Judging by an exchange of views on Twitter (since renamed as X) in late 2022, it seems that there is both debate and confusion regarding the language of educational standards for the preparation of nurses in the UK. There appears to have been a change in language from ‘competence’ to ‘proficiency’, which may have implications when assessing student nurses in practice. This prompted the authors of this article to try to unpick some of the salient issues regarding the terms competence and proficiency. We are not promising any hard and fast solutions, rather we seek to provoke further debate and dialogue.
According to the Collins online dictionary, ‘competence is the ability to do something well or effectively’, but according to the same source, ‘if you are proficient in something, you can do it well’, which might lead us to assume that these terms are interchangeable.
Other definitions suggest that ‘proficiency’ implies higher levels of skills and experience. For example, ‘great skills, ability and experience’ (Cambridge Dictionary online) or ‘the ability to do something well because of training and practice’ (Oxford Learner's Dictionary). So why does this terminology matter in a nurse education context?
Examining the language of the educational standards
The professional governing body for nursing in the UK, the Nursing and Midwifery Council (NMC), has long produced educational standards to support the preparation of those wishing to become registered nurses. However, between 2010 and 2018 (when the most recent standards were originally published), there appeared to be an important shift in the language used within the standards, which may be causing confusion; particularly among those who are assessing student nurses in clinical practice. This article seeks to explore the language of the educational standards, and consider what the implications might be for the assessment of student nurses.
NMC's (2010) Standards for Pre-registration Nursing Education used the language of competency:
‘The standards for competence … identify the knowledge, skills and attitudes the student must acquire by the end of the programme, as set out in the degree-level competency framework. This framework comprises four sets of competencies, one for each field of practice: adult, mental health, learning disabilities and children's nursing.
‘Each set comprises both generic competencies and field-specific competencies. The competencies are organised in four domains:
- professional values
- communication and interpersonal skills
- nursing practice and decision making
- leadership, management and team working.
‘The context in which the competencies are acquired in relation to the field of nursing defines the scope of professional practice at the point of registration.’
In this sense, students were judged to be competent (or not) in demonstrating a series of nursing interventions in relation to knowledge, skills and attitudes.
The NMC's most recent standards, Future nurse: Standards of proficiency for registered nurses, were published in 2018, along with the related standards for educational programmes and assessment. They use the language of proficiency rather than competency; indeed, there is only one mention of ‘procedural competency required for best practice’ within Annexe B (NMC, 2018: 37). There is a clarifying statement referring to ‘proficiency’ stating that:
‘The proficiencies in this document therefore specify the knowledge and skills that registered nurses must demonstrate when caring for people of all ages and across all care settings. They reflect what the public can expect nurses to know and be able to do in order to deliver safe, compassionate and effective nursing care.’
This implies that there has been a shift from competency to proficiency, but this shift in language is poorly articulated, leaving individual higher education institutions, practice supervisors and assessors to interpret what these terms mean and, more importantly, what the implications are for this new language in terms of assessing student nurses.
In an interesting blog for the BMJ (British Medical Journal), Maxwell and Leary (2020) examined professional judgement and the way that this is portrayed. They argued that a shift towards a competency-based approach to health care devalues professional expertise. Maxwell and Leary referred to the Dreyfus and Dreyfus (1980) model of knowledge acquisition, but, more importantly, they pointed out that nursing judgement is not amenable to being appraised by technical competencies.
The work of Benner (1984) is well known within nursing as a framework that helps to chart the progress as individuals develop from novices to experts. Benner identified five levels of development: novice, advanced beginner, competent, proficient and expert. Benner (1984) applied the Dreyfus and Dreyfus (1980) model to nursing and her work has often been used as a theoretical framework for pre-registration programmes;although the work was never intended to be used for pre-registration student nurse development; rather, the framework was used to chart the development of qualified nurses. Although Benner acknowledged the need for critical reflection in order to progress up the scale, she did not make it clear how to move between the levels described, which means that this is open to interpretation by nurse educators.
Drawing on the wisdom of the crowd
A November 2022 Twitter chat hosted by We Academics unearthed a range of views about the meaning and implications behind the two terms of competency and proficiency (see Table 1). Key themes that emerged were:
- Confusion around the NMC (2018) term ‘proficiencies’
- NMC (2018) proficiencies should relate to an established competency-based model
- Procedure-based proficiencies fail to reflect the four fields of nursing
Table 1. Key themes from Twitter chat
| Extracts | Themes |
|---|---|
|
|
|
|
|
|
|
|
Need for further clarification
Nurse educators have been widely interpreting and applying Benner's (1984) framework, underpinned by the Dreyfus and Dreyfus (1980) model, to pre-registration nursing programmes (Gonzalez and Kardong-Edgren, 2017; Francis and O'Brien, 2019). The central tenet of the Dreyfus and Dreyfus (1980) model is that learners acquire knowledge and skills through practice exposure in ‘real situations’. During the early novice and competence stages, the inexperienced learner relies on principles, rules, and procedures (Dreyfus and Dreyfus, 1980). Once a learner is exposed to a wider variety of real-world situations, they become proficient and then expert, mastering skills through experiential learning over time. It has been commonly assumed by nurse educators that student nurses should work towards a minimum ‘competent’ point during pre-registration programmes and aspire to become proficient (and expert) as they gain post-registration experience, as Benner (1984) intended.
The current procedure-based NMC (2018) standards of proficiency are not clearly set within the context of a competency-based model or framework. Therefore, the 2018-onwards NMC term ‘proficiencies’, as opposed to previous ‘competencies’, has confused many nurse educators. It is questionable whether signing off a set of procedure-based proficiencies means that a student nurse is experienced enough to be proficient, as defined by Dreyfus and Dreyfus (1980). Should we even be using the term proficiencies, without clearer explanation and acknowledgment of other stages within the Dreyfus and Dreyfus (1980) model?
It is also debatable whether the move to assessing students as ‘proficient’ is realistic and whether it is feasible for today's pre-registration nursing students to aspire to this. Nursing students may not be exposed to a wide variety of practice during their placement experiences, due to the pressure on current nursing placement providers. Therefore, is it pragmatic to re-frame student achievement as ‘standards of proficiency,’ amid a lack of practice supervisors and high nursing vacancy rates, as opposed to a more realistic minimum level of competence? However, the notion of competence as a minimum, continuum or gold standard is contentious and the debate ongoing (Blömeke, et al, 2015; Vernon et al, 2019).
Tension between quantifiable proficiency outcomes and a person-centred approach
Newly registered nurses must demonstrate a series of nursing procedures to meet proficiency outcomes that are outlined in the NMC (2018) document. Proficiencies have been related to procedural learning outcomes that predominantly focus on physical health procedures and the management of physical health, to the detriment of other fields of nursing (Warrender, et al, 2023a).
There has been recent criticism of the NMC's syllabus changes and the move towards genericism across mental health nursing (Connell et al, 2022). The move towards quantifiable skills and checklists of nursing procedures may restrict the more person-centred approach to care that is the essence of all fields of nursing. Connell et al (2022) and Warrender et al (2023b) have called on the NMC to reconsider its approach when developing pre-registration nursing programmes, and highlighted the need for a more collaborative approach involving mental health nurses to inform future work in this area.
Although there are no doubts that national and local procedures must be assured for nurses to provide safe care, does the professional body (ie, the NMC) also need to consider the impact of procedural checklists on pre-registration nursing programmes? The authors of this article acknowledge that competence relating to fundamental skills and knowledge development needs to be underpinned by evidence-based procedures, but how is the dominance of procedure-based checklists influencing a person-centred approach to caring?
Moving forward: what would be helpful?
In summary, most nurse educators understand what competencies are, within the context of a competency model. However, there is evidence of confusion around what is meant by the recently coined term ‘proficiencies’ that is not clearly supported by competency-based educational theory. Further clarification from the NMC of the term ‘proficiencies’, set within the context of competencies or a competency-based educational model, may increase understanding and avoid future confusion.
The differences between the four fields of nursing need to be acknowledged and valued when future standards of nurse education are developed, to ensure future standards and pre-registration nursing programmes are fit for purpose. Nurse educators should also consider the impact of procedural checklists on person-centredness across all fields of pre-registration nursing programmes.
KEY POINTS
- The language of nurse education changed in 2018, moving from ‘competency’ to ‘proficiency’
- This shift in language is poorly articulated and not necessarily understood by those charged with student assessment
- In the context of assessing student nurses in practice, this lack of understanding may result in different interpretations of what is required
- Students themselves may focus on annexe documents as ‘checklists’
CPD reflective questions
- Consider your own interpretation of what it means to be ‘proficient’
- Having reflected on what ‘proficiency’ means in relation to the nursing interventions practiced in your area, does your interpretation differ from that of other practice supervisors and assessors in your team?
- Is there an agreed outline for how you will assess proficiency in student nurses? If not, how would you go about developing one?