Full text of DOI:10.1111/j.1755-6686.2000.tb00106.x

Competency based standards for advanced
practice in nephrology nursing
G. Stewart1, A. Bonner2
1. Central Sydney Area Health Service, 2. University of Western Sydney
Australia.
Summary
The purpose of this paper is to present the outcomes of a nationwide nursing research project in Australia. Utilising
the Delphi technique, ninety-four clinically based nephrology nurses reviewed a series of competency based standards
documents. The purpose of this research was to reveal the ways in which nephrology nurses practice at an advanced
level. The results will facilitate the way in which advanced practice nephrology nursing is understood and inform nursing
curricula development.
Key words
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–
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Advanced practice
Competency based standards
Delphi technique
NTIL RECENT TIMES much of what nurses know and
how they practice has gone unrecognised. This fact has In 1987, the International Council of Nursing (ICN) argued for
Background
U
hampered the way in which specialisation in nursing practice a more orderly, collaborative approach to what is understood
has developed over time and has resulted in a rather haphazard about specialist nursing knowledge. The Council argued that
approach to the understanding of specialty nursing practice. there are four essential elements required in order to develop
This is nowhere more apparent than in nephrology nursing. and maintain nursing specialties; that is, education, experience,
Nephrology nurses are both practical and versatile and practice performance and advanced competence (1). It was suggested by
within and across a broad range of subspecialties within acute, the council that by establishing and maintaining these essential
community and more isolated settings. The complex range of elements, nursing specialties would be able to explicate specif-
knowledge, skills, attributes and management abilities they ic competencies at an advanced level. This notion was further
develop over time create therefore, innovative, insightful, developed and clarified to Australian nurses in 1991 by Dr.
reflexive, highly skilled practitioners.
Margretta Styles (2,3). Dr. Styles explained for the first time that
Because of its complex nature, articulating advanced prac- in order to integrate these elements, specialty nurses must first
tice within this specialised field of nursing has always been of all understand how to define their specialty, then identify ser-
problematic. This paper documents the results of a national vice demand and client group, develop minimum competency
nursing research project undertaken by the Renal Society of standards and establish systems of professional credentialing.
Australasia (RSA). The purpose of the research was to uncover Competency standards have the potential to optimise patient
the ways in which nephrology nurses in Australia practice, at an outcomes in a very real way and they also provide an appropri-
advanced level and to develop a competency based instrument. ate system of measurement with which to rationally and strate-
As the competency based approach to advanced nursing prac- gically influence the educational, workforce and skill mix
tice has developed in Australia, this instrument represents the requirements in the workplace.
benchmark by which the performance of advanced level
nephrology nursing practice is measured.
In 1994 the Australian Nursing Council Incorporated
(ANCI) produced competency standards (4) which represented
entry-level practice for newly registered nurses in Australia and
are the point of reference from which the Competency Stan-
dards for the Australian Advanced Practice Nephrology Nurse
have been developed. In 1996, the RSA established a national
working party to produce, ‘a national system of competency
based assessment for nephrology nurses practising at an
advanced level, in Australia’ (5).
Glenn Stewart was appointed as a Renal Clinical
Nurse Consultant in 1987. Her other roles include
tutor, CAPD Nurse and Honorary Associate and
External Advisor at the University of Sydney. She
is the Past President of the Renal Society of
Australasia.
Ann Bonner is currently a lecturer at the
University of Western Sydney Nepean and is
undertaking her doctoral studies. She also works
part-time as a Clinical Nurse Specialist. She is
Immediate Past President of the Renal Society of
Australasia.
The philosophical foundation on which the competencies
have been developed hinges on the following beliefs:
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Nephrology nursing is diverse and complex,
Nephrology nursing goals are directed towards facilitating
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the patient’s transition through an acute and/or chronic ill- technique, which incorporates a survey approach (6). A group
ness towards optimum health and independence, of experts formulate a draft document (competency standards)
The advanced practice nephrology nurse demonstrates which is then circulated to other experts (who are not part of
expert knowledge, skills, experience and leadership, the original group). Respondents critique the document, which
The advanced practice nephrology nurse is accountable and is then returned to the expert panel who collate the responses
responsible, and formulate a revised document for recirculation. This
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–
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The advanced practice nephrology nurse co-ordinates ser- process is repeated several times until consensus is reached (7).
vices, thereby facilitating both patient care, education and The advantages of this research technique are that a structured
rehabilitation,
format is required, responses are coordinated, high quality ideas
–
The advanced practice nephrology nurse practices in an eth- are generated, there is minimum peer pressure and the whole
ically responsible way to protect and defend the rights of process takes place over three or four rounds of data collection
patients and their families (5).
and analysis (8).
The scope of the project has been to fill the gap between the
ANCI entry level competency standards and those expected of
the nephrology nurse who practices at an advanced level. Of
equal importance, this project also provided the framework for
specialist postgraduate nephrology nursing curricula in Aus-
tralia and the opportunity to make recommendations regarding
both assessment and credentialling of the advanced practice
nephrology nurse.
The project commenced in 1996 and involved:
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Convening a nine member expert panel representing each
state/territory in Australia who developed and reviewed
each round,
Establishing a ninety-four member, national clinical review
team who were purposively sampled, who also agreed to
participate in the study, met the selection criteria, which
was modified from previous competency based research (9)
and represented the diverse nature of nephrology nursing
practice (see Table l),
Research design
The research method chosen for this project was the Delphi
–
The development, analysis and refinement of the document
Graph 1: Frequency and importance scale
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ꢀ Currently practising in the specialty, with at least three years
clinical experience.
Competency 15: Anticipates,
plans for effective utilisation . . .
Alpha: .88 (high)
ꢀ Has attended renal in-service/workshops/conferences etc. in
the last 12 months.
Average inter-item corr.: .65 (moderate)
N = 47
Item-total correlation,
Alpha if deleted
ꢀ Committed to continuing professional education.
ꢀ Seen to be a role model.
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Higher = better
for item-total
correlation.
ꢀ Available to review written documents during a 12-month
period.
Lower = better
for alpha if
item deleted.
ꢀ Respected by peers and others.
ꢀ Supports less experienced staff.
If alpha when
deleted > alpha
then item is
Reliability for this competency
is highly satisfactory.
Table 1: Selection criteria for clinical review team
problematic.
by the expert panel as it progressed through three consecu-
tive rounds.
C15 C15E1 C15E2 C15E3
Competency & element
Results
Competency 5: Recognises, enhances profes-
sional abilities, Alpha: .67 (moderate)
Average inter-item corr.: .34 (low)
Round 1
The clinical review team rated each domain, competency
statement, element of competency and performance criterion
using a 4-point Likert scale ranging from ‘strongly disagree’ to
‘strongly agree’. The team were also free to provide other com-
ments, corrections and suggestions. Sixty-eight reviewers (72%)
completed this round and the descriptive analysis for Round 1
revealed an overall mean of 3.49, median response of 3.95 and
a standard deviation of 0.50. In other words, most reviewers
rated ‘strongly agree’ for most items in round 1 (5).
N = 49
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Higher = better
for item-total
correlation.
Reliability for this competency is fair but
could be better.
Element 5 is the least satisfactory.
Lower = better
for alpha if
item deleted.
If alpha when
deleted > alpha
then item is
problematic.
C5
C5E1 C5E2 C5E3
Competency & element
Round 2
Competency 3: Demonstrates, justifies accounta-
bility for practice, Alpha: .63 (moderate)
On the basis of this analysis and with the added comments
offered, the expert panel revised the document and included
two new rating scales, ‘frequency’ and ‘importance’ for round 2.
The frequency rating scale referred to how often each clinical
reviewer believed she/he actually performed the competency or
element of competency, at an advanced level. The importance
scale referred to how important the clinical reviewer believed it
was for the advanced practice nephrology nurse to be able to
demonstrate the competency or element of competency (5).
Fifty-two clinical reviewers (55%) returned the round 2
document. Scores from both ‘frequency’ and ‘importance’ scales
were combined but extra weight was given to those
N = 50
Average inter-item corr.: .31 (low)
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Higher = better
for item-total
correlation.
Reliability for this competency is fair but
could be better. Element 3 is causing the
most problems.
Lower = better
for alpha if
item deleted.
If alpha when
deleted > alpha
then item is
problematic.
C3
C3E1 C3E2 C3E3
Competency & element
competency standards and elements of competency that the
reviewers considered to be either ‘essential’ or ‘highly desirable’
for advanced practice (see Graph 1). This meant that the com-
bined frequency and importance scale scores ranged from:
Competency 20: Demonstrates leadership quali-
ties, Alpha: .46 (moderate)
N = 51
Average inter-item corr.: .16 (low)
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
Higher = better
for item-total
correlation.
–
–
–
–
20 to 100 for an ‘essential’ rating,
6 to 19 for a ‘highly desirable’ rating and
1 to 5 for a ‘desirable’ rating.
Those rated as ‘never’ occurring, automatically scored zero
(5).
Reliability for this competency is
definitely suboptimal.
Element 3 is the most problematic.
Lower = better
for alpha if
item deleted.
If alpha when
deleted > alpha
then item is
In Graph 1 the vertical axis has been re-drawn to exaggerate the
lower section (a logarithmic scale). This enables closer inspec-
tion of low scores on the graph. It is readily apparent that a
wide range of scores was achieved on this scale. The highest
median was 100 (occurring 20 times) and the lowest was 6
(occurring 3 times) (5).
problematic.
C20 C20E1 C20E2 C20E3
Competency & element
Graph 2: Reliability for selected competencies
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In Graph 2 (Competency 15), the value of alpha is high, a good
thing in this case. The remaining 3 competencies (3, 5 and 20)
emphasise the importance of establishing a strong relationship
between each competency standard statement and its associat-
ed elements. This analytical process was conducted for every
competency standard and demonstrated that the relationship
between Competency 20 (Leadership) and its associated ele-
ments was the most difficult to establish. This appeared to indi-
cate that the clinical review team held very diverse opinions
about the role of leadership in advanced practice (5).
The results from round 2 suggested a high level of congruence
in the way the clinical reviewers prioritised the competencies in
terms of their frequency and importance for nephrology nurses
practising at an advanced level. There was less agreement about
competencies 6 and 20. The expert panel then undertook an
extensive revision of competencies 6 and 20 prior to circulating
the document for the third and final round (5).
Domain 1: Professional practice
1. Functions in accordance with
legislation and common law
affecting nephrology nursing
practice.
Domain 4: Clinical problem
solving
12. Holistically manages complex,
therapeutic renal interven-
tions.
2. Actively protects the rights of 13. Develops and manages a plan
individuals and groups.
3. Demonstrates and justifies
accountability for nephrology
nursing practice.
of care to achieve predicted
outcomes and considers
implications for ongoing care.
14. Anticipates and plans for
effective and efficient utilisa-
tion of resources.
4. Contributes to effective ethical
decision making relevant to
nephrology nursing practice.
Domain 2: Reflective practice
Domain 5: Teamwork
5. Recognises and enhances own 15. Effectively manages and
professional abilities and level
of clinical competence.
Co-ordinates the care of a vari-
ety of individuals and groups
with renal impairment.
6. Incorporates evidence-based
research into nephrology
nursing practice.
16. Collaborates as an active
member within the renal
health care team to achieve
optimal outcomes.
17. Creates and maintains a sup-
portive, collegial working envi-
ronment.
Round 3
Twenty-five clinical reviewers (27%) responded with final
comments. In fact there were very few comments and the lim-
ited response by the clinical review team appeared to indicate
that the majority had either no further comments to make or
had lost interest. Whilst this could be seen as a limitation in
terms of poor response to round 3, the expert panel considered,
in consultation with the statistician, that round 2 had exhaust-
ed the availability of new information in the form of competen-
cy statements or elements.
Domain 3: Empowerment
7. Establishes and maintains a
physical and psychosocial
environment which promotes
safety, security and optimal
health.
Domain 6: Leadership
18. Provides leadership within
nephrology nursing.
8. Actively enhances the dignity
and integrity of individuals
and groups.
9. Protects the individualís rights
to autonomy and facilitates
informed decision-making.
10. Establishes and maintains
open lines of communication
with individuals and groups.
11. Assists the individual and/or
group to plan for future
lifestyle changes associated
with chronic renal impair-
ment.
The expert panel therefore decided that further rounds
would not generate any new information and that sufficient
consensus had been reached (5).
Discussion
Several nursing competencies standard documents were already
in existence in Australia at the beginning of the research project
(4,10,11). The structure of these documents included the iden-
tification of areas of practice (domains), and the development
of:
Table 2: Competency standards for the Australian Advanced Practice
Nephrology Nurse
Figure 1: Structure of Competency Standards Document
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(a) competency standard statements unique to each domain,
(b) elements of practice which describe each competency stan- ments and performance criteria can be found in ‘Competency
dard and Standards for the Australian Advanced Practice Nephrology
description of the competency standards and their related ele-
(c) performance criteria which provide specific, concrete exam- Nurse‘ (5).
ples of the expected level of nursing practice (see Figure 1).
By utilising the Delphi technique, broad areas of clinical prac-
Conclusion
tice (domains) within which nephrology nurses work, were The benefits arising from this project are far reaching. The
revealed. Six (6) domains were identified (see Table 2) each of meaning of competence for the advanced practice nephrology
which illustrate the range, scope and diversity of advanced nurse has now been established in all its complexity and diver-
practice nephrology nursing. The eighteen competency stan- sity. Nephrology nurses have the opportunity to examine their
dard statements (see Table 2) contained within these domains, practice against a validated, well-researched, clinically relevant
describe the knowledge, skills and attributes of the advanced performance tool. In addition, this document serves as a cata-
practice nephrology nurse (5).
lyst for the future development of a system of credentialling
Each competency standard consists of a group of elements (which will recognize advanced practice knowledge and skills
and is an active statement of ‘what’ the advanced practice at a professional level) and for the accreditation of postgraduate
nephrology nurse does (10). The research identified sixty four educational courses. Furthermore, the overall outcomes of this
elements of competency which explore the ways in which research project have clarified for employers, consumers, edu-
(‘how’) the nephrology nurse demonstrates advanced practice cators and other health professionals at a national level, the role
within that particular competency standard (10). A detailed of the advanced practice nephrology nurse in Australia.
Address for correspondence
Glenn Stewart, Renal CNC
c/o Renal Unit, Concord Hospital
Hospital Road, Concord, N.S.W. 2139
Australia
Email: stewartg@crgmail.crg.cs.nsw.gov.au
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