Competency Assessment & Competency Assessment & Performance ManagementPerformance Management

Helping poor performing Helping poor performing nurses reach competencenurses reach competence

Regulatory BodyRegulatory BodyØØ The New Zealand Nursing Council (NZNC) is the The New Zealand Nursing Council (NZNC) is the

statutory body that regulates nursing in New Zealand statutory body that regulates nursing in New Zealand under the Health Practitioners Competence Assurance under the Health Practitioners Competence Assurance Act (HPCA) 2003. The role of the NZNC is to maintain Act (HPCA) 2003. The role of the NZNC is to maintain public safety and it does this primarily by ensuring public safety and it does this primarily by ensuring continuing competence of nurses (continuing competence of nurses (New Zealand Nursing New Zealand Nursing Council, 2008) Council, 2008)

ØØ The assessment of competence is an The assessment of competence is an evolving area for health care managers. evolving area for health care managers.

ØØCompetence is set out through a set of Competence is set out through a set of four domains, with each domain outlining four domains, with each domain outlining practice expectations (practice expectations (New Zealand New Zealand Nursing Council, 2008Nursing Council, 2008). ).

Our organisation’s obligations…Our organisation’s obligations…

ØØ Fairly and transparently identify any Fairly and transparently identify any competency issuescompetency issues

ØØ Employers must notify NC of any Employers must notify NC of any regulated nurses that have identified regulated nurses that have identified competence to practice issuescompetence to practice issues

ØØGrowing unease about potential litigation if Growing unease about potential litigation if the performance management process is the performance management process is poorly managedpoorly managed

ØØ Thus documentation of the process is very Thus documentation of the process is very importantimportant

Supportive Improvement and Supportive Improvement and Performance Improvement Performance Improvement

Management plansManagement plans

SIP and PIPSIP and PIP

ØØ Southern DHB has developed a Southern DHB has developed a framework to help identify competence framework to help identify competence issuesissues

ØØ As a preceptor you might be asked to As a preceptor you might be asked to participateparticipate

What's the problemWhat's the problem

ØØNurse J has been working in your area for Nurse J has been working in your area for the last 11 months. Other staff are the last 11 months. Other staff are beginning to voice their frustration when beginning to voice their frustration when working with her on a shift or in the shift working with her on a shift or in the shift following. Some people look at the daily following. Some people look at the daily allocation and sigh… when she is on.allocation and sigh… when she is on.

ØØ One RN has approached the CNM with her One RN has approached the CNM with her concerns. She describes the situation as no one concerns. She describes the situation as no one wants to work with Nurse J. They think wants to work with Nurse J. They think she is she is lazy and a bit uselesslazy and a bit useless. When asked for more . When asked for more information the RN says she information the RN says she can’t handle a can’t handle a normal work loadnormal work load and staff have started giving and staff have started giving her less complex patients with a maximum of her less complex patients with a maximum of three patient workload. This has been getting three patient workload. This has been getting worse for the last 6 weeks and worse for the last 6 weeks and everyone has everyone has had enough!had enough!

What does the CNM do about thisWhat does the CNM do about this

ØØOption 1 Option 1 –– Nothing it will all blow over Nothing it will all blow over ((wrong answer!wrong answer!))

ØØOption 2 Option 2 –– Call in RN J and tell her to pull Call in RN J and tell her to pull her socks up (her socks up (Wrong answerWrong answer!)!)

ØØOption 3 Option 3 –– Investigate the allegations and Investigate the allegations and try and define exactly what the issues with try and define exactly what the issues with RN J are and are they accurate and validRN J are and are they accurate and valid

ØØ ((yippee on the right trackyippee on the right track))

What tools/support does the CNM What tools/support does the CNM have?have?

ØØNursing Council competenciesNursing Council competenciesØØNurse DirectorNurse DirectorØØHuman Resource advisorsHuman Resource advisorsØØNZNO advisorNZNO advisor

What next?What next?

ØØ The CNM needs to establish if there is a The CNM needs to establish if there is a problem by talking with staff that raised the problem by talking with staff that raised the issueissue

ØØ The CNM asks them to explain exactly The CNM asks them to explain exactly what the issues arewhat the issues are

What the CNM found…What the CNM found…ØØ The CNM found that:The CNM found that:ØØ RN J was often late for shift so didn’t get a full RN J was often late for shift so didn’t get a full

handoverhandoverØØ She didn’t take her breaksShe didn’t take her breaksØØ Her patients missed care such as dressing Her patients missed care such as dressing

changes, IV antibiotic doses, patient changes, IV antibiotic doses, patient observations not doneobservations not done

ØØ Appears grumpy and moody at work particularly Appears grumpy and moody at work particularly to students and the HCAto students and the HCA

ØØ Failed to do her daily bedside safety checks Failed to do her daily bedside safety checks

ExerciseExercise

ØØ Look through the NC competency booklet Look through the NC competency booklet and come up with any competencies that and come up with any competencies that is relevant that are not being metis relevant that are not being met

How does this relate to the NC How does this relate to the NC competences?competences?

ØØCompetency 2.1Competency 2.1-- Provides planned Provides planned nursing care to achieve identified nursing care to achieve identified outcomes.outcomes.

ØØ Administers interventions treatments and Administers interventions treatments and medications within legislation, codes, medications within legislation, codes, scopes of practice and according to scopes of practice and according to authorised prescriptions and established authorised prescriptions and established policiespolicies

ØØCompetency 1.5 Competency 1.5 –– Promotes an Promotes an environment that enables client safety, environment that enables client safety, independence, quality of life and healthindependence, quality of life and health

ØØ Indicator:Indicator: Accesses, maintains and uses Accesses, maintains and uses emergency equipment and suppliesemergency equipment and supplies

ØØCompetency 4.1Competency 4.1-- Collaborates and Collaborates and participates with colleagues and members participates with colleagues and members of the health care team to facilitate and of the health care team to facilitate and coordinate carecoordinate care

ØØ Indicator: Provides guidance and support Indicator: Provides guidance and support to those entering as students, beginning to those entering as students, beginning practitioners and those who are practitioners and those who are transferring into a new clinical area.transferring into a new clinical area.

Is there a reason for RN J’s poor Is there a reason for RN J’s poor performance?performance?

Must explore if there are any Must explore if there are any reasons for this?reasons for this?

ØØ That means that the CNM should call in RN J That means that the CNM should call in RN J and raise the concerns with her and ask her if and raise the concerns with her and ask her if there are any reasons for the observed there are any reasons for the observed behaviours or practices?behaviours or practices?

ØØ Could be: Crisis at home, relationship issues, Could be: Crisis at home, relationship issues, sick family member, financial issues, domestic sick family member, financial issues, domestic violence, problem with other family memberviolence, problem with other family member

ØØ Could be a problem with alcohol, drug use, Could be a problem with alcohol, drug use, gamblinggambling

A good employer offers supportA good employer offers support

ØØ The CNM should offer Vitae (used to be The CNM should offer Vitae (used to be SEED or EAP) free counselling sessions x SEED or EAP) free counselling sessions x 3 paid for by the employer3 paid for by the employer

ØØNo one knows who goes or accesses it No one knows who goes or accesses it HR get a bill with no detail unless a HR get a bill with no detail unless a request by the employee to apply for more request by the employee to apply for more sessions.sessions.

Stage one Stage one –– Supportive Supportive Improvement Plan (SIP)Improvement Plan (SIP)

ØØ Based on supporting the Nurse to reach a Based on supporting the Nurse to reach a competent levelcompetent level

ØØ Is an informal process with no long term Is an informal process with no long term implications if the nurse returns to competenceimplications if the nurse returns to competence

ØØ However is time framed However is time framed ØØ If no improvement is seen with maximum If no improvement is seen with maximum

support then would move to a Performance support then would move to a Performance Management Plan (more formal with potential Management Plan (more formal with potential employment outcomes or reporting to regulating employment outcomes or reporting to regulating body possible)body possible)

The process SIPThe process SIP

ØØ LetterLetterØØ MeetingMeetingØØ Formulate the planFormulate the planØØ Choose a preceptorChoose a preceptorØØ Decide level of supervision to work along side or Decide level of supervision to work along side or

supernumerary nursesupernumerary nurseØØ Establish timeframeEstablish timeframeØØ Daily feedbackDaily feedback

SIPSIP

ØØ In the SIP the CNM and ND must make In the SIP the CNM and ND must make the plan simple so that RN J knows the plan simple so that RN J knows exactly what she needs to do to be exactly what she needs to do to be competentcompetent

ØØHow would she demonstrate this? How would she demonstrate this?

Why daily meeting with Preceptor?Why daily meeting with Preceptor?

ØØDaily feedback in real time helps to build Daily feedback in real time helps to build the relationship between those involved in the relationship between those involved in the process. the process.

ØØ The use of feedback is not well The use of feedback is not well understood as feedback is not merely a understood as feedback is not merely a stimulus but a complex intervention that is stimulus but a complex intervention that is dependant on the characteristics of the dependant on the characteristics of the individual recipients individual recipients

Research pointResearch point

ØØ At times of increased job stress managers At times of increased job stress managers who showed supportive behaviours and who showed supportive behaviours and staff that received more positive staff that received more positive recognition through the use of feedback recognition through the use of feedback increased the likelihood of the nurse’s increased the likelihood of the nurse’s intention to stay at work. intention to stay at work.

Feedback is dependent on:Feedback is dependent on:

ØØ The message The message –– what’s saidwhat’s saidØØ The provider of the feedback The provider of the feedback -- Who provides Who provides

feedbackfeedbackØØ The addressee The addressee –– the nurse involvedthe nurse involvedØØ The timeliness of feedback The timeliness of feedback –– close to eventclose to eventØØ The vehicle used to provide feedback The vehicle used to provide feedback ––

verbal or writtenverbal or written

Research supports:Research supports:

ØØGiving balanced feedback with both Giving balanced feedback with both positive feedback and an indication of positive feedback and an indication of where improvements could be made is where improvements could be made is more beneficial. more beneficial.

ØØ Verbal feedback is seen as powerful if Verbal feedback is seen as powerful if immediate, positive feedback is a potent immediate, positive feedback is a potent motivator and peer feedback is positive if motivator and peer feedback is positive if given consistently. given consistently.

ØØ Visual graph form about an individuals Visual graph form about an individuals performance did have a positive performance did have a positive reinforcing effect. reinforcing effect.

ØØ This supports that different styles of giving This supports that different styles of giving feedback are important and visual feedback are important and visual feedback may have a synergistic effect feedback may have a synergistic effect when coupled with timely verbal feedback. when coupled with timely verbal feedback.

ØØ “Gut feeling” “Gut feeling” –– may be right BUT you need may be right BUT you need to be specific to be fair and give the best to be specific to be fair and give the best chance for the individual to gain insight chance for the individual to gain insight into the improvement they need to makeinto the improvement they need to make

Daily Evaluation ScaleDaily Evaluation ScaleScale Standard procedure Quality of

PerformanceAssistance

Accomplished4

Safe and accurate Proficient, coordinated, confident, ethical and clinical role model for others.

Anticipates consistently and assists others

Independent3

Safe and accurate Competently performs tasks within an acceptable timeframe

Works independently without supportive cues

Assisted2

Safe and accurateMost of the time requires

prompts from preceptor

Can perform tasks but needs support and guidance, takes longer than expected to complete tasks

Occasional verbal and physical directive required to complete the task

Marginal1

Safe with direct supervision Unskilled, inefficient requiring a prolonged time period to achieve nursing outcomes

Requires direct supervision frequent verbal and physical directives in most areas

Date Grade Sign Comments

Uses a daily planning sheet to note drug/treatment/care times for patients

Is aware of scope of practice and seeks assistance when needed

Accurately assesses patients needs related to their condition

Uses resources to update knowledge by referring to ODHB policies and Midas system

Has knowledge of medication uses, doses, routes and side effects

Reassesses, plans and implements changes in response to changes in patient status

Practices procedures and skills competently and safely, for example carries out neurovascular observations, interprets results and updates care

Goal A

00.5

11.5

22.5

33.5

Date 2 4 6

Date

Scor

e GoalsA

Goal C

0

0.5

1

1.5

2

2.5

1 2 3 4 5 6 7 8 9

Date

Scor

eC

Progress on Daily Assessment of Goals Over time

A

A

A A

A A A A A

B

B B

B B

B B B B

C C C C C C C C C

D D

D

D D D D D D

E E E E

E E

E

E

E

F F F F

F

F

F F F

G

G

G

G

G G G G GH H H H H H H H HI

I

I I

I I

I I I

0

0.5

1

1.5

2

2.5

3

3.5

1 2 3 4 5 6 7 8 9

Days

Com

pete

nce

Scor

es

A

B

C

D

E

F

G

H

I

PIPPIPØØ Similar to SIP but the process is more formal Similar to SIP but the process is more formal

with more HR involvement and the with more HR involvement and the consequences strongerconsequences stronger-- possible termination, possible termination, reporting to NCreporting to NC

ØØ The process is not something that is quick but The process is not something that is quick but understand that it is labour intensive and costs understand that it is labour intensive and costs $$$$$$$$

ØØ Costs come from supernumerary time, CNM and Costs come from supernumerary time, CNM and ND, HR time, legal opinions, meetings, ND, HR time, legal opinions, meetings, documentationdocumentation

Reporting to Nursing CouncilReporting to Nursing Council

ØØ Nurse must be informed that this is occurring Nurse must be informed that this is occurring and are encouraged to self reportand are encouraged to self report

ØØ This occurs even if the nurse resignsThis occurs even if the nurse resignsØØ It is the organisations obligation to report the It is the organisations obligation to report the

nurse but it is the council who undertakes their nurse but it is the council who undertakes their own investigation own investigation

ØØ NC can direct the individual to undertake a NC can direct the individual to undertake a Competency Assessment Programme or further Competency Assessment Programme or further education.education.

NC process takes time…NC process takes time…ØØ The New Zealand Nursing Council annual report The New Zealand Nursing Council annual report

2010, shows the total number of nurses 2010, shows the total number of nurses practicing as at March 31, 2010 was practicing as at March 31, 2010 was 47,129.47,129.

ØØ The total number of nurses practicing in the DHB The total number of nurses practicing in the DHB setting was setting was 23,575 23,575

ØØ The current Nursing Council statistics show The current Nursing Council statistics show 90 90 nurses had concerns about their competence nurses had concerns about their competence notified to Council in 2010. Following the initial notified to Council in 2010. Following the initial inquiry, no further action was required in relation inquiry, no further action was required in relation to 38 nurses, to 38 nurses, 4242 nurses were assessed as nurses were assessed as requiring a competence review and requiring a competence review and 1010 were still were still at the inquiry phase at the end of the year. at the inquiry phase at the end of the year.

End result…. After a lot of input End result…. After a lot of input and opportunity to improveand opportunity to improve

ØØ Nurse deregistered for professional misconductNurse deregistered for professional misconductØØ HomeHome » » NewsNews » » DunedinDunedinØØ Thu, 31 Mar 2011 Thu, 31 Mar 2011 News: DunedinNews: DunedinØØ The Health Practitioners Disciplinary Tribunal has recommended a former Dunedin Hospital nurse be struck off the The Health Practitioners Disciplinary Tribunal has recommended a former Dunedin Hospital nurse be struck off the

register for falsifying patient records, failing to recheck abnormal test results and asking another nurse to register for falsifying patient records, failing to recheck abnormal test results and asking another nurse to "accumulate" medication for his wife. "accumulate" medication for his wife.

ØØ Rabindranath Joyram was fired from the hospital's neurosurgical ward in April 2009 after he admitted forging a Rabindranath Joyram was fired from the hospital's neurosurgical ward in April 2009 after he admitted forging a patient's respiration rate. patient's respiration rate.

ØØ Several days earlier he administered insulin to a patient based on a "significantly out of line" blood sugar test Several days earlier he administered insulin to a patient based on a "significantly out of line" blood sugar test result. result.

ØØ "Rather than rechecking the result, making sure the client had washed their hands or checking the calibration of "Rather than rechecking the result, making sure the client had washed their hands or checking the calibration of the machine, Mr Joyram increased the insulin rate...and then failed to advise his supervisor that her (the patient's) the machine, Mr Joyram increased the insulin rate...and then failed to advise his supervisor that her (the patient's) blood sugar had increased or the actions he'd taken," the tribunal said. blood sugar had increased or the actions he'd taken," the tribunal said.

ØØ The patient was later found drowsy and sweating. The patient was later found drowsy and sweating. ØØ In a disciplinary meeting with management, Mr Joyram said he had a "germ of dishonesty". In a disciplinary meeting with management, Mr Joyram said he had a "germ of dishonesty". ØØ Just days after he was fired, Mr Joyram emailed a former colleague asking her to steal medication from the ward. Just days after he was fired, Mr Joyram emailed a former colleague asking her to steal medication from the ward. ØØ "My wife needs some Tramadol capsules...all you need to do is accumulate as many as you can and, if you are "My wife needs some Tramadol capsules...all you need to do is accumulate as many as you can and, if you are

agreeable, to give them to me before I leave (the country)," he said. agreeable, to give them to me before I leave (the country)," he said. ØØ Hospital staff later discovered the ward used three times more Tramadol than normal while Mr Joyram's wife was Hospital staff later discovered the ward used three times more Tramadol than normal while Mr Joyram's wife was

in the country for a holiday. in the country for a holiday. ØØ The tribunal found Mr Joyram guilty of professional misconduct and recommended his nursing registration be The tribunal found Mr Joyram guilty of professional misconduct and recommended his nursing registration be

cancelled. cancelled. ØØ It also recommended he be formally censured and pay 40 percent of the costs associated with the investigation It also recommended he be formally censured and pay 40 percent of the costs associated with the investigation

and prosecution. and prosecution. ØØ Mr Joyram, who trained as a nurse in Mauritius, is thought to have left the country. Mr Joyram, who trained as a nurse in Mauritius, is thought to have left the country. ØØ

Research ProjectResearch Project

ØØ Research paper completed a research proposal Research paper completed a research proposal for investigating how the NC competency for investigating how the NC competency assessment process is undertaken for regulated assessment process is undertaken for regulated nursesnurses

ØØ Is the use of daily feedback useful for those Is the use of daily feedback useful for those involved in the process, CNM, Preceptor, nurse?involved in the process, CNM, Preceptor, nurse?

ØØ Survey all DHB’s to assess current situationSurvey all DHB’s to assess current situationØØ 6 CNM, 6 Preceptors, 6 nurses for their 6 CNM, 6 Preceptors, 6 nurses for their

experience how to improve the processexperience how to improve the process