questionnaire will take approximately 20 minutes of your time and is comprised of questions relating to your experiences and understanding of the “Continuing Competence Framework.”

Your participation in this research is entirely voluntary and you have the right to refuse to participate by simply not responding to this invitation. Completing and returning this ‘anonymous’ questionnaire implies your consent to participate in this research.

This evaluation research is being carried out under contract to the Nursing Council of New Zealand. The information collected will de-identified and will be coded, collated and analyzed. It will remain confidential to the researcher on a password protected computer in a locked office. The de-identified data will contribute to the final written report submitted to the Nursing Council of New Zealand. Aspects of the research may also contribute to Rachael Vernon’s Doctoral thesis through the University of Sydney, Australia.

Members of the research team are listed below. If you have any questions in relation to this study please contact Rachael Vernon (Lead Researcher).

Rachael Vernon (Lead Researcher) Head of School Nursing Faculty of Health & Sport Science, EIT Hawke’s Bay Private Bag 1201 Taradale New Zealand [email protected]

Professor Elaine Papps Professor of Nursing EIT Hawke’s Bay & Director of Nursing, HBDHB Faculty of Health & Sport Science, EIT Hawke’s Bay Private Bag 1201 Taradale New Zealand

Professor Mary Chiarella Professor of Nursing & Chair Australian Nursing and Midwifery Council Faculty of Nursing & Midwifery University of Sydney New South Wales Australia

Professor Denise Dignam Associate Dean (External Engagement) Faculty of Nursing, Midwifery & Health University of Technology Sydney New South Wales Australia


2-EVALUATION OF THE NURSING COUNCIL OF NEW ZEALAND CONTINUING COMPETENCE FRAMEWORK Created: November 23 2009, 8:20 PM Last Modified: November 23 2009, 8:20 PM Design Theme: Oceanic Aqua Language: English Button Options: Labels Disable Browser “Back” Button: False

EVALUATION OF THE NURSING COUNCIL OF NEW ZEALAND CONTINUING COMPETENCE FRAMEWORK

Page 1 - Heading

Demographic details

Page 1 - Question 1 - Choice - One Answer (Bullets) [Mandatory]

What is your scope of practice (Registration)?

Nurse Assistant

Enrolled Nurse

Registered Nurse


What is your highest qualification? (Select one)

Hospital Certificate

Graduate Certificate

Graduate Diploma

Bachelors Degree

Postgraduate Certificate

Postgraduate Diploma

Masters Degree

PhD

Other, please specify

Page 1 - Question 3 - Yes or No [Mandatory]

Do you hold a current Practising Certificate?

Yes

No

Page 1 - Question 4 - Yes or No

Are you currently employed as a nurse?

Yes

No

Page 1 - Question 5 - Choice - One Answer (Bullets)

Which area of employment most closely describes your current employment setting? (Select one)

DHB (Acute)

DHB (Primary Health/Community)

DHB (Other)

Private Hospital

Primary health (NGO / PHO)

PHO

Aged Care Sector (Rest home / Residential Care)

Nursing Agency

Self Employed

Maori Health Service Provider

Rural

Health Management

Educational Institution

Government Agency (MOH, ACC, Corrections Service, Defense Forces)

Other please specify


Which statement most closely describes your current area of nursing practice? (Select one)

Emergency and Trauma

Intensive Care/Cardiac Care

Peri Operative Care (Operating Theatre)

Surgical

Medical

Palliative Care

Obstetrics/Maternity

Child Health, including Neonatology

School Health

Youth Health

Family Planning/Sexual Health

District Nursing

Practice Nursing

Occupational Health

Primary Health Care

Public Health

Continuing Care (Elderly)

Assessment and Rehabilitation

Mental Health (inpatient)

Mental Health (community)

Addiction Services

Intellectually Disabled

Nursing Administration and Management

Nursing Education

Nursing Professional Advice/Policy Development

Nursing Research

Non-nursing health related management or administration

Other non-nursing paid employment

Not in paid employment

Page 1 - Heading

Competence and fitness to practise

Page 1 - Question 7 - Ranking Question [Mandatory]

The Nursing Council of New Zealand (NCNZ) indicators of continuing competence are: A. Signing a legal self-declaration of competence to practice (based on self-appraisal using the NCNZ competencies for practice). B. Verification of practice (minimum of 450 hours / 60 days in past 3 years). C. Verification of professional development (minimum of 60 hours in past 3 years). Rank the indicators below from 1 (Best) - 7 (Worst) which you believe provide the best evidence of continuing competence to practice. (Each ranking number can only be used once)

1 2 3 4 5 6 7

A, B, and C.

A and B.

A and C.

B and C

A only.

B only.

C only.

Page 1 - Question 8 - Ranking Question [Mandatory]

Rank the indicators below from 1 (Best) - 7 (Worst) which you believe provide the best evidence of continuing professional development. A. Signing a legal self-declaration of competence to practice (based on self-appraisal using the NCNZ competencies for practice). B. Verification of practice (minimum of 450 hours / 60 days in past 3 years). C. Verification of professional development (minimum of 60 hours in past 3 years). (Each ranking number can only be used once)

1 2 3 4 5 6 7

A, B, and C.

A and B.

A and C.

B and C

A only.

B only.

C only.


Do you think that the current NCNZ Continuing Competence Framework and process for renewing practising certificates, provides the mechanism to ensure that nurses are competent and fit to practise?

Yes

No

Page 1 - Question 10 - Rating Scale - Matrix [Mandatory]

Rate your agreement with each of the following statements: (1 indicates you strongly agree and 7 indicates you strongly disagree)

Strongly

agree 2 3 4 5 6

Strongly disagree

As a health professional I am

responsible for maintaining my own

competence to practice.

My employer is responsible for

maintaining my competence to

practice.

The Nursing Council of New Zealand

is responsible for maintaining my

competence to practice.

When completing my NCNZ

application to renew my practising

certificate I understand that I am

signing a legal declaration.

Page 1 - Question 11 - Rating Scale - Matrix [Mandatory]

Rate your understanding of each of the the following questions: (1 indicates excellent understanding and 7 indicates very poor understanding)

Excellent understan

ding 2 3 4 5 6

Very poor understan

ding

Have you completed a minimum of

450 hours of nursing practice in New

Zealand within the past three years?

Have you undertaken the minimum of

required professional development

hours (i.e. 60 hours) within the past

three years?

Do you meet the Council's

competencies for your scope of

practice?

Do you have a mental of physical

condition that means you are unable to

perform the functions required for the

practice of nursing?

Have you been the subject of an

investigation, disciplinary or criminal

proceedings or a disciplinary order in

New Zealand or any other country

since you last applied for a practicing

certificate?

Page 1 - Heading

Professional Development and Recognition Programmes


With regard to Professional Development and Recognition Programmes (PDRP): Do you think PDRP's should be compulsory?

Yes

No


Are you levelled on a PDRP?

Yes

No


Do you have access to a PDRP?

Yes

No

Page 1 - Heading

Recertification audit


Have you ever been asked to be a Peer Assessor for a colleague who was being audited?

Yes

No

Page 1 - Heading

If you responded NO to question 15 please go directly to question 17.

Page 1 - Question 16 - Rating Scale - Matrix

Peer Assessor:

Yes No

Were you provided with information

about the recertification audit process?

Were you provided

with documentation about the relevant

scope of practice and competencies?

Where you provided with a

competence assessment form?

Was your assessment based on

evidence?

Did you discuss your assessment with

your colleague?

Did you understand you were

completing and signing a legal

document?


When renewing your practising certificate with the NCNZ, have you ever been selected for recertification audit? If yes, please select the year.

No

Yes, 2005

Yes, 2006

Yes, 2007

Yes, 2008

Yes, 2009

Page 1 - Heading

If you responded NO to question 17 please scroll down and SUBMIT your questionnaire now. If you responded YES please complete questions 18 - 21.


When you were audited did you receive written information about:

Yes No

The recertification audit process?

The recertification audit time frame?

The domains of practice and

competencies for your scope of

practice?

The evidence you would need to

provide for the recertification audit?

Where you could obtain clarification if

necessary?

The process after submission of your

documentation?


From the documentation provided to you by the NCNZ, rate on a scale of 1 - 7 your understanding of how to provide evidence for each of the following requirements. (1 indicates excellent understanding and 7 indicates very poor understanding)

Excellent understan

ding 2 3 4 5 6

Very poor understan

ding

Evidence of practice hours.

Evidence of professional development

hours.

Self assessment of your competencies

for your scope of practice.

Peer assessment of your competencies

for your scope of practice.

Page 1 - Question 20 - Choice - One Answer (Bullets)

Following submission of my audit material I received (Select one).

A. No further correspondence

B. Single correspondence requesting further information

C. Multiple correspondence


With regard to your audit, rate your level of agreement with the following statements: (1 indicates you strongly agree and 7 indicates you strongly disagree)

Strongly

agree 2 3 4 5 6

Strongly disagree

The specified time frames were

acceptable.

The request for information and

correspondence from the Nursing

Council was clear.

The style of correspondence from the

Nursing Council was appropriate.

I was satisfied with the process.

Page 1 - Heading

Thank you for participating in this questionnaire.

Thank You Page

Evaluation of the Nursing Council of New Zealand Continuing Competence Framework Thank you for your participation in this research. Your feedback is important to us.

Screen Out Page

(Standard - Zoomerang branding)

Over Quota Page


Survey Closed Page


265

APPENDIX IV Stage Two – Delphi (Round Two): E-survey

[SURVEY PREVIEW MODE]

International Consensus Model for the Demonstration and Assessment of Continuing Competence

Delphi Round Two - Electronic Questionnaire (E-survey)

Thank you for agreeing to participate in this research

Please complete and submit this electronic questionnaire by Tuesday 12 July 2011

1

Do you have experience in the development and/or implementation of Continuing Competence Frameworks?

Yes

No

2

Describe the ways you believe it is possible and appropriate for nurses to demonstrate continuing competence:

3 Describe how you believe continuing competence should be assessed:

4 In your experience please describe the barriers and /or enablers that may exist when implementing a model for the demonstration and assessment of continuing competence:

[SURVEY PREVIEW MODE]

5 Do you believe it is possible to develop a ‘consensus model for the demonstration and assessment ofcontinuing competence' for implementation across countries?

Yes

No

Additional Comment

Powered by SurveyMonkey Check out our sample surveys and create your own now!

http://www.surveymonkey.com/

http://www.surveymonkey.com/mp/survey-templates/

266

APPENDIX V Stage Two – Delphi (Round Three): E-survey

[SURVEY PREVIEW MODE] Delphi Round Three - International Consensus Model for the Assessment of Continuing Competence Survey

http://www.surveymonkey.com/...IS_LINK_FOR_COLLECTION&sm=w7DmGQ4XLl69PlHackmi8nOF1XNWVNzJs7I2vZXMV8w%3d[23/04/2013 6:42:55 p.m.]

Delphi Round Three - International Consensus Model for the Assessment of Continuing

Competence

Definition of the term 'competence' and 'continuing competence' for nursing are similar in the jurisdictions

of Australia, Canada, Ireland, UK, USA, and New Zealand. Each definition includes the requirement to

meet a prescribed standard of knowledge, skills and decision making for safe practice. Definitions of

continuing competence also include the ongoing ability of the nurse to continue to integrate up-to-date

knowledge, skills, judgement and decision making appropriately in the context/role in which they practice.

Please rate your level of agreement with the following definitions:

Strongly Agree Agree Undecided Disagree

Strongly

Disagree

Competence is the

combination of

skills, knowledge,

attitudes, values

and abilities that

underpin the

effective

performance as a

nurse (NCNZ,

2009).

Continuing

Competence is the

ongoing ability to

keep up-to-date the

skills, knowledge,

values, attitudes,

and abilities

required to practice

effectively and

safely in

the context/role in

which they practice.

Please rate your agreement with the following statements:

As a registered health professional individual nurses are responsible for:


Strongly

Disagree

Demonstrating a

commitment to

continuing

competence

throughout their

professional careers.

1

2

Exit this survey



Ensuring that they

continue to meet the

relevant standards

and competencies

required for their

scope of practice

and relevant to the

role and context in

which they practice.

Actively participating

in and meeting the

requirements

specified by their

regulatory authority.

Participating in

ongoing educational

activities relevant to

their scope

of practice.

Providing

an appropriate, safe,

ethical and

competent standard

of nursing practice.

The definition of nursing practice varies between countries. However, the majority of responses to the

DELPHI survey R2 strongly indicated that a definition of 'nursing practice' should include all nursing roles

that contribute to Nursing.

Please rate your level of agreement with the following statement:


Strongly

Disagree

The definition of

nursing practice

should be inclusive

and encompass:

Nursing

Management;

Nursing Education;

Nursing Research;

Nursing Policy;

Nursing Regulation;

Nursing

Governance; and

Clinical Nursing

Practise.

Models and understanding of Continuing Competence frameworks (CCF) vary internationally. Thirty-four

3

4



(67%) of participants of the DELPHI Survey R2 identified that 'multi-source' or '360 degree' feedback is

critical when assessing continuing competence of nurses.

Please indicate your level of agreement with the following statements:


Strongly

Disagree

CCFs must be

financially viable,

flexible, applicable

to a variety of

settings, provide

options for

demonstrating

competence and be

clearly

communicated to all

stakeholders.

CCFs are tools that

are used to monitor

the continued

competence of the

profession and

individual

practitioners.

Competence

indicators are

measures

assess competence

against specified

standards.

Competence

indicators may imply

competence but

cannot ensure the

continuing

competence of an

individual.

Extensive research exists with regard to individual measures of competence / continuing

competence. Current research suggests that no 'individual' measure assures competence or public

safety. However evidence drawn from a variety of 'measures' provides a strong indication of competence

and may imply continuing competence.

Responses to the DELPHI survey R2 highlighted a general view that the measurement of continuing

competence requires contextualising in terms of the requirements of the practice environment and

individuals role.

Please indicate your level of agreement with the following statements:


Strongly

Disagree

Competence

5



indicators must be

flexible and relevant

to the scope in

which the nurse is

practising.

Assessment of

continuing

competence

requires the

integration of multi-

source assessment

i.e. a variety of

competence

indicators.

On its own

continuing

professional

development (CPD)

or professional

education is not an

adequate measure

of continuing

competence.

Hours of practice

are not an adequate

measure of

continuing

competence.

The following five 'competence indicators' received the highest count in terms of their importance for

inclusion in a consensus model for the demonstration and assessment of continuing competence.

Please rate your level of agreement with the indicators below that should be included in the consensus

model:


Strongly

Disagree

Practise hours i.e.

participation /

recency of nursing

practise.

Self assessment /

self declaration

(based on the

required standards

of nursing practise).

Peer assessment

(based on required

standards of nursing

practise).

6



Participation in

continuing

professional

development and /

or continuing

education.

Professional

portfolio

Three additional 'competence indicators' were identified by 6 participants (12%), as being important

indicators of competence for inclusion in a consensus model.

Please rate you level of agreement for their inclusion in a model.

Yes

Should be included Undecided

No

Should not be included

Examination

Objective Structured

Clinical Examination

(OSCE)

Audit of Practice

The following list of items were identified as both enablers and barriers to implementing a consensus

model for the demonstration and assessment of continuing competence.

From you experience please rate the importance of each item:

Significant

Enabler Enabler Undecided Barrier

Significant

Barrier N/A

Communication with

key stakeholders

Legislation

Authority of the

Regulatory Body

Professional Nursing

Organisations

Financial viability

Political Interests

Differing qualification

requirements

Expectations of the

Public

Number of nurses

on the register

7

8



Clarification with regard to who is responsible for the continuing competence of practitioners was

highlighted as an important consideration when implementing a CCF.

Please rate your agreement with the following statements:


Strongly

Disagree

Governments are

responsible for passing

legislation, and ensuring its

enactment.

Regulatory authorities are

responsible for protecting the

safety of the public by setting

the standards of nursing

practice and monitoring the

competence of the

profession.

Professional

organisations are responsible

for facilitating the

development of the

nursing profession.

Employers are responsible

for maintaining quality

practice environments that

support and facilitate

continuing competence

opportunities for nurses and

monitoring their continuing

competence.

Nursing education

organisations are responsible

for providing high quality

programmes that prepare

competent nurses and

provide relevant continuing

education opportunities.

88% of participants in R2 indicated that they believed it was possible to develop an international

consensus model for the demonstration and assessment of continuing competence (Australia, Canada,

Ireland, UK, USA, New Zealand)

Please rate your level of agreement with the following statements:


Strongly

Disagree

It is possible to

develop a

consensus model

9

10



for the assessment

of CCF.

It is possible to

develop consensus

on key principles in

relation to the

assessment of

continuing

competence.

The consensus

model must be

flexible and

adaptable to comply

with the legislative

and fiscal

requirements

of each country.

Any further comments?

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267

APPENDIX VI Stage Two – Delphi (Round Four): Summary Documentation

Rachael Vernon Page 1

Delphi Round Four – Consensus Model for the Assessment of Continuing Competence

The Purpose of this research was to investigate the possibility of developing an international consensus model for the demonstration and assessment of continuing competence across six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America).

The research has been undertaken using the Delphi Technique. Three overarching questions were posed:

1. What is the consensus view of regulatory experts in relation to best practice for nurses to demonstrate continuing competence and for regulatory authorities to assess continuing competence?

2. What, if any, differences are present between the current regulatory requirements for the demonstration and assessment of continuing competence in the six countries and the best practice model developed through consensus?

3. What changes, if any, would be required to policy and regulation in the six countries to align their regulatory framework with best practice for demonstration and assessment of continuing competence?

Three Delphi Rounds have been completed with two participant groups. The first expert panel (Group A) was made up of a purposive sample of 14 international regulatory and professional nursing representatives from the six countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America). The second panel (Group B) was a larger international group recruited specifically from within the individual regulatory boards in each of the six countries and through the International Council of Nurses, Regulatory Observatory. Recruitment of Group B participants used a snowball technique that was initiated by sending an electronic invitation directly to each individual regulatory board in each of the six countries and to the International Council of Nurses administration office in Geneva.

Summative content analysis was used to identify the themes generated from the qualitative data derived from the Delphi rounds one and two. Findings from these two data sets were further collated and major themes identified which formed the basis of the structured E-survey implemented in round three.

The round three e-survey was structured using statements drawn from the findings of the previous two Delphi rounds. The underlying design of the e-survey was based on a five point Likert (rating) Scale to elicit the participant’s level of agreement or disagreement with the statement items. This process sought to quantify the earlier findings from rounds one and two and to determine any convergence and consensus of opinion. The summary data were coded and collated independently and statistically analysed. Errors or inconsistencies in data were carefully screened out by evaluating the range of values generated by running the descriptive frequencies.

Determination of consensus

The consensus view was determined by assessing the stability of the participant responses to each Delphi round, in conjunction with the analysis of percentage scores indicating the participants’ level of agreement with the statements provided via the E-survey. A percentage score of 90% agreement or greater with a mean score of less than 2 (based on the five point Likert scale) was deemed as exhibiting a consensus view.

Findings were detailed and comprehensive, and full copies are available on request. However for the purpose of this review a summary of the overall findings is presented below.


Delphi Round One – Interviews (Participant sample -14 regulatory experts from the six participant countries).

Questions posed:

1. Tell me about your experience with, and understanding of, continuing competence frameworks/models.

2. In your view what is ‘best practice’ for the demonstration and assessment of continuing competence?

3. What, if any, are the current regulatory requirements for the demonstration and assessment of continuing competence in your country/jurisdiction?

4. What barriers and enablers exist in relation to the implementation of a model/framework for assessment of continuing competence?

5. Do you believe it is possible to develop an international consensus model for the assessment of continuing competence between the following six countries – Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America?

Summary Findings - Delphi Round One (Interviews)

Four thematic categories and associated sub-themes emerged:

1. Continuing Competence Frameworks - Consistency of purpose and understandings • Competence and continuing[ed] competence • Purpose of a Continuing Competence Framework • Public safety

2. Variation in legislation and policy • Permissive legislation • Light touch regulation

3. Best Practice • Legal status of framework • A common language • Assessment of continuing competence- competence indicators • Validity and reliability of competence indicators • Responsibility and accountability

4. Barriers and Enablers • Continuing competence - legislative requirement or career development • Variation in terminology and language • Consistency in roles and education requirements • Administrative and financial viability

In summary it was the unanimous view of the interview participants that development of an international consensus model for the assessment of continuing competence, between the six countries identified as the focus of this study is an important initiative that is possible. It was felt the new relationship between these countries in terms of the recently signed memorandum of understanding would facilitate this on-going work. Limited knowledge and understanding of the legislative, regulatory and educational requirements for nurses between countries was identified as a contributor to the perceived difficulty for nurses wishing to move between regulatory jurisdictions, within and between countries. Four participants noted that having a greater understanding of the legislative, education and qualification frameworks in each of the six countries was a critical factor in facilitating greater ease of mobility for nurses both within and between the countries. Another participant stated that “by working more closely together a greater level of trust would be developed between regulatory jurisdictions”.


The establishment of common values, beliefs and guiding principles contributing to an internationally agreed code of conduct, education and practice standards was also identified by seven participants in relation to the development of a consensus model. The variation in understandings related to the specific indicators that were embedded in the Continuing Competence Framework were not considered to be a critical issue provided that ultimately the model allowed flexibility in terms of its implementation requirements, was administratively feasible, financially viable and defensible in terms of providing some assurance of public safety.

Delphi Round Two – E-survey (Participant sample - 51 regulatory experts)

Questions posed:

1. Do you have knowledge and or experience in the development or implementation of Continuing Competence Frameworks?

2. Describe the ways you believe it is possible and appropriate for nurses to demonstrate continuing competence.

3. Describe how you believe continuing competence should be assessed.

4. In your experience please describe the barriers and /or enablers that may exist when implementing a model for the demonstration and assessment of continuing competence.

5. Do you believe it is possible to develop and international consensus model for the demonstration and assessment of continuing competence?

Summary Findings – Delphi Round Two (Qualitative E-survey)

Summary data from round two of the Delphi survey reflected stability with the findings of round one. This was particularly evident with regard to the purpose of Continuing Competence Frameworks, the definition of continuing competence and the selection of appropriate competence indicators. The data indicated that legislative frameworks particularly the jurisdiction of the individual regulatory authority and associated policy requirements, had a significant impact upon the ability to implement a Continuing Competence Framework. This item featured significantly as both a barrier and an enabler. The following items were highlighted for further investigation in the Delphi round three e-surveys:

• The definition of ‘competence’ and ‘continuing competence’. • An understanding of what constitutes ‘professional responsibility’ and ‘nursing practice’. • Responsibility and accountability. • The purpose and core requirements of a Continuing Competence Framework including the indicators

of continuing competence. • Implementing a Continuing Competence Framework – barriers and enablers.

Delphi Round Three – E-survey (Participant sample - 39 regulatory experts)

Overall Summary Findings - Delphi Round Three (Quantitative E-survey)

The consensus model

The view of the majority of the Delphi participants is that the development of an international consensus model for the assessment of continuing competence, between the six identified countries (Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America) is an important initiative that is possible (Agreement = 87%, M = 1.95, SD = .724, V = .524).

The consensus view of the participants is that there is initial work required to in order to determine a common foundation prior to development of the consensus model. It was the consensus view of the


participants that initially the development of key principles for the assessment of continuing competence be agreed (Agreement = 100%, M = 1.56, SD = .502, V = .252).

The most commonly expressed requirement identified by the participants is that the consensus model must be flexible and adaptable (Agreement 100%, M = 1.31, SD = .468, V.219).

Definitions

It was the consensus view of the participants that the inclusive definitions of ‘competence – the combination of skills, knowledge, attitudes, values and abilities that underpin the effective performance as a nurse’ and ‘continuing competence – the on-going ability to keep up-to-date the skills, knowledge, values, attitudes, and abilities required to practice effectively and safely in the context/role in which they practice’ were appropriate. Both definitions achieved the same agreement rating (Agreement 100%, M = 1.55, SD = .504, V = .254).

The inclusive definition of what constitutes nursing practise was agreed to include all ‘nursing roles’ that contribute to the nursing profession i.e. Nursing regulation; nursing governance; nursing policy; nursing management; nursing education; nursing research; and clinical nursing practice (Agreement 100%, M= 1.45, SD = .504, V = .254).

Responsibility and accountability

Responsibility and accountability for continuing competence were items that attracted wide ranging comment. A consensus view was achieved in terms of the understanding of what constitutes the individual registered nurses responsibilities for their continuing competence. There was consensus with regard to the overarching responsibility of the key stakeholder groups, particularly the employer with 40% (n = 15) of participants indicating they strongly agreed and 60% (n = 23) that they agreed employers are responsible for maintaining quality practice environments that support and facilitate continuing competence opportunities for nurses and for monitoring their continuing competence.

Continuing Competence Framework

Ninety percent of the participants ‘strongly agreed’ and 10% ‘agreed’ (M = 1.11) that it is important that the continuing competence model being administratively feasible, financially viable and defensible in terms of providing some assurance of public safety.

Flexibility in terms of the implementation and utilisation of embedded indicators of continuing competence was identified as a requirement. It is the consensus view (100%, M = 1.32) that competence indicators are measures that assess competence against specified standards. In addition the relevance of these indicators to the scope/context in which the nurse is practising is agreed to be important by 97% of the participants (M = 1.16).

Indicators or continuing competence

It is the consensus view that the following three indicators of continuing competence should be included: self-assessment / self-declaration (Agreement 90%, M = 1.53, SD = .687, V = .472); practise hours /recent nursing practise (Agreement 100%, M = 131, SD = .468, V = .219); and continuing professional development (Agreement 100%, M = 1.33, SD = .530, V = .281).

Barriers and enablers

A number of barriers and enablers were initially identified in relation to the development of a consensus model however, only two of the identified enablers were rated by the majority of the participants in round three: authority of the regulatory body (Agreement 92%, M = 1.77, SD = .627, V = .393); and communication with key stakeholders (Agreement 93%, M = 1.62, SD = .633, V = .401). Legislation had been identified as a significant enabler and barrier in round two however in round three it was rated an


enabler by 85% of participants and a barrier by only 8% of the participants. A further 8% were undecided. A number of the barriers previously identified by the participants for example, financial viability, political interests and the number of nurses on the register were again rated as barriers. However, none of these items achieved a consensus rating. Eighty percent (n = 31) of the participants indicated that ‘differing qualifications’ was no longer applicable as a barrier and 56% (n = 22) and 58% (n = 23) respectively indicated that ‘expectations of the public’ and number of nurses on the register’ were no longer considered to be barriers.

Key Principles

The following key principles have been derived from the findings of the Delphi rounds (one-three), and have been identified by the participants as underpinning the development of an international consensus model for the assessment of continuing competence between Australia, Canada, Ireland, New Zealand, the United Kingdom and the United States of America.

General

• The purpose of nursing regulation is protection of the public.

• The public has the right to expect that Registered Nurses, who are in practice, are and continue to be, competent.

• Revalidation, recertification, re-registration should occur annually and be associated with the requirement to declare and/or demonstrate the ability to meet required standards of continuing competence.

• Education and practice standards for Registered Nurses are similar between the six participant countries and imply the same expectations.

• Definitions of competence, continuing competence and nursing practice between and within the six participant countries are similar and imply the same meaning.

• Development of an international model for the assessment of Continuing Competence Framework requires agreement on a common language - lexis of terminology in relation to Continuing Competence.

• Whilst a ‘legislative mandate’ is a significant enabler in terms of implementation and compliance with Continuing Competence Frameworks it is not an essential component for the implementation of a Continuing Competence Framework.

Responsibility

• Registered Nurses are registered health professionals who are responsible, accountable, ethical, competent and committed to life-long learning and nursing practice.

• Registered Nurses are responsible for ensuring their own individual 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.



• The Continuing Competence Framework must have a clear and transparent purpose and processes that are credible and understandable to the public and the nursing profession.

• Continuing Competence Frameworks are tools that facilitate the assessment and monitoring of the continuing competence of the profession, and as such they have a role in assuring and ensuring public safety.

• Assessment of Continuing Competence requires triangulation of data from a selection of sources.

• No single indicator of competence can measure or appropriately assess ‘continuing competence’ or ensure valid reliable and consistent measurement of ‘continuing competence’

• The Continuing Competence Framework must be flexible and adaptable, administratively feasible, financially viable, and publically defensible.

Core components of a best practice consensus model

The Delphi participants identified that an international consensus model for the assessment of continuing competence should include the following core components:

• An internationally agreed and clearly communicated purpose statement that identifies the expectations of the Continuing Competence Framework and its functions in terms of a) protection of the public; and b) the monitoring and assessment of the continuing competence of nurses.

• An internationally agreed lexicon of terminology that includes agreed definitions of the terms ‘Competence’, ‘Continuing Competence’ and ‘nursing practice’.

• Criterion based assessment guidelines.

• Development of a tool box of indicators for ‘multisource assessment’ of continuing competence including but not limited to the following:

Core indicators Optional indicators

• Self-assessment / Self-declaration • Practice Hours (current and recent

practice) • Continuing professional development /

education hours

• Peer Assessment • Professional Portfolio • Observed Structured Clinical

Examination (OSCE) • Examination

268

APPENDIX VII Stage Two – Delphi (Round Four): E-survey

[SURVEY PREVIEW MODE] Delphi Round Four - International Consensus Model for the Assessment of Continuing Competence Survey

http://www.surveymonkey.com/...THIS_LINK_FOR_COLLECTION&sm=L5imAREssdFvcYIH1tQCfyWirEx9VyJnHoSWStVX8LU%3d[23/04/2013 6:59:16 p.m.]

Delphi Round Four - International Consensus Model for the Assessment of Continuing

Competence

* After considering the summary findings of the previous three Delphi Rounds what, if any, differences are

present between your current regulatory requirements for the demonstration and assessment of

continuing competence and the best practice model proposed through consensus?

* What changes, if any, would be required to policy and regulation to align your current regulatory

framework with best practice for demonstration and assessment of continuing competence?

The following key principles were identified by the participants in the previous Delphi rounds as

underpinning the development of an international consensus model for the assessment of continuing

competence.

Please indicate your agreement or disagreement with the following statements:

Agree Disagree Undecided

The purpose of nursing regulation is

protection of the public.

Other (please specify)

The public has the right to expect that

Registered Nurses, who are in practice,

are and continue to be, competent.


Revalidation, recertification, re-

registration should occur annually and

be associated with the requirement to

declare and/or demonstrate the ability

to meet required standards of



Education and practice standards for

Registered Nurses are similar between

1

2

3



the six participant countries and imply

the same expectations.


Definitions of competence, continuing

competence and nursing practice

between and within the six participant

countries are similar and imply the

same meaning.


Development of an international model

for the assessment of Continuing

Competence Framework requires

agreement on a common language -

lexis of terminology in relation to

Continuing Competence.


Whilst a ‘legislative mandate’ is a

significant enabler in terms of

implementation and compliance with

Continuing Competence Frameworks it

is not an essential component for the

implementation of a Continuing

Competence Framework.


Registered Nurses are registered

health professionals who are

responsible, accountable, ethical,

competent and committed to life-long

learning and nursing practice.


Registered Nurses are responsible for

ensuring their own individual 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.


The Continuing Competence

Framework must have a clear and

transparent purpose and processes

that are credible and understandable to

the public and the nursing profession.


Continuing Competence Frameworks

are tools that facilitate the assessment

and monitoring of the continuing

competence of the profession, and as

such they have a role in assuring and

ensuring public safety.


Assessment of Continuing Competence

requires triangulation of data from a

selection of sources.


No single indicator of competence can

measure or appropriately assess

‘continuing competence’ or ensure valid

reliable and consistent measurement of

‘continuing competence’


The Continuing Competence

Framework must be flexible and

adaptable, administratively feasible,

financially viable, and publically

defensible.




The Delphi participants identified that an international best practice consensus model for the assessment

of continuing competence, should include the following core components.

Please indicate your agreement or disagreement?


An internationally agreed and clearly

communicated purpose statement, that

identifies the expectations of the


and its functions in terms of: a)

protection of the public; and b) the

monitoring and assessment of the

continuing competence of nurses.


An internationally agreed lexicon of

terminology that includes agreed

definitions of the terms ‘Competence’,

‘Continuing Competence’ and ‘nursing

practice’.


Criterion based assessment guidelines.


Development of a tool box of indicators for ‘multi-source assessment’ of continuing competence was

identified as a core component of a best practice Continuing Competence Framework.

The following three items were identified as essential components:

Please indicate your level of agreement or disagreement?


Self-assessment /

Self-declaration

Practice Hours

(current and recent

practice) - specified

Continuing

professional

development /

education hours -

specified

4

5




The following four items were identified as optional and may be used for audit purposes.

Please indicate your agreement or disagreement?


Peer Assessment

Professional

Portfolio

Observed Structured

Clinical Examination

(OSCE)

Examination

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269

APPENDIX VIII Stage Two – Delphi E-survey: Research Information Sheet

Conceptual model for the demonstration and assessment of continuing competence

Information Sheet – Questionnaire/Delphi E-surveys We invite you to participate in this research. In doing so, you will have the opportunity to express your point of view and to have a role in influencing the development of a conceptual model and best practice framework for continuing competence for nurses.

Why are we doing this research? The purpose of this research is to develop a consensus view of best practice for nurses to demonstrate continuing competence, and for regulatory authorities to assess continuing competence.

The need for continuing competence is agreed by regulatory authorities to be necessary to protect the public in health processional regulation. Definitions of continuing competence within legislation and policy across developed nations have strong similarities. However, recent research conducted within New Zealand indicates that there is confusion over the level to which continuing competence needs to demonstrated and the criteria against which continuing competence should be assessed. This study aims to develop a consensus view amongst regulatory experts and authorities for a conceptual model for demonstration and assessment of continuing competence. In addition, a gap analysis will be undertaken to analyze the conceptual model against existing requirements. Recommendations will be made for legislative and policy change to align best practice with existing conditions. This research is the second stage of a larger study, completed under contract to the Nursing Council of New Zealand which focused on the evaluation of the continuing competence framework for nurses in New Zealand, and contributes to Rachael Vernon’s Doctoral thesis through the University of Sydney, Australia. The research is being undertaken using a sequential mixed-method evaluation research design. Ethical approval has been granted by the Health Research Council of New Zealand Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP and MEC/11/EXP/010, and ratified by The University of Sydney, Human Research Ethics Committee: Ref – 12618.

Participation, Confidentiality and Rights In order to participate, we invite you to respond to the attached questionnaire and describe the ways you believe it is possible for nurses to demonstrate continuing competence; how continuing competence is assessed; and the barriers and/or enablers that may exist. We anticipate this will take approximately 25-30 minutes of your time.

Your participation in this research is entirely voluntary and you have the right to refuse to participate by simply not responding to this invitation. Completing and submitting your written views about continued competence implies your consent to participate in this research. The information collected will be de-identified, coded, and analyzed. A summary of data findings from the first round will be sent to you for further comment and refinement. It will remain confidential to the researcher on a password protected computer.

The overall findings will contribute to the final written report submitted to Fulbright (NZ), participating Regulatory Authorities, Rachael Vernon’s Doctoral thesis, and publications arising from the research.

Rachael Vernon and her PhD research supervisors are listed below. If you have any questions in relation to this study please contact Rachael Vernon by email.

Rachael Vernon (Lead Researcher) Head of School, Nursing Eastern Institute of Technology New Zealand Fulbright Visiting Scholar School of Nursing University of Washington Seattle, WA, USA Email: [email protected] or [email protected]

Professor Mary Chiarella (Principal Supervisor) Professor of Nursing Sydney Nursing School University of Sydney New South Wales Australia

Dr Elaine Papps (Associate Supervisor) Health and Research Consultant Hawke’s Bay New Zealand

Professor Denise Dignam (Associate Supervisor) Associate Dean Faculty of Nursing, Midwifery & Health University of Technology Sydney New South Wales Australia

To participate in this research go directly to http://www.zoomerang.com/Survey/WEB22CAXLVKEL6/



270

APPENDIX IX Stage Two – Delphi Group A (Expert Panel Interviews):

Research Information Sheet and Consent Form


Information Sheet - Interviews We invite you to participate in this research. In doing so, you will have the opportunity to express your point of view and to have a role in influencing the development of a conceptual model and best practice framework for continued competence for nurses.

Why are we doing this research?

The purpose of this research is to develop a consensus view of best practice for nurses to demonstrate continuing competence, and for regulatory authorities to assess continuing competence.

The need for continuing competence is agreed by regulatory authorities to be necessary to protect the public in health processional regulation. Definitions of continuing competence within legislation and policy across developed nations have strong similarities. However, recent research conducted within New Zealand indicates that there is confusion over the level to which continuing competence needs to demonstrated, and the criteria against which continuing competence should be assessed. This study aims to develop a consensus view amongst regulatory experts and authorities for a conceptual model for demonstration and assessment of continuing competence. In addition, a gap analysis will be undertaken to analyze the conceptual model against existing requirements. Recommendations will be made for legislative and policy change to align best practice with existing conditions.

This research is the second stage of a larger study, completed under contract to the Nursing Council of New Zealand which focused on the evaluation of the continuing competence framework for nurses in New Zealand, and contributes to Rachael Vernon’s Doctoral thesis through the University of Sydney, Australia. The research is being undertaken using a sequential mixed-method evaluation research design. Ethical approval has been granted by the Health Research Council of New Zealand, Health and Disability Multi Region Ethics Committee, reference number: MEC/09/64/EXP and MEC/11/EXP/010, and ratified by The University of Sydney, Human Research Ethics Committee: Ref – 12618.

Participation, Confidentiality and Rights

We invite you to participate in a confidential interview. We anticipate the interview will take approximately 30-40 minutes of your time and is comprised of questions relating to your experiences and understanding of the assessment and demonstration of continuing competence; barriers and/or enablers that may exist; and your views with regard to the development of a conceptual model for the demonstration of continuing competence between six countries – Australia, Canada, Ireland, New Zealand, United Kingdom, United States of America. The interview will be recorded and then transcribed. All responses will be treated in confidence by the researcher and any identifying information removed. You may request to see your interview transcripts; decline to answer any questions; withdraw from the study at any time; ask any questions about the study at any time during participation; provide information on the understanding that your name will not be used unless you give permission to the researcher.

The information collected will de-identified, coded, collated and analyzed. It will remain confidential to the researcher on a password protected computer. The overall findings will contribute to the final written report submitted to Fulbright (NZ), participating Regulatory Authorities, Rachael Vernon’s Doctoral thesis, and publications arising from the research.

Rachael Vernon and her PhD research supervisors are listed below. If you have any questions in relation to this study please contact Rachael Vernon by email.

Rachael Vernon (Lead Researcher) Head of School, Nursing Eastern Institute of Technology New Zealand Fulbright Visiting Scholar School of Nursing University of Washington Seattle, WA, USA Email: [email protected] or [email protected]

Professor Mary Chiarella (Principal Supervisor) Professor of Nursing Sydney Nursing School University of Sydney New South Wales Australia

Dr Elaine Papps (Associate Supervisor) Health and Research Consultant Hawke’s Bay New Zealand

Professor Denise Dignam (Associate Supervisor) Associate Dean Faculty of Nursing, Midwifery & Health University of Technology Sydney Australia





I have read the Information Sheet and have had the details of the study explained to me. My questions have been answered to my satisfaction, and I understand that I may ask further questions at any time.

I understand I have the right to withdraw from the study at any time and to decline to answer any particular questions.

I agree to provide information to the researcher on the understanding that my name will not be used without my permission.

I understand that the information I provide will be used for this research and that it may also contribute to Rachael Vernon’s Doctoral thesis, and publications arising from both research projects.

I agree / do not agree to the interview being audio taped. (Please circle your choice)

I understand that I have the right to ask for the audio tape to be turned off at any time during the interview.

I agree to participate in this research under the conditions set out in the attached Information Sheet.

Signed: ................................................................................. Name: ................................................................................. Date: .................................................................................

271

APPENDIX X Ethics Approval Documentation

Human Research Ethics Committee

Web: http://www.usyd.edu.au/ethics/

ABN 15 211 513 464

Marietta Coutinho Deputy Manager Human Research Ethics Administration

Telephone: +61 2 8627 8176 Facsimile: +61 2 8627 8177

Email: [email protected]

Mailing Address: Level 6

Jane Foss Russell Building – G02 The University of Sydney NSW 2006 AUSTRALIA

Ref: MC/KR 3 March 2010 Professor Mary Chiarella Sydney Nursing School The University of Sydney Email: [email protected] Dear Professor Chiarella

Title: Evaluation of the Nursing Council of New Zealand Continuing Competence

Framework (Ref. No.12618)

PhD student: Ms Rachael Vernon Your application was reviewed by the Executive Committee of the Human Research Ethics Committee (HREC), and in doing so the Committee has ratified your study to include the PhD student – Ms Rachael Vernon. The Executive Committee acknowledges your right to proceed under the authority of Multi-region Ethics Committee, New Zealand. Please note, this ratification has been given only in respect of the ethical content of the study. Any modifications to the study must be approved by Multi-region Ethics Committee, New Zealand before forwarding a copy to The University of Sydney Human Research Ethics Committee. Yours sincerely

Marietta Coutinho Deputy Manager Human Research Ethics Administration cc Ms Rachel Vernon [Email: [email protected]]

http://www.usyd.edu.au/ethics/




From: Karen Greer on behalf of Human EthicsTo: Mary ChiarellaCc: Rachael VernonSubject: Noted CorespondenceDate: Friday, 13 July 2012 11:59:16 a.m.

Dear Prof Chiarella & Rachel

Title: Evaluation of the Nursing Council of New Zealand Continuing Competence Framework

Protocol No: 12618

Thank you for your correspondence dated 3 July 2012 providing additional documentation which

has been approved by the Health and Disability, Multi-Region Ethics Committee, New Zealand

This correspondence has been noted and placed on file for future reference.

Yours sincerely

Human Research Ethics Committee

The University of Sydney

KAREN GREER | Ethics Administration Officer

Office of Research Integrity | Research Portfolio

THE UNIVERSITY OF SYDNEY

Lvl 6, Jane Foss Russell Building G02 | The University of Sydney | NSW | 2006

T +61 2 8627 8171 | F +61 2 8627 8177

E [email protected] | W http://sydney.edu.au

CRICOS 00026A

This email plus any attachments to it are confidential. Any unauthorised use is strictly prohibited. If you receive this

email in error, please delete it and any attachments.

Please think of our environment and only print this e-mail if necessary .






http://sydney.edu.au/

Multi-region Ethics Committee c/- Ministry of Health

PO Box 5013 1 the Terrace

Wellington Phone: (04) 816 2655

Email: [email protected]

12 April 2011 Rachael Vernon Faculty of Health and Sports Medicine EIT Hawke’s Bay Private Bag 1201 Taradale Dear Ms Vernon - Re: Ethics ref: MEC/11/EXP/010 (please quote in all correspondence)

Study title: Developing a conceptual model for the demonstration and assessment of continuing competence.

Investigators: Rachael Vernon This study was given ethical approval by the Multi-region Ethics Committee on 5 April 2011. This approval is valid until 31 December 2011, provided that Annual Progress Reports are submitted (see below). Access to ACC For the purposes of section 32 of the Accident Compensation Act 2001, the Committee is satisfied that this study is not being conducted principally for the benefit of the manufacturer or distributor of the medicine or item in respect of which the trial is being carried out. Participants injured as a result of treatment received in this trial will therefore be eligible to be considered for compensation in respect of those injuries under the ACC scheme. Amendments and Protocol Deviations All significant amendments to this proposal must receive prior approval from the Committee. Significant amendments include (but are not limited to) changes to:

the researcher responsible for the conduct of the study at a study site the addition of an extra study site the design or duration of the study the method of recruitment information sheets and informed consent procedures.

Significant deviations from the approved protocol must be reported to the Committee as soon as possible. Annual Progress Reports and Final Reports The first Annual Progress Report for this study is due to the Committee by 5 April 2012. The Annual Report Form that should be used is available at www.ethicscommittees.health.govt.nz. Please note that if you do not provide a progress report by this date, ethical approval may be withdrawn. A Final Report is also required at the conclusion of the study. The Final Report Form is also available at www.ethicscommittees.health.govt.nz.

We wish you all the best with your study. Yours sincerely [e-signed] Rohan Murphy Administrator Multi-region Ethics Committee Email: [email protected]

272

APPENDIX XI Process of Qualitative Analysis

Process of Qualitative Analysis and Associated Data Files

Stage One - Evaluation of the NCNZ Continuing Competence Framework

Reference in document / Coded Data Files Page Number Phase One: Document Review and Policy Analysis (Chapter 4) 79-102 • Historical review

Descriptive analysis (4.3, p.80)) 80-92

• Document Review 94 separate NCNZ documents related to CCF; o Summary Table Document Code NC95/09 (RV) o Individual Documents #NC1/09 - #NC94/09 (RV)

92-95

• Policy Analysis – Musick’s (1998) Framework for Policy Analysis o Document Codes #CCF/09, #RAPP/09

57-59, 95-100

Phase Two: Interview Data (Chapter 5) Analysis - Thomas’s General Inductive Approach (2003)

103-121 61

• Qualitative Interviews (26) o Research information sheet and consent forms (Appendix II) o Findings (5.0)

59-61 263

103-121 Recorded interviews / Audio files o Document codes #A01/09 - #A26/09 (NVIVO_RV)

Interview transcripts o Document codes #T01-T26/09 (NVIVO_RV)

59-61, 103-104

Thematic categorisation and generation of sub-themes o Document codes #TC-QI/09, #ST-QI/09 (NVIVO_RV)

104-119

Summary Analysis o Document code #SA-QI/09 (NVIVO_RV)

119-121

Raw data and consistency of data theming at each phase of analysis was independently checked by Doctoral supervisors

103-104

Stage Two - The International Consensus Model for Assessment of Continuing Competence

Reference in document / Coded Data Files Page Number Delphi Technique Stage Two: Delphi Findings (Chapter Eight) • Delphi Round One – Qualitative Interviews (14)

o Expert Panel Research information sheet and consent forms (Appendix IX)

o Analysis – Content Analysis o Findings (8.2)

65-69, 71-73 164-208

67-70

270 71-72

165-181 Recorded interviews / Audio files o Document codes #A01/12 - #A14/12 (MP3_RV)

165-166

Interview transcripts o Document codes #T01-T12/12 (NVIVO_RV)

Thematic categorisation o Document codes #TC-QI/09, #ST-QI/12 (NVIVO_RV)

167-180

• Delphi Round Two – Analysis - Summative Content Analysis o Research information sheet (Appendix VIII) o Findings (8.3)

70-71 269

181-189 Consistency of initial data analysis and thematic categorisation and generation of sub-themes independently checked by a doctoral supervisor

166

• Delphi Round Three - Quantitative (statistical) E-Survey (8.4) 70, 203 • Delphi Round Four - The Consensus View (9.2)

o Summary Document (Appendix VI) o Qualitative Data Files #SM_DELPHI/R4_2013

71, 210-215 267

Ethical Approval (3.5) o Ethical Approval Documents (Appendix X)

74-75 271