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Download printable version (pdf)GENERAL PRACTICE NURSES
Unit Three
Competences from a general practice nurse’s perspective
Key Messages
Once you have read this Unit, you should have an understanding of:
- how to measure the competences required to extend the role of a general practice nurse (GPN)
- the knowledge and skills associated with both the Quality and Outcomes Framework (QOF) and the Knowledge and Skills Framework (KSF) in relation to levels of competence.
The quality of care provided to patients in general practice is now assessed through the QOF,1 and practices are rewarded in accordance with the level of care provided. This means that many GPNs are being asked to take on additional skills to assist in the management of patients with long-term conditions.
The Nursing and Midwifery Council (NMC) Code of Professional Conduct (section 6.2)2 clearly states that 'you must acknowledge the limits of your professional competence and only undertake practice and accept responsibilities for those activities in which you are competent'. It is therefore fundamental for both you and your employer to be aware of your own skills and abilities. The KSF3 is particularly useful in terms of reviewing your competences in a formal way. Even if the practice you work for has not adopted Agenda for Change4 (AfC), it may still be helpful for you to assess where you are on the KSF so that you can identify any personal development needs. The tools in this Unit will enable you to do that.
What is competence?
- Competence is the demonstrable ability and skills required to undertake a particular role or set of activities
- Assessment of competence provides
evidence of capability for the individual concerned, for the employer,
and for patients
GPNs should welcome any opportunity that encourages them to engage in assessing their level of competence. This means they will then be working at an appropriate level, making full use of their skills, but not involved in work for which they are inadequately prepared.
When defining your own level of competence, you should also look at the levels below and above your own position as this will help you identify the tasks that you can delegate appropriately to others (eg health care assistants). It will also clarify the tasks that you can pass on to more-senior colleagues.
In the context of this Toolkit, the term 'competence' means the 'ability to perform the tasks and roles required to the expected standard'. The NMC emphasis on not working beyond your level of competence means that you need to regularly self-assess your skills.2
Self-assessment of your skills should be done formally, at least once a year, in your annual appraisal. The training and education required should be recorded in your personal development plan. If you have a mentor, it will also be useful to discuss your self-assessment with them. You can then make an action plan of how you will acquire the additional knowledge and skills required. If you are undertaking formal education relating to your role (see Unit: Education and professional development of general practice nurses), your mentor will probably be required to assess and record your clinical competences. This provides a record that will be of great value to any future employers.
Skills for Health (www.skillsforhealth.org.uk) are compiling a variety of competence frameworks linked to specific areas (eg coronary heart disease). These frameworks help to identify the type of behaviours that link directly to the work that needs to be done. Rating scales assess which levels of competence are required at what stage. Benner's 'novice to expert' model5 defines five levels of practice, from novice to expert, which can be used to assess levels of proficiency. This will provide a broad overview of the level you are working at.
Benner’s novice to expert model5
- Novice – stage in skill acquisition where no background understanding of the situation exists, so that context-free rules and attributes are required for safe entry and performance, for example. Requires rigid protocols from which to work and can only work under supervision.
- Advanced beginner – can demonstrate a marginally acceptable performance. The advanced beginner has enough background experience to recognise aspects of the situation, for example, and can vary the approach used according to the needs of individual patients, although still requires supervision.
- Competent – a stage in skill acquisition typified by considerable, conscious, deliberate planning. The competent stage is evidenced by an increased level of proficiency, for example, the individual no longer requires supervision for routine tasks, but is aware of the limits of his/her knowledge and skills, and refers to others appropriately.
- Proficient – the proficient performer perceives situations as a whole rather than in terms of aspects, and performance is guided by maxims. The proficient performer has an intuitive grasp of the situation based upon a deep background of understanding, for example, the individual is experienced in the field of work, competent to modify procedures appropriately to match differing circumstances, and able to advise others on how to perform tasks.
- Expert – developed only when theoretical and practical knowledge is tested and refined in real-life clinical situations. An expert has a deep background of understanding of clinical situations based upon many past cases, for example, very experienced, work has been tested in difficult situations, and is able to teach others, with an understanding of the principles and exceptions in the work.
Why are competences needed?
The range of work undertaken by GPNs is increasing, following national guidance that promotes nursing autonomy,6-8 and the new General Medical Services contract (nGMS).1 Accurate assessment of an individual's capability will ensure that patient safety is not compromised by GPNs taking on additional roles that have traditionally fallen under the remit of the GP. GPNs should look critically at the work that GPs are expecting them to undertake and ensure that they are adequately prepared in terms of resources and skills. GPNs who work in small practices, with little peer support, may be at risk of being overworked and undertrained if their GP employers are not properly aware of their competences. In order to attain competence, there needs to be adequate provision of standardised, recognised and credible training at a local level. If, as a GPN, you prefer to practice traditional clinical skills and not take on advanced roles, this should be respected and valued by your employer. The key to safe practice is clear identification of all GPN roles within the practice. A competence framework will help you to achieve this clarity.
In order to be aligned with the National occupational standards and National workforce competences, all local documentation (including protocols) should be checked against these National occupational standards which can be found on the skills for health website (www.skillsforhealth.org.uk), also see Unit: Competence management approach, HCA Toolkit. See Tool - Skills assessment using a rating scale for a skills-assessment rating scale that will help both you and your employer feel confident about the specific areas that you are competent in, and will help to identify any areas that require further development.
What is a advanced nurse practitioner?
A recent consultation from the NMC has supported the proposal to introduce an additional level of
registration for advanced nurse practitioners. The proposal is currently awaiting approval from the
Privy council and will require changes to legislation before it can be implemented. This additional
sub-part of the nursing register will have defined standards for advanced practice. GPNs who are
currently acting in advanced roles (or using the title 'nurse practitioner') will have the opportunity
to demonstrate achievement of these advanced standards. The standards are linked to competence
in assessment and treatment, and must be achieved at a minimum of honours degree level.
Tool - Advanced nurse practitioner competence framework aligned to the KSF version 7 takes account of these standards.
Why link competences to the KSF?
Linking GPN competences to the KSF3 is one way of ensuring that appropriate pay scales are in place if AfC is adopted. The KSF is in itself a framework of competences that are referred to as dimensions.
The KSF helps to:
- identify the knowledge and skills needed for a particular post
- guide an individual’s development
- provide an indication of appropriate pay
- provide an objective framework to review staff development needs.
Tool - The process of linking GPN roles with the KSF shows the process that is followed to match GPN roles against the KSF.
The competence tools that follow on the next page have put the mapping process into action, and identified how various levels of work within general practice nursing are positioned within the KSF.1 These competences have been adapted by Torbay primary care trust (PCT) from work developed as part of a joint initiative by practitioners working within the Avon Gloucestershire and Wiltshire strategic health authority and the South West Deanery.* They therefore do not signify nationally approved standards. However, they are being considered for approval or adaptation by Skills for Health and the Royal College of Nursing, and provide a robust structure for GPNs to use to position themselves within the KSF.
Tool – Lead
GPN competences framework aligned to the KSF version 7
Tool – GPN competences framework
aligned to the KSF version 7
Tool – Senior
GPN competences framework aligned to the KSF version 7
Tool – Advanced
nurse practitioner competences framework aligned to the KSF version 7
*The competence framework originated in 2002 as an output from the educational advisory group comprising experienced GPNs from the south west. In 2003, Avon Gloucestershire and Wiltshire strategic health authority established a project group of personnel drawn from general practice, higher education institutes and the South West Deanery. They developed the work further, incorporating the job descriptions produced by Charnwood and North Leicestershire PCT, and aligning it with the Knowledge and Skills Framework (Version 6) of the NHS. In 2004, a Toolkit was completed and piloted. It is this Toolkit (called the AGS/SWD Toolkit) that has been adapted and piloted by Torbay PCT.
The Scottish Framework for Nursing in General Practice9 provides a less-detailed model that identifies components of the roles of staff nurse, specialist practice nurse and advanced nurse practitioner. Unit: Employment of general practice nurses also provides examples of the components of various roles within general practice nursing.
How is competence measured and by whom?
Defining the competences required for a role is a way of identifying whether or not you have the skills or capacity to undertake a particular job or activities. Your registration with the NMC provides evidence of defined standards in terms of professional practice. However, different levels and types of nursing care and skills are required for various posts. These need to be differentiated so that they are valued and supported at an appropriate level. A defined set of standards or benchmark statements therefore provide a level against which you can compare your own skills. You can help to measure your own competence, but this will also require verification from a senior nurse and your employer. There is often a lead nurse in the PCT who you could approach to discuss this with.
To attain competence in different areas of health care delivered in general practice requires access to courses that are recognised, standardised, assessed and credible. Courses are provided from a variety of sources including the local higher education institutions, colleges and independent providers.
Ensuring trusts and strategic health authorities are well informed of courses required by GPNs is essential to attain competence.
References
- Department of Health. Investing in General Practice: The New General Medical Services Contract. London: Department of Health; 2003. Available at :http://www.dh.gov.uk/assetRoot/04/07/19/67/04071967.pdf.
- Nursing and Midwifery Council (NMC). Code of Professional Conduct. London: NMC; 2002.
- Department of Health. The NHS Knowledge and Skills Framework. London: Department of Health; 2004. Available at: http://www.dh.gov.uk/assetRoot/04/09/08/61/04090861.pdf.
- Department of Health. Agenda for Change: What Will It Mean for You? London: Department of Health; 2004. Available at: http://www.dh.gov.uk/assetRoot/04/09/08/59/04090859.pdf.
- Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Munao Park: Addison-Wesley; 1984.
- Department of Health. The NHS Plan – a Plan for Investment, a Plan for Reform. London: Department of Health; 2000. Available at: http://www.dh.gov.uk/assetRoot/04/05/57/83/04055783.pdf.
- Department of Health. Making a Difference: Strengthening the Nursing Midwifery and Health Visiting Contribution to Health and Healthcare. London: Department of Health; 1999. Available at: http://www.dh.gov.uk/assetRoot/04/07/47/04/04074704.pdf.
- Department of Health. Liberating the Talents, Helping Primary Care Trusts and Nurses to Deliver the NHS Plan. London: Department of Health; 2002. Available at: http://www.dh.gov.uk/assetRoot/04/07/62/50/04076250.pdf.
- Scottish Health Executive. The Scottish Framework for Nursing in General Practice. Edinburgh; 2004. Available at: http://www.scotland.gov.uk/Resource/Doc/25725/0012830.pdf.