Clinically Competent Peers and Support for Education: Structures and Practices That Work

Structures that foster clinical competency include annual reviews, educational support, recognition, review sessions, and best-practice teams.“By your actions they will know you.”“My goal is to provide the best care possible to each of my patients, based on knowledge that flows from my brain to my fingertips with compassion.”“The signs were subtle, but I knew this patient was going to get into more trouble, so I bugged them [physicians] until they did something.”“We take pride in being superbly competent; it’s “in the water” here—part of our culture. And the hospital backs up this expectation by providing resources, educational programs, tuition and fees, and time so that you can go. The physicians in PACU [postanesthesia care unit] provided review courses for our national specialty certification exams.”“I wish there was some way that I could learn and could help others meet all our responsibilities at once.The preceding excerpts from interviews with staff nurses in magnet hospitals reflect the key messages reported in this article. (Unless otherwise stated, all excerpts are from staff nurses who were interviewed for this study. The professional role of the speaker is cited for physicians [MDs] and nurse managers [NMs].) Competency is multifaceted and evident through actions. Clinically competent peers is all about competent performance, not the potential for performance. Both performance and potential are important for quality patient care, but here we focus solely on what others see or hear that leads to the judgment or conclusion that nurses on the front line in acute care hospitals are clinically competent.We describe what clinical nurses have to say about 2 elements that staff nurses identify as essential to a healthy work environment: clinically competent peers and support for education. This article is based on the last of the 3 structure-identification studies (Table 1) in which we interviewed 244 staff nurses, 105 managers, and 97 physicians on 101 clinical units in 8 magnet hospitals selected because staff nurses on these units had previously reported satisfying, productive work environments. In other words, we interviewed experts to find out what works. What are the structures and best practices that foster competent performance? That support education?Working with other nurses who are clinically competent has long been cited by staff nurses as a key feature of a satisfying and productive unit work environment, that is, an environment in which personal needs can be met and in which clinical nurses at the front line can give quality patient care. The AACN Standards for Establishing and Sustaining Healthy Work Environments1 define such an environment as one that is healthy. Since 1984, when the characteristics of an excellent work environment were first measured using the 65-item Nursing Work Index constructed from the original magnet hospital criteria,2 thousands of staff nurses in magnet, community, county, Veterans Affairs, and academic hospitals have consistently cited clinically competent peers as the No. 1 attribute of a satisfying unit work environment in which nurses can give high-quality patient care.3 In 2001, when the criteria of a magnetic work environment were shortened to those 37 attributes most often selected by thousands of staff nurses who completed the Nursing Work Index, staff nurses in 14 magnet hospitals cited clinically competent peers as the most important of the 8 attributes essential to a healthy work environment.4 We labeled these 8 attributes the Essentials of Magnetism (EOM) and designed the EOM tool to measure them.5 Each of the 8 essentials has a subscale and a score; the aggregate score of the 8 essentials is a measure of a healthy work environment. Using the same instrument, home health nurses in 9 states selected clinically competent peers as the fourth highest essential attribute.6 Competency is also one of the Baldrige criteria for performance excellence.7Support for education, another of the 8 essentials, is based on the “availability” of educational programs, opportunities, and practices that foster development of competency, but an environment that “supports” education is a necessity. The question investigated and answered in this article is, How is support for education manifested? Support for education is also one of the Baldrige criteria for improving performance excellence7; it is included as an aspect of the Professional Development Force of Magnetism8; and it is identified by the American Organization of Nurse Executives9 as 1 of the 9 elements of a healthy work environment.Competent is usually equated with adequacy, with accepted standard of practice. Webster’s dictionary10(p253) defines it as the quality or state of being functionally adequate or having sufficient knowledge, judgment, or skill. The professionals we interviewed—nurses, managers, and physicians—talked about competent performance as more than baseline performance or adequacy. Baseline performance or adequacy produces safe care; competency produces quality care.To find out “what works,” we wanted to be sure that we were interviewing experts, that is, professionals who were knowledgeable about the competency of the nurses and would be able to identify and describe organizational structures and best practices that helped nurses develop and maintain this exquisite competence. At the beginning of each interview, we used a 1 to 10 rating scale (10 = high), similar to the pain rating scales that nurses use daily. We asked, What number would you select to indicate the level of competent performance of the nurses on this unit? The mean rating for all 446 professionals interviewed was 8.7. Physicians rated staff nurses’ competency as 8.9, significantly higher (P=.004) than did nurse managers (8.4). Staff nurses rated their peers’ competency as 8.7. These ratings are very high, even higher than the ones we obtained when we asked the same question of 279 staff nurses in 14 magnet hospitals in interviews in 2001.4Most of the nursing literature is about core competencies and educational programs to promote or develop the capacity for competent performance. After reviewing studies on nursing core competencies from 1990 to 2000, Zhang et al11 identified multiple different, but overlapping, classifications of core competencies and concluded the following:To obtain descriptions of effective performance, we asked each interviewee, How do you know that a nurse is competent; what do you see or hear that tells you that a nurse (one of your peers) is performing competently? The 446 interviewees generated 749 descriptions and examples of competent performance. Using constant comparative analyses,12 we first independently analyzed the descriptions and examples and nominated potential categories. Then we reanalyzed the data as often as necessary to ascertain categorical fit and to broaden the categories into 6 competency performance domains. Responses that fit more than a single domain were assigned on the basis of context; a few that fit no domain were eliminated. Table 2 lists, in order of frequency, the competency domains described by interviewees in all 8 hospitals. The domains are not necessarily new or different. However, the relative importance and performance manifestations may differ from those usually found and reported, and some may be a surprise. The excerpts given here have some similarities to examples cited by Benner13; this situation is not surprising, because we were interviewing nurses who were clinical experts. By analyzing and thoroughly understanding what interviewees were describing in each performance domain, we can learn not only what organizational structures and best practices promote competent performance but also what additional educational programs and practices may be needed for the development of competent performance in each domain.Making independent, quick and correct decisions and acting “out of the box” in the best interests of the patient were responses given by 58% of the staff nurses, 16% of the managers, and 93% of the physicians. This domain includes commitment, a desire and zeal to acquire the knowledge, competence, and self-confidence necessary to make independent decisions (in the nursing unique sphere of practice) and interdependent decisions (in that sphere of practice where nursing overlaps with medicine and other disciplines).Commitment and patient advocacy were the primary aspects of competency in the autonomy domain described by nurses.Interviewees described 5 structures or best practices that enable staff nurses to develop competent performance. Some of the best practices are specific to a domain, whereas others span several or all domains. Table 3 lists, in descending order of frequency, the best practices that promote competency development and performance and also the domains most affected.Autonomous clinical decision making is facilitated through patient-care review sessions. These sessions are regularly scheduled reviews and updates of clinical practice and pathways, are often interdisciplinary, are an inherent aspect of collaborative practice programs,14,15 and are an integral part of the renegotiation of scope of practice16,17 essential to clinical autonomy. Some hospitals had interdisciplinary updates on each patient’s condition and plan of care 3 times per week. Patient-care review sessions often resulted in the formation of evidence-based practice teams. The primary contribution of these teams in enabling clinical competency was through an increase in knowledge. Perceived clinical competence, a necessary precursor to autonomous practice, has been described before18 and was also often cited by interviewees in this study.Responses related to prioritizing and multitasking, the second most cited domain, were given by 59% of the nurse managers, 27% of the staff nurses, and 1% of the physicians. Prioritizing means putting activities in their proper sequence and order as dictated by patients’ care needs. Multitasking is the mental process of prioritizing care/cure activities for multiple patients and doing so calmly, with concern and empathy and without losing sight of any patient’s needs. As in popular literature and context, multitasking is thinking and doing, or thinking and listening, at the same time. Both nurses and managers repeatedly emphasized that the word tasking does not quite capture the essence of this domain: “It’s not just the physical tasks; it’s a whole array of activities, thought, and work processes that have to be juggled and prioritized, and for multiple patients.” Some described multitasking as follows:Acquiring the capability to multitask is undoubtedly a slow and arduous process, particularly for new graduates. But as the following excerpts illustrate, once the capability is acquired, competent performance appears to be a rather startling transition.Experienced nurses also encounter difficulties in multitasking and prioritizing, but from different sources. Experienced nurses are the ones who are most often called on to take care of the most difficult and acutely ill patients, patients being treated with new technologies, and to assume the increasing array of professional responsibilities and activities—acting as preceptors to new staff members, attending council meetings, and participating in interdisciplinary meetings to develop protocols. A relatively new concept, identified and labeled by researchers in Minnesota as complexity compression,19 is a way of analyzing the competencies demanded by multitasking and, more importantly, of devising methods for mentoring and teaching new and experienced nurses how to develop this competency. Complexity compression is defined as “what nurses’ experience when expected to assume additional responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame.”19Complexities described by our interviewees varied among clinical units. Nurses in intensive care units most often cited patient care and system complexities such as increased patient acuity, limited system resources of critically ill patients, sensory overload for the nurses, technology bombardment, and rapid institution of multiple, new therapies (drugs, robotics). Nurses in other units described complexities due to multiple patients; rapid assessments, triaging, and treatment demanded by multiple and almost constant patient admissions and discharges; and increasing age and numbers of patients with latent or active comorbidities. Comorbidities make high demands on competency because “you have to be alert as to when latent might become active, so that you can do the proper thing in a timely fashion.” Nurses on all units noted “planned and unplanned additional responsibilities” such as emergency admissions, orientation of new nurses, increased expectations of involvement in research and evidence-based practice teams, council activities, interdisciplinary meetings, and working with physicians and others on development of critical pathways, autonomous decision-making reviews, and reviews of collaborative or nursing orders. As one interviewee stated, “With increasing professionalism comes increasing demands on your time, your expertise, your knowledge, your judgment, and your areas of competency.”The compression aspect of complexity compression almost always boils down to time. For new nurses, the compression is primarily the time it takes to develop, execute, and prioritize plans of care for multiple patients. For more experienced nurses, the compression factor is the time and mental alertness required to weave demands of patient care with multiple professional activities. For all, the continued short length of patients’ stays means that a larger number of work processes such as patient teaching must be done in shorter periods. Other compression factors are shortages in staffing, which are often due to increased acuity of the patients, or shortages of “the right kind of staff—not numbers, but skill and preparation.”Of all the structures and best practices needed to facilitate competence development and competency performance, the one cited most often as missing was how to teach and mentor nurses to prioritize and multitask. This competency domain is the only one for which no structures or practices were identified or described by interviewees in at least half of the 8 hospitals. Several pre-service interventions that could be taught to students in schools of nursing have been described. Multitasking for multiple patients and how to decide what to delegate can be taught by having students identify and translate patients’ needs into active and inert tasks or activities on the basis of expected resistance.20 This strategy could also be used for graduate nurses and residents. In an interdigital professional competency model,21 students can be taught to develop care plans and activities for 3 patients and then interdigitize these plans and activities on a priority basis.In 3 hospitals, interviewees described some methods used by their in-service education department to teach multitasking and prioritizing. A preceptor described a “thinking out loud” technique that she uses to teach nurses how to multiprocess, prioritize, and plan care and cure activities for the patients for whom the preceptor and the newcomer are responsible. In another hospital that has a well-developed nurse residency program, residents present their patient assignment and how they prioritized and managed it for critique and analysis by their peers. This approach could also be used in orientation sessions. Two nurse managers in intensive care units described what they called a program for teaching multitasking to new hires. They send new nurses out to the general medical-surgical unit before orientation to the intensive care unit; the nurses in the general medical-surgical unit “know how to prioritize and multitask, and hopefully they can teach it. It’s better to learn this in a less acute environment.”We suggest development of analytical seminars or critique sessions to identify the complexities extant and prevalent on units. The knowledge and needed to these complexities could then be and could be used to and prioritize the multitask needs of the patients and programs have been designed to teach critical could be used to develop similar programs to teach prioritizing and of of the responses fit the domain of they were almost among nurses, managers, and physicians. 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In the article in this we and for the essential of clinical autonomy.