The Journal of Continuing Education in Nursing

Original Article 

From Competence to Continuing Competency

Bette Case Di Leonardi, BSN, MSN, PhD, RN-BC; Debra Hagler, PhD, RN, ACNS-BC, CNE, CHSE, ANEF, FAAN; David R. Marshall, JD, DNP, RN, FAONL, FAAN; James X. Stobinski, PhD, RN, CNOR, CSSM(E); Sarah (Sally) Welsh, MSN, RN, NEA-BC

Abstract

In 2011, a task force sponsored by an organization that has Accreditation Board for Specialty Nurse Certification–accredited programs published a definition of continuing competence. Eight years later, the organization sponsored the work of another task force to revisit that definition, with the 2018–2019 task force broadening its focus beyond the U.S. borders and beyond nursing. After an extensive literature review, task force members collated their findings into four categories: Identifying Competencies, Validating Competencies, The International Perspective on Competency Assessment, and Competency in Disciplines Other Than Nursing. The task force identified perspectives on continuing competency and found that although licensing and credentialing organizations addressed the topic thoroughly, little attention was devoted to the perspectives of the public, individual clinicians, and recipients of clinicians' services. This article identifies that little consensus exists on definitions of competence and competency, international perspectives have much to offer, and theoretical frameworks for research on competence and competency are lacking. [J Contin Educ Nurs. 2020;51(1):15–24.]

Abstract

In 2011, a task force sponsored by an organization that has Accreditation Board for Specialty Nurse Certification–accredited programs published a definition of continuing competence. Eight years later, the organization sponsored the work of another task force to revisit that definition, with the 2018–2019 task force broadening its focus beyond the U.S. borders and beyond nursing. After an extensive literature review, task force members collated their findings into four categories: Identifying Competencies, Validating Competencies, The International Perspective on Competency Assessment, and Competency in Disciplines Other Than Nursing. The task force identified perspectives on continuing competency and found that although licensing and credentialing organizations addressed the topic thoroughly, little attention was devoted to the perspectives of the public, individual clinicians, and recipients of clinicians' services. This article identifies that little consensus exists on definitions of competence and competency, international perspectives have much to offer, and theoretical frameworks for research on competence and competency are lacking. [J Contin Educ Nurs. 2020;51(1):15–24.]

It is easy to reach agreement on the premise that nurses and other health care professionals should be prepared for competent practice and should continue to practice competently throughout their careers. However, the ways that professional competence of health care professionals is defined, managed, supported, evaluated, and regulated varies across professions, credentialing organizations, and jurisdictions. The purpose of this article is to explore the evolution of professional competence and competency, identify current requirements and methods of validating competence for credentialing across professional and geographical boundaries, and suggest areas for future work supporting competence in health professions.

A need to design meaningful recertification requirements that reflect continuing competence of certificants sounded a call to action for a certification organization that has Accreditation Board for Specialty Nursing Certification (ABSNC)-accredited programs.

In order to respond to the call, the organization sponsored the Continuing Competence Task Force to present a definition of continuing competence (Case Di Leonardi & Biel, 2012). The task force carefully identified and agreed on beliefs underpinning continuing competence. The task force then modified a definition that the Canadian Nurses Association and Canadian Association of Schools of Nursing had published in a joint 2004 position statement (Canadian Nurses Association & Canadian Association of Schools of Nursing, 2004). The task force formulated the following definition: “Continuing competence is the ongoing commitment of a registered nurse to integrate and apply the knowledge, skills, and judgment with the attitudes, values, and beliefs required to practice safely, effectively, and ethically in a designated role and setting” (Case Di Leonardi & Biel, 2012, p. 350).

A total of 15 professional organizations endorsed this definition. In addition to endorsements, one task force member initiated a survey of nursing specialty certification boards and state and territorial boards of nursing. Members listed in the online membership directory of American Board of Nursing Specialties (ABNS) (i.e., organizations that have made a commitment to improving patient outcomes and protecting consumers by promoting specialty nursing certification) were asked, among other things, whether their organization had reviewed The Statement on Continuing Competence: A Call to Action (Hospice and Palliative Credentialing Center, 2011). A total of 19 of the 32 (59%) listed ABNS regular member organizations completed the survey. Most of the specialty certification boards responded, with 82% (n = 14), having had reviewed The Statement on Continuing Competence for Nursing: A Call to Action (Hospice and Palliative Credentialing Center, 2011), and 56% (n = 10) having adopted or endorsed the statement. Most, or 77% (n = 13), also responded that their organization does not have a formal definition of continuing competence, and 71% (n = 12) responded that their organization does not use a conceptual or theoretical framework for continuing competence (Marshall, 2015).

Six years after publishing the definition of continuing competence, the time arrived to revisit this definition, taking account of developments in continuing competence since the original publication of the definition. In order to embrace broader perspectives, the organization formed a new task force that included a university faculty member, a chief nurse executive, a journal editor, and the president of the ABSNC.

This new task force accepted the charge of updating the 2012 definition and began its work with a literature review. The task force reviewed literature identified in a CINAHL® search, using the search terms continuing competence, continuing competency, continued competence, and continued competency. The search identified 50 articles.

Task force members identified several definitions on continuing competence, presented in Table 1. Task force members also identified the type of article (e.g., expert opinion, descriptive study) and included the study sample size. The literature addressed some perspectives thoroughly, such as the views of licensing and credentialing agencies. However, the task force found an absence of other perspectives, such as that of the individual clinician and the recipient of clinician's services. Table 2 presents the perspectives in descending order of frequency as identified in the literature review. Gaps in the literature suggest fertile ground for further study.

Definitions of Continuing Competence and Similar Terms in the Literature

Table 1:

Definitions of Continuing Competence and Similar Terms in the Literature

Perspective addressed in the Literature: Descending Order of Frequency

Table 2:

Perspective addressed in the Literature: Descending Order of Frequency

Task force members discovered that the articles aligned with one of four categories: Identifying Competencies, Validating Competencies, International Models, and Models in Nursing, Medicine, and Allied Health Professions. Some articles addressed more than one category. Four task force members, one for each category, collated the literature related to each category. Two additional task force members reviewed and commented on each collation.

Identifying Specific Competencies

RN licensing and specialty nursing certification programs typically perform a job analysis, or practice analysis, to specify the content of licensing and specialty nursing certification examinations. Respondents to job analysis surveys indicate how frequently they perform specific activities and the relative importance of those activities (ABSNC, 2017; National Council of State Boards of Nursing, 2018; Schaeffer, Rodolfa, Hatcher, & Fouad, 2013). These data guide the systematic construction of examinations for both initial RN licensure and RN specialty nursing certifications. A systematic process of examination construction ensures the validity, reliability, psychometric soundness, and legal defensibility of examination results. Examination results, along with additional eligibility criteria, indicate that licensees and nursing specialty certificants have achieved entry-level competency as a licensed RN or specialty nursing certificant, respectively.

Establishing entry-level competency is surely important, but the public demands more. A survey sponsored jointly by the Citizens Advocacy Center and the AARP® in 2007 (Alexander, 2012) found that more than 95% of the respondents believed that health care professionals should be required to show that they have the current knowledge and skills necessary to provide quality care as a condition of maintaining licensure.

Researchers and credentialing agencies representing several health care professions and countries around the world use various methods to identify health care professionals' competencies. These health care professionals seek to protect the public and the integrity of their respective professions.

Specific competencies for a given profession are often grouped together to form categories or domains. Domains of competencies for specific health care professions include the noncognitive competencies of medical doctors in the United States (interpersonal and communication skills, professionalism, system-based practice) (Williams, Byrne, Williams, & Williams, 2017); competencies of occupational therapists in New Zealand (knowledge, critical reasoning, interpersonal skills, performance skills, ethical practice) (Wekell, Aspegren, & Holmgren, 2014); competencies of interprofessional preceptors in Brazil (education, professional values, basic public health sciences, management, health care, teamwork, communication, community orientation, professional development) (Rodrigues & Witt, 2013); competencies of medical family therapists in the United States (direct patient care, indirect patient care, values) (Michaels, Lamson, White, McCammon, & Desai, 2014); and effective leadership attributes for public health nursing leaders (collaborative change management, lifelong learning, being visionary) (Reyes, Bekemeier, & Issel, 2014). The Asia-Pacific Economic Corporation identified four overarching competencies necessary for the 21st century workforce: lifelong learning, problem solving, self-management (of which self-directed learning is a part), and teamwork (Esterhuizen & Kirkpatrick, 2015).

Lingard (2016) has also underscored the importance of teamwork competencies for health care professionals. She writes that a team may function competently even when one team member is incompetent. She notes that an incompetent team member can interfere with the functioning of a team but that other members may make up for the incompetence of one member. The same team can be competent in one situation and incompetent in another (Lingard, 2016).

The competencies required for health care professionals who focus their careers on research and teaching in their clinical discipline differ from those who focus their careers on direct care (Michaels et al., 2014). Benton (2017) advocated for the role of bibliometrics—a method of statistical analysis of published works—as a means of establishing competency for academic health care professionals. He noted that bibliometrics is compatible with revalidation requirements of the Nursing and Midwifery Council— the professional regulatory body for nurses and midwives in the United Kingdom—and offers nursing academics a valid means of completing revalidation requirements.

Esterhuizen and Kirkpatrick (2015) asserted the value of cultural and intercultural-global competencies among health care professionals and leaders in other fields. Their literature review cites models of cultural–global competence and contains numerous resources for assessing and teaching cultural competence. The Transcultural Nursing Society offers a national cultural competence certification, and several universities offer degrees and focused study on global health issues and cultural competence (Esterhuizen & Kirkpatrick, 2015). Michaels et al. (2014) also supported the need for cultural competencies among medical family therapists.

Whitehead, Austin, and Hodges (2013) conducted a study comparing 360-degree assessment with the Dreyfus model of skill acquisition (novice to expert), a classification system measuring skill acquisition. Williams et al. (2017) found a relationship between the Dreyfus model and 360-degree assessment. However, the researchers also found that the Dreyfus model “fails to measure some characteristics of behavior captured in the direct assessment of behavior in the 360-degree assessment” (p. 53). The authors (2013) suggested that meaningful competency validation calls for an increased use of qualitative measures.

Although recognizing the challenges involved in assessing competency in practice, credentialing organizations are exploring possibilities for measuring noncognitive, judgment, team competency, and psychomotor skills. Major barriers encountered in development of behavioral measures include administrative and documentation difficulties and acceptability by certificants and licensees (Gillespie, Polit, Hamlin, & Chaboyer, 2012). Assessors may combine multiple measures such as a multiple choice examination, an objective structured clinical examination, and a portfolio (e.g., a reflection on the collaborator role) to determine whether a medical student has successfully completed the year and may progress to residency training (Whitehead et al., 2013).

Two studies validated competency assessment tools used in the operating room setting: the Perioperative Competence Scale-Revised (PPCS-R) used in Australia (Gillespie et al., 2012), and the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) used in Canada (Ingwerson, 2016).

A study of occupational therapists in New Zealand (Coffelt & Gabriel, 2017) identified the importance of postgraduate skill development for entry-level occupational therapists, once again echoing the need for assessment of competency in practice.

Practice analysis, or job analysis (ABSNC, 2017; National Council of State Boards of Nursing, 2018), and content analysis (Michaels et al., 2014) are the methods most frequently used to identify competencies for health care professions. Researchers and credentialing organizations express a need for means to measure judgment, team competency, and psychomotor proficiency. Measures must meet A.P.P.L.E. criteria: administratively feasible, publicly credible, professionally acceptable, legally defensible, and economically affordable (Mehrens, 1992).

Validating Competencies

Responsibility to promote competence and monitor continuing professional competency is shared among the regulatory body, the individual professional, and the employer (Casey et al., 2017). Regulatory bodies are charged by statute or organizational mission to protect the public. Individual professionals are responsible for maintaining their own competency in practice. Employers are responsible for the safety of the patients/clients who are being cared for by health care professionals. In licensure and certification processes, competencies are often aligned with a required minimum educational level (e.g., baccalaureate, master's, doctoral, or postgraduate levels). Schaeffer et al. (2013) noted that educators' renderings of the skills required for safe practice may differ from the skills emphasized by licensing boards charged with protecting the public. Other stakeholders, including consumers of health care, have additional views on what health care professionals should do to maintain competence and promote safety.

Measuring competency in the context of professional licensure or certification process is a subcategory of the more general challenge faced when measuring authentic performance across work settings. The general challenges in measuring performance also apply to measuring competency in professional roles. Based on a systematic review of performance evaluation in health care, Lizarondo, Grimmer, and Kumar (2014) suggested there are five major factors to consider in selection of performance measures: determining goals of the evaluation; including structure, process, and outcome measures; basing measures on standards of care; prioritizing measures that are comprehensive, valid, reliable, reproducible, discriminative, and easy to use; and incorporating multiple measures. These factors may also be useful in selecting measures for validating knowledge or performance.

After a credentialing organization reaches some level of agreement about the goals of credentialing and what proficiencies should be required for a particular professional credential, the question turns to how those proficiencies can be measured and evaluated and, more specifically, how those proficiencies can be validated and revalidated periodically in a defensible yet financially and logistically feasible way.

One of the most common ways to validate competence for credential renewal in health care professions is by providing evidence of attendance at formal or informal educational sessions. Participation in a quality educational session can lead to measured increases in knowledge and perceived competence. For example, long-term care nurses (N = 84) who attended a certification preparation course were highly successful in passing the certification examination (98.5%). More importantly, these nurses showed statistically significant improvements in competency for care of the older adult as measured by self-report and supervisor responses (Cramer et al., 2014).

However, attendance and participation in continuing education (CE) programs through completion of academic coursework, self-study courses, and conferences or workshops does not ensure improvement in behavior or everyday practice (Coffelt & Gabriel, 2017). Busy professionals may attend sessions that are convenient or affordable but do not reflect their areas of greatest learning needs or do not offer a high-quality educational experience. Even after thoughtful selection of quality educational activities, participants may not be able to understand, retain, or use the information that was provided.

Many certification organizations provide the option of taking a written examination to demonstrate current knowledge at the time of recertification. Successfully passing an examination at the end of the certification period may be used to validate continued competence in lieu of other activities. Documentation of practice hours in the specialty or content area is commonly required for renewal of credentials. Organizations may ask renewal applicants to self-report total practice hours or to log details of practice hours, or they may require verification of practice hours from an employer (Hagler, 2018).

Some credentialing organizations accept evidence of scholarship through publication and professional presentation as a way to validate ongoing competence, assigning various weights based on the rigor and type of production. Benton (2017) described a rigorous process using bibliometric analysis of an individual's published work to demonstrate professional development and provide an audit trail for validation in credentialing processes.

Portfolios, as electronic or paper-based compilations of data, are used by many regulatory and voluntary organizations as a source of evidence for credentialing. In Canada, seven of 10 regulatory organizations have implemented a portfolio requirement (Vachon, Rochette, Thomas, Desormeaux, & Huynh, 2016). Portfolios commonly include aspects of self-reflection and products of work or other types of data as evidence of learning and practice. Some portfolios require that peer and client feedback be incorporated in the reflection activities.

One way of providing data from multiple sources is the use of a formal 360-degree assessment. Using multiple sources, the American Board of Medical Specialties triangulated data about the abilities of 264 physicians holding supervisory roles. Raters including the physicians' leaders, peers, and support/reports provided assessment of interpersonal and communications skills, professionalism, and system-based practice. The mastery scores based on multiple sources were significantly related to scores from items used in the medical education core competency framework (Williams et al., 2017).

Human patient simulation and virtual (computer-based) simulation have become widely accepted as teaching tools (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014) but less progress has been made using simulation for performance assessment and evaluation of competence in credentialing. Yoder-Wise (2013) and others have advocated for wider use of simulation in teaching and CE, and in promoting patient safety: “Simulations are costly, yet if they help us get better at what we do, are not simulations cost-effective?” (p. 196).

Use of simulation for prelicensure and postlicensure competency assessment in medicine is expanding. Since 2005, the American Board of Family Medicine has required completion of self-assessment modules that incorporate a knowledge assessment for a chosen topic (e.g., diabetes, hypertension, asthma, coronary artery disease) and computer-based clinical simulation scenarios. The United States Medical Licensing Examination involves computer-based simulations and interactions with standardized patients. As of 2014, simulation-based education is a mandatory prerequisite for all newly trained anesthesiologists, as well as those seeking recertification (Ross & Metzner, 2015).

Some regulatory bodies have adopted a comprehensive approach to validating competency. The College of Registered Nurses of Manitoba has developed a multifaceted continuing competence program review consisting of three components: assessment of the RN's portfolio, verification of the RN's practice hours, and practice review including multisource feedback and competency-based interviews. All applicants for renewal must compile their portfolios, submit practice hours, and complete a CE module on jurisprudence, and a percentage of applicants are randomly selected to have feedback collected from colleagues and clients. Based on the evaluation of that multisource feedback, applicants may be judged to have completed the requirements for licensure renewal or may be required to undergo a competency-based interview and possible remediation (Brown & Elias, 2016).

The International Perspective on Competency Assessment

A review of the current international literature on continuing competency revealed notable differences in competency assessment practices between the United States and the other countries. A key differentiator is the decentralization of competency assessment in the United States: in this country, the nurse and the employer take a central role and the boards of nursing have a lesser role. The use of competency assessment in the United States is concentrated at the employer level, with little integration beyond the facility or system level. Viewed collectively, the state boards of nursing lack consistency compared with the approaches taken by the countries featured in this section.

The U.S. Approach to Competency Assessment

The decentralization found in this country is a much different approach than what was found in the works of authors from countries outside the United States. The literature review revealed a concentration of published work from the Nordic countries of Europe, Japan, China, Canada, Australia, and New Zealand. As documented in this selection of articles, these countries take a more holistic approach and feature a much closer relationship between regulatory and licensing agencies and the individual nurse than is found in the United States.

The U.S. approach may be best summed up in a statement from a concept analysis paper from Tilley (2008) on competency assessment: “Currently, in most states, a nurse is determined to be competent when initially licensed. Continued competency is assumed thereafter unless otherwise demonstrated” (p. 60). Although Tilley's article is now more than a decade old, there has not yet been widespread change to competency assessment and the integration to licensure and renewal of licensure processes among the diverse approaches used by the state boards of nursing in this country.

In the United States, the emphasis is on rigorous standards for entry into the profession. However, the requirements to maintain licensure are far less stringent than those for securing entry into the profession. The requirements for maintenance of licensure and remaining in practice are far less robust in relation to competency assessment than what is found in many foreign countries. In the United States, the organizations administering certification programs approach competency assessment differently and may have more rigorous standards versus the state boards of nursing. However, the fact remains that much of nursing certification remains a voluntary process embraced by a minority of American nurses.

The National Council of State Boards of Nursing has acknowledged the need for competence assessment in a 2005 position paper, but this influential body states that “there has not been an elegant national regulatory solution for evaluating continued competence” (p. 1). Therein lies the fundamental difference between the United States and other countries. Although the state boards of nursing in the United States have taken some tentative early steps into the use of competency assessment in licensure processes, the regulatory bodies in other countries have taken a variety of innovative approaches and engaged more directly with the practicing nurse.

From an International Perspective: The Key Differences

When considering the international perspective on continuing competency compared with the American view, differences are readily apparent. A common thread is that many other countries outside of the United States stressed a need to work at and sustain competency throughout the span of a career. There are descriptions of proactive purposeful work versus the more passive approach found in the United States. On the international front, the nurse assumes more responsibility for ongoing assessment of competency and continuous professional development (CPD) activities. Such a perspective is not commonplace in the United States and is not universally embraced among the state boards of nursing.

The term fitness to practice is often used in the international setting regarding the regulation of nursing practice (Holland et al., 2010). This perspective assumes that actively working to determine one's fitness for practice has value and is a responsibility of the nursing profession. There is no assumption that a nurse continues to possess fitness for practice until otherwise demonstrated, as Tilley has stated (2008).

Research Activity

Some notable contributions exist related to theory and research in the literature review. Franklin and Melville (2015) presented a discussion of the pedagogical issues regarding competency assessment instruments. The authors speak to the requirement for demonstration of competence in countries such as the United Kingdom, Canada, and Australia. The argument is made that nursing must move beyond the simplistic checklists used in skills fairs to a more robust system measuring knowledge, skills, and experience.

A second concept analysis article was published in the Journal of Nursing Regulation by Moghabghab, Tong, Hallaran, and Anderson (2018), who are affiliated with the College of Nurses of Ontario, Canada, exploring the concepts of competence and competency. These authors identified inconsistencies in the use of these terms as they sought to execute their work as regulators of nursing practice. The premise of their work was that even though nurses practicing in Ontario must participate in mandatory competence assessment programs, the use of the terms was inconsistent. Suggestions for definitions of these terms are offered; these definitions are consistent with usage in the United States.

Competency Assessment Methods

The use of competency assessment instruments is also far more widespread outside the United States. However, the regulation and oversight of nursing licensure programs is much different in these countries. For example, the European Union (EU) countries have experienced a migration of nurses within the EU, necessitating a need for more refined competency assessment methods. The Nordic countries (Finland, Norway, and Sweden) of the EU have a relatively long history in the development and use of competency assessment instruments.

The development of competency assessment instruments and the reporting of research using such instruments was another feature of the international literature, with seven competency instruments documented in the peer-reviewed literature. Of these seven instruments, four may be classified as generalist instruments with wide application in nursing. Three additional instruments focused on one nursing specialty: perioperative or operating room nursing.

Some commonalities exist in the richly diverse collection of international articles. One common element is that few of the articles cite a theoretical framework. Also, use of the terms competence, competency, and continuing competency is inconsistent across the articles, and few of the articles offer definitions of these terms.

Literature Review Articles

Two literature review articles were found. The first article was from Canada (Wilkinson, 2013) and described the availability of competence assessment instruments and the use of these instruments in the context of nursing professional development. A case study of a nurse in need of practice improvement framed the article. Four self-assessment competence assessment instruments were discussed, and the author then described a professional development process to improve the nurse's practice. The nurse's responsibility for professional development was stressed, and the context of the Canadian nursing licensure system was discussed.

The second literature review was presented in an article by Liu and Aungsuroch (2018) on the definitions of competency and competency assessment instruments. The concept of competency is presented within the framework of skills, knowledge, attitudes, and judgement. The article presented an extensive review of a limited number of factors related to competency and some of the instruments that can be used for competency assessment.

Summary of the International Perspective

The use of competency assessment instruments is more extensive outside of the United States, and there has been increased activity in instrument development studies in both generic instruments and instruments specific to the specialty of perioperative nursing. The research has progressed to wider application to include specific subsets of nursing populations, including nursing students and newly graduated nurses. Cross-cultural comparisons have also been made, and this promising early work lays the foundation for wider use of these instruments.

The lack of theoretical frameworks and the inconsistent use of terminology with the terms competence and competency are a common thread among the reviewed articles. The concept of fitness for practice appears frequently among these articles. Fitness for practice is a concept worth further examination for academics and researchers in the United States.

Competency in Disciplines Other than Nursing

For nearly two decades, a national call to protect patients from harm and improve patient outcomes has echoed. Part of the call has been for assurance of the continuing competence of health care professionals. Because nurses are the largest group of health care professionals, the call has been heard within the nursing community with responses from boards of nursing and nursing specialty certification organizations. In addition, the call has been heard and acted upon by other groups of health care professionals, as shown in the examples below.

Dental Hygienists

Bernie, Couch, and Walsh (2016) surveyed dental hygienists in California to ascertain respondents' perceptions about mandatory continued competence requirements. The quantitative cross-sectional survey was distributed by e-mail to the members of the California Dental Hygienists' Association. The survey response rate was 19.5%. Of those who responded, 93% felt that they had remained competent to deliver care since entry into practice. An additional 81% agreed that “continued competence is important for patient safety and well-being.” However, only 47% supported mandatory continued competence as a requirement for continued licensure.

Medicine

Lockyer et al. (2017) called for CPD to ensure that physicians maintain competence throughout their careers, an issue that has gained attention, as has the use of competency-based medical education in postgraduate medical education and CPD. There have also been calls from Canadian writers for future CPD systems grounded in the everyday workplace, integrated into the health care system, oriented to patient outcomes, guided by multiple sources of performance and outcomes data, and team based; CPD systems should employ principles and strategies of quality improvement and should be taken on as a collective responsibility of physicians, CPD-provider organizations, regulators, and the health system (Sargeant, Wong, & Campbell, 2018).

In December 2015, the American Board of Internal Medicine, reacting to feedback and opposition from its diplomates, suspended its requirements for maintenance of certification until the end of 2018 (American Board of Internal Medicine, 2015).

Physical Therapy

Domenech and Greenspan (2015) described the American Board of Physical Therapy's model for Maintenance of Specialist Certification. This model for credentialing focuses on continuing competence of physical therapists with four elements: professional standing and direct patient care hours, commitment to lifelong learning through professional development, practice performance through examples of patient care and clinical reasoning, and cognitive expertise through a test of knowledge in the specialty area (Domenech & Greenspan, 2015).

Psychology

In an attempt to study the relationships between lifelong learning, professional competence, and engagement in professional and scholarly activities, Taylor and Neimeyer (2015a) adapted the Jefferson Scale of Physician Lifelong Learning to develop the Jefferson Scale of Psychotherapist Lifelong Learning. Just over 20% (n = 136) of the membership of the Illinois Psychological Association completed the survey. Respondents perceived that formal CPD contributed to fulfilling the objectives of CE (i.e., maintaining competence, enhancing service delivery, and ensuring public trust) to a greater extent than did informal, nonformal, and incidental forms of CE (Taylor & Neimeyer, 2015a).

Taylor and Neimeyer (2015b) also surveyed potential consumers of psychological services. Taken from a random sample of 10,000 of 90,000 faculty, students, and staff at a large state university in the southeast, 742 individuals completed a survey. Respondents assessed the public's perception of psychologists' CE activities. Survey results revealed a relationship among lifelong learning, professional competence, engagement in CPD, and scholarly activity. The authors concluded that “most formal forms of learning (e.g., becoming board-certified, participating in formal CE) were viewed favorably, but several incidental forms of learning (e.g., serving on professional boards, teaching classes) were viewed as contributing relatively little to the objectives that CE was designed to fulfill” (Taylor and Neimeyer, 2015b, p. 140).

Future Directions in Continuing Competence Practices

A review of the recent international literature regarding the terms continuing competence and continuing competency reveals ample opportunities for stakeholders in American nursing. The professional literature from other industrialized countries reinforces one key difference and several challenges for American nursing in relation to the work of the international community. First, it must be acknowledged that it would be difficult to make meaningful change in the licensing processes relative to the adoption of competence assessment in nursing practice in this country.

There is a great diversity of approaches by the U.S. state boards of nursing on the issue of continuing competence. A commonality in the international literature is that maintenance of competency requires active work by the nursing professional. There is no assumption that competence is present through the course of a career. Academia and national-level nursing organizations in non-U.S. countries are collaborating on innovative approaches to include competency assessment instruments and fitness for practice initiatives. As Tilley (2008) stated, the American system of nursing licensure operates under an assumption of continuing competence once a nurse enters the profession unless an exception is reported.

There is no national consensus that an assessment of competency or work at maintaining continuing competence is an integral part of ongoing licensure. Reaching consensus among the many state boards of nursing to change this perspective is a significant hurdle. A fundamental shift away from the employer as the responsible party for nursing competence to a paradigm where competence is a professional responsibility is needed if the United States is to reach the level of the best practices in the international community.

Second, there is a lack of common terminology regarding nursing competence and competency in the international literature. The terms competence, competency, and the plural competencies are used interchangeably and with a variety of meanings. On a worldwide level, the nursing profession would benefit greatly from standardization of terms.

Finally—and most significantly—the international literature review on this subject also revealed a paucity of theoretical frameworks. A cohesive, overarching theoretical framework could facilitate assessments of current practices and analyses of gaps, and then guide the conduct of future research in this area.

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Definitions of Continuing Competence and Similar Terms in the Literature

Definitions of Continuing Competence in the LiteratureReference
“Continuing competence is the ongoing commitment of a registered nurse to integrate and apply the knowledge, skills, and judgment with the attitudes, values, and beliefs required to practice safely, effectively, and ethically in a designated role and setting.”Case Di Leonardi & Biel, 2012, p. 350
No definition of continuing competence statedBenton, 2017; Kujath, 2014; Vachon, Rochette, Thomas, Desormeaux, & Huynh, 2016; Wilkinson, 2013
“Competence has been defined as ‘The combination of skills, knowledge, attitudes, values, and abilities that underpin effective performance in a professional/occupational area.’”Sinclair, Bowen, & Donkin, 2013, p. 35
“Continuing competence, therefore, is a nurse's ability and responsibility to demonstrate maintaining competency against the competency standards of a particular jurisdiction.”Sinclair et al., 2013, p. 35
“Continuing competence is a dynamic and multidimensional process in which the occupational therapist and occupational therapy assistant develop and maintain the knowledge, performance skills, interpersonal abilities, critical reasoning, and ethical reasoning skills necessary to perform current and future roles and responsibilities within the profession.”Wekell, Aspegren, & Holmgren, 2014, p. 1
“In health care, the term competency is generally used to describe the ability of the practitioner to be able to independently function in the practice setting in a safe and effective manner.”Hurlbutt & Asadoorian, 2016, p. 9
Interprofessional competencies in health care are “integrated enactment of knowledge, skills, values, and attitudes that define the areas of work of a particular health profession applied in specific care contexts.”Interprofessional Education Collaborative, 2016, p. 9
Competency is described as “broad clusters of general attributes” and is described as context dependent.Liu & Aungsuroch, 2018, p. 193

Perspective addressed in the Literature: Descending Order of Frequency

Identified Perspectives
Licensing agency
Credentialing agency
Health profession
Health care organization
Country or subset of country, such as provinces in Canada
Public
Individual clinician
Recipient of clinician's services
Authors

Dr. Di Leonardi is Consultant, Chicago, Illinois; Dr. Hagler is Clinical Professor, College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona; Dr. Marshall is Senior Vice President and Chief Nursing Executive, Cedars-Sinai, Los Angeles, California; Dr. Stobinski is Chief Executive Officer, Competency and Credentialing Institute, Denver, Colorado, and Adjunct Faculty, Ron and Kathy Assaf College of Nursing, Nova Southeastern University, Fort Lauderdale, Florida; and Ms. Welsh is Retired Chief Executive Officer, Hospice and Palliative Credentialing Center, Hospice and Palliative Nurses Association, and Hospice and Palliative Nurses Foundation, Savannah, Georgia.

The authors dedicate this article to Sandra Lee Schafer, who was a prime mover in this project; Ms. Schafer died in 2018.

Debra Hagler is the Deputy Editor for The Journal of Continuing Education in Nursing. She had no influence on the review or acceptance of this manuscript. Patricia Yoder-Wise, who was a consultant on this project, is the Editor of The Journal of Continuing Education in Nursing. She had no influence on the review or acceptance of this manuscript. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Bette Case Di Leonardi, BSN, MSN, PhD, RN-BC, Consultant, 653 North Kingsbury Street #2103, Chicago, IL 60654; e-mail: casedileonardi@gmail.com.

Received: April 24, 2019
Accepted: July 30, 2019

10.3928/00220124-20191217-05

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