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Beyond competencies in Australian Nursing
AEJNE Volume 5 - No.1 August, 1999.
Steve Goldsmith has recently returned to clinical nursing practice after a three year stint as a lecturer at Deakin University. His interest in nursing competencies was fired by his work with nurses at undergraduate and postgraduate level, and the gap he observed between academia and clinical reality. Steve is currently working on a research project for his Master of Education, employing discourse analysis in exploring epistemological and cultural issues in nursing curricula.
Implicit in the trend toward competency-based practice has been the goal, encouraged by successive Australian governments, of increasing workforce flexibility and mobility through the formulation of measurable industry standards of work practices (Sutton & Arbon, 1994; Keating, 1994). Advocates of competencies assert that the adoption of such standards assist in the attainment and maintenance of competitive advantage, through fostering the development of leadership skills (Krejci & Malin, 1997) as well as ëcoreí competencies for novice employees (Benner, 1982).
The notion of competencies first arose in the vocational education sector, advocated by policy-makers as a means of extending the pool of 'job readyí' workers for industry (eg. Keating, 1994). The emphasis in vocational education on competencies, whether industry-specific or generic, is held up as a prime strength of vocational education programs in equipping young people for employment (Horner, 1995). However, this paper will argue that competencies are a double-edged sword. The emphasis in vocational education, and by extension in nursing on competencies may be necessary, but is certainly not sufficient to ensure professional and industrial growth.
The paper begins with an overview of some concerns about competencies, focusing on the Victorian landscape of mental health nursing education as an example of a competency-based education program acting to decrease the employability of graduates, and rendering the specialty of mental health nursing unable to attract sufficient numbers of suitably qualified nurses to meet industry demand. This situation has severe potential implications for the integrity of the nursing profession as a whole (ACDN, 1996, 1997), but may be overcome by a progression of nursing education beyond competencies towards more evidence-based, critically reflective paradigms which are integrated with industry rather than attempting to operate in parallel to it.
Competencies and Education
The effect on education of a competency-based approach has tended to involve a change in emphasis from process to outcomes (Ashworth & Morrison, 1991; Hodkinson, 1992; Sutton & Arbon, 1994). That is, a focus on achieving the desired behavioural result (acquiring a competency or skill) takes precedence over the process of teaching and learning, and leads to goal-driven, directive teaching methodologies with little time allowed for material considered ëextraneousí. Although competency-based education enhances exposure to specific, real-life situations, this exposure can work to inhibit the development of problem-solving abilities necessary for the acquisition of genuinely ëtransferableí skills.
The advent of competency-based practice in nursing has long had its critics. A questioning of behavioural definitions of competence centred around skill acquisition (Ashworth & Morrison, 1991; Burchell & Jenner, 1996) has led to debate over the sufficiency of competency-based practice to define professional activity. For example, Hodkinson (1992) proposed an interactionist model of competence which took account of the perceptions and prior experiences of people, and the work context. In her seminal work ìFrom Novice to Expertî, Benner (1982) described five levels of proficiency in skill development, of which 'competency' was only number three. Professional development from 'competent' to 'proficient' and then to ëexpertí involves a ìqualitative transformation' (Benner, 1982, p.406) in practice which does not lend itself to the empirical analysis required for the administration of competency standards. This transformation is the result of experience:
not the mere passage of time or longevity; it is the refinement of preconceived notions and theory by encountering many actual practical situations that add nuances or shades of difference to theory (ibid., p.407).
By their empiric, reductionist nature, competency-based practices give only a limited view of professional practice, and have difficulty incorporating abstract notions such as intuition or somology (Sutton & Arbon, 1994) which are inherent in expert practice (Benner, 1982). Overreliance on competencies can lead to a stunting of a professions development, as only minimal standards tend to be established; future directions are not adequately addressed and become clouded in uncertainty. An example of this is the current predicament of mental health nursing in Victoria (see Box 1, below).
Box 1: Focus on Mental Health Nursing in Victoria
Nursing education has undergone significant changes in Victoria in recent years. The move away from hospital-based, apprenticeship-style training towards university courses has not been without its problems. As elsewhere, the development of meaningful competencies in nursing has been impeded by a perceived widening ëgapí between theory and practice (Cook, 1991; Rodger, 1998).
One of the specialties adversely affected has been mental health nursing, which saw its three-year undergraduate degree program incorporated into the new 'comprehensive' degree (Nurses Act, 1993). Recommendations regarding the mental health component in undergraduate nursing courses (Commonwealth Human Services, 1996; Human Services Victoria, 1996) have met with what can best be described as a mixed response (Happell, 1997), and the specialty has to date been unable to attract sufficient comprehensively trained graduates to maintain professional growth. As a result, mental health nurses run the very real risk of losing competitive advantage over other health professions (notably psychology), with potentially severe adverse effects on the employment prospects of future nursing graduates.
Evidence-Based Practice: Beyond Competencies?
Acknowledgment of the problems inherent in competency-based education has been partly responsible for the rise of what has come to be known as evidence-based practice. The development of so-called ìadvanced competenciesî (McMillan et al, 1996) has been accompanied by the collection of empirical data in attempts to objectively determine 'best practice' models of work design (Hicks, 1997).
However, evidence-based practice is not universally seen as suitable to nursing; as has been shown, many of the work practices in nursing do not readily lend themselves to empirical analysis (Benner, 1982; Hicks, 1997). In fact, Hicks (1997, p.512) asserts that the qualities required for [quantitative] research are almost diametrically opposed to those embedded and nurtured within the corporate psyche of nursing.
This is especially true of the largely intangible focus of mental health nursing (Ellis, 1996; Brooker et al, 1996), to the point where evidence-based practice in this field is still in its early stages, and justifying its growth on economic, rather than clinical grounds. Paradoxically, however, it is through evidence-based practice that a way beyond competencies may be found.
Ellis (1996, p.27) states that 'a change to reflective thinking may result in widespread evidence-based practice'. Discontinuity between theory and practice in nursing (Cook, 1991; Rafferty et al, 1996) and difficulties incorporating research into clinical settings (Hicks, 1997) have been ascribed to the insufficiency of quantitative research methodologies to adequately describe nursing practice. Further, as Cook (1991, p.1467) acknowledges, there is a 'conflict between the theory taught in schools of nursing, and the theories which underpin clinical practice'. Similarly, Rafferty comments on nurses' performance of their teaching/training role, identifying 'a discrepancy between sisters' espoused and actual teaching role' (1996, p.687).
Action Research, Reflective Practice, & Learning Organisations
The idea, alluded to above, that ëespoused theories' are not always consistent with ëtheories in use' (Argyris et al, 1985; Edmondson, 1996) is the basis of action science. Action research utilising critical reflection upon work practices (Argyris & Schon, 1974) can lead to the ìgeneration of informal theory from practice itselfî (Rafferty et al, 1996, p.688). The dual role of action research in generating theory and implementing change (Greenwood, 1994) makes it an ideal vehicle for the growth of the nursing profession beyond the limitations imposed by competencies and evidence-based practice. Nurses' participation in action research can be taken, argues Breda et al (1997), as a sign of growing professional autonomy and empowerment, a development she asserts is not universally encouraged in human resource development programs (p.81).
In her description of attempts to synthesise three seemingly disparate theories of organisational learning, Edmondson (1996) concludes that Scheinís theory of corporate culture, Senge's systems dynamics paradigm, and Argyris' action science are all complementary to the extent that 'tacit sources of ineffectiveness must be made explicit in order to be changed'. (p.590). Recognition, through critical reflection of a conflict between espoused theories and theories-in-use can also be equated with the ìdisorienting dilemmasî Mezirow refers to as precursors to perspective transformation (in Callin, 1996, p.29), the centrepiece of his model of adult education. This describes a key role of reflective practice, evident particularly in action science, in enhancing organisational effectiveness and accordingly affecting the functioning of the organisation as a viable destination for participants in vocational education programs.
The generation of theory from practice is apparent in notions of ëinformalí learning (Marsick & Watkins, 1990) and in assertions that 'work is the primary school for adult learning and development' (Welton, 1991, p.9). Notions of ìlearning organisations '(Welton, 1991) have been reflected in recent Australian policy debate (Crowley, 1997; West, 1998), which recognise the need to move beyond competencies towards a focus on ëlifelong learning'. However, recent cutbacks in funding to higher education (and TAFE) indicate this recognition may not be universal. It may be considered self-evident that andragogical theories of empowerment and self-directed learning (Welton, 1991) are better suited to higher education than the 'institutional arrangements' inherent in competencies (Sweet, 1992, p.341), but the short term economic advantages of the latter approach has had undeniable appeal. The adoption of competency standards may give to employee selection processes the appearance of objectivity (Drucker, 1974), but they give little indication of an employeeís capacity for independent job performance. On the other hand, the notion of the workplace itself being a setting for, and a subject of education is driven by the assumption that ìindividuals 'beliefs and insights are...critical influences on organisational effectiveness' (Edmondson, 1996, p.571).
The competencies movement, for all the practical difficulties it encounters, has a vital part to play in 'bridging the gap' between theory and practice in the workplace (Cook, 1991). However, continuing reliance on competencies and other empirically-driven methodologies such as evidence-based practice are necessary, but not sufficient to ensure continuing professional development, and hence long term employment growth and security.
The effectiveness of competency-based education programs is directly affected by the capacity of employing organisations to incorporate new ideas and practices. In a competitive, changing work environment, strategies which are cogniscient and responsive to the specific requirements of individual professions are essential to ensure the continued viability of both education and industry sectors (Marginson, 1999). Action research informed by reflective practice can build on the foundations laid by competencies and evidence-based practice, to ëcustomiseí the relationships between the health professions, and their corresponding education programs.
List of References
Argyris, C., & Schon, D.A., (1974) Theory in Practice: Increasing Professional Effectiveness, Jossey Bass, San Francisco
Argyris, C., Putnam, R., & Smith, D.M., (1985) Action Science, Jossey Bass, San Francisco
Ashworth, P, & Morrison, P., (1991) 'Problems of competence-based nurse education', Nurse Education Today, 11: 256-60
Australian Council of Deans of Nursing [ACDN], (1996) Position Statement: generic health workers
Australian Council of Deans of Nursing [ACDN], (1997) Position Statement: unregulated health workers
Benner, P., (1982) 'From Novice To Expert', American Journal of Nursing, 82(3): 402-07
Breda, K.L., Anderson, M.A., Hansen, L., Hayes, D., Pillion, C., & Lyon, P., (1997) 'Enhanced nursing autonomy through participatory action research', Nursing Outlook, 45(2): 76-81
Brooker, C., Repper, J., & Booth. A., (1996) 'Examining effectiveness of community mental health nursing', Mental Health Nursing, 16(3): 12-15
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Cook, S.H., (1991) 'Mind the theory/practice gap in nursing', Journal of Advanced Nursing, 16: 1462-69
Crowley, R., (1997), Beyond Cinderella: towards a learning society / a report of the Senate Employment, Education and Training Committee, A.G.P.S., Canberra
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Edmondson, A.C., (1996) 'Three faces of Eden: the persistence of competing theories and multiple diagnoses in organizational intervention research', Human Relations, 49(5): 571-95
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Marginson, S., (1999) 'The changing nature and organisation of work, and the implications for vocational education and training in Australia: A critical review and summation of the international literature', in preparation
Marsick, V.J., & Watkins, K.E., (1990) 'Toward a theory of informal and incidental learning', in Informal and Incidental Learning in the Workplace, Routledge, London
McMillan, M., Andrews, J., & Bujack, E., (1996), 'A question of advanced competence', Australian Nursing Journal, 4(3): 30-1
Parliament of Victoria (1993) Nurses Act, State Government Printer, Melbourne
Rafferty, A.M., Allcock, N., & Lathlean, J., (1996) 'The theory/practice 'gap': taking issue with the issue', Journal of Advanced Nursing, 23: 685-91
Rodger, M.L., (1998) Bridging the Theory Practice Gap with a Collaborative Learning Strategy for Senior Nursing and Medical Students: report of the medical and nursing clinical collaboration project, Edith Cowan University, Perth
Sutton, F.A., & Arbon, P.A., (1994) 'Australian nursing - moving forward? Competencies and the nursing profession', Nurse Education Today, 14: 388-93
Sweet, R., (1992) 'Can Finn deliver vocational competence? ', Unicorn, 18(1): 31-43
Welton, M., (1991) Toward Development Work: The Workplace as a Learning Environment, Deakin University Press, Geelong
West, R., (1998), Learning for life: final report: review of higher education financing and policy / Higher Education Financing and Policy Review Committee, A.G.P.S., Canberra
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