Developing competency objectives as a basis for planning and assessing health visiting practice in training Kate Cernik and Janet Evans

Evaluating student performance in health visiting practice is complex. This paper reports the development of a schedule which combines identification of learning needs, planning of learning experiences, implementation of student activities and the evaluation of student competencies for the fieldwork component of a Health Visitor Diploma. The schedule is intended to encourage students and community practice teachers to develop a shared approach to the planning of learning and the assessment of competence. The approach described may have implications for the planners of post-registration nursing courses who wish to meet the learning needs of students with a variety of professional and academic backgrounds.

especially

INTRODUCTION For some time nurse education has been in the process

of developing

tinuous

assessment

competency Scott tions

standard’. is fraught

iourial

The

settings

definition

guidelines

(1990)

a particular

it useful

outcomes

measure 1988;

competency

is ‘The

ability

to

to a prescribed competency

Nurse educationalists

to make

use of product

easily measurable for

con-

Board’s regula-

to measure

with difficulties. with their

to

(France of

activity

The attempt

have found objectives

designed

in the English National

and

perform

and implementing

in practical

1984).

accepted

in the

behaviourist

assessment

behav-

purposes,

technique,

domain.

is used -

is asked to demonstrate aseptic

If a

where a student

a specific

measurement

skill such as becomes

rela-

tively easy, but such approaches

tend to stifle

initiative and imply that terminal

objectives

satisfactory.

There

are

has been much debate about

the relative merits of using a process approach

in

the

as

construction

opposed iourist

1986).

objectives

strategies

a task-orientated

at the expense

objectives

or behaviourial

Product

assessment

emphasise Benner

of educational

to a product

(Sheehan

defined

identified

appear

approach

characterises

approach and behav-

can

of the psycho-social

(1984)

‘an interpretively formance

Kate Cernik BSc RGN HV Cert Cert Ed Lecturer in Health Visiting, Janet Evans BA RGN HV Cert RHV Tut, Lecturer in Health Visiting, Department of Nursing, The Whelan Building, University of Liverpool, P.O. Box 147, Liverpool L69 3BX. UK (Requests for offprints to KC) Manuscript accepted 15 October 1991

psycho-motor

approach

to

to nursing

dimension.

competency

area of skilled

and described

as per-

by its intent,

function and meanings’. She stresses the importance of the content and context of particular functions

and skills. There

involved

in the

are many subtleties

interpretation

of

competent

skills. The behaviourist approac:h to the assessment of such skills is blunt, insensitive and of

38

NURSE EDUCATION

TODAY

limited value. Bircumshaw traditionally

(1989) points out that

quantitative

competency

will

measures

used to test

measure

qualitative

not

their knowledge standards

and skills in order

in the nursing

The andragogical

experience.

training

The advantages approach

is open ended (FEU

greater

approaches

influence,

control

of skill, but highlights this approach

-

with professional practice

in order

nationally

tration

andragogical

and the acquisition

open ended.

and

of

assess-

would seem to be at odds

perceived

of

learning

to this approach

syllabus

such

Learning

1989).

is

should thus be

in terms of potentialities

development

The

that learning

outcomes

in order

to choice post-regis-

(Simmons stresses

This

restrictions

by other

planners

of a

(ENB).

being restricted material;

points

allow

by the requirement

approach

as terminal further

which

negotiation

acknowledged

course

and making use of

are limitations

prescribed

have been

having

and

visiting.

building on previous

approaches

of

There

of project/seminar

Sheehan

the major disadvantage

the

degree

responsi-

over

training

requires

learning

results in negotiation

by including

the difficulty of terminal

ment. The approach

a

emphasise

such as those imposed

the

involve learners

the value of the learner

bility for their own learning

which

with

education

such as health

for development

objectives.

The

also makes

and review dimension.

stresses

1980).

potentialities.

Unit (FEU)

actively in their own development the reflection

for

in terms of the continu-

of desirable

Education

point that process

knowledge self-directed

are described

ous development

(1986)

associated

for continuing

for specialisms

These strategies

of the process

A process approach

Further

approaches

as a whole.

the work of Knowles (1984) appear to be particularly appropriate

Outcomes

to enhance

profession

rather

than

to encourage

the

of expertise.

such as health visiting

provision

to protect

of a licence the safety

to

of the

FIELDWORK PRACTICE

public. Health

visiting

exclusively (NHS)

has

been

within the National

since reorganisation

fundamental structure

changes

carried Health

in 1974.

in the organisation

found implications

of Project

2000

visitors

and

adapted

Community

1989) and

facilitates

have pro-

families

for the role of health visitors

Practice

for

arranging

in training

from

her

CPT

assessing the student’s competence

a generalised

frame-

a period

need

skills which can be

needs.

In developing

a

new course curriculum, a student-centred approach (Houle 1972; Knowles 1984) to learning was taken, which would encourage

indepen-

of supervised

The CPT

workload

and

in the gen-

is also responsible

health

this

of the

by providing

experiences

of uncertainty,

to develop

to meet future

(CPT).

learning

appropriate The

During

is the responsibility Teacher

visiting

takes place

placement.

the student’s

eral caseload.

this backdrop

work in which

fieldwork

time, student learning

in the future. Against

A large part of health visitor training in a practical

Proposed

of the Health Service (DHSS

the implementation

out Service

practice

for

to undertake during

which

time the student is assessed whilst working with a limited caseload. Fieldwork practice opportunity

provides

to articulate

Much of the learning

students

practice

with an

and theory.

which takes place during

dence on the part of the student, together with the ability to continue to develop educationally

fieldwork

and professionally

Burnard (1989) as any learning which increases the facilitation of experiential knowledge, that is practical knowledge revealed through practice.

in a rapidly changing

Health

Service structure. The post-registration training and practice project (PREPP) discussion paper implies that such approaches are necessary in order to encourage individual practitioners to take responsibility

in updating

and developing

practice can be described

tial. Experiential

learning

as experien-

has been described

by

Burnard suggests that aspects of experiential learning can be usefully combined with an andragogical approach through the use of

NURSE EDUCA-I-IO& TODAY

negotiation

Malk

and self assessment.

It was felt that an androgogical fieldwork

combined

approach

to

with the opportunity

for

negotiation would help students to develop the skills of self-sufficiency and flexibility required by new practitioners change

outlined

in view of the climate

of

schedule

competencies for

the

newly

evaluation

of health visitors is undertaken between

Institutes

of Higher

Practice Teachers course

educationalists Education

in teaching.

- which reflected

number

of existing

considered.

The

teaching

(1989)

assessment

one which

was described of continuing

tool.

schedules proved

A

were

to be the

by Dimauro

and Malk

the Dimauro

and

to

to

of the

emphasise

the

the competencies call

them

it

in an

competency

THE SCHEDULE

and

Table 1 Competency

objectives taken from the Competency

Competency

objective

and Malk (1989) schedule

of four corresponding ties,

criteria,

reinforce

the ability

Specific

the competency

Assessment

criteria

more

of context

The evaluation

competence

resources.

.’ in order

nature

to

of the learn-

make the intent of

explicit

and

as emphasised methods

list provides the with suggestions

stress

the

by Benner

suggest a range

or tools of assessment.

(Table

The

using terms such

to .

the non-terminal

ing process.

(1984).

and

were constructed

as ‘developing

consists

lists which are: competen-

evaluation

competencies

resources student

for clinical

nurse specialists. A first step to modifying

open

of strategies

for an American

education

The

of skill development,

to construct

way

the structure

order

was decided

importance

for the fieldwork

and had been designed

programme

and

and which

as an assessment

most suitable for modification element

a

which could be used to

provide a basis for fieldwork also be used

of lecturers

In

nature

The Dimuaro

and Community

A group

visitor.

in

(CPTs) who have undergone

CPTs devised a schedule could

as a

based

health

objectives.

DEVELOPING A PRACTICALLY BASED ASSESSMENT SCHEDULE partnership

qualified

design.

developmental

The training

up a list of the

which were felt to be appropriate

competencies were divided between four groups _ assessment, planning, implementation and course

earlier.

was to draw

39

assessor for

Lastly, the and

the

achieving

1).

Schedule (Cernik 81 Evans 1990)

Criteria

Evaluation

Resources

Has the ability to communicate effectively using the written word.

Writes accurate, concise and comprehensive records and reports.

Using records, H.V. studies and report writing exercises.

Policy documents -

Develops skills of verbal communication with clients, colleagues, others,

Demonstrates verbal skills when conducting consultations in one to one, group, or meeting situations and on telephone.

Through observation of Clients and colleagues, the student in suitable H.V. studies situations. Clinics, In consultation with clients Meetings. and colleagues.

Identifies and uses appropriate mechanisms of referral and liaison for the benefits of clients.

Compiles a comprehensive file of referral agencies and refers clients appropriately.

Production and use of a referral file.

Clinic information, Social services, Libraries, Voluntary organisations etc.

Develops the ability to conduct effective consultations with clients.

Demonstrates the initiation, guiding and termination of consultations in clinics and in homes.

Observation, Role play.

Clients Clinics.

H.V. studies,

local.

40

NURSE EDUCATION

TODAY

USING THE SCHEDULE Copies of the schedule are given to both the student and the CPT at the beginning of the course. Students are asked to rate their existing competency on a scale (the scale will be described in detail later). These ratings can then be used as a basis for negotiation with the CPT in the provision of appropriate learning opportunities. The initial self rating will be made with the guidance of tutors and CPTs. The schedule acts as a focus for identifying learning needs during the early part of the field work experience and becomes an assessment tool in the later part of the course. A student with particular expertise in an area may be rated above the required point (R), in which case the teaching programme can be modified accordingly. Any wide disparities between the ratings made by a student and the CPT require arbitration by the supervising lecturer. CPTs have commented that, where such disputes have occurred, it has been due to students undervaluing their previous experience. Disparities arising early in the course may indicate to supervising lecturers potential difficulties with either the student or the CPT- the schedule acts as a diagnostic tool for detecting problems in this situation. Towards the end of the course the assessing nature of the schedule becomes more important. The explicit nature of the criteria used in assessing the competencies assists CPTs if they need to refer a student on fieldwork practice. In the event of referral, the student will have a precise indication of why they have been referred, which will asssist them to focus on specific skill deficits during a further period of fieldwork and assessment with a new CPT. The schedule can be used to provide evidence in the case of student appeals.

ASSESSMENT

SCALES

The assessment scales used are based on the work of Knowles (1984). Henfield and Waldron (1988) describe the use of such scales in the assessment of competency for courses in con-

tinuing education. They point out the approthe of the rating scales in priateness development of negotiated learning contracts as they enable students to assess their own competence and make a commitment to further learning. It could be argued that the use of rating scales conflicts with Knowles’s basic philosophy on adult education, but the vocational nature of nurse training course with the associated issuing of licence to practice makes this compromise necessary (Table 2). The student and CPT make independent assessments of the present level of competence (P) at the commencement of the course and at intervals throughout the course for comparison to the predetermined required level (R) of competency for each item in the schedule. The rated scales should then provide a basis for planning of learning activities and discussion of progress. The rated scales should clearly demonstrate to both the CPT and to the student any particular areas of strength or of deficiency or weakness. The R rating was determined by independent groups of CPTs before the schedule was used. Judgements were based on previous experience of health visiting and fieldwork teaching. The high level of agreement between CPTs in determining the required levels increased the confidence of individual teachers in the use of the schedule for assessment purposes. After three terms of combined college work and field work practice, students are examined on theory and assessed on competence to practice (intermediate examination) before going to supervised practice. At this stage of the course students are expected to work independently managing a modified caseload. They are allocated to a new assessor - the Assessor of Supervised Practice (ASP) - who must be able to write a satisfactory report on the students’ ability and competence to enable them to gain their qualification. The schedule will provide the basis for that assessment. The use of two successive assessors - the CPT and the ASP for each student increases the reliability of the assessment process in relation to giving licence to practice. The English National Board (ENB) issue a standard assessment form for this part of the course; the

NURSE EDU(:A-I-ION

Table 2 Competency

will be assessed using the following

scale

2

1

High

Moderate conceptual understanding 3

Low

Absent awareness 0

41

TODAY

competent 4

5

~______________________________~ ______________________________I ______________________________) ______________________________) _____________________________ 1

The student and assessor will make independent assessments of the competency on each item; this can be denoted by indicating the -P- (or present level) of competence. The -R- (required level) for the two assessment points will be predetermined. Definition of terminology Awareness Basic appreciation/comprehension Uses previous knowledge and experience Conceptual understanding Tying in of theory to practice Ability to a) identify b) analyse c) consider appropriate Fitting the individual into the wider context

action

Competent Safe to practice Conceptual understanding and willingness to continue developing as an individual Performs at a consistently acceptable level

form asks the ASP to comment of practice

on specific areas

on ability other than safety to practice. caused difficulties had a problem students

teacher

but does not call for any judgement This has

identifying

the specific

the criteria

help to make decisions

The new schedule

criteria

taken more accountable.

approach

ensure

number

of

reasons

why

to the fieldwork

this prac-

of the course:

1. The schedule

is consistent

gogical philosophy

provision

The schedule

with the andra-

2. The design offers students the opportunity

of

a

to be addressed.

updated

isolated

on a course

of this

to practice.

nature where students enter training with a

on the use of the instrument relevance

2000

students

competencies

come on stream

training. together

the

criteria on which they are based are made explicit to both the student and fieldwork

provides

some

and addresses The

the

arranging

of

notes

and re-examine

the

of items and the appropriateness

of

the required (R) levels for each item on the assessment scales will help to maintain the status of the schedule

with

the

one for fieldwork

for assessors to compare

wide diversity of previous experience. This trend is likely to become a more apparent for post-registration

are

is a vexed ques-

practice

for the students,

meetings

to

its use will

reliable

reliability

and one for supervised

regular

value

about

How

tion; the use of two assessors,

of particular

CPTs

base.

questions

Inter-rater

issue of safety

3. The

regularly

is still in the process of develop-

need

to identify their own starting points. This is

as Project

consistent

list will enable

and several

protection

of evaluation

to assessment.

ment

assessors?

of the course as a whole.

isolation

a more

update their knowledge

is appropriate

tice component

than it has been in the past.

should

approach

DISCUSSION a

of assessment

visiting work. The inclusion

and so

resources

are

of the course

process

from each other due to the nature of health

The

There

the

CPTs often work in comparative

reasons

for safe practice

from the beginning makes

more rigorous

in the past because ASPS have

have been referred.

will clarify

which

as a live and responsive

tool. At

present, the schedule does not assess whether the student’s performance is excellent or mediocre as it is intended to act as a gateway to the

42

NURSE EDUCATION TODAY

profession, but its formative approach should enable students to continue to strive for improving their professional performance beyond qualification.

CONCLUSIONS Developing a schedule of this nature has proved to be a useful exercise in many ways. It has enabled course planners to examine the practical nature of health visiting, a process which should be the starting point for any reorganisation of theoretical course content. The combined schedule can be used for the identification of learning needs, the planning of learning experiences, the implementation of learning activities and the evaluation and assessment of student performance which conforms to the systematic approach to the practice of health visiting which is currently being applied. The tool embraces an adragogical approach to learning and caters for students who may have a wide of previously acquired skills and range experience. The schedule is presently being used with a student cohort for the first time. Informal evaluation of its use in practice indicates that it is favourably received by students and CPTs and that it has assisted CPTs in assessing a student’s competence. A detailed evaluation will be made at the end of the present academic session. The evaluation will form a basis for review and refinement of the schedule as well as examining its use as a practical tool. The evaluation will be carried out using a questionnaire issued to CPTs and students, and modifications made accordingly. In this way the tool should remain viable in a fast-changing practice environment. An essential component of any course which provides a licence to practitioners in the provision of stringent safeguards in its assessment methods to protect the interests of the public and of the profession, This requirement may be at odds with the desirability of using a process approach. It is hoped that the explicit nature of this schedule combined with a consistent

approach to rating scales will carve an appropriate middle course. Students who have the ability to direct their own learning will be better equipped to deal with the rapidly changing working environment which they will be encountering. With Project 2000 producing registered practitioners with a wide range of skills, and attracting students of differing ages and professional backgrounds, approaches of this nature may be useful for a range of post-registration training courses. The PREPP discussion document draws heavily from the ideas of Houle in advocating the increasing responsibility of the individual practitioner in maintaining and improving professional standards, underlining the importance of developing tools of this kind which can be used to assess practice in the context of continuing education.

References Benner P 1984 From novice to expert. Addison Wesley, California Bircumshaw D 1989 How can we compare graduate and non-graduate nurses? A review of the literature. Journal of Advanced Nursing 14: 438-443 Burnard P 1989 Experiential learning and andragogy negotiated to learning in nurse education: a critical appraisal. Nurse Education Today 9: 300-306 DiMauro K and Malk L B 1989 A competency-based orientation programme for the clinical nurse specialist. The Journal of Continuing Education in Nursing 20, 2: 74-78 DHSS 1986 Neighbourhood nursing - a focus for care. HMSO, London DHSS 1989 Working for patients. HMSO, London ENB 1990 Regulations and guidelines for the approval of institutions and courses. English National Board, London FEU 1980 Developing social and life skills. Further Education Curriculum Review and Development Unit. London France M 1988 Dawn of a new age; assessment and evaluation. Senior Nurse 8, 12: 25-27 Henfield V J, Waldron R 1988 The use of competency statement to facilitate individualised learning. Nurse Education Today 8: 205-2 I I Houle C 0 1972 The design of education. Jossey Bass, San Francisco Knowles M 1984 The adult learner: a neglected species. Gulf, Houston, Texas Luker K, Orr J (eds) 1985 Health visiting. Blackwell Scientific, Oxford Robinson C 1988 Health visiting in practice. Churchill Livingstone, Edinburgh

NURSE EDU(:ATIOIV TODAY

Scott B 1984 A competency based learning model for critical care in nursing. International Journal of Nursing Studies 21, 1: 9-17 Sheehan J 1986 Curriculum models: product versus process. Journal of Advanced Nursing 11: 671-678 Simmons S 1989 An exercise in curriculum

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