Wednesday, 25 February 2015

Commentary: Relevance of competence and competencies to nursing

Sally Lima, Fiona Newall, Sharon Kinney, Helen Jordan, Bridget Hamilton

Commentary on O’Connell J. Gardner, G. & Coyer F. (2014) Beyond competencies: using a capability framework in developing standards for advanced practice nursing. Journal of Advanced Nursing 70(12), 2728-2735

The debate about the relevance of competence and competencies to the nursing profession has been going on for decades. On one side are those who argue competencies have no place in the professions, relevant only for vocational training. On the other side are those who support a broader conceptualisation that can be applied to all levels of training, education and practice. The recent paper by O'Connell et al. (2014) has added another perspective suggesting that competencies, while relevant to undergraduate nursing education and beginning practice, are not appropriate for advanced practice nursing. Instead they recommend the use of a capability framework for the development of advanced nursing standards.

In beginning their discussion, O'Connell et al. (2014) describe competence as a nebulous concept, with varying definitions. Without question the literature is replete with discussion papers on the meaning of competence and its value to nursing. In his discussion of competence, Eraut (1998) states ‘those who like a tidy world will be disappointed’ (p. 127). Rather than avoid or complicate the issue, Eraut (1998) proposes the most worthwhile discussions about competence occur when there is clarity around why the word is being used, the issues that are being addressed and the assumptions that are being made.

O'Connell et al. (2014) are quite clear that their conceptualisation of competence relates primarily to the ability to perform clinical skills in a stable environment. Heywood et al. (1992) refer to this as a behaviourist approach to competence. In this context, competencies, in effect, are tasks in which there can be no disagreement as to what is required. O'Connell et al. (2014) argue that nurses in advanced practice roles do not function according to a prescribed list of tasks, but instead, incorporate cognition and recognition of context in complex environments to inform practice. O'Connell et al. (2014) claim there is a necessity to move beyond competencies to capabilities, particularly when developing standards in advance nursing practice. Heywood et al. (1992) refer to this as an attributes based approach to competence. From an attributes based perspective, competence represents one’s potential to perform (Watson et al. 2002), or what one is capable of (Eraut 1998).

The assumptions inherent in O'Connell et al. (2014) argument is that advanced practice nurses go beyond competent to capable; from a behaviourist approach to competence to an attributes-based approach. However, Heywood et al. (1992) propose a third approach to competence; one that has received little attention in the literature. From a holistic perspective, Heywood et al. (1992) propose that the behaviourist and attributes-based approaches are two sides of the same coin, and that while both approaches to competence attempt to gain evidence to determine the level of competence attained, each has inherent strengths and weaknesses. The application of a combination of both approaches, a holistic approach, is recommended. According to Chen and Watson (2011) the holistic approach to describing competence is accepted by researchers and regulatory bodies alike. At the same time Chen and Watson (2011) state the acceptance of a holistic approach has been at the level of gaining consensus as to what competence is, rather than operationalising the concept.

Instead of proposing a capability framework, it may be more beneficial to see how O'Connell et al. (2014) might operationalise the holistic approach to competence to advanced practice nursing. O'Connell et al. (2014) claim a key driver for the necessity to move beyond competencies to capabilities is the unpredictable and dynamic environments that advanced practice nurses work in. Yet, given the complexity of health care in the 21st Century, it is widely recognised that all nurses work in challenging, demanding, dynamic environments from the time of registration.

O'Connell et al. (2014) claim the focus in undergraduate studies places emphasis on development of psychomotor skills. Yet ask those responsible for developing the curricula, or the undergraduate nursing students completing their studies, and the response will be that the focus is on developing competent, qualified professionals who have the capacity to reflect, think critically, and act in dynamic, unpredictable environments. Supporting this argument, the Australian Qualifications Framework Council (2013) provide the specifications that guide accrediting authorities in both the education and training sectors in Australia. The Australian Qualifications Framework make explicit the expected knowledge, skills, and application of knowledge and skills from Level 1 training (a basic certificate in a vocational area of practice) to Level 10 education (a doctoral degree) (Australian Qualifications Framework Council, 2013). At Level 7 (a bachelor’s degree), it is stated the graduate will ‘analyse, generate and transmit solutions to unpredictable and sometimes complex problems’ (Australian Qualifications Framework Council, 2013, p. 47). Therefore, it is not capabilities that distinguish the advanced practice nurse. Rather, it is the extent to which those capabilities are applied along a continuum of competence.

In her seminal work, Benner applied the Dreyfus Model of Skill Acquisition to nursing, describing the five levels of development nurses pass through; novice, advanced beginner, competent, proficient, and expert (Benner, 2001). Notice that the competent level sits in the middle. It is important to recognise the Benner does not claim novices or advanced beginners as incompetent, and acknowledges that an expert might return to a novice or advanced beginner stage should the area of practice change. Perhaps, Dreyfus and Dreyfus (1980), did the professions and nursing no favours by placing the word competent in the middle of a model describing a continuum of competence (cited in Benner, 2001).

Heeding the words of Eraut (1998) that there should be clarity regarding terminology, the following definition of competence from a holistic perspective was proposed in a recently completed PhD thesis: ‘Competence is the application of abilities, knowledge, skills and attributes, for the benefit of the community being served. It is evolutionary, contextual and impermanent, requiring commitment to ongoing development’. Moving forward, the authors of this letter suggest re-focussing our priorities from discussing the division between advanced and non-advanced practice to better understanding and enabling the development of competence, as defined above, across the continuum of nursing practice.

Sally Lima, PhD, MN, Grad Dip, BN, RN
Royal Children’s Hospital Melbourne, Australia

Fiona Newall, PhD, MN, BSc (Nsg), RN
Royal Children’s Hospital Melbourne, Australia

Sharon Kinney, PhD,MN, BN, PICU Nursing Cert., Cardiothoracic Cert.
Royal Children’s Hospital Melbourne, Australia

Helen Jordan, PhD, DipEd, BSc(Hons)
University of Melbourne, Australia

Bridget Hamilton, PhD, BN (Hons), RN
University of Melbourne, Australia

The authors of the original article have responded to this commentary.


Australian Qualifications Framework Council. (2013). Australian Qualifications Framework. 2nd edition. Retrieved February 13, 2015, from

Benner, P. (2001). From novice to expert: excellence and power in clinical nursing practice (Commemorative ed.). Upper Saddle River, NJ: Prentice Hall.

Chen, Y., & Watson, R. (2011). A review of clinical competence assessment in nursing. Nurse Education Today, 31(8), 832-836.

Eraut, M. (1998). Concepts of competence. Journal of Interprofessional Care, 12(2), 127-139.

Heywood, L., Gonczi, A., & Hager, P. (1992). A guide to development of competency standards for professions. Canberra: Australian Government Publishing Service.

O'Connell, J., Gardner, G., & Coyer, F. (2014). Beyond competencies: using a capability framework in developing practice standards for advanced practice nursing. Journal of Advanced Nursing, 70(12), 2728-2735. doi: 10.1111/jan.12475

Watson, R., Stimpson, A., Topping, A., & Porock, D. (2002). Clinical competence assessment in nursing: a systematic review of the literature. Journal of Advanced Nursing, 39(5), 421-431.

Monday, 23 February 2015

Clinicians’ use of smartphones at work

Lin Perry, Editor
Wayne Varndell, Clinical Nurse Consultant in Emergency Care, Prince of Wales Hospital, Randwick NSW, Australia

After 20 years of prohibition the blanket ban on mobile phones in hospitals was lifted. Smartphones and mobile computing devices are becoming an integral part of working lives in almost every industrial and professional field. Use of such devices presents opportunities and challenges for professional nursing practice: enhanced clinician and patient education, patient engagement (Doswell et al. 2013) and communication (Wu et al. 2011), but also potential erosion of professional behaviours and attitudes, patient privacy, confidentiality, safety (Westbrook et al. 2010) and infection control (Brady et al. 2007). McBride (2015) focuses on one aspect of risk – that posed by clinician distraction by smartphone use. Citing claims that lack of consensus definition is hampering progress in understanding and managing this hazard, McBride sets out to address this by undertaking a concept analysis.

There is no question that this topic is contentious, and that the pace of changing practice has far outstripped research and policy. Surveys suggest that over 70% of nurses and physicians already use smartphones in daily clinical practice (Dolan 2012, Kiser, 2011), with over 30,000 medical apps (applications) available across all mobile device platforms ( 2015). While this may decrease the need for clinicians to commit and retrieve information from memory (thereby reducing error potential), how this is managed within routine care is less clear. There is little clear evidence this is a problem in healthcare, and issues elsewhere of appropriate use but inappropriate timing have been conflated with inappropriate use (‘cyber-loafing’). How patients feel if their nurse is using a phone is unknown. Do they feel any less cared for? Do patients accept that clinicians are not necessarily a fount of information and may need to look things up? (But wouldn't they rather clinicians did if they needed to?) However, lack of robust regulation and peer review processes are causing growing concerns over the credibility of information provided by some applications (Haffey et al. 2013), whilst deficiencies have been flagged in some nurses’ knowledge and discrimination of internet resources (Gilmour et al. 2008). Further, whilst combining high resolution photography and messaging (text, voice) allows sharing of more detailed information between clinicians (Hsieh et al. 2015), this may entail transmission across unsecured devices and networks. The urgent need for health technology development and uptake, and research-based policy, is obvious.

Does this concept analysis progress this agenda? A concept analysis has merits as a mechanism to establish clarity where there is otherwise inconsistency or confusion. A critic might consider the attributes of distraction identified in this paper obvious as well as evidence-derived, but this is perhaps irrelevant if the paper establishes consensus. The temptation on the part of policy-makers might be to see this paper as vindication of smartphone use as ‘distraction’ and hence problem. The situation is clearly more complex, with urgent need for high quality information on a range of perspectives.

In the short term, a return to knee-jerk blanket bans is neither appropriate nor achievable. Whilst we wait for the research and new technologies, policy-makers are probably prudent in adopting a cautious approach. A concept analysis may help with this.


Brady, R., Fraser, S., Dunlop, M., King, P., Paterson-Brown, S. & Gibb, A. 2007. Bacterial contamination of mobile communication devices in the operative environment. Journal of Hospital Infection, 66, 397-398.

Dolan, B. 2012. Survey: 71 percent of US nurse use smartphones. [Online]. MobiHealthNews. Accessed 27/01/2015 at:

Doswell, W., Braxter, B., Devito Dabbs, A., Nilsen, W. & Klem, M. 2013. mHealth: Technology for nursing practice, education, and research. Journal of Nursing Education and Practice, 3, 99-109.

Gilmour J.A., Scott S.D. & Huntington N. 2008. Nurses and Internet health information: a questionnaire survey. Journal of Advanced Nursing 61(1), 19–28 doi: 10.1111/j.1365-2648.2007.04460.x

Haffey, F., Brady, R. & Maxwell, S. 2013. A comparison of the reliability of smartphone apps for opioid conversion. Drug Safety, 36, 111-117.

Hsieh, C., Yun, D., Bhatia, A., Hsu, J. & Ruiz De Luzuriaga, A. 2015. Patient perception on the usage of smartphones for medical photography and for reference in dermatology. Dermatologic Surgery, 41, 149-154.

Kiser, K. 2011. 25 ways to use your smartphone. Physicians share their faviourite uses and apps. Minnesota Medicine, 94, 22-29.

McBride, D. 2015. Distraction of clinicians by smartphones in hospitals: a concept analysis Journal of Advanced Nursing DOI: 10.1111/jan.12674

Pocketgamer.Biz. 2015. App store metrics [Online]. Accessed 27/01/2015 at:

Westbrook, J., Woods, A., Rob, M., Dunsmuir, W. & Day, R. 2010. Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine, 170, 683-690.

Wu, R., Rossos, P., Quan, S., Reeves, S., Lo, V. W., B, Cheung, M. & Morra, D. 2011. An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study. Journal of Medical Internet Research, 13, 1-15.

Wednesday, 11 February 2015

Clarity Needed in Studies on Gender and Access to Cardiac Rehabilitation

Women are less likely than men to attend secondary prevention or cardiac rehabilitation services, but this problem may not be exclusively attributable to gender. Both women and men can benefit from secondary prevention and cardiac rehabilitation interventions, and there is a need to understand the barriers to uptake that exist for both genders.

A new review and synthesis of qualitative studies on the issue, published in JAN, found that despite the abundance of social theories of gender, few papers have specified a definition or theoretical position on gender.

Jan Angus, lead author of the paper, says: “Gender is frequently treated as a demographic variable or a property of an individual, not as the relational concept feminists intended it to be. Researchers then assume that men’s or women’s views are the result of gender, but overlook the social, material or institutional circumstances that contextualize and shape these meanings. Without conceptual clarity about the social origins of gender, we miss important analytic steps.”


Angus J.E., King-Shier K.M., Spaling M.A., Duncan A.S., Jaglal S.B., Stone J.A. & Clark A.M. (2015) A secondary meta-synthesis of qualitative studies of gender and access to cardiac rehabilitationJournal of Advanced Nursing. doi: 10.1111/jan.12620

Saturday, 7 February 2015

Wednesday, 4 February 2015

World Cancer Day 4 February 2015

To mark World Cancer Day we asked Professor Alex Molassiotis, the Angel S.P. Chan Lau Professor in Health and Longevity, Chair Professor of Nursing and Head of the School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China and Editor in Chief of the European Journal of Oncology Nursing to select some papers on cancer from JAN and to comment; here is what Alex had to say:

Professor Alex Molassiotis
I first selected two longitudinal studies by Stephens et al. (2014) and McSorley et al. (2014). The study by Stephens et al. comes from Australia and focuses on the experiences of patients with multiple myeloma, an under-researched topic for a rare cancer. Through 47 interviews of ten patients over time it provides a deeper understanding of the patient’ attempts to balance their new reality, their illness demands and the need to continue with a ‘normal’ life. It also shows the emotional labour of living with this illness and the issues shaping their survivorship experience. The unique and complex design of this study deserves a special note, as it allows us to understand the dynamic nature of the illness experience within the same person over time. McSorley et al. studied 149 patients with prostate cancer in Northern Ireland using mixed methods focusing on the assessment of coping strategies used by patients. Several positive coping strategies were identified, used more often in the early stages after diagnosis but less often 6 months or a year later. Only a minority used maladaptive coping. This study also shows that the partners of the patients had unmet needs as well as single patients, suggesting the need for early identification of their needs and intervention as appropriate.

In a feasibility trial by Wu et al. (2014) in children and adolescents with cancer, a psychoeducational intervention, which has shown positive effects in coping and symptom experience in the past in other settings and populations, was tested for acceptability and feasibility in a Taiwanese setting. The intervention was shown to be acceptable and there were significant differences in terms of gastrointestinal symptoms and pain between the experimental and control group. Other symptoms alongside coping were not different between groups, although the small sample size of this under-powered trial may be the reasons.

A systematic review of a Finnish group of researchers Hökkä et al. (2014) adds to the pool of
systematic reviews focusing on managing pain in advanced cancer, using non-pharmacological interventions. Due to problems and limitations in the reviewed studies, no concrete conclusions could be made, although massage, biofeedback with relaxation, physical therapy, or cognitive strategies had some marginal effects. Nevertheless, no statistically nor clinically significant changes of note were observed between experimental and control arms in the trials. There is a need to focus on more rigorous trials with a wider range of non-pharmacological interventions.

From the UK, a qualitative study by Warnock and Tod (2014) focuses on an under-researched topic, that of the patient experience in the presence of spinal cord compression. The significant level of impairment in this patient population and the effects on daily life are described. These data add to our limited understanding of this debilitating and complex condition, not surprisingly with hope and uncertainty being key aspects in shaping this experience. Finally a qualitative study from Australia (Barlow et al. 2014) focuses on early-stage vulvar cancer patients’ experiences. This particular paper focuses on part of the study findings, those related to sexuality and body image. The majority of women had minimal physical symptoms. However, radical vulvar excision, multiple vulvar procedures and/or the development of lymphoedema were all linked with negative emotions and highlight them as risk factors that health professionals could be aware of and assess in these women.

The selected papers will be free to access for 3 weeks.


Barlow EL, Hacker NF, Hussain R, Parmenter G (2014) Sexuality and body image following treatment for early-stage vulvar cancer: a qualitative study Journal of Advanced Nursing 70, 1865-1866

Hökkä M, Kaakinen P, Pölkki T (2014) A systematic review: non-pharmacological interventions in treating pain in patients with advanced cancer Journal of Advanced Nursing 70, 1954-1969

McSorely O, McCaughan E, Prue G, Parahoo K, Bunting B, O’Sullivan J (2013) A longitudinal study of coping strategies in men receiving radiotherapy and neo-adjuvant androgen deprivation for prostate cancer: a quantitative and qualitative study Journal of Advanced Nursing 70, 625-638

Stephens M, McKenzie H, Jordens CFC (2014) The work of living with a rare cancer: multiple myeloma Journal of Advanced Nursing 70, 2800-2809

Warnock C, Tod A (2014) A descriptive exploration of the experiences of patients with significant functional impairment following a recent diagnosis of metastatic spinal cord compression Journal of Advanced Nursing 70, 564-574

Wu L-M, Chiou S-S, Sheen J-M, Lin P-C, Liao YM, Chen H-M, Hsiao C-C (2013) Evaluating the acceptability and efficacy of a psycho-educational intervention for coping and symptom management by children with cancer: a randomized controlled study Journal of Advanced Nursing 70, 1635-1662