Introduction

What is the best way to determine if a nurse is competent? This question is increasingly being asked by employers, regulators, certifying agencies, insurance companies, and professional associations. Currently in many states, a practitioner is determined to be competent when initially licensed and thereafter unless proven otherwise. Yet many believe this is not enough and are exploring other approaches to assure continuing competence in today's environment where technology and practice are continually changing, new health care systems are evolving and consumers are pressing for providers who are competent. The American Nurses Association (ANA) has been asked this question as well by its members, other associations, consumers and the public. Since competence of the registered nurse has become a primary concern of the profession, ANA has embarked on the development of policy addressing the continuing competence of practicing registered nurses.

The purpose of the article is to review various approaches and views related to continuing competency and examine the difficult policy, development and implementation issues related to continuing competency.

Mechanisms for continuing competence include regulatory and private sector approaches, as well as approaches by the ANA and the National Council of State Boards of Nursing (NCSBN). Each approach will be discussed in turn. Nursing policy questions are addressed in the section describing ANA approaches.

Regulatory Approaches to Continuing Competence

Health care practitioners are regulated by state regulatory boards with the purpose of protecting the health, safety and welfare of the public. When a practitioner is initially licensed, they are deemed by the state to have met minimal competency standards. The challenge of licensure boards is to assure practitioners are competent throughout their practice career not just with initial licensure.

The ongoing demonstration of continuing competence is not a new regulatory issue. According to (Schmitt Shimberg 1996), a national commission on health manpower sponsored by the U.S. Department of Health, Education and Welfare recommended physicians undergo periodic reexaminations. In 1971, a similar report recommended that requirements to ensure continued competence should be developed by professional associations and states. The alternative to periodic reexamination was deemed to be continuing education (CE) and states began requiring mandatory CE as a condition of licensure renewal for a variety of professions.

This approach to continuing competence proved to be controversial. Given the broad parameters of what continuing education consists of and the lack of formal research to support the correlation between participation in continuing education and continuing competence related to improved practice outcomes, this method has been called into question. ANA however, is working to make this link by designing a longitudinal descriptive research study to determine the relationship between nurses' attendance at selected education sessions at the 2000 ANA Biennial Convention and its impact on the nurses' practice as reported through self and peer evaluation.

State Legislation/Regulation

In 1994, the board of nursing in Colorado removed CE as a criteria for renewal of licensure because it did not believe CE guarantees competence. (Colorado Board of Nursing, 1994.) However, 26 states continue to require continuing education for nurses' licensure renewal.

There have been other attempts at regulatory approaches to continuing competence. A 1978 law in Michigan allowed professional boards to develop pilot projects to establish mechanisms to assess continuing competence through means other than continuing education. Due to lack of funding and adequate models, no action was ever taken. (Schmitt Shimberg, 1996). In 1986, the governor of New York proposed periodic re-licensure of physicians based on examination and other options. The Medical Board deemed the proposal burdensome and instead proposed re-credentialing of physicians and focused remediation for potential problem physicians. (Schmitt Shimberg , 1996).

In the past few years, state legislative action related to continuing competency has increased. In 1999, legislation was passed in Tennessee requiring the development of continuing competence requirements of occupational therapists. In the same year, legislation was passed in Vermont mandating continuing competency evaluations of physicians, chiropractors, and podiatrists. In the first quarter of the 2000 state legislative sessions alone, 11 states have introduced legislation relative to continuing competence of health professions. Most legislation would required licensees to demonstrate continuing competence to a licensure board upon re-licensure while some bills would require a provider to demonstrate competency in the workplace setting. Of interest is a bill in Massachusetts that would authorize the Board of Registration (Board of Nursing) to require periodic competency testing of all licensed and registered nursing including testing of current nursing practice and procedures. Failure to pass this test would result in automatic suspension of a nurses' license until competency was established A bill introduced in Hawaii would require nurses in hospitals to demonstrate competence in providing care in order to be assigned to a nursing unit. Other continuing competence bills apply to chiropractors, podiatrists, dentists, dietitians, physicians, occupational and physical therapists, pharmacists and speech-language pathologists.

Boards of Nursing (BON) have advocated for the development of nursing projects to assess competency. Minnesota developed a pilot project to assess competency by testing prior to re-licensure, as part of the sunset review process. In 1996, Texas enacted legislation authorizing pilot projects to assess nursing competency. Last year, Tennessee enacted legislation authorizing the BON to establish continuing education requirements.

Recently, the College of Nurses of Ontario (the nursing regulatory board in Ontario, Canada) has been effective in addressing continued competence through three very different methods. The first component is under development and will include a competence evaluation and remediation. The second component is reflective practice or self-assessment to identify strengths and learning needs, peer feedback and implementation of a learning plan. The third component is a Practice Setting Consultation Project to assist employers, through consultation, to examine organizational characteristics that promote quality in professional practice. (Campbell, 1997.)

Certification

As states regulate advanced practice nursing, they are turning to certification as an indicator of entry-level competence. Certification in these instances is therefore not a voluntary process, but instead constitutes a regulatory requirement to ensure public safety and enhance public health. As a result, certifying bodies are expected to demonstrate that their initial certification exams truly reflect entry level and that their recertification process reflects continuing competence.

The underlying assumptions regarding the use of certification to ensure competence and its inherent value have been increasingly questioned since the late 1970's. There is a dearth of empirical data from nursing and other fields which substantiate the predictive power of certification and recertification exams, which has led to the assertion that certification does not have an impact on patient outcomes. However, the American Nurses Credentialing Center's (ANCC's) Institute for Research, Education, and Consultation (IREC) recently completed the first phase of a three part certification research effort that identifies some promising results related to patient outcomes. A survey was sent to a randomized sample of over 40,000 certified nurses in the United States and Canada, of whom 19,000 responded. In completing this survey the nurses compared their pre-certification and post-certification practice. In describing their post- certification practice:

• 51% reported greater confidence in their practice
• 35% felt greater confidence in their decision-making ability
• 28% reported more confidence in their ability to detect complications
• 23% reported more effective communication and collaboration with other health care providers, and
• 6% reported fewer adverse events and errors in patient care than before they were certified.Ann Cary, PhD, RN, principal investigator of the study stated that the data from this study is paramount to an initial understanding of the nature of quality outcomes and patient safety factors that may be optimized by certification (Trossman, 2000).

Private Sector Approaches to Continuing Competence

Joint Commission of Accreditation of Healthcare Organizations

The Joint Commission of Accreditation of Healthcare Organizations (JCAHO) requires hospitals to assess the competency of employees when hired and then regularly throughout employment. The competence assessment is defined as "the systematic collection of practitioner-specific data to determine an individual's capability to perform up to defined expectations." (Joint Commission on Accreditation of Healthcare Organizations, 1998).

Pew Commission

Pew Commission Reports on health professions licensure issues have been a catalyst in bringing the issue of continued competence to the public's attention. In its 1995 report, Reforming Health Care Workforce Regulation: Policy Considerations for the 21^st Century, one of the proposed recommendations is as follows: "States should require each board to develop, implement and evaluate continuing competency requirements to assure the continuing competence of regulated health care professionals." Accompanying the recommendation was a series of policy options. In formal responses to the report from the public, this recommendation received the highest score for level of concern and one of the highest scores for level of support. There were 76 formal responses to the report; 45% were from the nursing community which included state and national organizations as well as nursing boards; 26% of the responses were from individuals; and 29% from other health care professions including occupational therapy, physical therapy, medicine, pharmacy and dentistry. (Gragnola, Stone, 1997).

Some respondents challenged the policy option requiring all regulated health professions to periodically demonstrate competence because they believe it is not necessary and would be too costly. Identified barriers to reform included the complexity of the health care environment and the vast differences in practice. These differences make testing for competence difficult as areas of expertise may not fit into standardized testing. Respondents agreed that some form of continued competence was important but struggled with how to test competency and who should be responsible for competency assurance. Other respondents expressed lack of resources and political quagmires as barriers to continued competence assurance. Suggestions for assuring continuing competence included continuing education with exit testing, peer review programs, practical demonstrations of competency, proactive fellowship programs, and holding employers responsible for ensuring competence of their staff (Gragnola, Stone , 1997).

ANA, in its formal response to the report agrees that mechanisms should be established for determining and ensuring continued competence to practice; however, devising a means of testing is not a simple matter because of the diversity of nursing roles. Certification as a measure of continued competence is one approach and ANA is not quick to dismiss the role of CE. More research is needed to describe the relationship between certification, continuing education and the competency of registered nurses (American Nurses Association, 1996).

A second Pew Report, Strengthening Consumer Protection: Priorities for Health Care Workforce Regulation was released in October of 1998. One of the three priority issues included in the report was continuing competence. The report recommended that state regulatory boards should be held responsible to require health care practitioners to demonstrate competence throughout their careers. However, the report added that the "actual assessment of competence may best be left to the professional associations, private testing companies and specialty boards" (Pew Health Professions Commission, 1998).

Interprofessional Workgroup on Health Professions Regulation

The Interprofessional Workgroup on Health Professions Regulation, which represents 17 health professions, including nursing (ANA is a member), received a Pew Foundation grant to sponsor a continuing competence Summit entitled, "Assessing the Issues, Methods and Realities for Health Care Professions," July 25 - 26, 1997 in Chicago, Illinois. The objective of the Summit was for participants to recognize the significance of ensuring continued competence for health care professionals. The Summit focused on analyzing the issues related to continuing competence and promoted discussion of various methods of assessing continuing competence.

Continuing competence continues to be a priority for the Workgroups' future endeavors including a meeting in Chicago on June 5, 2000. All health care organizations working on or interested in developing continuing competency initiatives are invited to attend. There will be an opportunity to discuss the work that has been done as well as collaborate on common definitions and standards that may be universal for all health care professions.

Other Approaches

Other measures to promote competence have been indirectly aimed at the prevention of potential problems through accreditation of educational institutions, background checks on licensees and the threat of disciplinary action if the licensee is reported to the board.

American Nurses Association

Appointment of an Expert Panel

In May 1999, the ANA Board of Directors appointed an expert panel whose charge was to develop policy recommendations and an action plan with a proposed research agenda regarding continuing competence. Endorsement by the state nurses associations, nursing specialty groups and the Tri-Council would be sought as part of the process. Members of the panel include Cecilia Mulvey, PhD, RN as chairperson representing the American Nurses Association and the American Nurses Foundation; Sara L. Jarrett, RN, MS, EdDc representing State Nurses Associations; Carolyn K. Lewis, PhD, RN, CNAA representing the American Nurses Credentialing Center; Anne Manton, PhD, RN, CEN representing the Nursing Organization Liaison Forum; Joan Shaver, PhD, RN, FAAN representing the American Academy of Nursing; and Vickie Sheets, JD, RN representing the National Council of State Boards of Nursing.

Nursing Policy Questions

ANA outlined the following nursing policy questions and concerns for the Expert Panel to consider while making their policy recommendations:

What is the definition of continuing competence?

Currently there is no agreed upon definition of continuing competence. A review of the literature finds that most definitions reflect the context from which they were developed. As a result, regulatory groups define competency based on the "scientific method" of direct measurable outcomes that has a specific disciplinary based response. Public agencies and employers look at the continuum of competence based on the professional attributes of an individual in a particular situation or practice setting. Educators tend to see competency as a blending of knowledge, skills, attitudes and judgement based more on a psychological construct. Agreement on a definition must be reached before a work plan can be developed and the goal continued competence can be actualized.

Whose role is it to assure continuing competence?

Is it the role of the individual nurse, professional association, employer, regulatory board, or certifying agency to assure continued competence? Should all of the stakeholders be involved, or just one or two?

Is it the role of the individual nurse? The American Nurses Association Code for Nurses (1985) states: "The profession of nursing is obligated to provide adequate and competent nursing care. Therefore it is the personal responsibility of each nurse to maintain competency in practice....The nurse must be aware of the need for continued professional learning and must assume personal responsibility for currency of knowledge and skills.......evaluation of one's performance by peers is a hallmark of professionalism and a method by which the profession is held accountable to society. Nurses must be willing to have their practice reviewed and evaluated by their peers." (The American Nurses Association, 1985). Nurse practice acts hold nurses accountable for their practice based on their education and experience. Is the knowledge of the requirements for competence outlined in the code of nursing and nurse practice act sufficient for nurses to take responsibility to maintain professional competence?

Is it the role of the professional association? The role of the professional nursing association is multifaceted. The professional association develops the standards and guidelines upon which the performance and competency of the professional nurse is based; provides support to the individual nurse to maintain and enhance performance and competence through education and professional development opportunities, certification examinations, and influences changes in nurse practice acts. The professional organization also provides ongoing monitoring of the systems which affect the practice of nursing by developing health policy and supporting nursing research which links nursing interventions to patient outcomes and the ability of the individual to competently practice within the specific practice setting or health care delivery system. Is it the role of the profession to assure the continuing competence of its members? Is continued competence best viewed from within a professional association context versus a disciplinary context as proposed by regulatory boards?

Is it the role of the employer? Employers carry out the requirements of JCAHO, NCQA and other accrediting bodies to assure the ongoing competencies of employees. Many employers provide educational opportunities for employees as well as self-insure against liability for incompetent practices. The work setting influences and dictates the content and quality of nursing practice. What influence does the massive cutbacks and cost containment strategies pursued by many health care networks and facilities have on the ability of nurses to be competent practitioners?

Is it the role of the board of nursing? The board of nursing is required to protect the health and safety of the public, not only when a licensee is initially licensed, but as long as the professional holds a license. Boards take action if the nurse practice act is breached. What role should the board play in developing continuing competence standards and monitoring adherence to the standards? What is the potential for the board to take a positive role in assisting nurses in maintaining their continuing competence? What is their role in monitoring and evaluating the system/employer's ability to support employee RNs in maintaining their continuing competence?

Is it the role of a credentialing entity? A majority of certification agencies have developed re-certification procedures with the main purpose to demonstrate that the practitioner has maintained competence that has not diminished over time. What could their future role be?

How could continuing competence be measured?

There are increasing proposals for determining continuing competence including a written re-examination, peer review, self assessment, client/case review, supervised practice experience, practice evaluation, computer simulated and virtual reality testing, targeted continuing education with outcomes measurement, employer skills testing and practice evaluations. Which approach really measures competence? Which requires an appropriate expenditure of time and cost?

Who should be evaluated?

This question asks whether all nurses should be evaluated, or if instead certain triggers should be identified that would highlight nurses who need to be evaluated. Such triggers may include returning to the workforce after an absence from the workplace, changing the nature of practice or working with few peers.

Who pays for testing?

Who will bear the costs to assure competency? Will it be the individual nurse, the employer, the professional association or ultimately the consumers of care? What percentage of providers are not competent? Is it worth the cost to have all providers demonstrate their continuing competence?

How does the work environment impact on continuing competence?

The rapidly changing environment is driven by health care restructuring and a singular focus on cost-cutting measures. This environment makes it more difficult for nurses to practice based on the standards/guidelines and the Code of Ethics for Nurses which are the basis for competency and for which they are held accountable. At what point should the system/employer be held accountable for impacting on the nurses' ability to maintain their continuing competence or to practice in a competent manner?

Should basic competence or specialized competence be measured?

Should general competence be measured or the specialized practice area where the nurse is currently practicing? Should a nurse who has practiced for 25 years be evaluated in the same manner as a nurse who has just graduated from nursing school? What are the differences and core similarities of evaluating continuing competence of a nurse at difference time periods during their career in nursing - i.e. greater than 1 year; 3 -5 years; 10 years; 10 - 15 years; 15 - 10 years and over 20 years?

What are the legal issues related to continuing competence?

Although many of the issues outlined in the policy section require policy analysis, this new and expanded area of regulation will require legal scholars to address concerns about the implications continuing competence has on the licensees, consumers and institutions. Building on the body of law related to certification and accreditation, malpractice and administrative law, some of the following questions will arise with any system used to measure competency. How could continuing competence be measured? Are the measurements accurate enough to withstand lawsuit? How will boards of nursing determine Afair@ cutoffs when differing measurements are utilized?

Continuing competence tools will have to clearly and precisely measure knowledge, skills and abilities to be psychometrically sound and legally defensible. Tools will have to be developed to clearly compare differing testing systems to each other. Moreover, unless systems are standardized, there will be problems akin to those arising under any federated model B why does one state accept one score and another state accept a second, differing score? Can measurement tools be developed that are free of bias, cultural, and ethnic advantages/limitations? Questions will arise about whether non-governmental organizations or associations who test for continuing competence will be immune from lawsuits arising out of the use of those tests for licensure purposes.

Additional questions include the following. What impact will competency measurement have on malpractice and liability? Who will be liable for nursing malpractice? Will positive continuing competence measurements be used as a bar to lawsuits or a limitation on damages? Should continuing competency measurement be punitive or rehabilitative? The present disciplinary system has components of both; however, additional issues arise when actions are taken by the board of nursing and/or the certifying organization which may reflect deficiencies in practice. Should the board mandate and supervise corrective action or should such action be voluntary? What is the responsibility of the board of nursing if this information remains confidential? Will competency results become discoverable in malpractice litigation?

How will competency measurement be used in licensure and regulation?

If regulatory boards require nurses to demonstrate continuing competence, what role will they play? Will they develop the criteria for competence assessments based on standards and guidelines established by professional associations? Should boards do the actual assessment of competence or should they leave it up to the professional association, credentialing entity or others? How can regulatory boards develop a more positive role in terms of assisting the nurse to maintain and improve competence?

How will competency measurement by used in the workplace?

Does the board have a right or obligation to report to the employer the deficiencies of the licensee? And, does the employer have the right to use such deficiencies to evaluate performance or mandate corrective action? Should such information be placed in employment or board of nursing disciplinary files? Could the continuing competence measurement be used in an arbitrary way by employers to dismiss higher paid employees?

Continuing Competency Forum at the House of Delegates

After the appointment of the Expert Panel, a forum was held at the ANA House of Delegates, June 19, 1999, in Washington, D.C., to explore the difficult questions surrounding continuing competence and the implications for the individual nurse, ANA, regulatory and certifying organizations and others.

Bill Campbell, College of Nursing, Ontario, stated that almost all professions in Canada have a plan for assuring continuing competence and it is mandatory in four of ten provinces. One of the major questions he discussed was, "What is the purpose? Is it public protection or professional growth? One must know the purpose of the continuing competence in order to design the program."

Catherine Dower, Pew Commission, shared the thinking of the Pew Commission's 1998 report which recommended the establishment of a national body to evaluate evidence of professional continuing competence and to set national uniform standards for each profession. She believes the purpose of continuing competence is consumer protection.

Anne Rhone, American Association of Colleges of Nursing, outlined the issues that need to be addressed by the profession and educators, including the clarification of the purpose and intent, and the identification of how standardized testing or assessment could address broad variance in specialty needs. She emphasized the type of measurement methodology should not pose a burden to the nurse.

Dennis Wentz, American Medical Association, pointed out that 90% of physicians take specialty board examinations and pass. There are continuing medical education requirements for recertification. Fourteen programs are now operational and moving toward maintenance of competence rather than testing at intervals.

Sara L. Jarrett, ANA, raised questions requiring study which included: What are the issues and political agendas around continuing competence? What are the options for determining continuing competence? and Who are the key stakeholders?

Joyce Johnson, American Organization of Nurse Executives, shared the employer's perspective on continuing competence. Johnson believes that it is a shared responsibility between the employer, RN and regulatory agency.

Work of ANA's Expert Panel

The Expert Panel has now discussed a variety of methods for ensuring continuing competence and made recommendations. Based on the premise that the vast majority of the nation's 2.6 million RNs are practicing in a competent manner, The Expert Panel appointed in 1999 has formulated the following assumptions regarding continuing competence:

1. The purpose of ensuring continuing competence is the protection of the public and advancement of the profession through the professional development of nurses.
2. The public has a right to expect competence throughout nurses' careers.
3. Any process of competency assurance must be shaped and guided by the profession of nursing.
4. Assurance of continuing competence is the shared responsibility of the profession, regulatory bodies, organizations/workplaces and individual nurses.
5. Nurses are individually responsible for maintaining continuing competence.
6. The employer's responsibility is to provide an environment conducive to competent practice.
7. Continuing competence is definable, measurable and can be evaluated.
8. Competence is considered in the context of level of expertise, responsibility, and domains of practice. (American Nurses Association 2000).

In its deliberations, the Expert Panel formulated these definitions:

• Continuing competence is ongoing professional nursing competence according to level of expertise, responsibility, and domains of practice.
• Professional Nursing Competence is behavior based on beliefs, attitudes, and knowledge matched to and in the context of a set of expected outcomes as defined by nursing scope of practice, policy, Code for Nurses, standards, guidelines, and benchmarks that assure safe performance of professional activities.
• Continuing Professional Nursing Competence is ongoing professional nursing competence according to level of expertise, responsibility, and domains of practice as evidenced by behavior based on beliefs, attitudes, and knowledge matched to and in the context of a set of expected outcomes as defined by nursing scope of practice, policy, Code of Ethics, standards, guidelines, and benchmarks that assure safe performance of professional activities. (American Nurses Association, 2000.)

The Expert Panel developed a Continuing Professional Nursing Competence Process that is based on the development of a professional nurse portfolio by individual nurses. The documentation of information included in the portfolio will be unique to each nurse based on career stage and practice specialty. It is intended that the portfolio will reflect ongoing behaviors that have been identified as influential in promoting competent practice. The process includes external evaluation by peers with feedback to the individual nurse regarding the evidence of continuing competence behaviors. The total process is meant to promote self-reflection and guidance for maintaining and advancing ongoing professional competence. (American Nurses Association, 2000).

The work of the Expert Panel was supported by the ANA Board of Directors in March, 2000. The next step will be review and comment of the Expert Panel's work by the profession. After the review and comments are received and evaluated, the program will undergo a testing and refining pilot phase that involves a sample of volunteer RNs and advanced practice registered nurses. Although federal and state regulators, policy groups and academicians attempt to represent the concerns of the patient consumer, none of the groups looking at policy related to continuing competence had been given the organizational mandate to comprehensively represent the interest of the registered nurse licensee. While all were mindful of the competing interests, the ANA focus has been upon the concerns, needs and implications that continuing competency has on nurse education; nursing practice; nursing regulation; nursing satisfaction and morale; nurse career development; and quality of practice

American Academy of Nursing

The American Academy of Nursing and the Coalition of Nursing Futures convened a meeting entitled "Nursing Futures and Regulation" in 1997 to discuss regulatory issues. This meeting was funded through a grant from the Pew Foundation. Members of the coalition included ANA, the American Organization of Nurse Executives, Commission of Graduates of Foreign Nursing Schools, National League for Nursing, American Association of Colleges of Nursing, National Federation of Licensed Practical Nurses, the National Association for Associated Degree Nurses, State Nurses Associations (SNAs), State Boards of Nursing and nursing organizations representing specialty practice.

A primary objective for this conference was to help nursing leaders discuss diverse perspectives on several important regulatory issues and to identify areas of agreement and disagreement; continuing competence was one of the important regulatory issues addressed (Brooks, 1997). It became clear, however, that each entity -- regulators, specialty nursing organizations, SNAs and professional organizations -- held different definitions and views of competence. ANA agreed to take the lead in organizing a representative group of the profession to explore this issue.

American Nurses Credentialing Center

The American Nurses Credentialing Center (ANCC), established by ANA in 1973 to improve nursing practice and promote high-quality health care services through voluntary credentialing programs and related services. Currently over 150,000 nurses are certified through ANCC in over 30 specialty areas.

ANCC is continuing to collect data on certified nurses, their employers, and characteristics of the practice of certified nurses to determine the impact of certified nurses' practice on patient outcomes. As credentialing bodies continue to examine their certification processes, test various methodologies to measure competencies and gather empirical data, the reliance on certification and recertification will increase. Certification or recertification may provide a credible mechanism for validating and evaluation continued competence.

ANCC must attest to the state boards of nursing that the advanced practice nurse has met an entry level standard of knowledge, skills and abilities, and can practice safely at the entry level. At the five year recertification point, ANCC must again attest through their recertification processes, that the nurse practitioner has continued to remain competent. Because of this responsibility, ANCC initiated a research project to determine if there is a better way to validate continued competence other than through continuing education for nurse practitioners. The ANCC Task Force began working on recertification and competence related to nurse practitioners in 1998 (ANCC, 1998).

The ANCC Continued Competency Task Force came up with a four dimensional model to serve as a framework for the research. This model consisted of 1) standards, 2) domains of practice, 3) competencies, and 4) measurable outcomes. The adult and family nurse practitioner groups will serve as the population for the study, and from these groups a random sample will be selected. In 1998, ANCC conducted an empirical job analysis of all six nurse practitioner specialties - family, adult, gerontology, pediatric, school nurse, and acute care. The job analysis/role delineation study (RDS) identified tasks of practicing nurse practitioners and classified these by frequency and criticality. This RDS will be used to guide the participants in correlating the task with desired measurable outcomes and will also assist in developing the particular content areas for the different methodologies.

The methodologies currently under investigation for measuring the competencies for the two groups are the professional portfolio, computer simulation, and interactive video. ANCC will be working closely with those who have already implemented or tested some of these methodologies (NCSBN and the College of Nurses of Ontario) in order to incorporate the best aspects of work already done. These methodologies will be refined in 2000.

National Council of State Boards of Nursing

Building on existing regulatory models and the mission of its organizations, the National Council of State Boards of Nursing (NCSBN) has explored various approaches to determine continued competence. NCSBN has investigated the use of computer simulated testing (CST) for assessing nursing competence, reviewed and utilized mandated continuing education, and is now focusing on the licensee's responsibility for individual competence. NCSBN has also explored through the Continuing Competence Accountability Profile (CCAP), a self assessment tool, which "provides a framework for nurses to track and document a synthesis of professional growth activities across a nurse's career." NCSBN recognizes that continued competence is a multifaceted issue that compels the profession, consumers and other to assist in comprehensive development of options to best assure ongoing nursing education and skill levels. (National Council of State Boards of Nursing, 1998).

Summary

This article has reviewed a variety of approaches and views related to continuing competency. As early as 1967, a national commission on health manpower sponsored by the U.S. Department of Health, Education and Welfare recommended licensed physicians be re-examined periodically; this commission later recommended CE as an alternative to re-licensure. Currently about half the nursing and medical licensure boards require CE as a component of re-licensure although the link between CE and continuing competence has been questioned. At the same time, other states have attempted to mandate alternative approaches to continuing competence; these approaches have failed due to the lack of funding, inadequate models, and the view that the requirements would be burdensome.

State legislatures continue to address continuing competence; and this year alone 11 states have introduced legislation with varying approaches from re-testing to requiring a provider to demonstrate competency in the workplace. The nursing regulatory board in Ontario, Canada, has implemented a program where continuing competence is determined through evaluation, reflective practice and a Practice Setting Consultation Project to assist employers to promote quality in nursing practice. Certification has also been promoted as a means to assure competency although the link between certification and continuing competence has not been well established. Indirect approaches to continuing competence, include accreditation of educational and health care institutions; licensee background checks; and the threat of disciplinary action.

The Pew Commission Report once again brought the issue of continuing competence to the public's attention though 1995 and 1998 reports, calling for states to assure the continuing competence of regulated health care professionals. The nursing community including the American Nurses Association, the American Academy of Nursing, the American Nurses Credentialing Center and the National Council of State Board of Nursing have been grappling with approaches to assure continuing competency of nurses including a professional portfolio, computer simulated testing, and reviewed CE. There have also been many discussions surrounding difficult policy questions related to continuing competency including: What is the definition of continuing competency? Whose role is it to assure continuing competency? How could continuing competence be measured? Who should be evaluated? Who pays for it? How does the work environment impact on continuing competence? Should basic competence or specialized competence be measured? What are the legal issues related to continuing competence? How will competency measurement be used in licensure and regulation? and How will competency measurement be used in the workplace?

An expert panel was appointed in 1999 by the American Nurses Association's Board of Directors to address these issues and make policy recommendations. Based on the premise that the vast majority of the nation's 2.6 million nurses are practicing in a competent manner, the expert panel developed a Continuing Professional Nursing Competence Process (CPNCP) that is based on the development of a portfolio by individual nurses. The work of the panel was supported by the ANA Board of Directors in March, 2000 and the next step will be to disseminate the CPNCP for comments and review by the profession. After comment and review, a testing and refining phase will take place. ANCC is also exploring the link between continuing competency and certification.

The ANA is the only group or agency that has been given the organizational mandate to look at policy related to continuing competence and represent the interest of the registered nurse licensee. ANA is taking seriously its cutting-edge responsibility to represent the nursing profession on this important issue.

Authors

Susan Whittaker, MSN, RN

Susan Whittaker, MSN, RN, is Associate Director of State Government Relations for the American Nurses Association. Creating strategies for implementation of state legislative initiatives that are important to nurses, Ms. Whittaker represents the American Nurses Association at national meetings of state legislators and regulators, governors, and special interest groups. Prior to joining the American Nurses, Ms. Whittaker worked on health and social service issues as a professional staff member for the Senate Labor and Human Resources Committee in Washington, D.C. for Senator Orrin Hatch (R, Utah). Her clinical nursing experience includes providing perinatal and emergency care in hospitals, homes and on air transports.

Winifred Carson

Winifred Carson is nurse practice counsel for the American Nurses Association. As practice counsel, Windy is responsible for drafting, reviewing and commenting on state and federal legislation, administrative rules and regulations, providing legal opinions on clinical issues, and responding to legal inquiries related to nursing.

Windy has extensive experience in regulatory affairs and has been involved with the regulation of nursing more than fifteen years. Prior to joining the ANA, she served as the Legislative Staff Director for the Council of the District of Columbia, Committee on Consumer and Regulatory Affairs and as a legislative analyst for the D.C. Department of Consumer and Regulatory Affairs. In these positions, Windy worked with the occupational licensure boards on statutes and regulations. She drafted legislation covering licensure, insurance, hospital, environmental matters, housing, businesses and service facilities. Previously, Windy served as a legislative analyst to the Maryland General Assembly and as an intern to the U.S. Senate Committee on Appropriations.

Windy writes and lectures on nursing practice. She is a contributor to the American Nurse, Nurse Practitioner Forum and Nurse Practitioner magazines. She recently completed a chapter for the book Nurses, Nurse Practitioners: Evolution to Advanced Practice and is a member of the editorial board for the American Journal of Nurse Practitioners. She is also on the Editorial Advisory Board for Health Law Week. This year, Windy was the guest editor of Issues and Trends, an ANA publication on policy matters, for the May and December editions. These issues addressed collaboration and advanced practice and the legal implications of nursing standards. Windy also writes, reviews and consults on legal issues related to nursing. She speaks throughout the country and internationally on the legal issues related to nursing.

Windy has been an active member in the National Health Lawyers Association, and the American College of Legal Medicine. She is an active member of the American Bar Association, and has served as co-chair of the Medicine and Law Committee. She is the immediate past secretary, Board of Directors of Woodley House, a nonprofit organization which provides community based mental health services.

Windy received her undergraduate degree in History and Political Science from Duke University and her law degree from George Washington University.

Mary C. Smolenski, EdD, RN, CS, FNP

Mary C. Smolenski, EdD, RN, CS, FNP, Director of Certification Services, American Nurses Credentialing Center (ANCC) has over twenty-eight years in the health care field in a variety of settings ranging from clinical practice, nursing education, government and private sector consulting, military, and association work. She received her doctorate in education in 1988, with an emphasis on curriculum and instruction. She is a certified family nurse practitioner.

Dr. Smolenski currently serves as the Director of Certification Services for the American Nurses Credentialing Center, a subsidiary of the American Nurses Association. She directs the certification and recertification processes of over 150,000 nurses in 30 different specialties. She is on the Executive Committee of the Board of Directors for the American Accreditation Healthcare Commission/URAC and a member of many professional organizations.

Some of Dr. Smolenski's awards include Who's Who of American Women in 1994 and Who's Who in Nursing in 1994 and 1996. She recently co-authored a chapter in the 2^nd edition of Advanced Practice Nursing: Roles and Clinical Applications, Practice Credentials: Licensure, Approval to Practice, Certification, and Privileging, Chapter 4, pp. 66-81. In addition, Dr. Smolenski was recently awarded a Tri-Service Nursing Research grant to complete the Air Force Nursing Services History.