This issue of Critical Care Nurse is devoted to the theme of “Enhancing Clinical Competency,” an important and pivotal element in providing optimal care for critically ill patients and—as one paper in this issue11 so clearly describes—in affording an optimal work environment for critical care nurses. Verifying, ensuring, and developing the competency of health care staff represent concerns acknowledged for many years now by virtually all categories of critical care nurses, including administrators, managers, clinical nurse specialists, staff development and academic educators, preceptors, and other staff nurses.

Competency-based approaches to critical care orientation and staff development programs was introduced in the 1980s.22 The usefulness of of these approaches then expanded in the 1990s33 when the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) Human Resource standards established requirements for initial and ongoing assessments of staff competency.44 Since then, resources that explain how to develop competency assessment programs55; meet JCAHO requirements in this area66; and unravel the why, who, what, when, how, and where issues related to staff competency assessments77 have continued to evolve to meet the ongoing need for information.

A PubMed database search on the term “staff competency” elicits nearly 800 citations for materials published just within the last few years, so the prevalence of interest in this topic seems both apparent and enduring. When this extended body of literature is sorted out, moreover, a clearer picture emerges for why the clinical competency of healthcare staff is so critically important to quality patient care:

  • As the JCAHO notes, a healthcare facility cannot fulfill its mission to meet patients’ needs, ie, to “provide safe, reliable, and appropriate health care,”66 unless its staff is competent to do so.

  • As thousands of staff nurses have identified since 1984, the No. 1 attribute of a satisfying work environment where nurses are able to provide quality patient care is having clinically competent peers.11 

  • When the 37 magnet program attributes were distilled into 8 considered essential to a healthy working environment, the attribute that nurses from 14 magnet facilities considered most important among these select few was having clinically competent peers in their work unit.11 

  • As the Institute of Medicine attempts to translate its findings related to the prevalence of medical errors in the United States health care system88 into reforms necessary in the educational preparation of health care professionals for the 21st century, integration of a set of 5 core competencies is required.99 

  • As the American Association of Critical-Care Nurses’ (AACN) Synergy Model for Patient Care1010 reflects, optimal care of critically ill patients is best achieved when a patient’s needs are effectively matched by the complementary set of nurse competencies necessary for meeting those needs.

  • As the AACN Standards for Establishing and Sustaining Healthy Work Environments1111 stipulate, appropriate staffing of patient care areas requires an effective match between patient needs and nurse competencies.

  • As the American Nurses Association asserts,1212 assurance of a nurse’s competence reflects the profession’s responsibility to protect the public and is a responsibility shared among regulatory bodies, the nursing profession, employers, each nurse, and other stakeholders.

Does Incompetence Exist Among Today’s Nurses?

If the competency of health care staff is as pivotal to the provision of optimal patient care as these assertions and attestations suggest, it seems reasonable to consider what we know about the obverse of this issue—ie, what do we know about incompetence among today’s nurses? Does it exist? If so, to what extent and in what forms?

In contrast to the sizeable body of literature related to nurse competency, comparatively little has been published about incompetence in nursing. One reason for this paucity of literature may be attributable to the sweeping condemnation of a professional’s practice that the term incompetent connotes. Indeed, despite what Hughes1313 refers to as “the everydayness of errors” in provision of health care services, practitioners have traditionally perceived errors as signs of an individual’s incompetence.1414 In a 2005 survey,1515 VitalSmarts in partnership with AACN genereated a few findings directly related to this issue:

  • Eighty-one percent of physicians (n=106) and 53% of nurses (n=1143) and other health care providers (n=266) located in urban, suburban, and rural hospitals throughout the United States expressed concerns about the competency of a nurse or other care provider with whom they worked.

  • Sixty-eight percent of physicians and 34% of nurses and other health care providers had concerns about the competency of a physician at their facility.

  • More than 50% of survey respondents had witnessed broken rules, mistakes, and incompetence displayed by their colleagues, many instances of which resulted in harm to patients.

Has the prevalence of incompetence in nursing diminished since those 2005 data? One online survey1616 in 2007 suggests that it has not: When asked, “Are the nurses you work with competent?,” 52% of respondents (n=1410) answered no and 48% answered yes.

Do you work with critical care nurses who are incompetent? Have you witnessed one or more instances of incompetence in critical care nursing, including incidents related to the 8 nurse competencies in AACN’s Synergy Model of Patient Care? Critical Care Nurse would like to hear from you. Go to the CCN Web site at ccn.aacnjournals.org and click on the red link at the top of the page titled “Instances of Clinical Incompetence by Critical Care Nurses” and complete the brief survey. No demographic data will be recorded, all responses will be anonymous. Be sure to respond before October 31, 2008.

References

References
1
Schmalenberg C, Kramer M. Clinically competent peers and support for education: structures and practices that work.
Crit Care Nurse
.
2008
;
28
(4):
54
–65.
2
Alspach JG. Designing a competency-based orientation for critical care nurses.
Heart Lung
.
1984
;
13
(6):
655
–662.
3
Alspach JG. Competency-Based Orientation Program for a Medical-Surgical Intensive Care Unit. New York, NY: Cahners Publishing Co;
1990
.
4
Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission Resources;
2008
.
5
Alspach JG. Designing Competency Assessment Programs: A Handbook for Nursing and Health-Related Professions. Pensacola, FL: National Nursing Staff Development Organization;
1995
.
6
Joint Commission on Accreditation of Healthcare Organizations. Assessing Hospital Staff Competence. Oakbrook Terrace, IL: Joint Commission Resources;
2007
.
7
Alspach JG. Staff Competency Assessments: We’ve Still Got ISSUES Here! Pensacola, FL: National Nursing Staff Development Organization;
2007
.
8
Kohn LT, Corrigan JM, Donaldson MS, for the Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press;
2000
.
9
Greiner AC, Knebel E. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press;
2003
.
10
American Association of Critical-Care Nurses. AACN Synergy Model for Patient Care. http://new.aacn.org/WD/Certifications/content/synmodel.pcms?pid=1&&menu=#Basic. Accessed June 11,
2008
.
11
American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2005. http://www.aacn.org. Accessed June 11,
2008
.
12
American Nurses Association. Draft Position Statement on Competence and Competency. 2007. http://www.nursecredentialing.org/cert/archives/2007/CompetenceCompetencyPositionStatement.pdf. Accessed June 11,
2008
.
13
Hughes RG. Nurses at the “sharp end” of patient care. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality, US Department of Health and Human Services;
2008
.
14
Donaldson MS. An overview of “To Err Is Human”: re-emphasizing the message of patient safety. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality, US Department of Health and Human Services;
2008
.
15
VitalSmarts. Silence Kills: The Seven Crucial Conversations for Healthcare. http://new.aacn.org/WD/Practice/Docs/PublicPolicy/SilenceKills.pdf. Accessed June 11,
2008
.
16
Survey responses. Are the nurses you work with competent?
Nursing 2007
.
2007
;
37
(2):
34
.