Nursing collaborates on project to address
issues related to professional competency

On Feb 18th this year the Ministry of Health hosted a meeting initiated by nurse leaders to collaboratively examine a number of professional issues relating to extended and advancing practice and to a number of matters loosely related to credentialing.   The day was jointly organised and chaired between NZNO and the College of Nurses.
This brief paper aims to inform the wider nursing community of the meeting and its intent and the plan for ongoing work.

 

Mark Jones (Chief Nurse)  welcomed participants and outlined his understanding of the purpose of the day which was to discuss the boundaries of the RN scope of practice and potential expansions of that; the multiple existing frameworks for specialty practice and competencies and the interface of various organisations in determining frameworks and credentialing mechanisms.  The aim is a fit for purpose workforce which provides public safety.
The meeting began with a brainstorm of the key issues which had prompted nurse leaders to begin such a  discussion and to identify work needing to be done.   Areas identified included:
• There is constant need for endorsement  from multiple agencies (education contracts, Ministry, specialist practice, new groups of specialty nurses, strategy developments and service specifications). 
• There are multiple sources of competency documents being  developed as the drive to define and own particular specialties increases.
• There is growing need for improved capacity to meet the needs of increasingly complex clients.
• New Zealand, like all countries, is faced with ensuring that the health workforce is flexible and responsive to need rather than locked into older practice arrangements
• The existence of the MoH multi disciplinary credentialing working party considering  organisational credentialing means that nursing must have a consistent and coherent response.
• There is lack of clarity and consistency between concepts such as extended, expanded and advanced practice which are sometimes used interchangeably. There would be tremendous value in a shared terminology utilised by the profession in all forms of communication both internal and external.
• NCNZ recently released a letter suggesting a review of the RN scope and some have raised the potential for development of another scope of practise linked to PDRP (level 4)
• The issue was raised late last year as to whether RNs were competent to perform mental health assessment for cognitive impairment.
• NCNZ have been considering the issues of nurses doing first surgical assist; or procedures such as  colposcopy. These are but two examples of  increasing demand for added tasks or procedures.

The PDRP framework is  the process by which nursing determines and  assesses levels of competency to practice.  However nationally there is low participation in the PDRP program and a high level of resistance from some nurses.  There are also issues of  national consistency versus regional interpretation and many perceive a  need to streamline the process and to  increase participation.   There is now a need to gain clarity as to how the PDRP process might relate to or underpin other credentialling activities.

Those present at the meeting agreed that clarification of terminology was obviously required. The larger task is the development of an overarching framework which clarifies or creates the links or intersections between processes such as standards development, PDRP assessment, competency review and any organisational credentialling of additional tasks.

Those present at the meeting agreed 4 prioritised issues for future work but also began a discussion of these key areas and how they might be progressed.
• mutual understanding of terminology;
• framework and credentialing of extended and delegated tasks noting any relationships with PDRP;
• Rules of engagement for moving a unified nursing view forward and a process to address any emerging tensions;
• Marketing the project and outcomes of the work.

1.Common terminology

There is an existing National Nurse Organisation (NNO)   Glossary of Terms from Australian NNOs and Heartfield (2006) documents for reference.  Terms for a NZ glossary were listed  by those present and included: expanded, extended, advanced, expert, specialty, specialist, generalist, standards, competency, and practice indicators.  The group worked on the definitions and related information – see below.

Competence – there is an existing NCNZ definition.

Extended – addition of a particular skill or task (Daly & Carnwell 2003) to nursing practice.  This may be a delegated task from, or substitution of, another health professional.  It is an activity which would not be considered the norm within the scope of RN practice.  Over time this extended activity may come into the “normal” scope of RN practice as has already occurred over the years. The meeting agreed that this would be an organisational credentialing activity rather than a regulatory activity.  The term “Bolt-ons” was used and it was acknowledged that they will always happen.   The major focus of this discussion was agreement that nursing as a discipline supports nurses doing such tasks as long as;
• they are added to a base of confident nursing practice.  As an example it is expected that in conducting any such tasks or procedures  a nurse would continue to provide relevant  health education and care for the recipient of the task in a comprehensive manner.
• mechanisms are in place to ensure that the nurse is safe to practice due to appropriate preparation and the presence of an appropriate and supportive environment.  NZNO has always provided the advice that the employing organisation has a policy which supports this extended practice, the nurse is assessed as having the knowledge and skills to undertake the extended procedure, and that is documented and then regularly assessed.

Expanded and advanced – growth and development of nursing practice rooted in philosophy of nursing.  Extended practice was seen as a pathway to expanded and advanced practice which included a much more comprehensive understanding and embedding into the philosophy of nursing.

Nurse Practitioner  – encompasses both expanded and extended activities to a level set by the NCNZ competencies.

PDRPs – is there a relationship between extended practice and the PDRP?  There could be.  If there is to be an extended practice procedure then should the nurse be practising at a certain level on the PDRP for a particular extension?  There was robust discussion around this issue however it was agreed that there should not be a bureaucratic, costly process or unnatural barrier.   The meeting agreed there is a necessity to refine PDRP evidential portfolio requirements before there could be enforcement of PDRP requirement and this could be one of the streams of work that comes out of this project.

Further terminology discussion and agreement included;

Expert – about the individual and their knowledge, skills and attributes.

Specialty – area of practice.

Specialist – level of practice.

Generalist –ICN specification (see Heartfield 2003, 13) not particularly helpful.  

Concluding remarks about terminology - If a shared understanding of terminology for the future is agreed then we need an algorithm/framework for testing a new case against our terminology.  Then nursing can identify principles of what needs to be in place to protect the client, nurse and service provider.  From this basis it  could then be determined where the credentialing should sit.  Discussion occurred about whose responsibility it was to approve the extension of practice within the organisation.

Rules of engagement for any tensions and challenges arising from ongoing work

The meeting agreed that it was important to work on this area as a successful framwork would require co-operation from a range of stakeholders in nursing.  This is identified as an area for future work.

The Framework
The participants then worked on a framework which outlined all of the current actions,  stakeholders and  processes related to credentialling or competency review,  A diagram was produced which simply outlined “who does what” without attempting to resolve any identified issues or concerns. Such an outline clarifies where processes can be strengthened and where greater consistency or simplicity is possible.

Agreed assumptions and values (standards) inherent in developing a framework

• Public safety/leverage
• National consistency
• Stakeholder co-operation/collaboration
• Enabling/flexibility
• Within legislative framework
• Not overly bureaucratic
• Nurses will expect to be appropriately prepared
• National terminology
• Professional reference point
• Congruence in framework and expectations
• Models/guidelines will be developed with a robust consultative process

One key point arising from this first meeting is the need to get legitimacy of professional standards/guidelines implemented nationally. We must ensure the profession is able to inform the Health and Disability Commissioner confidently, that there are agreed and shared standards for practice in every area of practice against which any particular practice can be compared or assessed.

Stakeholder roles identified in the framework

Regulator - Public safety, determining fit for purpose.  A point to remember is that Council has already approved programmes run by other organisations for competency eg PDRP, Practice nurses accreditation and so there is a precedent for other programmes which may emerge.

Professional Associations - set standards,  articulate practice , professional  advancement models, standards-competencies.  Support and leadership for quality nursing outcomes

Employers - concerned with a safe service.  Grappling with issues of expediency and so current issue is that employers are currently determining standards for specialist practice because they perceive a void.  Organisational credentialing  vs Statute vs contractual credentialing – need to sort who does what.

Education sector:  Need to ensure graduates are aware of existence of professional standards and credentialing per se.  Responsive to need – professionally and regionally.  Education funding models (TEC/CTA) to match.

Ministry of Health -   workforce development and sustainability and quality outcomes/systems are the priority.

Future Development:

The College of Nurses and NZNO agreed to prepare a joint statement for the current MoH consultation documenton credentialling.  The statement reads as follows;

Professional Association View
The New Zealand Nurses’ Organisation and the College of Nurses, Aotearoa believe that nursing needs to be responsive and flexible in meeting future health need.  An enabling scope of practice will allow the evolution of a quality nursing service.  Nursing is constantly responding to changes in health service provision and patient care and treatment approaches.  At times this means taking on new responsibilities such as procedural techniques, which may have traditionally been undertaken by other health professionals. This is always in the context of nursing practice.  In these circumstances the credentialing process to ensure public safety needs to assure that a nationally consistent standard is applied, that employing organisations have policies in place which support the nurse undertaking the extended activity, that nurses have the level of knowledge and skill appropriate to undertake the activity independently and that the quality and
outcome is monitored.
 
The respective roles of the regulation authority, the professional associations and the employing organisations in credentialing extensions to practice are not clear at present.  It is the view of the professional associations that they set the standards of practice and that a national system is required to implement and recognise those standards in the employment situation.  The importance of one to one feedback at annual appraisals and professional development planning meetings cannot be underestimated in a quality improvement system and this process needs to occur for everyone.  It is also the view of the professional associations that credentialing of extended practice for nurses should occur within the employment setting and to a consistent national standard and that the regulation authority should regulate scopes of practice using authorization only in a very limited range of situations.

Mark Jones closed the day by saying that what was required was a national nursing reference point to set and/or approve standards which is recognised as having legitimacy and authority by stakeholders.  He offered two potential models for consideration and development while acknowledging that others may emerge.  They were:

i) an umbrella group of NNOs similar to the Australian model, or

ii) individual NNOs agreeing that standards developed by nationally recognised groups will receive endorsement by others according to an agreed process.
No discussion has yet occurred on such suggestions but it is to be incorporated in future work.

A teleconference was then held on MARCH 6TH   to determine work streams emerging from the meeting which were identified and potential leads/actions proposed.  They are:

• Finalising a lexicon of terminology and definitions for NZ.  NETS to be asked to progress this work.
• Refinement of PDRP evidential requirements.  NZNO and NENZ to be asked to progress this work.
• Structure and process for national nursing recognition of standards and specialty competencies.  NZNO, CNA(NZ), CMHN and NCMN to be asked to develop this.  It was also felt that a process to work through any emerging tensions would evolve through this process and the meeting proposed in the next bullet point.

It was agreed that ongoing work would require a further face to face meeting of representatives from NCNZ (CEO, Chair and VChair), professional membership organisations, NENZ and NETS which will be held on 27th April 2009.