Nursing competence: too elusive to be assessed?

Abstract

While university-based baccalaureate nursing programmes are recognized for developing more knowledgeable and analytical nursing graduates, there are ongoing, universal concerns about the clinical competence of graduates. In this presentation, we argue that the graduates’ apparent skill deficits are an artifact of how nursing competence is conceptualized. Specifically, when nursing competence is conceptualized in a behavioristic manner with an emphasis on tasks and skills, nursing graduates are assessed on the basis of what they can do, rather than on the cognitive and affective skills needed for safe, effective practice. On the other hand, a holistic approach focusing on the general underlying attributes, such as knowledge and critical thinking, would more adequately measure the overall competence of the graduates. In this sense, a holistic conceptualization encompasses the intersection of the fields of ‘generic competencies’, ‘discipline knowledge’ and ‘professional practice’ (Barrie, 2006). Thus, how nursing competence is conceptualized has implications for competence assessment. For example, a behavioristic conceptualization of nursing competence is more likely to adopt a direct observation of task performance whereas measurement of underlying competencies is inferred through competent performance of tasks in the context of holistic competence assessment. We suggest that difference in competence conceptualization is the root cause of the longstanding criticisms about insufficient attention given to developing nursing graduates’ clinical competence. Assessing nursing competence holistically, however, is challenging. It is likely that a multi-method approach may yield more promising results than the use of a single method of assessment. The more recent developments in assessment (e.g. critical companionship), in addition to the more established ones (e.g. OSCEs and portfolios), may also offer additional methods of competence assessment. Irrespective of the assessment methods, it is important to bridge the gap between education providers and clinicians on how nursing competence is defined and assessed, so that an integrated approach to competency development and assessment can be implemented spanning the period of pre-registration, through registration, to post-registration. Finally, not only should the theoretical frameworks that underpin competency assessment be made explicit, rigorous evaluation of the different assessment methods is also essential.