Measuring the competence of agency nurses.

NEXT MONTH--September 18--the Health Practitioners' Competence Assurance Act (HPCA) 2003 comes into effect. This Act replaces the Nurses Act 1977 and the Nurses Regulations 1986 and will change the way nurses in New Zealand apply and receive annual practicing certificates (APCs).

The Nurses Act 1977 and the Nurses Regulations 1986 have governed nurses' practice in New Zealand. To practise legally in this country, a nurse must be on the register of nurses, which is regulated by the Nursing Council. To become registered, a nurse must pass a tertiary education programme from an accredited tertiary institute. The Council sets basic competencies that need to be met by all student nurses prior to sitting a state examination, and tertiary institutes ensure these competencies are met. All nursing students sit the same state examination, set by the Council. When a student has passed the exam, their name is entered on the Register.

To practise legally, a nurse must also hold a current APC. At present nurses pay for an APC every year, covering the period from the beginning of April until the end of March the following year. Up until now, nurses have not needed to prove they have continued with any ongoing education since their initial registration. The Council now states that renewing an APC does not guarantee competence to a nurse. Under the HPCA, the Council--like other registering bodies for their particular professional groups--is required to monitor nurses' competence regularly, not just at initial registration. As a result, the Council is introducing competence-based practising certifications, with all registered nurses (RNs) expected to maintain a professional portfolio to demonstrate their competence from March next year.

In its Guidelines for Competence-based Practising Certificates, the Council writes that "... continued changes in technology, new directions in the delivery of services, expectations about evidence-based practice, and choices for consumers ..." has led to a need for the public to be assured that nurses maintain their competence to practise. (1) The guidelines, which are currently being reviewed to take into account the HPCA, state that it is each RN's responsibility to maintain competence in the area they are working in. It introduces the requirement that, to maintain professional practice, a nurse is required, over a five-year period, to undertake:

* 100 days (750 hours) of practice as an RN;

* 10 days (75 hours) of professional development relevant to their area of practice;

* and to demonstrate current competence in their area/scope of practice.

This equates to a nurse working at least two days per month and undertaking approximately two days of professional development per year.

Professional development

Health care facilities often view education as an employee reward, rather than a critical component of their own success. This is because of the difficulties in proving research evidence that education and continued training produce positive results. Research on this subject is contradictory. (2)

Links have been found between nurses who have undertaken recent specialised education and improved performance outcomes for patients. (3,4,5) However, other writers have found evidence that mandatory continuing education or professional development does not guarantee improvement in knowledge or performance. (6,7)

Very little literature focuses on the experiences of agency workers and their need for professional development. Agency staff are in a position where they have a relationship with the agency they are employed by, as well as with the organisation(s) they are sent to work for. When looking at countries where nurses are obliged to undertake mandatory continuing education, little literature exists stating who is responsible for ensuring that any continuing education has occurred for the agency nurse. Some agencies develop long-term relationships with their employees, and provide opportunities to meet their needs for ongoing employment and professional identity. (8)

In a Singaporean study, the main motivations behind workers taking up temporary or contract work were identified as the need for flexibility, and choice in work and work hours. (9) The researchers found the training of temporary workers was a consideration that temporary agencies needed to undertake but at present did not. They concluded that ongoing training would reap benefits for the organisation in both higher job satisfaction for their workers and improved performance.

A study that focused on the subjective experiences of interim managers (IMs)--people with specialised management skills who are employed by an organisation for a specific job, for a set time--identified that a key issue for IMs is professional development. (8) In the business world, careers can be cultivated by moving between organisations within the same industry. The study found that employers are reluctant to subsidise employees whose contracts are such that any investment in formal professional development (such as university work and courses) would only benefit the employee and subsequent employers. (8) The researchers concluded that IMs needed to come to terms with the concept that they were responsible for their own personal and professional development.

Help from managers

Nurses are more likely to undertake further education if their managers encourage them. To ensure staff undertake further education, managers need to provide the resources and the time to do the courses. (10) Help in paying or reimbursing course fees is also important. It has been identified that nurses are ready and keen to undertake post-registration education but that the time to do so is often not provided. (11) If organisations with some degree of commitment to their permanent employees are having a difficult time providing the time and resources required for ongoing education, how are agency nurses expected to fulfil their needs for further education?

Another study found that nurses working for temporary agencies received lower benefits compared to nurses working for permanent employers. (12) Nurses chose temporary work for its flexibility and variable hours of work, and because of the choice of whether or not to accept work. Agency nurses compromised work benefits for work flexibility. The introduction of competency-based practising certificates may have a dramatic effect on the working conditions of the casual nursing workforce.

Changes in the general (non-nursing) work environment over the past few years have led to an increase in the "flexible" workforce. This workforce is contracted for short periods to fill in where the permanent workforce is unable to do so. Between 1991 and 1995, the number of temporary workers doubled in Europe, Asia and the United States. (9)

Maintaining staffing levels

In health, the increase in preventative medicine, the use of out-patient clinics and shorter hospital stays in acute care settings have all led to an increase in fluctuations of patient populations in hospitals, as well as in the community. (12) Hospitals and other health care facilities depend on agency nurses to meet the changes in patient demand and at times require agency nurses to maintain staffing levels for safety purposes. Agency nurses are also required to meet the demand of unexpected sickness and absenteeism of permanent employees. Staff turnover in health facilities also creates shortages that need to be filled--in the short term--by agency nurses.

At present, retention of nursing staff in permanent positions is falling, along with the number of hours that nurses work each week. (13) Many nurses are seeking employment overseas or outside nursing. Fewer students are enrolling in nursing programmes because of high entry-level criteria, financial pressures and perceived limited career pathways. Approximately 1000 nurses graduate each year from tertiary undergraduate programmes but the number of nursing vacancies far exceeds the number of available nurses. This means that, as life expectancy increases and the population gets older, there will be fewer RNs to provide the high quality care required.

The average age of nurses in New Zealand is also increasing, from 40 years in 1994 to 43 years in 1999 (13) and this trend is not just within New Zealand. In the United States, half of all nurses working today will reach retirement age within 15 years, leading to staff shortages. (14) It has been predicted that, within Australia, there will be a shortfall of 31,000 nurses by 2006. (15)

It is casual or agency nurses who fill the present staff shortages in health care facilities. Therefore, until the causes of high attrition are addressed, the need for agency staff can only increase, as nurse shortages continue to worsen.

Agency, or temporary workers can "build and utilize their learning cumulatively as they go and treat the accumulated knowledge as a form of tradeable career capital". However, with the introduction of mandatory professional development, accumulated knowledge will no longer be enough for nurses to obtain an APC. This may have a significant effect on agency nurses' practice.

Many hospitals and rest-homes, and other areas where nurses are employed, provide ongoing education for nurses. Nurses are required to resit annual resuscitation certificates, intravenous therapy courses and people management workshops. Practice nurses are encouraged to go to vaccination seminars, infectious disease workshops, and regular courses on a variety of primary health-related issues. Nurses in rest-homes undertake gerontology courses, and calming and restraint workshops. Nurses organise and attend conferences on a large and varied number of topics throughout the country every year. The organisations that employ these nurses pay full, or part, costs of the staff's continuing education. They provide their employees with time off work and, in some cases, financial incentives (pay increases) to complete courses. The nurses are rewarded with increased understanding of their workplace practices and of their clientele.

But whose responsibility is ongoing education for the casual nurse? Will they be required to pay for their own ongoing education and will they have to do this in their own time?

The potential effects of the new legislation are extensive. It will affect nurses who are currently practising who have not undertaken any further study since their registration. Part-time staff may now need to put in extra hours to achieve the required 75 hours of ongoing education as specified in the Council guidelines. (1) Nurses who have left the workforce and are contemplating coming back will be required to undergo training courses before being allowed an APC.

If agency nurses are not able to, or not prepared to, finance their own learning and thereby not able to renew their APCs, there will be a marked decrease in the number of available casual nurses. This may have a significant impact on the general health environment. Hospitals, rest-homes and medical centres will all be adversely affected by staff shortages.

In the year 2002-2003, there were 35,814 RNs employed in full or part-time work in New Zealand. Of these, only 980 were employed by a nursing agency. (16) However, nursing is an area with a significant employee shortage. The potential effects of further reducing the number of nurses practising or returning to the workforce needs to be addressed.

REFERENCES

(1) Nursing Council of New Zealand. (2001) Guidelines for Competence-Based Practising Certificates for Registered Nurses. Retrieved May 14, 2003 from http://www.nursingcouncil.org.nz.

(2) Burke, A. (2000) Competency and Education Organization Wide. Retrieved June 3, 2003 from http://www.nursingceu.com/NCEU?course/comp/.

(3) Postler-Slattery, D. and Foley, K. (2003) The fruits of lifelong learning. Nursing Management. February, 35-37.

(4) Cary, A.H. (2001) Certified registered nurses: results of the study of the certified workforce. American Journal of Nursing; 101: 1, 44-52.

(5) Dybec, R.B. (2000) Study documents nurses' assessment of the value of certification. Plastic Surgical Nursing; 20: 2, 97-104.

(6) Prater, L. and Neatherlin, J.S. (2001) Texas nurses respond to mandatory continuing education. Journal of Continuing Education in Nursing; 32: 3, 126-132.

(7) Eustace, L.W. (2001). Mandatory continuing education: Past, present, and future trends and issues. Journal of Continuing Education in Nursing; 32: 3, 133-137.

(8) Inkson, K., Heising, A. and Rousseau, D. (2001) The interim manager: Prototype of the 21st century worker? Human Relations; 54: 3, 259-284.

(9) Tan, H-H. and Tan, C-P. (2002) Temporary employees in Singapore: What drives them? Journal of Psychology; 136: 1, 83-102.

(10) Fitzpatrick, M.A. (2003) Certified practice: We owe it to our patients and ourselves. Nursing Management. March, 6.

(11) Nursing Times. (2002) Post-registration training is on the up--if you can get off the ward. Nursing Times. 16: 5, 16-22.

(12) Bellemore, F.A. (1998). Temporary employment decisions of registered nurses. Eastern Economic Journal; 24: 3, 265-279. Retrieved May 31 2003 from Proquest database on http:// proquest.umi.com/pqdweb.

(13) Kiwi Careers (2003) Retrieved June 4, 2003 from http://www.kiwicareers.govt.nz.

(14) Mee, C.L. and Robinson, E. (2003) What's different about this nursing shortage? Nursing2003; 33: 1, 51-55.

(15) Armstrong, F. (2003) Confronting the nursing shortage. Australian Nursing Journal; 10: 6, 22-23.

(16) Nursing Council of New Zealand (2003). Retrieved June 6, 2003 from http://www.nursingcouncil.org.nz.