Developing the Heart Failure Specialist Nurse Competency Framework

Since the seminal work by Lynda Blue et al (2001), evidencing the benefits of heart failure specialist nurses (HFSNs) in improving patient outcomes, the management and care of heart failure has become more advanced and complex. With an ageing population, the prevalence of patients with heart failure is increasing, along with the demand for resources to manage care (Conrad et al, 2018). Despite this increase in the number of people diagnosed with heart failure, the number of heart failure nurses to manage demand has remained static (Masters et al, 2019). The development of the Heart Failure Specialist Nurse Competency Framework (Barton et al, 2021) was in recognition of the need to provide a standardised educational pathway that is flexible and that enables and supports HFSNs to become confident and accountable practitioners in an ever-changing healthcare economy.

Background to advanced nursing practice

In recent years, globally, the profile of the nursing profession has increased and with it the demand for nurses to work at advanced levels of nursing practice, with such roles requiring a range of diverse skills and knowledge. Although many in the profession embrace this evolving, changing face of nursing, the emergence of new roles also brings challenges associated with the plethora of different titles, job descriptions, grade boundaries and differing commissioning expectations.

The International Council of Nurses’ Guidelines on Advanced Practice Nursing (Schober et al, 2020) sets out descriptors of advanced nursing practice to offer clarity in the attributes required for these roles. The guidelines advocate that nurses working in advanced practice have acquired expertise through clinical experience and professional development to be equipped to manage patients with complex needs through competent clinical decision-making and evidence-based practice.

In the UK, the Royal College of Nursing (RCN) considers advanced nursing to incorporate four pillars (RCN, 2020):

• Advanced clinical practice
• Leadership
• Facilitation of education and learning
• Evidence, research and development.

Importantly, the RCN deems advanced practice to be a level of nursing that incorporates the four pillars rather than a type or specialty of practice.

Despite international and national guidelines, in the UK a wide range of job titles relating to advanced nursing practice persist. Leary et al (2017) proposed that the drivers for the creation of job titles can be employers and commissioners who seek to meet their own local service provisions. As such, roles have developed in an unco-ordinated manner with clinical rather than professional perspectives as the key priority. This had led to a fragmented understanding of advanced nursing and its integral characteristics. It is because of the nebulous nature of roles and titles in advanced practice that consideration should be given to regulation, educational requirements and the preparation required (Lowe et al, 2012).

What's in a name?

Advanced nursing practice commonly encompasses job titles such as clinical nurse specialist, specialist nurse/nurse specialist, advanced nurse practitioner, nurse practitioner and nurse consultant (Leary et al, 2017; Schober et al, 2020).

A review conducted by Cooper et al (2019) explored advanced nurse practitioner and nurse specialist roles to pinpoint parallels and variances in the job expectations. Both roles offer nurses a high degree of autonomy and require advanced clinical decision-making skills and knowledge. Core components are patient care, leadership and service development, education, research, audit and service administration (Donald et al, 2013).

Nurse specialist roles are commonly linked to a specialist clinical area such as heart failure. Specialist nurses tend to have greater depth of knowledge of the clinical focus and service delivery than other nurses (Cooper et al, 2019). Cooper et al (2019) proposed that transparency is required on the requisite competencies for specific advanced nursing roles and the preparation required to fulfil these requisites.

A strategy to achieve such transparency is the development of competency frameworks for defined specialist nurse roles.

Heart Failure Specialist Nurse Competency Framework

The HFSN Competency Framework (Barton et al, 2021) was developed as a collaboration between the authors – a heart failure nurse consultant, heart failure specialist nurses, and nurse academics, along with the RCN and commissioners.

HFSNs are autonomous practitioners working in advanced nursing roles. The purpose of the competency framework was to offer a definition of competency and competency requisites required for nurses working as an HFSN.

The framework is intended to support the development of nurses’ knowledge and skills and can be used in several ways, including:

• To support HFSNs to plan their professional development in heart failure
• To inform and guide managers on the competency required at the various levels of HFSN professional development
• As a reference for planning and commissioning heart failure educational programmes
• As information for commissioners in identifying appropriate staff to deliver services to meet local need.

What is competence?

Competence can be described as the ability to perform a work role to a defined standard with reference to real working environments, which ideally includes the individual's ability to demonstrate their knowledge, skills, behaviours and attitudes in any given situation (Boritz and Carnaghan, 2003; Ilic, 2009). Health Education England (2017) produced a multi-professional framework for nurses and others working in advanced roles to establish a workforce capable of meeting the changing demands of the patient population. The framework advocates that practitioners and their managers understand the individual's learning needs to support them in meeting the four pillars of advanced clinical practice. The HFSN Competency Framework aims to provide a structure and measurable guide to facilitate this professional development process.

Within the framework document, there are 15 competencies, each relating to a skill and the knowledge required to practise as a proficient HFSN (Barton et al, 2021). The competencies were chosen to reflect the ongoing level of advanced clinical competency required of an HFSN. The British Society for Heart Failure Nurse Forum recognised that, alongside the significant advancements in nursing practice and heart failure management in the past 20 years, there is considerable variation in practice, standards and equity of service delivery across the UK. It was therefore vital that a competency framework was developed to support the HFSNs’ professional development and ensure consistent high standards of care nationally. The development of this framework also provided stakeholders, commissioners and service users with evidence of the standards required to develop and maintain sustainable services.

Applying Benner's novice to expert pedagogy

The HFSN Competency Framework is underpinned and mapped to the theoretical framework ‘novice to expert’, based on Dreyfus and Dreyfus’ model of skill acquisition (Dreyfus and Dreyfus, 1980), which was later adapted by Patricia Benner in her seminal work From Novice to Expert (Benner, 1984). According to Benner (1984) the nurse will pass through five stages of proficiency:

• Novice
• Advanced beginner
• Competent
• Proficient
• Expert.

Skill attainment requires an ordinal progression through each of these proficiency levels, acquiring knowledge and skill, until the taxonomy level of expert is accomplished. A key benefit of Benner's model (1984) is it takes into account prior learning and experience (Landers et al, 2020). This was considered as important by the project team as they were keen to acknowledge that individual HFSNs would enter this competency framework at different stages, based on their knowledge and experience. A fundamental component of this model is the emphasis on reflection in practice and the integration of an evidence base to enhance clinical decision making. These are all attributes considered important when considering advanced nursing practice (Gee et al, 2018). The ease of transition from one proficiency level to another meant this model of learning and skill acquisition was appealing to the HFSN community, plus the model has a degree of familiarity to nurses, important when considering its application to advanced clinical practice. Rischel et al (2008) and Lyneham et al (2008) argued that nurses are likely to demonstrate skills up and down the hierarchy despite an individual's level of experience and competence. The authors acknowledged during the development of this competency framework that the journey of an HFSN is not linear; in fact, for many, further clinical skill acquisition and education will be required due to the complex ever-changing demands of the specialism (Kerr and Macaskill, 2020). With this in mind, a consensus was agreed among the authors that the initial assessment of the nurse would need to reflect both past and current clinical experience and that identifying gaps in skills and knowledge would influence where on the Benner model (1984) of proficiency the HFSN would begin their learning journey.

Assessment of competence

Assessment of nurses in clinical practice can be challenging for a number of different reasons (Wilkinson, 2013; Franklin and Melville, 2015). First, assessment often involves complex interpersonal knowledge and judgement measures, which often require the individual to reflect, respond and interpret evidence (Yanhua and Watson, 2011). Second, the process of assessment is reliant on an individual expert nurse undertaking the assessment without bias, something that has been fervently debated in the nursing literature (Khan and Ramachandran, 2012). Benner (1984) believed that competency assessments should reflect the competency level of individual nurses and often the development of competency-based assessments tools fail to factor in the differing levels of skills and knowledge between nurses. Moreover, little consideration is given to the skill and knowledge of the expert nurse – important factors to consider when undertaking the role of assessor in reviewing clinical competence (Benner, 1984).

The assessment of competency within the HFSN framework is designed to mitigate some of these concerns by acknowledging prior learning and building different methods of assessment into the framework. These different methods provide the HFSN with a degree of flexibility as to how each competency is assessed and subsequently achieved. Boritz and Carnaghan (2003) recommended that competency-based assessment should not only integrate knowledge and skills but should also be made on evidence gathered on a number of occasions across a variety of contexts and principles. With this in mind, the assessment of competencies includes the following:

• Direct observation of practice (DOP)
• Case-based study (CBS)
• Reflective dairies/accounts/reports (RAD)
• Questions and answers (Q&A)
• Feedback from colleagues and patients (FCP)
• Attendance at nationally recognised courses (NRC) and
• Attendance at locally attended courses (LAC).

Table 1 provides an example of part of the competency framework (Barton et al, 2021). The framework sets out the competencies expected of an HFSN, and provides evidence that the nurse has achieved each one, along with relevant dates, and is signed off by an assessor. It is important to mention here that integral to this assessment process will be the undertaking of a self-assessment of prior learning by the nurse before commencing the competency framework.

Constructive feedback and feed-forward for future development is an important consideration when undertaking competency assessment (Epstein, 2007). Ideally, it should be undertaken by more than one person (the assessor). It is envisaged that the HFSN would be assessed by several professionals from different backgrounds working across the discipline of heart failure. This, it is hoped, would provide a fair and impartial assessment and allow a wider range of perspectives, knowledge and expertise. The plan was to provide nurses with written feedback and feed-forward on the competencies performed; particularly important when considering progression on the proficiency scale. For competencies not achieved, the assessor and the nurse would agree an action plan; direction and support would be given before the reassessment. The HFSN framework is integrated into the nurse's professional portfolio and becomes part of their Nursing and Midwifery Council revalidation. This allows for self-reflection and evaluation and helps in the long-term planning of future competencies along the Benner (1984) novice-to-expert continuum.

RCN endorsement of the framework

The RCN offers the opportunity for competency frameworks to be endorsed by the RCN's governing body. From the outset of the project, it was the intention of the project team to map the process and outcomes of developing the resource to the endorsement standards required to achieve RCN accreditation. It was agreed by the team that achieving this would offer national credibility by an independent professional nursing body. Categories for endorsement of a competency framework include that:

• It is of direct relevance to nursing
• It is concerned with services, practice, staffing levels and/or competencies
• The process of development to gather and synthesise evidence and related existing work was rigorous
• The resource builds on existing work – does not duplicate.
• Nurses have been involved in the development of the standard
• The contribution/impact of nursing is clear and stated on the resource
• Other key stakeholder views and expertise are included.

The project team was delighted that the RCN endorsed the framework in 2021. The framework has been in use since March 2022 (Barton et al, 2021).

Future plans

The process of evaluation is an important step when developing any educational competency-based framework (Bastable, 2014). Understanding what has gone well and what needs to be changed from the perspective of the users is an important feature in the cycle of learning (Biggs and Tang, 2011). A questionnaire will be used to evaluate the implementation of the HFSN Competency Framework. A questionnaire will be mailed to all users 12 months post-implementation to gather intelligence on the usability, transferability and applicability of this framework in clinical practice.

Conclusion

This project was undertaken to address the need to provide a competency framework that is fit for purpose and recognises the demands on HFSNs in an ever-changing health service.

The authors recognise that the demands for heart failure services is increasing, which is why the development of a competency framework is so vital in ensuring the delivery of safe and quality care for patients, families and their carers. The competency framework recognises the complexities of this role and so provides a standardised and flexible route for HFSNs to develop their confidence and competence within the boundaries of safe and accountable practice. The authors recognise this is only the first step in a journey of constant evaluation and change and, like the evolution of health care, the competency framework will need to evolve and change to keep pace with the ever-changing dynamics of heart failure care.

KEY POINTS

• A competency framework provides a standardised way to approach the training and assessment of a heart failure specialist nurse (HFSN)
• The competency framework addresses the need to retain HFSNs and to begin the conversation around career progression within this specialty
• Assessment of the HFSN is provided by several professionals, allowing a fair and transparent method of assessment
• The framework recognises experience and prior learning and therefore allows any HFSN at any level or grade to assess where they feel they have gaps in knowledge

CPD reflective questions

• What resources do you think you would need to successfully implement a clinically based competency framework?
• What practical measures do you think need to be in place when assessing an individual's level of clinical competence?
• Would there be an occasion where you felt a clinically based competency framework would not be appropriate and, if so, why?