The research aimed to explore the function of competencies in shaping the organisation of nursing work. The aim was to generate an understanding of how competencies have constructed knowledge development and subsequently influenced practice. Through this process the research sought a better understanding of how, where and why competencies are positioned in nursing.
The theoretical framework underpinning the research was grounded in the broad tradition of critical theory and more specifically the work of Jürgen Habermas. Critical theory is perceived as liberating in nature and a tool for explaining and transforming all the circumstances that have constrained human beings. Critical theory also seeks to combine philosophy and social science in developing explanations of broad social structures and human actions in the construction of our social worlds. The focus is emancipatory which cannot be achieved without the interplay these factors.
Habermas (1981) argued that language was critical to the pursuit of democracy and a rational world. Habermas identified three forms of knowledge each associated with certain interests which he termed technical, practical and critical knowledge forms. Technical knowledge reflects positivist interests, practical knowledge interpretive interests and critical knowledge emancipatory interests. Each form is considered legitimate except where one dominates and suppresses other knowledge forms. Thus, these interests function together to provide a way of interpreting a social context and were applied as the theoretical lens in this research.
The site of data generation was a large metropolitan hospital in Queensland with 500+ beds. The hospital had developed a competency framework that allowed registered nurses (RNs) and enrolled nurses (ENs) to demonstrate skills (competencies) and to build a more adaptable and flexible workforce. The research sample included both ENs and RNs to allow for a full exploration of the function of competencies within the clinical environment. Inclusion criteria was that nurses were permanent or part-time staff and had completed mandatory hospital competencies.
A total of 16 individual interviews were undertaken with eight RNs and eight ENs. There were also three RN focus group interviews with a total of 14 participants and two EN focus group interviews with a total of 11 participants.
To ensure a depth of data within the research there were three key data sources:
- A contextual review of literature
- Individual interviews were conducted.
- Focus group interviews
The process of analysis explored the functions of competencies within the nursing workplace. This exploration allowed the research to develop an understanding of how and why competencies had shaped scopes of practice and the role identification of both EN and RN participants.
The review of literature identified educational institutions, employers, governments and regulatory authorities that separately and combined defined standards of practice for nurses. The generic nature of competencies and the drive to ensure consistency in the delivery of care had created an environment where what was considered competent was defined through the efficiency lens of the organisation.
Data analysis sought to explore how the use of competencies reshaped the practices of ENs and RNs within an organisation. Nursing competencies as technologies were grounded in the assumption that the standardization of nursing work would mean less variation in practice and therefore better outcomes for patients. The standardization of knowledge, or the creation of uniformity and consistency, restricted the space within which nurses could practice autonomously and eroded the potential for reflection and for practice based on critical thought.
A second level of analysis explored the concept of communicative action and associated mutual understanding through a shared and undistorted language. The underlying assumption in establishing the competency framework was that ENs and RNs would have a shared understanding of the two roles and that this understanding would be developed through interaction. Nonetheless, of competencies, as techniques, had displaced the space within which nurses interpreted their work and the context in which nurses’ work. The result was constraints on the development of a shared understanding through critical thinking considered to be an essential part of the role of the RN.
Thus, competencies further shaped the everyday practice of nurses in limiting differences in the performance of skills. The coincidence of arguments about a theory-practice gap in nursing and the appearance of competencies gave support to the new emphasis on practical skills as a consistent and measurable standard of practice that was transferable between different roles and across clinical areas.
The third analytical dimension turned to emancipation in nursing. The underlying subculture within nursing of role delineation, as defined by educational standards and skill acquisition, was eroding as a result of competencies. Hence, competencies served particular political interests and in the context of this research, neither the interests of RNs nor ENs.
Relationships between RNs and ENs and between these practitioners and the organisation were subject to the norms of rewards and responsibilities dictated by the organisation. These rewards and responsibilities were associated with the redistribution of workload between nurses creating a changed in the dynamics between EN and RN. For ENs, the competency framework was a strategy that gave legitimacy to expanded practice. Yet, the RN was at risk of being deskilled through practice standardization and the manipulation of skill-mix. Furthermore, and although the scope of practice of ENs had been expanded, this latter group was not financially remunerated for taking on the increased levels of responsibility.
Since the 1980s there has been a pedagogical shift in nursing education that has emphasized the importance of critical thinking and autonomy for nurses. Yet the domain of governmentality endures where language and other strategies are used to ensure a disciplined standardization of nursing practice. These governmental practices or technologies become normalized and taken for granted, which obscures the space needed for critical reflection. Competencies have thus become neutral technologies that are not viewed as instruments of power but as individual assets. The competency framework had created a process of production where the focus had become, not the acquisition of knowledge, but greater control over the nursing workforce. The move to greater workforce flexibility saw the rise of a set of generic measures of skills that obscured the complexities of nursing practice and allowed for RNs and ENs to be perceived as equal participants in patient care.