The August 2008 editorial in Critical Care Nurse (CCN) examined the pivotal role that staff competency serves for both ensuring the provision of optimal and safe patient care as well as in determining whether nurses judge their work environment to be satisfying.1 Regardless of whether the context of discussion is how the nursing profession meets its obligations for public safety, how the Synergy Model for Patient Care2 facilitates meeting patient needs, or which of the 37 magnet program features nurses rate as most important,3 the answer to all of these crucial concerns is rooted in the competency of nursing staff.

In addition to highlighting the readily recognized importance of staff competency, the editorial also broached the infrequently acknowledged issue of incompetence in nursing. More directly, the editorial asked readers whether they had observed incompetence among their critical care colleagues and challenged readers to share their observations by completing a brief online survey at the CCN Web site. This is a report of the findings from that survey.

The “Instances of Incompetence in Critical Care” survey was divided into 3 parts and included a total of 15 questions. Part 1 addressed general instances of incompetence by asking whether respondents had witnessed each of the following 5 types of incompetence:

  • Omission: Failure to provide care that was ordered or warranted

  • Commission: Provision of care that was not ordered or warranted

  • Skill set: Inability to provide basic nursing and/or patient care skills

  • Quality: Provision of care that is inconsistent with hospital or unit policies, procedures, or protocols

  • Self-knowledge: Failure to recognize the limits of one’s competency (demonstrated by making decisions beyond that limit)

The response options for all survey items in parts 1 and 2 included only 2 categories: “have witnessed” or “have not witnessed.”

Part 2 addressed instances of incompetence specific to the 8 nurse competencies identified in the American Association of Critical-Care Nurses (AACN’s) Synergy Model for Patient Care.2 These competencies were targeted in the survey because of the pivotal role that nurse competencies have in this model as the fundamental mechanism by which patient needs are met and patient care is optimized. For purposes of the survey, the aspect of practice encompassed in each nurse competency was rephrased in the following manner to reflect incompetent practice:

  • Clinical judgment: Used faulty/poor (erroneous, incomplete, inappropriate for situation) clinical judgment

  • Caring practices: Failed to create or maintain a therapeutic environment for the patient or family

  • Advocacy and moral agency: Neglected to act on the patient’s or family’s behalf

  • Collaboration: Interactions with others discourage mutual contributions toward patient goals

  • Systems thinking: Actions failed to recognize interrelationships among elements in health care systems

  • Response to diversity: Failed to incorporate diversity differences in care provided

  • Clinical inquiry: Neglected questioning or evaluating aspects of practice when warranted

  • Facilitator of learning: Failed to facilitate patient and family learning

Part 3 provided 2 open-ended items for readers to identify other instances of incompetence that may not have been captured in other survey questions.

Eighty (80) readers participated in this survey. Because of the nature of the information solicited, neither identifying nor demographic data on survey respondents were collected.

Part 1: General Types of Incompetence Witnessed in Critical Care

Each of the 5 broad categories of incompetence used in the survey (omission, commission, skill set, quality, self-knowledge) were witnessed by at least 65% of respondents. Among these, the type of incompetence most frequently (91%) observed related to the quality of care, ie, that the care provided was inconsistent with established policies, procedures, or protocols. As Figure 1 illustrates, the second most frequently witnessed form of incompetence, reported by 89% of respondents, related to omission of care, ie, not administering patient care that was ordered or warranted. Observations of critical care staff who make decisions that exceed their competency level (81%), who lack basic nursing/patient care skills (76%), and who administer care that is not ordered or warranted (65%) comprised, respectively, the third, fourth, and fifth most commonly witnessed forms of incompetence in critical care.

Part 2: Incompetence Specific to the Synergy Model Witnessed in Critical Care

Among the 8 nurse competencies included in the Synergy Model, incompetence was witnessed by a majority of survey respondents in all but one area: response to diversity (48%). The area in which incompetency was most frequently (93%) witnessed was in clinical judgment. As Figure 2 illustrates, incompetence in these and the remaining Synergy Model nurse competencies was witnessed in the following order of frequency, starting with the most frequently witnessed:

  • Clinical judgment

  • Clinical inquiry

  • Caring practices

  • Facilitator of learning and systems thinking (tie)

  • Collaboration

  • Advocacy and moral agency

  • Response to diversity

Part 3: Other Witnessed Instances of Incompetence in Critical Care

Open-ended survey items 14 and 15 provided participants with an opportunity to add any other instances of incompetence they wished to identify. These items elicited more than 30 additional replies. The TableT1 provides a summary of these responses grouped by the category of incompetence to which each appeared to relate.

Although this survey was brief, unscientific, and available to readers for only a limited amount of time, its findings are consistent with those contained in some of the few reports available on the issue of incompetence in nursing. In a 2005 VitalSmarts survey4 completed in partnership with AACN, 53% of the 1143 nurses who completed the survey identified concerns about the competency of another critical care nurse or care provider and more than 50% of the physician and nurse survey participants related that they had observed displays of incompetent practice by colleagues. A comparable finding was reported in 2007 in a single-item online survey5 that asked nursing journal readers whether the nurses they work with are competent, and 52% of the 1410 respondents answered no.

Despite the many limitations of this survey, a few important distinctions in the CCN survey findings are worth noting. In contrast to earlier surveys that reported concerns or observations of incompetency among nurses at rates ranging from 50% to 53%, the mean number of witnessed incidents of incompetence in the CCN survey is considerably higher. Among the 5 general types of incompetence used in the survey, the percentage reported as “have witnessed” ranged from a low of 65% to a high of 91% and averaged 80%. Among the 8 nurse competencies included in the Synergy Model, the percentage of incompetence reported as “have witnessed” ranged from a low of 48% to a high of 93% and averaged 73%. Although data are limited, these findings clearly suggest that concerns related to perceived episodes of incompetence among critical care nurses have escalated over the past few years. Whether this reflects merely a numerical difference or a fact remains to be verified.

This is the first report of which I am aware (if you know of other reports, please send CCN a reference citation or Web site URL) that makes an attempt to distinguish among different types or categories of incompetence in the practice of critical care nursing. If at some point it becomes apparent that incompetence in nursing is a problem that warrants remedy, it may be useful to examine the various forms in which it may exist.

In addition, this is the first report of which I am aware that addresses the issue of incompetency among critical care nurses as it specifically relates to the 8 nurse competencies embodied in AACN’s Synergy Model of Patient Care. In addition to studies aimed at validating one or more of those nurse competencies for achieving optimal patient outcomes, it may be time to consider whether a nurse’s incompetence in one or more of those aspects of practice is associated with a diminished attainment of optimal patient outcomes.

In the open-ended items that concluded the survey, a number of replies mentioned by respondents for “Other instances of incompetence” could not readily be categorized using either the general or Synergy Model practice areas. Those replies, moreover, appear to actually reflect rather glaring ethical and/or legal breaches that include the following:

  • False documentation by nurse managers and staff nurses

  • Illegal documentation, ie, (charting) medications and/or treatments that were not provided

  • Failure to document/report medication errors

  • Staff hitting a brain surgery patient (reported to manager/supervisor without evidence of consequence)

  • Managers destroying incidents reports

  • Unreported sentinel event cases in more than one hospital

We have no way of knowing whether the incidents reported in fact happened, but some readers took the time to relate these for this survey, so some level of concern about that possibility persists. In any case, please remain vigilant in your own facility to ensure that your patients receive the best care possible and to raise the specter of incompetence in critical care nursing practice should that become warranted. Our thanks to those who participated in this CCN survey.

Alspach JG. Recognizing the primacy of competency and exposing the existence of incompetence.
Crit Care Nurs
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American Association of Critical-Care Nurses. AACN Synergy Model for Patient Care. Accessed November 19,
Schmalenberg C, Kramer M. Clinically competent peers and support for education: structures and practices that work.
Crit Care Nurs
VitalSmarts. Silence kills: the seven crucial conversations for healthcare. Accessed November 24,
Survey Responses. Are the nurses you work with competent?