Episode 3: Research on the Public’s Perception of Continuing Competence

June 12, 2018

Line Dempsey: Thanks for joining us and welcome to our podcast, Regulation Matters: a CLEAR conversation. I'm your host, Line Dempsey, the senior investigator with the North Carolina Dental Board, and I'm the current chair of the National Certified Investigator Training Committee with CLEAR. CLEAR, or the Council on Licensure, Enforcement and Regulation, is an association of individual agencies and organizations that comprise the international community of professional and occupational regulation. Our podcast is a chance for you to hear about the latest and greatest in our community. Today, I'm joined by Jennifer Best, practice consultant with the College of Registered Nurses of Nova Scotia. Welcome, Jennifer.

Jennifer Best: Hi, thank you for allowing me to be here today.

Line: Absolutely, and thanks for joining me. You've been involved in research that has looked at the public perception of the mechanisms to promote continuing competency. Obviously, there are some significant differences between continuing education and continuing competency. Could you briefly talk about that, just so our listeners can understand?

Jennifer: Sure, absolutely. So as regulators, we do talk about continuing competence and a variety of mechanisms, and the literature talks about what is continuing competence in a variety of ways. Things like continuing competence really seeks to determine whether or not individual healthcare professionals have continued to provide safe competent care by maintaining their current knowledge and skills since the time of licensure, things like the ability of professionals to demonstrate that they've maintained their competence to practice in relation to their context and with the relevant competency standards which they gain and retain their license to practice. At the College of Registered Nurses of Nova Scotia, we define continuing competence as the ongoing ability of a registered nurse or nurse practitioner to integrate and apply the knowledge, skills, and judgment required to practice safely and competently. Where continuing education is a mechanism for professionals to maintain their competence, so continuing education is a way for professionals to maintain their continuing competence within their profession.

Line: Do you guys actually have some type of exam or test or something that actually proves their competence?

Jennifer: We do; we have a program that's defined in our legislation, which is comprised of a variety of ways in which nurses promote their continuing competence. We don't profess to say that our program ensures continuing competence, but we require individual nurses to do certain activities which will promote their activities within continuing competence. So things like a learning plan with identified learning needs, goals, and objectives and an evaluation plan on how they're going to achieve those goals and objectives. We also have introduced in the last several years continuing education as mandated by the regulator. So we have picked a topic, developed a learning module, and the registrants are required to do that learning module and do a test at the end to demonstrate their understanding of the learning module.

Line: Well, that makes good sense. Now your research recently took a look at 400 randomly selected individuals that had received healthcare from a registered nurse in Nova Scotia. Could you tell us a little bit more about this research? And I guess, why is it important for us as regulators to understand, in particular, the public's perception of what continuing competence is and how it affects them?

Jennifer: Well, thanks for the opportunity to allow me to share this research. And I also want to take this opportunity to thank the National Council of State Boards of Nursing. They generously supported this research that I conducted as part of my completion of the Fellowship in Regulatory Excellence Program that's sponsored by National Council of State Boards of Nursing. In the last 20 years or so in regulation, healthcare regulators, and regulators in general, really have focused on developing programs as I talked about earlier to promote that continuing competence of members, and really it's in response to the public's increased expectations for safe, competent, and ethical care. Since the early 1990s, there's been a wide variety of reports and studies that really have focused on a link between patient safety and continuing competence. So, many landmark studies some of the listeners would be familiar with, such as “To Err Is Human: Building a Safer Healthcare System,” and “Crossing the Quality Chasm: A New Healthcare System for the 21st Century,” were examples of those reports in which the public has really demonstrated a greater interest in patient safety and are demanding greater transparency by regulators in the ways that they promote continuing competence.

Line: Absolutely, we see that regularly.

Jennifer: For sure. In contrast, so when you think about that, the public is really demanding that as regulators we're showing that, and as regulators our mandate is public protection. We're here for the public, that same public who's concerned about safe care, but have we asked them what they think would be the best ways for professionals to demonstrate and to promote their continuing competence? So when you review the literature, it would say, no, that there's a gap there, that regulators have failed to adequately engage the public in formulating policy decisions related to continuing competence. And so this research really is an attempt to answer some of the questions related to this really historical disconnect between the members that we're here for and the regulatory policy decisions that as regulators we make. So the research really was attempting to answer questions such as, what are the public's perceptions of what is continuing competence and what are their expectations of health professionals in regards to the ongoing maintenance of competence? And then what is the role of the regulator, and how should the regulator make these policy decisions in an informed way? So the research focused on understanding that gap between regulatory policy decisions related to continuing competence and public expectations. So as you mentioned, we examined how the public of Nova Scotia defined competent nursing practice, what influences practice, and how continuing competence can be effectively measured. Interestingly, there's very little literature that's out there on this topic, and one kind of study that I did find was conducted in 2006 by the Alabama State Board of Nursing. And so I used portions of the questionnaire that they used in 2006 to develop a modified telephone questionnaire to survey 400 randomly selected Nova Scotians.

Line: That was a question I was going to ask, whether or not this was a telephone survey or if this was a written survey. So you guys did a telephone survey for this, right?

Jennifer: We did, we did. There were a total of seven questions and they were a combination of open-ended seeking verbatim answers and then there were structured questions in which the subject chose from a list. We did the study over a two week, three week time period, and got 400 Nova Scotians who had received healthcare in the last year from a registered nurse.

Line: What kind of healthcare were they receiving? Was it at home? Was it at a facility? Did you look into that information as well?

Jennifer: We didn't do any screening questions related to where the care was received; it was just that they received care from either a registered nurse or nurse practitioner. And if they had a member of the family that was a registered nurse, a nurse practitioner, or a physician, they were excluded from the study because we really wanted that view of the public who may not have an understanding what a family member had to do in order to maintain their continuing competence. So we looked at the survey, the survey went well. We got the results back and did a variety of analysis on the data, then we did some statistical tests of significance to make sure that the observed differences are real and not due to any abnormal occurrence or sampling error. We did do some correlation. We did want to look at demographics and if there was any correlation between demographics and survey responses, and this analysis really allowed for a deeper understanding of the survey results. And we did find some key differences existed amongst various sub-populations that we surveyed.

Line: What kind of differences did you see?

Jennifer: Well, we did see some differences between what the perception was of the public's understanding of whether or not nurses should demonstrate continuing competence and their income levels and level of education. When we asked the question around whether or not a license should be good for life, there was definitely a statistically significant relationship between those demographics. So as income levels were lower and the education level was lower, so below the high school level, the respondents felt that a nurse should not have to demonstrate competence on a regular basis to maintain a license.

Line: But the opposite was true when you looked at a higher education and more advanced socio-economic area?

Jennifer: Yes, so as income levels and education increased, there was a positive relationship. And so the respondents felt that there should be more stringent measures in place for nurses to maintain their license.

Line: Interesting. Well, I guess talking more about what the public thought as far as what influences a nurse's competence - level of education, income - how did that impact their perceptions of it?

Jennifer: Yeah, so we asked two separate questions related to what the public felt influenced a nurse's competence, and then we did some analysis on how the education and income impacted their perception. So I'll first talk about what their responses were to those questions we asked. So we asked about what they felt influenced their competence, and the way we define competence in the study was what influenced their ability to apply their knowledge and skills, which would be how we would define competence. So that was the first question. And the second question we asked is, what did they feel influenced their continuing competence, so their activities to maintain that competence. We asked two separate questions.

So the first one was the respondents were asked, how much influence do you think the following [and we asked them to choose from a list of factors] have on nursing competence, and they graded the list on a scale of 1 to 10, with 1 being no influence and 10 being extremely influential. The results showed the top-rated factors in terms of the level of influence on nurses' ability to apply their knowledge and skills. The first at 80% was procedural knowledge. So having knowledge of the procedure greatly influenced their ability to apply their knowledge and skills. Interestingly, at 69% attitude came up second. We saw a lot of verbatim related to nurses' attitude and how they approached their work as an influence on competence. Educational preparation came in third at 68%, and then working conditions came in at 62%, so the working conditions in which the nurse had to work. The least influential listed were the number of patients and the length of shift at 55% and 53% respectively. We then asked, besides this list, was there anything else that you could think of that would influence a nurse's ability to apply their knowledge and skills? And so we received 133 verbatim responses, so we analyzed those and themed them, and five themes emerged. The first two themes really fit with the list. So it was working conditions and attitude. Attitude came up again. Despite the respondents being able to choose it from a list, they felt like they wanted to talk more about the attitude, so that was in the verbatim response. So that was an interesting result. Additional themes, the three additional themes that we discovered were teamwork, so the ability to work in the team; the number of patients that they may have been assigned to; and then personal factors such as health, lifestyle, and the amount of stress in their life influence their ability to apply their knowledge and skill.

So then we asked respondents what would influence their continuing competence, their ability to not apply the knowledge and skills, but to maintain that knowledge and skill. And again, it was a list that they chose from, and they used a scale of 1 to 10 to rate that list. The highest on the list, which I don't think would be surprising to any of the listeners, the initial licensing exam at 74% rated this as the top. So we're not going to do away with the initial licensure exam. People thought that that was a measure of competence. Followed distantly by continuing education is mandated by the licensing authority, certification and specialized practice, and then continuing education as selected by the nurse, and employee evaluation, was how the list kinda fell out.

Line: Interesting, and I think looking back on the information you just provided, attitude coming up twice in two different measures. Obviously, chairside and bedside manner is not something that we can tremendously regulate as far as someone's attitude. But it's really interesting to see that that's something that really impacted the public's perception of their provider.

Jennifer: Absolutely, it's very interesting that the public equates competence with attitude and so caring behaviors, being kind, listening is what the public equate competence to. We talked to lots of nurses and through talking to students and talking to different clients, we would often say the client may be okay with you saying 'This is my first time inserting an IV', or 'I'm sorry I'm a little slow with the medications', but as long as you talk to them and you were kind, they're going to feel as if you're there and you're caring and you're a good competent nurse. But, when you're not present and there in the moment, they equate that to being incompetent. So that's very interesting results.

Line: Very interesting. I guess now, looking at this, you've got this research, how can regulators use this in making informed evidence-based decisions when they're looking at their own regulatory policies?

Jennifer: Yeah, so I think that the results of the study generated a wealth of information, that not only we were able to use at the College of Registered Nurses of Nova Scotia to influence our continuing competence program, but I think there's lots of information that other regulators could use to inform future projects or to potentially influence some of their own policy decisions. I think primarily really the data demonstrated that there is a lack of understanding of how and why nurses maintain competence. The verbatim responses that we analyzed, some of them referenced nurses, when I talked about personal factors, they referenced nurses needing to be able to balance caring for their children and maintain their skills, making sure they were home to make supper and how are they gonna do that as well as keep up with their skills. So it really revealed to us that the public still may have a stereotypical version of nurses and that the public may understand nursing as a vocation and not as a science, which I think the study clearly demonstrates that, and the literature demonstrates we should engage the public in policy decisions. We may have some upfront work to do educating the public on a professional regulation and the reasons why we have continuing competence programs in place within the regulatory body.

I think the results of the study interestingly also revealed that the public in Nova Scotia, and I would say probably could translate to other areas within the United States and Canada, are concerned with the age of nurses. We know that our population generally is aging. In Nova Scotia, the age of nurses is rising. And so based on some of the verbatim responses we saw, you could translate the changes that the respondents are seeing in themselves, they may be thinking about as the same for nurses who are aging. So some verbatim comments, such as, I think as we get older, our abilities and our mindset changes to a certain degree and with our deteriorating health, we may get to the point where we can't lift the way we used to. So the nurse gets older, they would have more difficulty moving the patient around. So this kind of leads us to the conclusion that maybe the public sees older nurses as maybe being less competent. As regulators, I really feel like we need to explore some of these perceptions further and do some more research on the aging nurse and whether or not there is actually evidence to support that they're less competent. And if there's not, then we should share that information with the public.

I think the project also did demonstrate that the public seems to have a good understanding of what regulators have traditionally considered as good measures to influence continuing competence. So the data that was reported such as the initial licensing exam - that validates some of our decisions. Continuing education is mandated by licensing authority - that's a newly added component to our own continuing competence program here in Nova Scotia. So, it validates that we're on the right track with what we're currently doing with continuing competence here in Nova Scotia.

I think the survey also revealed that the public has some ideas about different ways in which we could promote continuing competence. Some of the verbatim responses the public talked about - we asked, could you suggest ways? And so one of those suggestions was patient feedback as a way to influence the continuing competence of nurses. So comments suggested that nurses could benefit from receiving patient feedback in the form of surveys. Regulators have examined peer review as a mechanism to promote continuing competence, but the concept of patient feedback as a mechanism related to continuing competence is still an emerging field and one that we maybe could explore a little bit further. As I said in the opening, we're here for the public, so it would make sense that maybe you could ask them in our continuing competence programs.

Line: Yeah, certainly, and especially since again, that attitude aspect keeps coming back in. As another licensee examining another practitioner, they may not be focused on that particular aspect, where it's clearly something that the public perceives as important and a measure of competency.

Jennifer: Absolutely.

Line: Well, thank you, Jennifer, for your time and being part of this podcast. It's wonderful to have the opportunity to share and learn from each other. And a thank-you to our listeners as well for joining us. We'll be back with another episode of Regulation Matters: a CLEAR conversation very soon. Please subscribe to our podcast and feel free to visit our website at www.clearhq.org for additional resources. You should be able to find us on iTunes and Spotify. And finally a special thanks to CLEAR staff, specifically Stephanie Thompson, our content coordinator and editor of our program. I'm Line Dempsey, and I hope to be speaking to you again soon.

The audio version of this podcast episode is available at https://podcast.clearhq.org/e/research-on-the-publics-perception-of-continuing-competence/

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