Continued Competence

1. Continued Competence Maryann Alexander, PhD, RN Chief Officer, Nursing Regulation NCSBN

2. Welcome to the Continued Competence Committee

4. 2012 • Voice of consumer is getting louder • Patient safety movement • Knowledge explosion: An average of 1000 articles per day is added to Medline (1 million in three years) • New knowledge needs to be embedded in practice • How do individual practitioners remain current? • Global issue that crosses professions

5. Assumptions • Boards of Nursing have a responsibility to assure the competency of all licensees. • APRNs should demonstrate competence throughout their career.

6. Continued Competence for APRNS • Varied methods • Should be based on APRN competencies • Amount of rigor varies • No evidence that any specific method assures competence • State may have requirements/Certifiers have requirements

7. 2007 AARP and CAC Study • More than 95% of the respondents believe that health care professionals should be required to show that they have current knowledge and skills necessary to provide quality care as a condition of maintaining licensure. • 90% indicated periodic re-evaluation of health care providers as being very important. • 68% indicated they thought this was already being done.

8. Currently Known Methods

9. Continuing Education Easily obtainable Already mandated in many states

10. Continuing Education Evidence indicates that individuals attend conferences that provide education on what they already know or perform well. They also choose sessions that they think are interesting, but not necessarily where they lack knowledge.

11. Peer Review/ Performance Appraisals An effective way of assessing interpersonal skills, professional behaviors and some aspects of patient care. Already being done in patient care settings.

12. Peer Review/ Performance Appraisals Reproducible results rely on multiple evaluators (5-10 or more) Difficulty orchestrating data collection from a potentially large number of individuals Often considered confidential Legal defensibility questionable If the APRN is not employed in a direct patient care setting, peer evaluation of knowledge and skills will not be attainable.

13. Patient Surveys An effective way of assessing interpersonal skills, professional behaviors and patient care. Reliability estimates of .90 and higher have been achieved through this method, however these vary according to setting and type of practitioner.

14. Need to obtain enough to provide reproducible results, resources needed to collect, aggregate and report responses. Many employers and unions argue that patients should not be involved in this process. Patient Surveys

15. DiagnosticAssessment Psychometrically sound Legally Defensible Easy to administer Publicly credible Provides direction for CEs

16. Diagnostic Assessment Individuals feel intimidated Expensive to produce Measures what you know, not necessarily what you can do Need evidence that this method is effective

17. Practice Hours • Practice is important- maintain skills and keeping current • Not enough to assure competence

18. Portfolio/Self-Reflection Useful for evaluating mastery of competencies that are difficult to measure in other ways such as use of scientific evidence in patient care. Useful for determining individual accomplishments and learning gains.

19. Portfolio/Self-Reflection Substantial evidence now exists that this is not an effective method for continued competence. All but the highest performers tend to overestimate their ability. Those that perform in the lowest 25th percentile are the worst at self assessment and identifying gaps in their knowledge. Not administratively feasible.

20. Multiple Methods • Exam-written and/or skills test • CEs based on the exam results • Remediation • Peer review

21. FSMB • Require licensees to take objective knowledge and skills assessment. • Use comparative data and performance expectations to assess quality of care they provide and then use best evidence. • Each licensee must complete one designated activity per year.-Practice relevant CE and documentation of components two and three every 5-6 years. • Evidence of ongoing participation in ABMS maintenance of certification to have fulfilled all three components.

22. Simulation An effective method to assess clinical decision-making and the application of nursing knowledge. Assesses both knowledge and skill. Demonstrated by the aviation industry to be an effective measurement of performance.

23. Extensive resources are needed Expensive Test reliability concerns Numerous centers needed within a state Simulation

24. Objective Structured Clinical Examination • Can assess actual skills the practitioner needs including ability to communicate with the patient. • Has been shown to be a consistent, fair, and valid exam process.

25. OSCE • Expensive • Time intensive

26. Basic Requirements • Administratively feasible • Publicly credible • Professionally acceptable • Legally defensible • Economically feasible

27. Whose responsibility is this? Where’s the evidence? Do we need this? What’s the best method?

28. Consumers Professional Nursing Organizations Stakeholders Legislators

29. Overarching Principles • We want individuals to know when they don’t know. • We want individuals to know how to problem solve. • We want to foster a learning environment and a culture of competency.

31. What is in the Future?

32. 2008-2010 NCSBN Strategic Initiative #3 Measurement of Entry and Continued Competence