Competency is usually linked to the ability to practise a skill within an individual's scope of practice. The Nursing and Midwifery Council (NMC) (2018) states that each nurse is accountable for understanding and working within their scope of practice, indicating that registrants must be procedurally competent to provide best evidence-based practice, recognising their own level of competence and limitations through reflection. They must also exercise professional accountability to ensure patient safety in accordance with laws, policies and regulations.
Nursing is hugely diverse with a multitude of specialties and individual nurses working to differing levels within these. So how do nurses manage their competencies over a range of skills and ensure these are fully developed and maintained? According to the NMC (2018), they should engage with continuing professional development and revalidation.
The definition of nursing competency includes nursing practice and decision-making as core principles (NMC, 2018). The Health and Safety Executive (HSE) (2024) describes competency as a combination of skills, training, experience and knowledge that enable a person to perform a task, alongside their attitude and physical ability. These descriptions demonstrate the complexity of competency and its inter-dependent elements.
A further layer of intricacy is present when determining self-assessed competency, because it is dependent on one's own insight and reflective practice. There is a concerning correlation between reduced self-awareness and inadequate reflective practice, leading to unsafe performance (Vernon et al, 2019).
‘There is a lack of evidence to guide how often a clinical skill should be practised and whether this varies from skill to skill or nurse to nurse’
As detailed in the four stages of developing competency, the learner begins as unconsciously incompetent, developing conscious incompetence, progressing to conscious competence, until achieving unconscious competence (Broadwell, 1969). However, the Kruger-Dunning effect of overestimating one's own competence can have dire patient safety consequences (Kruger-Dunning, 1999).
Even though each nurse is accountable for their own scope of practice, employers have a responsibility to provide structures such as job descriptions, training, education, clinical competencies, guidelines and policies. These strategies provide a framework that supports working within one's scope of practice and minimises the risk of inadequate self-reflection. However, organisations take different approaches to competency in terms of education and training, for example optional or mandatory learning sessions and pathways, with routine or non-compulsory updates or reassessments.
Nutritional care
There are many clinical competencies for nutritional care, such as nutrition screening and supporting oral consumption of nutrition and hydration, combined with understanding modified oral consistencies, completing food and fluid balance charts, interpreting blood results, inserting and managing enteral feeding tubes, managing parenteral nutrition and many more.
Specifically for nasogastric tubes (NGTs) competency there is a substantial patient safety risk with recurrent Never Events occurring – this is despite national guidance (NHS Improvement, 2016; Jones, 2020; NHS England, 2023). NGT insertion and management are usually nurse led and the recent Never Event report highlights issues with pH testing (NHS England, 2023). A Healthcare Safety Investigation Branch (HSIB) (2020) report on NGT safety highlighted concerns regarding disparities in training, and further comments that one episode of competency-based training is not sufficient for patient safety because this involves complex clinical care with multiple human factors. It is notable that obtaining a certification of training does not equate to competency in all situations, and that understanding one's abilities and limitations is far more important.
Hignett et al (2018) describe human factors from a physical, cognitive, and organisational perspective, demonstrating how these build to develop the ‘Swiss cheese’ effect. It is not clear from the Never Event report what the issues were with pH testing (NHS England 2023); however, it is clear that problems persist with NGT care delivery and continue to place patient safety at risk. One of the recommendations from HSIB (2020) is for a national standardised competency training programme to eliminate inconsistencies in NGT care; to date, this has not come to fruition.
Clinical skills competence
Rahmah et al's (2021) research considered how nursing competency developed and found that, in addition to organisational strategies, nurses needed to build their confidence and clinical skills through experience. The HSE's (2024) recommendations align with these findings. This is not dissimilar to Benner's (1982) ‘novice to expert’ theory in terms of proficiency of clinical skills development. This indicates that competence development and maintenance varies and is likely to depend on how frequently a skill is practised, and it is therefore at risk of fading.
‘Skill fade’ has been well investigated in the military (Maddocks, 2020) and in aviation (Mizzi et al, 2022), all agreeing that competency and confidence are at risk of decline when skills are not practised frequently. There is a lack of evidence to guide how often a clinical skill should be practised and whether this varies from skill to skill or nurse to nurse, with factors such as experience that may be of consideration.
There is a noticeable shift towards nurses self-assessing their competency in clinical skills; this is a useful resource to support reflection and identify where a nurse is lacking in skill and/or confidence (Wangensteen et al, 2018). However, there is a significant risk of incongruence between perceived competence and actual ability, as evident in Liang et al's (2021) and Smith and Hatchett's (1992) research.
There is doubt regarding whether self-assessment is enough on its own to provide an accurate assessment of clinical skills, decision-making ability and evidence-based knowledge to ensure patient safety. A nurse can only self-assess on their own knowledge, which may have limitations of which they are unconscious, depending on their self-awareness (Vernon et al, 2019).
In addition, these are challenging times with high staff vacancy rates in the NHS and mounting pressures on services with increased acuity of patient care. These demands have been intensifying over the past 30 years, with the decrease in the number of NHS hospital beds by over 50% (Ewbank et al, 2021). These factors impact on clinical decision making and the development of confidence and competence in clinical skills, which contribute to unsafe practices (Vernon et al, 2019). This has the potential to culminate in patient safety risks or harm from the increase in human factors present, resulting in human errors (Hignett et al 2018).
Responsibilities
Nursing practice is evolving in complexity, meaning that organisations need to develop strategies to support nurses and reduce patient safety risks. Nurses should understand how they learn, maintain competency, and update their practice. They should be empowered to interact with others in their organisations (such as line managers, supervisors and practice development teams) as education partners to inform them of what they need so that they can deliver safe, evidence-based care within their scope of practice.
In addition, nurses should practise regular reflective self-awareness so that they know when they are at risk of competency decline, and can therefore put strategies in place to maintain their skills. Regular use of revalidation tools can support this.
Evidence needed
More research is needed to improve understanding in this area to ensure structures and strategies support staff and reduce the risk of human factors. This will enable nurses to provide safe clinical care, particularly in areas where patient safety is at risk, such as in NGT management.