Ethics: Ethical Thoughtfulness and Nursing Competency

The history of ethics reveals that the issues are constant; only the particular application of the principles changes

(Hall, 1996, p. 15).

The articles presented in this issue of OJIN (Initial and Continuing Competence in Education and Practice: Why Should It Be Mandatory?) identify a method that professionals in general and nursing in particular may use in the quest for attaining and maintaining professional competence or " . . . the advance assessment of ability." (Hall, 1996, p. 213). As we embark on a new century, it is incumbent upon the nursing profession and each practicing nurse to examine how we are preparing for new skills and updating ongoing skills. Therefore, the purpose of this column is to raise questions that encourage ethical thoughtfulness about issues related to competency and to suggest actions that can increase thought, reflection, and discussion of competence.

Commonly, professions use external measures for assuring competence. Qualification for practice is assured by licensing laws and by professional standards. Familiar examples in nursing for assuring competency include: licensing exams for practice entry, continuing education (CE) for renewal of practice license, work-based orientation programs, and graduation from an accredited program of study.

Laws and rules are generally considered to uphold the lowest minimum standard for practice. Licensing laws for example, protect patients from harm, but do not hold professionals accountable to a skill level that promotes quality. Hall (1996) writes: "Law is the minimum ethic and, therefore, legal behavior is not necessarily the highest ethic" (p. 49). As a profession, nursing does not want to rely on self-reflection on competence as the sole method to assure the public and ourselves that nurses are competent. Nor should we be satisfied that external measures such as licensing laws, CE, or competency-based evaluations will provide the absolute assurance of competency. Competency is a complex construct that requires numerous measures. To practice competently requires us to comply with external competence measures and to reflect ethically about competence.

As professionals, nurses must individually and collectively raise questions related to competency measurement. What is the minimum standard of care? When are we meeting the minimum care standard? When should we strive to go beyond the minimum standard? When should the minimum standard be raised? How will we know when we are exceeding minimal standards? What can we do to assure minimal standards? What can we do to help move beyond the minimal standard of care? How can we be active in defining competency? What external measures will best verify the public trust in our competence? Should remuneration be competence based? What course of action should we take when faced with our own incompetency and/or incompetency in others? How is the changing health care environment impacting on competency and the delivery of competent care? How can competency be measured for nurses in non-clinical settings such as policy, research, and education?

The answers to these questions require thought, reflection and discussion. Processes that are difficult under the best of circumstances may seem more elusive when health care restructuring, reallocation of resources, shifting client populations, new ways of delivering health care, and new and different technology are challenging us. It is, however, in times of turbulence when nurses need to examine competence collectively and individually, or outside regulatory forces will step in and mandate how competence will be measured. Florence Nightingale (1859/1992) prophetically wrote:

That the female head in charge of any building does not think that it is necessary to visit every hole and corner of it everyday. How can she expect those who are under her to be more careful to maintain her house in a healthy condition than she who is in charge of it?" (p. 17).

Photo of Florence Nightingale courtesy Country Joe McDonald's Tribute to Florence Nightingale web site

While Nightingale was speaking of managing houses and servants, this quote seems appropriate to the discussion at hand. Can we expect outside groups to do a better job than the heads of nursing (each nurse individually and collectively) in examining issues of competence?

Self-reflection is an initial, ongoing and integral step to assuring competence. Self reflection is essential whether a novice, an expert, or a nurse somewhere in between on the continuum and whether the nurse is speaking broadly of competency as " . . . the knowledge, skills, and values essential in carrying out one's role . . ." or more narrowly defining it as the ability to do a given skill correctly (Oermann, 1998). Reflection is directly tied to experience and job role and intimately influenced by one's spiritual, physical, intellectual, and emotional well-being. Self-reflection on practice may take different forms, but ultimately it is an active process.

What actions can enhance ethical thoughtfulness, reflection and discussion of competency, whether staff nurse or nurse manager; whether primary care or tertiary care provider; whether educator, researcher, or policy maker? First, assess your competencies. Read the nurse practice act in the state in which you practice, your job description, your Standards of Practice, and the American Nurses Association (ANA) Code for Nurses. For each competency listed, identify how it is measured externally and within you? Are external and internal measures congruent? A psychomotor skill-based competency that could show incongruence between external and internal measurement is Cardiopulmonary Resuscitation (CPR). Have you passed CPR certification, but feel that you could not do it adequately? A psychosocial skill-based competency that could show incongruence between external and internal measurement is how you deal with conflict? Do you positively seek solutions to it or do you avoid it and thus hamper its resolution?

Second, involve yourself in groups that set policy regarding competency. Professional, organizational, and legislative opportunities abound. If you are an educator, you may choose to serve on a promotion and tenure guidelines committee. If you are a staff nurse, you may choose to serve on the practice committee of the local chapter of the American Nurses Association (ANA). If you are a nurse manager, you might consider serving on the policy and procedures committee of your agency.

Third, be informed. Organizations such as those just described may provide information on competency. The 1999 ANA House of Delegates, for example organized a forum to examine the issues dealing with competency. The same documents that can assist you in identifying your competencies also can provide you with insights and information about your competencies that you may have overlooked. For example, the interpretative statements for the ANA code are a starting place for better understanding the role of the individual nurse in self-regulatory behavior. The following excerpts from the Code (1985) are pivotal to the issue of competence:

The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.

The nurse assumes responsibility and accountability for individual nursing judgements and actions.

The nurse maintains competence in nursing.

The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibility and delegating nursing activities to two others.(p. 1).

Fourth, think proactively. When a new competency is introduced, or a potential new competency is discussed, examine the actual and potential ethical implications. For example, you might ask the following questions about a new technology-based competency: What are potential harms that can arise with this new technique? What new skills are needed to achieve competency? Will access to skill development be equal? How will skills be tested?

Issues related to competence are not easily resolved but are nevertheless crucial to the trust that has been placed in nursing by society. The accountability of the profession demands that nurses individually and collectively:

1. identify competencies central to nursing;
2. participate in groups influential to competency measurement;
3. be informed about competency issues; and
4. think proactively and raise questions about competency whether it is broadly or narrowly defined.

If you engage in the preceding four activities, your ethical thoughtfulness will show.

Author

Ruth Ludwick, PhD, RN,C