Professional development, competence and education

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Chapter 3
Professional development, competence and education

Mary Drozd1 and Sinead Hahessy2

1 University of Wolverhampton, Walsall, West Midlands, UK

2 National University of Ireland, Galway, Ireland

Introduction

The aim of this chapter is to discuss ongoing or continuing professional development (CPD) for orthopaedic and trauma nurses. Nursing is a constantly changing profession and continuing professional development is a compulsory part of being a professional. Keeping up to date with best practice and research and acquiring new skills helps to facilitate an effective contribution to patient care. Patients have a right to expect, at the very least, a practitioner who is competent in their sphere of practice. One existing competency framework (Royal College of Nursing 2012) will be discussed along with specialist orthopaedic and trauma nurse education, mentorship in orthopaedic and trauma nursing practice and the role of reflection in continuing professional development.

Professional development

Continuing professional development (CPD) can be defined as ‘the systematic maintenance, improvement and broadening of knowledge and skills, and the development of personal qualities necessary for the execution of professional, managerial and technical duties throughout one’s working life’ (Tomlinson 1993, p. 231) and is at the heart of professional development (Hawkins and Smith 2008). Activities to promote professional development can take the form of both informal and formal activity and can help the practitioner to move beyond prescribed parameters of practice and develop expertise.

Professional regulation is the hallmark of professions and ensures that standards are met and that practice is maintained and developed (Munro 2008). In many countries regulatory bodies require practitioners to meet specific standards for both practice and education. The purpose is to link professional development and the maintenance of competence to protect the public through safe practice. Nurses have a specific professional responsibility to engage with CPD (O’Shea 2008) and employers recognise that their most valuable resource is their staff, but it is often learning and development opportunities that are sacrificed in financially constrained environments. Barriers to professional development often include financial issues, employment demands, work schedules, anxiety, the learning climate, support for learning, lack of job satisfaction (Cooley 2008), individual motivation and lack of financial support from employers (Lawton and Wimpenney 2003).

The employer has an important role in facilitating and encouraging CPD and in investing in staff to ensure that professional learning occurs in the workplace alongside development of the organisation (Gopee 2002). They expect individuals to contribute to their own learning and that of others because of the perceived benefit to the individual and team’s professional growth, future employability and ability to perform their current role effectively. Modernisation agendas for health services include the development of a culture of learning that enables staff to progress and develop. CPD is often an obligatory element of this that values evidence of personal development and this is achieved in various ways.

Literature detailing the relevance of CPD emerged in the 1980s and is mainly UK orientated (e.g. Charles 1982, Brown 1988, Hunt 1991). It focused on philosophical debates, underpinning frameworks, the relevance of continuing education and the challenges associated with implementation. Barriball et al. (1992) noted a lack of empirical data analysing nurses’ perceptions of their continuing education needs. Further debates focused on what constituted an effective continuing professional education (CPE) system (Nolan et al., 1995) or the tensions between the ‘luxury or necessity’ of the endeavour (Perry 1995). Nonetheless, CPE has developed at an accelerated pace. The pioneers of educational change embraced the pursuit of ‘new’ knowledge through various curricular and pedagogical approaches. Concepts central to the professionalisation debate such as pursuing the accumulation of a distinct body of knowledge through research activity and reflective practice have emerged. CPE in orthopaedic and trauma nursing strives to promote the specialist nature of knowledge and the majority of postgraduate/post-qualifying programmes are designed to address this. The ‘artistic’ forms of nursing knowledge such as intuition and experience are increasingly being accepted as valid forms of knowledge.

The current focus of CPD has now moved to evaluating the impact of post-registration programmes from the perspectives of the student and the impact learning has on clinical practice and patient outcomes, although there is a paucity of research in relation to the latter. A review of the CPD literature (Hegarty et al., 2008) concludes that patient outcomes are neglected in 61 studies and they advise that future research endeavours should aim to include patient outcomes. Gijbels et al.’s (2010) systematic review focused on the student perspective and concluded that nurses welcomed the effects that CPD has on professional and career trajectories. There is little research that has addressed the impact of orthopaedic and trauma CPD from either the student perspective or measurement of patient outcomes as a consequence of CPD (See box 3.1 for a general example).

Box 3.1 Evidence digest: printed educational materials – effects on professional practice and healthcare outcomes

Mentors

Literature from a wide range of disciplines refers to the use of mentoring to assist career development. This is practiced differently in particular locations, settings and healthcare professions. Mentors are crucial in facilitating the development of other practitioners as they assist the next generation in developing skills and knowledge. They must have a sound evidence-based knowledge and skill base along with an understanding of how individuals learn and grow professionally in order to be able to nurture practitioner development (Gray 2011). At the point of socialisation to the orthopaedic and trauma environment the mentor can help to instill values associated with life-long learning and professional development in the specialty by relating a ‘sense of partnership’ (Ali and Panther 2008) in which the student or practitioner feels assimilated into the clinical setting.

Mentors provide a spectrum of learning and supportive behaviours such as challenging and being a critical friend, being a role model, helping to build networks and develop resourcefulness, simply being there to listen, helping people work out what they want to achieve and planning how they will bring change about (Clutterbuck 2004). Price (2004) suggests that a mentor will be in a position to shape other nurses’ understanding of practice and practice wisdom for years to come. The specialist knowledge and skills such as postoperative orthopaedic care, the prevention and recognition of complications or the application of traction are best learned in the practice setting. Great responsibility for this is placed on mentors even though resources are finite and mentors must juggle the delivery of care with their teaching and supportive roles (Price 2004). No other role in nursing has such power to shape other nurses’ practice and knowledge and nothing can be more important than passing on clinical skills and knowledge to others while caring for patients and their families (Price 2004). A system of mentorship is essential in enabling the less experienced practitioner to be supported in specialist knowledge and skill development and such a mentor should aim to provide leadership in developing learning (Gopee 2011).

Competence

Competence has become a defining feature of practice-based professions (Bradshaw 2000). Axley (2008, p. 217) argued that “there is no officially agreed upon theoretical or operational definition of competency among nurses, educators, employers, regulating bodies, government and patients” and that the attributes of ‘competency’ are multi-faceted and context-dependent, which can lead to confusion. Aspects of competence most frequently cited are:

  1. knowledge (information, teaching, training)
  2. actions (ability, skill)
  3. professional standards (criteria, requirements, qualification)
  4. internal regulation (accountability, attitude, autonomy)
  5. dynamic state (ongoing change, consistent improvement).

Competence is not fixed or static but part of the development of expertise and an intrinsic aspect of professional practice (Eraut 1994). It is concerned not only with skill acquisition and application but also with the development of knowledge to support assessment and decision-making (Proctor-Childs 2011). Other professional qualities such as attitude, motives, personal insight, interpretative ability, maturity and self-assessment should be included (Axley 2008).

It is essential that decision making is examined (Hagbaghery et al., 2004) and understood by orthopaedic and trauma nurses to ensure critical analysis is applied to the decision making process, as this enhances competency development. Patients with orthopaedic or traumatic conditions or injuries require specialist knowledge and skills which develop over time, and via various strategies that will be discussed later. Benner (1984) highlights that a nurse who was expert in coronary care found it difficult to perform even at the competent level on an intermediate care surgical unit, supporting clinical specialisation and a structure of clinical preceptors or mentors to teach the beginning nurse or the experienced nurse who transfers to a new unit.

Orthopaedic and trauma practitioner competences

Contemporary healthcare requires efficiency and competence. The Royal College of Nursing (RCN) Society of Orthopaedic and Trauma Nurses (SOTN) in the UK has recently provided an example of specialist competences for orthopaedic and trauma practitioners (RCN SOTN 2012). The benefit of a competency framework is that it provides a foundation on which to develop and evaluate safe and effective practitioners. The framework aims to provide a solid foundation to optimise evidence-based practice and provide safe and competent care.

Orthopaedic and trauma practitioner competences highlight the specialist nature of orthopaedic and trauma practice and provide clarity for organisations regarding what they can expect from orthopaedic and trauma practitioners. They can also be used as benchmarks for organisations to use in recruitment, selection, development, appraisal and individual performance management as well as contribute to the CPD of practitioners. The specialist orthopaedic and trauma practitioner domains within the RCN (2012) framework include the following:

Partner/guide

The partnership between the patient and the health care professional highlights the unique role in guiding the patient through their journey in orthopaedic and trauma health care. Supporting the patient and ensuring they are at the centre of their care is essential, as is working in partnership with the patient’s family/informal carers along with liaison and collaboration with all members of the multi-professional team (MPT) to ensure seamless, holistic care.

Comfort enhancer

Comfort is a concept which is fundamental to the care of the orthopaedic/trauma patient. It is a complex human experience which can be interpreted in different ways. It is closely related to the experience of pain, especially for patients who have received an assault to musculoskeletal tissue (Cohen 2009). The comfort of orthopaedic/trauma patients is central to good healthcare outcomes. This aspect of care may become more complex for the patient depending on the nature of their condition, injury or surgery. Musculoskeletal instability and movement can result in significant pain and discomfort. Competence in providing essential care within this context is therefore central to high quality care and highlights the need for that care to be provided in a specialist setting where practitioners possess the requisite specialist competence (Santy et al., 2005, Drozd et al., 2007).

Risk manager

One of the most central aspects of orthopaedic and trauma practice is the fact that orthopaedic and trauma surgery and injuries may carry with them a high risk of complications. The range of complications varies from those which are common to all situations where there is immobility and /or an assault to body tissues. However, there are a number of complications which are specific to trauma and orthopaedic patients such as compartment syndrome, fat embolism, osteomyelitis, neurovascular impairment, venous thromboembolism (VTE) and complex regional pain syndrome. It is the nature of these complications which requires highly specialised care.

Technician

The highly technical aspects of orthopaedic and trauma practice require knowledge, understanding and skill in managing, for example, specialised devices and equipment which are used to either treat orthopaedic conditions and injuries or to protect patients from complications. The practitioner needs to be competent in managing such treatment modalities which are highly specialised and carry their own risk of complications (linked to the risk management domain). Some practitioners develop enhanced expertise in specific aspects. For example, while many practitioners care for patients with casts, additional expertise is required for the application of casts. In turn, these highly skilled and educated practitioners require focused, in-depth training and education. Appropriate education, training and development of practitioners is essential in ensuring that the right level of practitioner, with the requisite knowledge, understanding and skills are caring for orthopaedic and trauma patients. Maintaining the currency of such specialist skills is imperative for safe and effective care. For example, the use of traction for adults is now used less extensively and such competences may require regular updating.

Although these domains relate directly to UK practice, there is scope for transferability internationally with work ongoing by the International Collaboration of Orthopaedic Nurses (ICON) to produce international related competences.

There are various strategies for achieving ongoing professional development within orthopaedic and trauma nursing, such as:

  • self-study by engaging with current evidence-based material (see Chapter 2)
  • seeking learning opportunities in the workplace
  • supervised practice by experienced mentors
  • case studies
  • viva voce
  • observed structured clinical examinations (OSCE)
  • oral and/or written reflections about care
  • critical incident analysis
  • reflecting on practice
  • self and peer assessments
  • formal appraisals with line managers
  • in-house courses and study programmes
  • accredited university progammes
  • learning through electronic means such as online applications and other mobile media with instant access to evidence-based information
  • professional portfolios containing evidence of learning and development.

Learning can also occur through personal experience, for example, from personal family experiences that can be transferred to the work context (Munro 2008). There should be a forum for discussion of clinical practice in which nursing knowledge is coherently charted and explored (Benner 1984). Careful record keeping and sharing of paradigm cases are important strategies for documenting the significance of nursing practice. Teaching rounds/master classes by expert nurses open vistas to other nurses while recognising the value of expertise and its importance in transmitting wisdom and judgment.

Reflection

An essential aspect of professional development is to undertake structured, facilitated reflection as a central component of CPD (Cowan et al., 2007, Kim 2007) in order to explore practice and competence, although CPD does not guarantee competence. Lillyman (2011) believes that reflection is a strategy that helps the practitioner to link evidence-based theory with current practice. Alongside this, reflective learning involves actively thinking about and learning from experience. Moloney and Hahessy (2006, p. 50) state that:

“for educational development to happen the reflective nurse must see knowledge attainment as part of a developmental cycle where new knowledge is mixed with existing knowledge and practice, in order for a change in practice to occur.”

This is in accordance with Schon’s (1987) notion of integrating formal and espoused theory to develop personal knowledge.

The majority of reflective models suggest three main stages including awareness, critical analysis and the development of new perspectives (Freshwater 2008). Effective reflection requires a supportive and reflective culture and is a process that all individuals can use to develop professionally and maintain professional accreditation as part of their involvement in daily care delivery (Lillyman 2011). Learning can change attitudes as well as outdated practices and is often stimulating and rewarding, but can also be associated with a degree of discomfort as existing knowledge is tested and attitudes challenged (Pross 2005).

Education

Pre-registration nurse education and training programmes may cover limited aspects of orthopaedic and trauma nursing and it can be wrongly subsumed under the surgical nursing specialty without the recognition of it as a separate specialism. Orthopaedic and trauma practitioners require specific, specialist knowledge and skills at different levels of practice (Clarke 2003, Santy et al., 2005, RCN 2005, Lucas 2006, Flynn and Whitehead 2006, Drozd et al., 2007, RCN 2012). An assumption is often made that postqualifying/graduate nurses who undertake further academic courses relating to orthopaedic and trauma nursing will have an appreciation of basic anatomy and physiology of the musculoskeletal system. This is often unsubstantiated and basic anatomy and physiology needs to be revisited early in postqualifying orthopaedic and trauma nursing courses in order to build upon this underpinning basic knowledge.

One way that nurses can achieve personal and professional growth is by learning through formal defined education programmes (Munro 2008) at postgraduate levels, but learning can also be non-accredited workplace learning. It is vital that the evidence of this ongoing learning and development is documented by practitioners. Further education can lead to opportunities for advancing role development but there is a lack of standardisation of orthopaedic and trauma nursing education in many countries.

Summary

It is essential that practitioners are enabled to provide the highest quality of effective orthopaedic and trauma patient care and professional development should be an ongoing and integrated activity. Practitioners must recognise and seize opportunities for professional development. Ongoing learning and role development is essential for the dramatic changes practitioners are experiencing but educators also have a significant responsibility to maintain links with the clinical environment to ensure that they remain cognisant of clinical developments along with appropriate pedagogical approaches. Meskell et al. (2009, p. 789) have argued that:

“lecturers must demonstrate a value for the practice component of the role and the maintenance of clinical credibility appears to be crucial in order to address the theory-practice divide and preserve the right to continue teaching nurses.”

Various strategies for accessing ongoing professional development have been discussed along with active engagement in reflection and the consistent support and challenge from current mentors in practice. Excellence in orthopaedic and trauma nursing practice is the aim of CPD. Registered nurses have a code of conduct and statutory requirements for maintaining registration that necessitate CPD. Other practitioners in orthopaedic and trauma settings must also keep updated and continue to develop both personally and professionally.

Orthopaedic and trauma nursing will continue to evolve and encouragement is needed to pursue lines of inquiry and raise research questions from clinical knowledge and practice for the benefit of patients. It is clear that further research is required into the effects and outcomes of CPD on patient care in clinical practice as currently there is a dearth of evidence.

Recommended further reading

  1. Gopee, N. (2011) Mentoring and Supervision in Healthcare, 2nd edn. Sage, London.
  2. McIntosh, A., Gidman, J. and Mason-Whitehead, E. (eds) (2011) Key Concepts in Healthcare Education. Sage, London.
  3. RCN Society of Orthopaedic and Trauma Nurses (SOTN) (2012) Orthopaedic and Trauma Practitioner Competences. RCN, London. Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0010/476047/004316.pdf (accessed 14 October 2013).

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