Continuing competence in selected health care professions

Journal of Allied Health, Winter 2002 by Lundgren, Burden S, Houseman, Clare A

Definitions and Evaluation of Continuing Competence

The issue of continuing competence is intimately bound to the issue of competence itself-how it is defined and measured. The NCSBN definition of competence focuses on applied skills within a health care environment. Competence is "the application of the knowledge and the interpersonal, decision-making and psychomotor skills expected for the nurse's practice role, within the context of public health, welfare and safety."47 Kane48 offered what may be the simplest definition: "The level of an individual's competence in some area of practice can be defined in terms of the extent to which the individual can handle the various situations that arise in that area of practice." This perspective raises the notion, however, that competence varies according to the situation. If so, the measurement of competence in one area is not generalizable to other areas.

The definition of competence must be understood in the context of professional activity (i.e., how professionals make and implement decisions). Combset al.49 note:

[T]he system of evaluation rooted in multiple choice examination questions reflects the theory that a physician's clinical practice, and by extension that of other health professionals, is based on the dominant epistemology that professional practice is one of technical rationality. In other words, health professionals learn information, and, in a clinical situation, make decisions based primarily, if not solely, on that information.

Schon5 noted that professional schools often follow a twotiered curricular model in which initial studies deal with the science of the discipline and later studies address application. In this, they have followed a Positivist cultural paradigm in which science-based technical practice supplanted craft and artistry and in which problem solving became the end of practice. By this analysis, the technical rationality model severely restricts the definition of professional activity and ignores the notion that problem setting is central to professional activity. According to Schon,50 "problem-setting is a process in which, interactively, we name the things to which we will attend and frame the context in which we will attend them."

Schon 50 argued that professionals reframe each situation in terms of the application of their discipline's body of knowledge and of the unique elements of that situation (e.g., that particular client). Professionals construct each situation, a process that resembles art at least as much as science. By Schon's model, evaluation of competence is possible only in the actions of professionals and only on a case-by-case basis. It also suggests that evaluators should attend to the questions professionals ask, not simply the answers to questions that are put to them.

Building on Schon's work, Shapiro and Reiff" built a multilayered model of reflective practice in which distinct moves made by practitioners reflect theories, which in turn are based on the core philosophy of the profession. Is competence multilayered? How would a profession go about testing multiple layers of knowledge and action and the changes in them over time? Grossman argued24 that it is not possible to evaluate competence for every professional experience. It is possible only to evaluate a sample of behaviors and extrapolate to the practice totality. Such a procedure not only presents issues with regard to generalizability, but also with a test's ability to predict future and present performance. 24