Investigating the Relationship Between Continuing Competence and Insight in Nursing and Midwifery Practice

Abstract

Introduction In the absence of a universally accepted, quantifiable nursing competence assessment, many regulatory jurisdictions implement continuing competence frameworks. These frameworks use a variety of evidence-based assessment tools to assure the public and regulators that nurses and midwives are competent. Yet, some nurses and midwives are still subject to performance notifications or practice complaints for failing to demonstrate competencies. Objective This research examines the role of insight, or competence awareness, in understanding the gap between performance assessment and performance competence or practice. Methods A convergent mixed methods design was used to explore the relationship between performance competence and insight. A convenience sample of 712 nursing and midwifery performance complaints made during a six-year period (years run July through June, per the regulatory authority's annual reporting dates) in New South Wales, Australia (July 2010 – June 2016) were analyzed. The data were triangulated with two other data sets: qualitative thematic findings from a subgroup (n = 142) of practice complaint cases that specifically identified as a factor in the complaint and/or adjudication process; and analyses of individual interviews (n = 22) with a purposive sample of regulatory experts, competence assessors, and complaint and adjudication panel members from Australia and New Zealand. Results The majority of practitioners who were the subject of a performance complaint were 50 years of age or older (n = 424; 60%). The largest number of performance complaints were made against registered nurses. The top four areas in which registered nurses, enrolled nurses, or registered midwives were subject to complaints were aged/senior care (n = 150; 21%), mental health (n = 69; 10%), midwifery/maternity services (n = 66; 9%), and emergency department (n = 53; 7%). Six interconnecting themes emerged: (a) personal and employer expectations; (b) motivation and self-awareness; (c) continuing professional development and performance competence; (d) personal behavior and communication; (e) clinical reasoning encompassing self-awareness, insight, and reflection; and (f) the context of practice and/or workplace environment. These themes related to performance competence complaints (or notifications), the process of the investigation, and the process outcome in terms of counseling, remediation, or sanctions. Key elements that demonstrate how insight, or the lack thereof, manifest in practice are identified. Conclusion More work is needed to identify the behavioral characteristics underpinning insight and performance competence in the nursing and midwifery professions. Future requirements include (a) agreement on the language used to describe insight (or the lack thereof); (b) development of guidelines as to how insight is identified, assessed, and measured; and (c) if insight can be taught, how it should occur.