Looks Good on Paper but what about Competence? Managing (In) Competency in the workplace

1. Looks Good on Paper but what about Competence?Managing (In) Competency in the workplace Cathy Gilmore Professional Nursing Advisor New Zealand Nurses Organisation cathyg@nzno.org.nz

2. Outline of this session • HPCA Act 2003 • What is competency • Nursing Councils role • Information about competence issues • The workplace • Natural Justice • SIP’s & PIP’s

3. Health Practitioners Competence Assurance Act 2003 (HPCA) To protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practise their professions • Registration and practising certificates for health practitioners • Competence, fitness to practise and quality assurance • Complaints and discipline

4. What is nursing competency • Many literature reviews (NCNZ 2010, Vernon et al. 2011) show that confusion exists for nurses in relation to the meaning of competence, continuing competence, and performance • NCNZ implemented the continuing competence framework in 2004 following the enactment of the HPCA Act. It primary purpose was to provide mechanisms to ensure that nurses were competent and fit to practise their profession.

5. How to determine competency Its more than just NCNZ competencies! • The debate continues widely throughout the world about the conceptualisation of continuing competence • What is clear is that there is a need for flexibility – given the multifaceted nature of nursing practice and the diversity of practice settings (Vernon et al. 2011). • The insight of individuals in relation to their expertise and limitations is critical. • There is a direct correlation between lack of insight and the potential or actual unsafe practice (Pearson et al. 2002a).

6. The Nursing Council of New Zealand (NCNZ) is the regulatory authority for nurses in New Zealand. Vernon et al. 2011, state “The onus for demonstrating and maintaining competence is clearly the responsibility of the individual nurse since the enactment of the HPCA Act, 2003. NCNZ. 2009a, defines competence as “the combination of skills, knowledge, attitudes, values and abilities that underpin effective performance as a nurse”.

7. However, managing competence in the workplace is the responsibility of all parties – the nurse and the employer.

8. Information about competence issues • There are common patterns of issues occurring in nursing practice: • Some issues could be avoided by better selection and orientation • Some nurses are not suited to particular nursing environments • Some managers are not good at managing competence issues in the workplace • The environment does not induce growth and development or good practice

9. Competence review revelations Some nurses have: • Poor insight into their practice and behaviours • Poor decision making skills • Limited critical reasoning • Inadequate nursing knowledge • Minimal assessment skills • Don’t know their limitations

10. Some managers..... • Have a poor understanding of practice needs and the contributory factors for the nurse who may be experiencing practice difficulties in the workplace • Are not fair and reasonable in their approach and processes when a competence issue arises • Are punitive and intimidating in their approach to resolve a nurses competence issues

11. Other managers.... Bend over backwards to assist a nurse to meet competence requirements in the workplace and keep them in practice.

12. Every nurse is vulnerable Personal stressful circumstances affect nursing practice and result in: • Mistakes • Over-reaction or under-reaction to situations Excessive monitoring and supervision causes nurses to: • Make mistakes • Lose confidence and self esteem • Become stressed and anxious

13. Some indicators of continuing competence The nurse seeks out and does: • Post graduate education • professional development beyond what the employer provides • nurse initiated mentorship/support/ supervision to help them reflect on their practice • Identifies changes in nursing practice to keep up to date • Actively use evidenced based practice • Behaves professionally • Proactively seeks out knowledge and skills to improve their practice

14. The workplace Factors that contribute to the growth of nurses’ competency: • Culture - open and innovative • Management style – fair but firm, open and transparent • Staffing numbers adequate to meet the demand • Support – clinical supervision • Communication – open

15. Maslow’s Hierarchy of Needs Usually used to understand patient behaviour but how does it apply to nurses: • Five levels of human needs from basic lower order needs to social and psychological needs of a higher order • People need to have lower order needs met first before they can focus on higher order needs i.e. patients who struggle with the ability to feed and house themselves may not be able to take in health education Fabre, (2005).

16. Maslow’s Hierarchy of Needs • Consider the following: Nurses who transfer patients from their beds to their chairs, with too few staff. This is frequently a cause of serious back injury, a violation of basic physical needs

17. Maslow’s Hierarchy of Needs What about the registered nurse who arrives at work to find that she is on with 3 healthcare assistants instead of the usual five. She is told by management “We’ll do what we can to help you”. The RN is scared and left angry! Scared that she will miss treatable complications or make a serious medical error. Angry because so many previous nurses have resigned due to multiple understaffing situations. Management has violated this nurse’s basic need for safety and security Fabre, (2005).

18. Maslow’s Hierarchy of Needs Nurses thrive in Maslow-conscious environments because; Physically: • They are supported and consequently more productive. • They have more energy and patience for the demanding work. • Nurses support each other by working together. Safety: • Nurses flourish because they are supported by safety conscious organisations Fabre, (2005).

19. Maslow’s Hierarchy of Needs Socially: their organisation resonates with friendliness and warm support encouraging good rostering and the support of each other. Nurses feel appreciated. Self-esteem: Nurses feel validated because their organisation views them as autonomous professionals Self actualisation: these nurses innovate, outline improved work practises, and influence other staff members to function at peak performance. Fabre, (2005)

20. Plans should...... • focus on supporting the nurse, not on disciplinary measures; • set fair, reasonable and achievable goals for the nurse that are clear and well-explained; • follow workplace policies; • ensure a reasonable and agreed timeframe for achieving improvements; • ensure training, mentoring and supervision is provided to the nurse; • be collaborative – ensuring the nurse is involved in developing the performance plan

21. be fair and ensure impartial assessment of the nurse’s performance; • ensure performance criteria are objective, specific, measurable, agreed, realistic and time bound; and • ensure subjective performance criteria have clear descriptions and examples of the type of behaviour expected and can therefore be assessed fairly. (Duncan, 2007; Boyte, 2006)

22. The Principles of Natural Justice This has a specific meaning in employment law and comprises two rules: • The rule against bias and • The right to a fair hearing Natural justice encompasses the following components: • Prior notice of an issue • Fair opportunity to answer to any issues raised and • The opportunity to present their case properly Smith & Partners

23. Employer & Organisation Obligations • To fairly and transparently identify any competency issues • To follow a process of investigation and identification of any issues ensuring the process is fair and follows natural justice principles. NB.( this will keep you out of trouble)

24. There is growing unease among managers about the potential for a personal grievance if the performance management process is poorly managed • Process and documentation of the process is critically important

25. SIP’s and PIP’s Many workplaces have developed a framework to help them to identify competence issues or they use the NCNZ competence framework. These frameworks are based on peer preceptor assessment and feedback on a daily basis on identified competency to practice issues.

26. What's the Problem? RN J has been working in your area for the last 11 months. Other staff are beginning to voice their frustration when working with her on a shift or in the shift following. Some people look at the roster or daily allocation and sigh... when she is on!

27. One RN has approached the Charge Nurse Manager with her concerns. She describes the situation as no one wants to work with J. They think she is lazy and a bit useless! When asked for more information the RN says she (J) can’t handle a normal workload and staff have started giving her less complex patients with a maximum of three patient workload. This has been getting worse for the last 6 weeks and everyone has had enough!

28. What does the CNM do about this? • Option 1 – Does nothing it will all blow over • Option 2 – Call in RN J and tell her to pull her socks up • Option three –investigate the allegations and try to define what the issues with RN J and assess are they accurate • What step is missing here? • Ask the RN to document her concerns then.....

29. What tools/support does the CNM have? • Nursing Council Competencies and guidelines • Nurse Director and/or Director of Nursing • Human Resource Advisors • NZNO Industrial and Professional Nursing Advisors

30. What tools/support does RN J have? • ????

31. What the CNM found... • RN J was often late for shift so didn’t get a full handover • She didn't take her breaks • Her patients missed care such as dressing changes, IV antibiotic doses, patient observations not done • Appears grumpy and moody at work particularly to students and the Health Care Assistants • Failed to do her daily bedside safety checks

32. Is there a reason for RN J’s poor performance? • The CNM must explore this with RN J after she has identified to RN J there have been issues raised and she needs to talk to her about them. RN J should always have the opportunity to have a support person with her at any meeting with the CNM Could be: Crisis at home, relationship issues, domestic violence, problem with another family member etc.... Could be: a problem with alcohol, drug use or gambling.

33. A good employer offers support • EAP • Assistance to address competence issues

34. Moves through a continuum SIP PIP Agreed Timeframe

35. Stage One – Supportive Improvement Plan (SIP) • Based on supporting the nurse to reach a competent level of practise related to her current level of practice • Is an informal process with no long term implications if the nurse returns to competence • Is time framed, supported and measured regularly • If no improvement within the timeframe then would move to a Performance Management Plan (more formal with potential employment outcomes and/or reporting to regulating body)

36. Research • At times of increased job stress managers who showed supportive behaviours and staff that received more positive recognition through the use of feedback increased the likelihood of the nurses intention to stay at work Fabre, 2005 • Positive reinforcement encourages participation Flannagan et al. 2000

37. Research supports: • Giving balanced feedback with both positive feedback and an indication where improvements could be made is more beneficial • Verbal feedback is seen as powerful if immediate • Positive feedback is a potent motivator • Peer feedback is positive if given consistently

38. Why are nurses getting into trouble with competency – one reoccurring scenario You the CNM, arrive at your office on Monday morning. Jackie, one of your most competent nurses, asks for a few moments of your time. She hands you a letter of resignation. She is the third RN to do so in the last 2 months. Even as you think about how you are going to fill the roster you wonder why she is leaving. After all, the nurses have just received a substantial pay rise and they have the best conditions in their contract. However you must address what is becoming a vicious cycle of resignations and overtime for the remaining staff. You need to prevent more resignations and burnout.

39. Jackie's point of View Consider one of her workdays: • She arrives at work and discovers the unit will be short staffed • During her shift she encounters disrespectful behaviour from doctors, managers, or other nurses and wonders why she bothers. Patients are usually the prime source of support the nurse receives • She has had no break because of the heavy workload, causing her to be exhausted early and less effective as the day wears on

40. During a staff meeting she makes some suggestions that would improve care, but management table them, leaving her frustrated and angry • There are several patient admissions that afternoon, but the staff have the attitude of “every nurse for herself”, each struggling to finish her work and unwilling to lend a hand where its needed At the end of the day, certain tasks that would have made a big difference to patients remain undone, and Jackie leaves work feeling that the patients received poor care

41. Ongoing Management • Competence assessment of practising nurses is crucial to maintaining professional standards • Nurses should be assessed at the level of their continuing competence related to the complexities of nursing practice within the context in which it is occurring (Vernon et al. 2013) • Systems problems prevent nurses from performing at their full professional capacity • Organisations that provide environments where nurses can perform at their best attract and retain the best people

42. References • Cook, Pauline (2011). Demystifying Supervision. Kai Tiaki Nursing New Zealand 16(11), 34. • Fabre (2005). Smart Nursing • Flanagan, J., Baldwin, S. & Clarke, D. (2000) Work-based learning as a means of developing and assessing nursing competence. Journal of Clinical Nursing, 9, 360–368. • Health Practitioners Competence Assurance Act 2003 • Nursing Council of New Zealand. (2010). Evaluation of the Continuing Competence Framework. Report prepared for the Nursing Council of New Zealand. Downloaded 03/03/2014 file:///C:/Documents%20and%20Settings/cathyG/My%20Documents/Downloads/Evaluation%20Continuing%20Competence%20Framework%20(2).pdf • Pearson, A., FitzGerald, M. & Walsh, K. (2002a) Nurses’ views on competency indicators for Australian nursing. Collegian, 9 (1), 36–40. • Smith & Partners. Retrieved 03/03/2014. http://www.smithpartners.co.nz/library/articles/litigation/what-is-natural-justice/ • The competence review process. (2008) Nursing Council of New Zealand • Vernon, R.; Chiarella, M.; Papps, E. (2011). Confidence in competence: legislation and nursing in New Zealand. International Nursing Review. Mar2011, Vol. 58 Issue 1, p103-108. 6p. • Vernon, R.; Chiarella, M.; Papps, E.; Dignam, D. (2013). New Zealand nurses' perceptions of the continuing competence framework. International Nursing Review. Mar2013, Vol. 60 Issue 1, p59-66. 8p.

43. Thank you