Key Words: Continued competence, continued competency, continuing competence, politics, policy
Continued competence, how to assure competent beginning and ongoing practice, is a wonderful example of the difference between policy and politics. Diers (1985) differentiates between the two concepts and defines policy as dealing with the "shoulds" and "oughts," setting direction and determining goals or other principles. Politics is the use of power for change and may implement or impede policy. Stevens (1985) focuses on practical decision making rather than the ideal and states that politics "seeks the right decision for this issue in this political climate at this time" (p. 19).
So what is this issue? There is no agreement on the definition of continued competence. Definitions reflect the various stakeholders perspective, the this political climate part of the definition of politics. In other words, politics has impeded policy and we are at the first step of the policy process which is identification of the policy issue.
Policy goals have long been overshadowed by politics in nursing on numerous occasions. Diers (1985) points out that entry into practice lost its policy goal and only deals with educational credentials. She believes that the "rightness" of the position would be explicit if entry into practice were conceived as a policy statement such as "Nursing is complicated work and the American people deserve the most intellectually able and best-educated practitioners to deliver care and humanize institutions" (p. 54).
Nursing needs a policy statement about continued competence that specialty nursing organizations, state nurses associations, state boards of nursing and professional nursing organizations can agree upon. A policy statement might be that registered nurses are practicing in complex environments where technology and practice are constantly changing and the American public deserves registered nurses with adequate knowledge and skills to provide safe quality care. Use of this policy statement would render mute the argument that continued competence only deals with the possession of knowledge and skills rather than performance of care using knowledge and skills. All nursing stakeholders, and indeed all stakeholders, should be able to agree that the primary goal of continued competence is to assure safe, quality, nursing care/practice to clients/the public. Barbara Blakeney, in her keynote address at the 1999 Ohio Nurses Association Convention, mentioned that nurses were the first and consistent voice to identify quality rather than safe care as a goal in the health care debate. The "rightness" of this position is difficult to argue.
Back to politics and "in this political climate." Let's look at the stakeholders. Each of the nursing stakeholders have members and in order to stay in business, they can not disenfranchise their members. One might ask the question if nursing organizations, in their attempts to stay financially solvent, have strayed from what is "right" and best for the public and the nursing profession by basing policy decisions on politics and the very real and imagined fear of losing members. A variety of major credentialing agencies are exploring the feasibility of offering certification exams for registered nurses without baccalaureate degrees. Specialty practice has long been recognized as advanced rather than basic practice and is defined as "a voluntary process of competency assessment conducted by a professional or specialty nursing organization that denotes that the individual has achieved a level of competence in practice beyond the entry-level measured by licensure" (Loquist, 1994, p. 113). Entry level was accepted as the bachelor's degree in a position statement by the American Nurses Association in 1965. Associate degree and diploma nurses who want to be certified need to get their bachelor's degrees. The professional association needs to explore ways to facilitate baccalaureate education for RN's rather than decrease standards by eliminating the baccalaureate requirement. This also raises the question if this policy decision is overshadowed by what will generate income for the organization, allowing it to exist as well as to wield power. The same questions of basing policy decisions on the pocketbook and constituents apply to all organizations.
Continued competence is a major nursing issue at this time, the last part of the definition of politics. Although continued competence as a regulatory issue has been with us since a 1967 Commission on Health Manpower sponsored by the U.S. Department of Health, Education and Welfare recommended periodic re-examination of physicians, the current debate has largely been stimulated by the 1995 Pew Commission Report, "Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century." The Pew Commission recommended that states base nurse practice acts on demonstrated initial and continued competence. This has led to an exciting, positive step in the policy process. A Continued Competency task force of 25 stakeholders including the American Nurses Association, specialty and other nursing organizations, the National Council of State Boards of Nursing, National Council of State Legislators and experts has formed and is working to address this issue. They have developed a definition of continued competence and moved forward to conduct research related to development of continued competency assessment models. We have moved beyond the first step in the policy process of problem identification and are immersed in the second step of policy formulation. Only after options and alternatives have been thoroughly analyzed will we be ready to move to the last three steps of the policy process as identified by Ferguson (1985) - policy adoption, policy implementation and policy evaluation.
Bradham (1985) provides two considerations well worth remembering. They are that "major changes can not be reasonably expected from any system because, by definition, a system seeks homeostatic position and consequently tolerates small changes more readily" (p. 171) and a "political system based in democratic procedures will almost surely result in incremental changes acceptable to the majority" (p. 171).
It is inevitable that politics will play a significant role in determination of policy about continued competence. The likelihood that initial policy will probably incorporate small rather than large changes is acceptable because experience with implemented policy always leads back to the first and subsequent steps of the policy cycle. Let's hope that the Continued Competency Task Force works together so that politics implements, not impedes, policy.
Letters about this article
- Letter to the Editor on "The Policy and Politics of Continued Competence"
by Cady L. Salisbury (May 26, 2000)
with reply by author, Greer Glazer (May 26, 2000)
Greer Glazer, PhD, RN, FAAN
Director, Parent Child Nursing
College of Nursing
Kent State University
Kent, OH 44202
Email Address: GGlazer@kent.edu
Dr. Glazer is Professor and Director of Parent Child Nursing at Kent State University College of Nursing. Besides her many research activities in the field of women's health and stress, Dr. Glazer is chairman of the Ohio Nurses Association Government Affairs Committee, a combination legislation committee and PAC. She is currently the legislative liaison to congressman Steve LaTourette and has previously been on health care committees at the state and national level. Locally she serves on the Board of the Cuyahoga County (Ohio) Children's Trust Fund and recently completed four years on the Health Care Committee allocation panel for United Way in Cuyahoga County.
Blakeney, B. (Oct 4, 1999). Nursing in the new millennium, access, advocacy, accountability. Keynote Address Ohio Nurses Association Biennial Convention. Columbus, OH.
Bradham, D. (1985). Health policy formulation and analysis. Nursing Economics, 3, 167-172.
Diers, D. (1985). Policy and politics. In D. Mason & S. Talbott. Political action handbook for nurses. Menlo Park, California: Addison-Wesley Publishing Company, p. 53-59.
Ferguson, V. (1985). Overview of the concepts of power, politics, and policy in nursing. In R. Wieczorek Power, politics and policy in nursing. NY: Springer Publishing Co., p. 5-15.
Loquist, R. (1999). Regulation: Parallel and powerful. In J. Milstead Health policy and politics. Gaithersburg, Maryland: Aspen Publications, p. 105-146.
Pew Health Profession Commission. (1995). Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century.
Stevens, B. (1985). Nursing, politics, and policy formulation. In R. Wieczorek Power, politics and policy in nursing. N.Y.: Springer Publishing Co., p. 16 - 21.
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