The competency landscape: a critical realist exploration of the
ways nurses understand and utilise competency standards
by Kathryn Terry (B Nursing, MEd)
Submitted in fulfilment of the requirements for the Degree of Doctor of Philosophy
University of Tasmania (May 2013)
Statement of Original Authorship
This thesis contains no material which has been accepted for a degree or diploma by the
University or any other institution, except by way of background information and duly
acknowledged in the thesis, and to the best of my knowledge and belief no material
previously published or written by another person except where due acknowledgement is
made in the text of the thesis, nor does the thesis contain any material that infringes
copyright.
Name: Kathryn Terry
Signed:
Date:
Statement of Authority
This thesis may be made available for loan and limited copying and communication in
accordance with the Copyright Act 1968.
Name: Kathryn Terry
Signed:
Date:
ii
Abstract
Controversy surrounds the way in which the ANMC Competency Standards for Registered
Nurses (the Standards) are understood and applied in the assessment of nurses’
competence for practice. Adopted by the Australian Nursing Regulatory Authority in the
early 1990s the Standards provide a description of the registered nurse on entry to practise,
and have been used to determine both beginning level and ongoing competence to practise
for over two decades. How nurses’ interpret and make sense of the Standards particularly
when making an assessment of competence is unknown. The study examines the deeper
mechanisms which influence nurses’ interpretation and application of the Standards in the
context of assessment from a critical realist perspective. This perspective, together with a
mixed methods methodology, enabled the re-conceptualisation and critique required to
enhance understanding of the assessment of competence landscape.
A two-phase exploratory mixed methods sequential design was employed. The
questionnaire was used to gain prior insight into the context and to gain a general
understanding of nurse’s opinions around competence and its assessment in relation to the
Standards. These findings were analysed to inform the qualitative phase. Interviews were
then conducted with fifteen nurses comprising of; academics, clinical facilitators, preceptors
and graduate nurses. Thematic analysis using a continual cross-comparative approach was
used to explore how and why nurses operate at the interface between agency and
structures in the context of competency assessment. Threads from both phases were drawn
together and mixed at the data interpretation stage to achieve a cohesive set of findings.
The thesis offers unique contributions into understanding the ways in which nurses create,
negotiate and perpetuate the status quo of the Standards by focusing on the interface of
nursing assessment processes and events, and their interactions with mechanisms and
structures. Nurses create and operate in a state of tension created by their perception of
the Standards as an important professional structure and the difficulty that they experience
putting them into action in the context of practice. On the one hand, nurses support the
Standards' as a mechanism to promote the collective identity of the nursing profession and
accept the Standards as an integral part of the safety and quality agenda. On the other
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hand, nurses found the Standards difficult to operationalise for their key function of
assessment.
The thesis sheds new light on the way nurses interpret and use the Standards to assess
competence; it is these subjectivities that are considered to be a critical new factor in the
development of any future assessment framework. This is not only important new
knowledge, but given the link between competence and the safety and quality agenda it has
implications for the quality of patient care. The implications of the study findings for
practice are therefore significant. Research into how competency assessment impacts on
the quality of patient care needs to move beyond a quantitative, objective measure, to
consider the generative potential of the socio-cultural context of practice.
An urgent critical review of the Standards is needed to determine whether they continue to
be a suitable assessment framework. The future success of any framework that assesses
competence will be dependent on ensuring that both the structural forces and agentic
subjectivities that shape nurses decision making are acknowledged and addressed.
iv
Acknowledgements
I would firstly like to thank the nurses who participated in the study and who so generously
and enthusiastically shared their experiences.
My sincere thanks are extended to my supervisors, Dr Christine Stirling, Professor Rosalind
Bull and Professor Denise Fassett for their skilful guidance and support during my
candidature and for challenging my intellectual capacity. I am most grateful for your
expertise, critique and advice.
I would like to thank Ms Rebekah Burgess who provided copyediting and proofreading
editorial advice for this thesis in line with Standards D and E of the Australian Standards for
Editing Practice.
I would like to acknowledge the support of the UTAS Graduate Research Office, who
supported this PhD through the provision of a scholarship. I also sincerely thank the UTAS
Graduate Research Conference Fund Scheme and UTAS SNM Conference Fund Scheme,
these funds allowed me to travel to the 2011 International Mixed Methods Conference in
Leeds to present paper – this was the definite highlight of my candidature. It was here that
I attended Professor Alan Bryman workshop ‘Quality in Mixed Methods Research. Since the
conference workshop, Prof Bryman has generously continued to provide ongoing support
and advice by answering my questions on mixed methods and critical realism.
I also wish to acknowledge my colleagues in the PhD Reading Group for the opportunity for
rigorous debate. Thank you Melanie, David and Damhnat for sharing your PhD journey with
me.
Special thanks go to my children Claire and William, thank you both so much for being there
for me. Finally, I would like to dedicate this thesis to my husband Craig, in grateful thanks for
his patience, support and continued enthusiasm throughout the project.
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Acronyms and terms
AC
Academic
AHPRA
Australian Health Practitioner Regulation Agency
ANCI
Australian Nursing Council Incorporated
ANMC
Australian Nursing and Midwifery Council
ANRAC
Australasian Nurse Regulatory Authorities Conference
CF
Clinical Facilitator and Sessional Teachers
COPA
Competency Outcomes and Performance Assessment
GN
Graduate Nurse
NOOSR
National Office of Skills Recognition
NMBA
Nursing and Midwifery Board of Australia
PR
Preceptor
SNM
School of Nursing and Midwifery
SSI
Semi-structured interview
The Principles
Principles for the Assessment of National Competency Standards for
Registered and Enrolled Nurses 2002
The Standards
The Australian Nursing & Midwifery Council Standards for the
Registered Nurse 4th Edition January 2006
UTAS
University of Tasmania
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Appendices
Appendix 1 – Letter of request for participation in the research project
Appendix 2 - Questionnaire information sheet
Appendix 3 – Questionnaire
Appendix 4 - Consent Form
Appendix 5 –Questionnaire quality checklist
Appendix 6 - Semi-structured interview guide question guide
Appendix 7 - 15-point checklist of criteria for good thematic analysis
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Tables
Table 1 - The mixed methods research process
Table 2 - Six phases of thematic analysis
Table 3 - Model of qualitative analysis utilised
Table 4 - Data extract with code applied from questionnaire and SSI data
Table 5 - Quality issues in the mixed-method research project
Table 6 – Coding scheme
Table 7- Demographic details of the study population
Table 8 - First nursing qualification and highest qualification of questionnaire the study
sample
Table 9 -Practice area and when study sample learnt about the standards
Table 10 - Descriptive statistics by participant group of their opinions of assessment of
competence using the Standards
Table 11 - Descriptive statistics by participant group of opinions regarding undertaking an
assessment of competence
Table 12 - Formal training on the Standards
Table 13 - Formal training on assessment skills
Table 14 - Example categorisation of open ended questionnaire responses
Figures
Figure 1 – The theoretical framework
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Conference Presentations and Journal Article
A co-authored conference paper was presented in July 2011 at the 7th International Mixed
Methods research Conference in Leeds, United Kingdom entitled ‘Real world application of
mixed methods: a novice researcher perspective’.
UTAS, 10th Teaching Matters Annual Conference 2011, Sharing practice. ‘Learning together
through a collaborative and scholarly community of practice.’
Greenwood, M. D. and K. J. Terry (2012). "Demystifying mixed methods research:
participation in a reading group ‘sign posts’ the way." International Journal of Multiple
Research Approaches 6(1): 73-83
Statement of Co-Authorship
The following people contributed to the published peer-reviewed manuscript:
Name and institution = Kathryn Terry, UTAS SNM PHD Candidate, Author 1
Name and institution = Melanie Greenwood UTAS SNM PHD Candidate, Author 2
Author details and their roles:
Demystifying mixed methods research: participation in a reading group ‘sign posts’ the
way."
Authors 1 and 2 were the sole authors of the article. Author 1 and 2 equally contributed to
the idea, its formalisation development, its refinement and the final presentation.
We the undersigned agree with the above stated “proportion of work undertaken” for the
above published peer-reviewed manuscript:
Signed: __________________
______________________
Date:__________________
Date:__________________
Author 1:________________
Author 2:_______________
School of Nursing and Midwifery
University of Tasmania
School of Nursing and Midwifery
University of Tasmania
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Table of Contents
Statement of Original Authorship
ii
Abstract
iii
Acknowledgements
v
Acronyms and terms
vi
Appendices
vii
Tables
viii
Figures
viii
Conference Presentations and Journal Article
ix
Table of Contents
x
Chapter 1 – Background
1
Introduction and Overview
1
The research problem
3
Motivation for the study
7
Research aim and questions
8
Research questions
9
Historical evolution of competency standards
9
Professionalisation and the adoption of competency standards
11
Educational agendas converging on the adoption of competency standards
13
Political agendas converging on the adoption of competency standards
16
Conceptions of the notion of competence
18
Outline of the thesis
20
Conclusion
22
Chapter 2 – Literature Review
23
Introduction
23
Literature review process
24
Current literature
24
The safety and quality healthcare agenda
25
Competency based standards as a key policy direction
27
Professionalisation with competency standards
31
Regulation of practice with competency standards
35
The difficulty in defining competence
37
Challenges in assessing competence
40
Relationship between performance and competence
41
Conclusion
58
x
Chapter 3 – Research Approach
60
Introduction
60
Historical background to critical realism
62
Construction of a critical realist research framework
63
Elements of a Critical Realist Theory
65
Application of critical realist theory to the nursing environment
66
Benefits of using a critical realist approach
77
Limitations of critical realism
80
Summary
81
Mixed methods methodology
81
Historical background to mixed methods
83
Reflexivity
86
Conclusion
88
Chapter 4 – Research Design and Methods
Introduction
Data selection
Phase one questionnaire
91
91
93
95
Study setting
95
Sampling
96
Purposive research sample
97
Recruitment
98
Questionnaire development
100
Data analysis methods
104
Phase two semi-structured interviews
106
Target population
106
Purposive research sample
107
Recruitment of participants
108
Data Collection Method Phase Two
108
Semi structured interview development
109
Completion of the semi-structured interview
110
Data analysis method
111
Mixed methods quality
114
Ethical Conduct
117
Representation
117
Confidentiality
118
Data storage
118
Conclusion
119
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Chapter 5 - Nurse perspectives on the use of the Standards
120
Introduction
120
Questionnaire demographic information
120
Descriptive statistics by participant group
124
Open–ended questionnaire responses
131
Conclusion
133
The contextual nature of the Standards
134
The disconnect between the function and the application of the Standards
140
Student introduction to the Standards
151
Impact of roles when operationalising the Standards
155
Conclusion
159
Chapter 6 - Structural factors which shape nurses’ collective identity
161
Introduction
161
Professional governance
161
Professional accountability
168
Beginning level competence
173
Safety and quality agenda
176
Conclusion
178
Chapter 7 - Discussion
180
Introduction
180
The Standards as a social structure
182
The effect of Agency and re-interpretation of the Standards
189
The morphostatic nature of the Standards
196
The Standards and the nurse identity
201
The safety and quality agenda promoting morphostasis of the Standards
202
The cultural context of nursing practice: influencing morphostasis
204
Conclusion
Chapter 8 – Conclusion
206
209
Introduction
209
Conclusions arising from the study
217
Recommendations
219
Strengths of the research approach
221
Limitations of the research approach
222
Directions for future research
223
In closing
224
References
226
Appendices
270
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Appendix 1: Letter of request for participation in the research project
270
Appendix 2: Questionnaire information sheet
271
Appendix 3: Questionnaire
273
Appendix 4 Consent Form
281
Appendix 5: Checklist for developing a questionnaire adopted
282
Appendix 6: Interview Guide for the Semi-structured Interviews
283
Appendix 7: 15-point checklist of criteria for good thematic analysis
285
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