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Nurses' understandings of the professional development recognition programme.

Abstract

Professional Development and Recognition Programmes (PDRP) for nurses have developed out of the Clinical Career Pathways (CCP) of the 1990s. The Health Practitioners Competence Assurance Act (2003) has now required all health professionals to provide evidence that their practice meets criteria set by the individual regulatory body, which, for nursing, is the Nursing Council of New Zealand. In 2002 a tool was developed to measure knowledge and attitudes of the then CCP which was tested with 239 nurses. This paper is a report on the second application of the tool in the same hospital in New Zealand. Results show that knowledge and attitudes of the PDRP are similar to those found in the previous study. It also suggests that greater understanding of the PDRP and the implementation process increases the likelihood of a positive response to the programme.

Key Words: Professional development recognition programme, competency review, knowledge and attitudes.

Background

Clinical career pathways (CCP), also called Level of Practice Programmes (LOPP), and Professional Development Programmes (PDP) emerged in the 1970s to become established in New Zealand during the 1980s. These programmes are based on the work of Patricia Benner (1984). They have been accepted by nursing in New Zealand (NZ) as a structure, which fits with a nursing philosophy and recognises that a nurse's role encompasses clinical practice, education and research. The NZ context and Te Tiriti O Waitangi are recognised and implemented throughout the programme.

A national framework and the guidelines for the current programme, Professional Development and Recognition Programmes (PDRP), were established in 2004. Later that year a uniform PDRP recognition/ payment system became part of the industrial agreement (MECA) that covered all District Health Boards (DHBs).

The PDRP process is an expected but not compulsory requirement in employing organisations. The process requires each nurse to present a professional portfolio for assessment, which demonstrates their ability to meet the Nursing Council of New Zealand (NCNZ) competencies. The PDRP process not only ensures that nurses are achieving the competency standards deemed necessary for safe practice, they are also used as a mechanism for acknowledging and rewarding achievement and progress to higher levels of practice.

The passage of the Health Practitioners Competence Assurance Act (HPCA), 2003, enabled NCNZ to establish a competency based practising certificate requirement enforced by a random audit process. This has presented new issues and challenges to nurses both collectively and personally as it has made competency review compulsory. Nurses have the option of responding individually when selected for audit or of joining a PDRP. Organisations which run a PDRP may apply to the NCNZ to have their programme approved (NCNZ, 2005c) in which case nurses recognised on that programme will not be audited by NCNZ. As of June 2007, 20 separate PDRPs had received this approval (NCNZ, 2007). This means that if a nurse who is selected for competency audit by the NCNZ is already recognised on an approved PDRP no further action is required by the nurse to address competency review.

The organisation in which the study was conducted expects all nursing staff to complete a professional portfolio, and has continued to educate and encourage nurses as to the process and its value. Numbers completing the process have increased and we were keen to see what changes in knowledge and attitude had occurred as a way of providing feedback to the PDRP co-ordinator.

Aims

The aims of the current study were:

1. To assess levels of knowledge about the PDRP and to see whether they have changed since they were last assessed in 2002.

2. To gauge nurses' attitudes towards the PDRP and to see whether there has been any major attitudinal change since 2002.

3. To identify any relationships between knowledge and attitudes and to consider whether they are linked to participant characteristics.

Method

Following submission to the relevant ethics committee it was deemed that ethical approval was not required for this study.

Questionnaire

The questionnaire, which respondents answered anonymously, was divided into three sections. The first was designed to assess nurses' knowledge of the PDRP and consisted of 13 multi-choice questions. Each question was accompanied by three to five response alternatives, including a 'don't know' option. These questions and the subsequent attitude statements were developed for the previous survey (see Carryer, Budge & Russell 2002). As a result of changes to the PDRP process since the previous application of the measure, several of the knowledge questions were reworded, but the main themes remained the same and all but one of the questions could be directly compared across the CCP and PDRP versions of the measure.

The second section consisted of 38 attitudinal statements about the PDRP process and professional development in general. Instructions requested participants to indicate their level of agreement with each statement on a scale ranging from 'strongly disagree' to 'strongly agree' with three options ('disagree', 'neither agree nor disagree' and 'agree') between. A 'don't know' option was again provided. The first five options were used as ratings on a 5-point likert scale. The first 23 statements were applicable to all participants, regardless of their PDRP enrolment status. Statements 24 to 29 were designed for nurses who had never submitted a PDRP portfolio whereas statements 30 to 38 were designed for those who had. In addition, a blank page was provided with a request for any comments or explanations participants would like to include. The third and final section contained demographic questions concerning qualifications, practice areas, education, sex and age.

Procedure

Questionnaires were sent out to all registered and enrolled nursing staff from the acute hospital and one small rural hospital. An introductory letter and return envelope was included to provide information about the study and to request their participation. A six-week time frame for responding was given, with a reminder sent to all after three weeks.

Participants

Of the 868 study packages sent out 429 were returned, two of which were predominantly blank and were consequently discarded. The final sample therefore consisted of 427 forms, giving a response rate of 49%. Although demographic information provided was incomplete, we do know that 369 females and 23 males took part, and the participant group was divided equally in terms of full and part-time employment. Years of practice ranged from 6 months to 46 years (M=17.5, SD=10.2). With respect to registration, 88.6% of the respondents were RNs. The largest subgroup was aged between 41 and 50 (46.1 %), followed by those aged 51 to 60 (21%) and 31 to 40 (19.5%). A further 10.7% of participants were aged between 20 and 30 years and 2.7% were over 60. Just over half of the respondents (53.4%) had submitted a PDRP portfolio, in comparison with 19.7% in 2002. Of these approximately two-thirds were tertiary rather than hospital trained and 18% indicated they were currently studying towards a higher qualification.

Results

Knowledge of the PDRP The first aim of this study concerned knowledge of the PDRP, and how current knowledge compares to that of the 2002 sample. Figure 1 shows the percentage of correct responses to each of the 12 comparable questions in this and the previous application of the measure.

[FIGURE 1 OMITTED]

Figure 1 shows that the number of correct responses was similar across the two study times in 7 of the 12 questions. The greatest discrepancies occurred for question 6, where knowledge about the level at which nurses are required to start on the PDRP appears to have dropped since 2002; question 9, where again knowledge has decreased--in this instance concerning the financial reward associated with PDRP level attainment; and question 10, where it can be seen that knowledge levels have increased regarding the frequency of portfolio reassessment.

A knowledge score for each participant was calculated by summing the number of correct answers to the 13 questions. These scores ranged from 0 to 13, with a mean of 7.11 and a standard deviation of 1.96. This is slightly higher than the range of 1 to 12, mean of 6.91 and standard deviation of 2.25 found in 2002. Following the previous application of the survey it was found that those nurses who had already submitted a portfolio scored better on the knowledge questions (M = 8.38) than those who had not (M = 6.57). A similar comparison with the current sample was performed and again those who had submitted a portfolio (M= 7.30) achieved a higher average score than those who had not (M = 6.89). Despite the smaller difference between the two groups' mean scores this time, an independent samples t-test demonstrated that the difference was still significant (t = 2.08, df = 396.21, p < .05). In the previous survey no relationship was found between knowledge scores and duration of practice, but in the current sample a weak, positive correlation was found (r = .13, N = 379, p < .05) suggesting that nurses with greater experience also had better knowledge of the PDRP.

Attitudes Towards the PDRP

The second aim focused on attitudes towards the PDRP. As in the previous survey, two groups of statements were selected from the first set of 23, which was answered by all participants, based on the ideas expressed in the questions being either in favour of (Pro PDRP), or against (PDRP Process) the PDRP initiative. These groups of items were combined to form subscales, Pro PDRP consisting of five statements and PDRP Process comprising seven. A third subscale (PDRP Benefits) was constructed from four of the nine attitude statements directed at those who have already submitted a portfolio. As the name implies, these statements express positive views of the professional development and recognition pathway. The items included in all three subscales can be found in Carryer, Budge and Russell (2002). Summary statistics for the subscale results from 2002 and 2006 appear in Table 1.

It can be seen from Table 1 that there has been little change from the first to the second application of the survey, although the mean PDRP Process score has decreased slightly which represents an increase in positive feeling. Although the Cronbach's alpha for the Pro PDRP subscale has lowered it is still acceptable. The average score on 'PDRP benefits' appears to have lowered slightly, as was indicated by the item scores, and the variability, or spread of scores, has increased slightly. The Cronbach's alpha reliability coefficient for this subscale increased from .70 previously to .79 this time.

The third aim of this study was to identify any relationships between knowledge and attitudes and to see whether they are linked to participant characteristics. Table 2 presents the Pearson's correlations carried out to address this aim.

From these results it can be seen that all three attitude subscales are correlated with each other, with the strongest relationship occurring between the two positive attitude subscales. All three are also significantly correlated with knowledge, suggesting that greater understanding of the PDRP and the way it is implemented in the study hospital, the more positive the attitudes towards it. No correlation was found between duration of practice and any of the attitude subscales.

Qualitative findings

A broader purpose of this and the previous study was to use the positive and negative answers to both the knowledge and attitude questions to shape further planning and education about the PDRP presented to nurses at the study hospital. An opportunity to comment was given in both surveys and this opportunity was used by 56% of those responding in 2001 and 47% in 2006. The main themes evident in both surveys will now be presented. They have not changed since administration of the first survey.

Time Involved in Portfolio Development

There was resentment expressed in both surveys about the considerable amount of personal time outside work hours that needed to be invested in portfolio development. However, 77% in 2001 and 75% in 2006 indicated that they would be happier about using their own time if the organisation supplied some paid time as well. It should be noted here that the national industrial agreement (National DHB MECA, 2004) gives 1 day for level 3 portfolio development and 2 days for Level 4 portfolio development. This seemed to vary depending on the area where the nurse worked, as many nurses cannot actually utilise the time provided because of variables such as workload and patient acuity.

PDRP Requirements are Excessive

Participants expressed the consistent view that the process for demonstrating competency is excessively time consuming, unnecessarily "wordy" and insufficiently directly linked to measuring clinical competence. Such views were strongly voiced in 2001 and have not diminished in 2006. In addition the 2006 survey demonstrated that there was confusion between requirements for NCNZ audit and requirements for PDRP, with many respondents unclear about the requirement difference between a competency audit (NCNZ) and a level of practice programme (PDRP) facilitated by the organisation. Nurses who had not completed their PDRP portfolio most consistently expressed this confusion, suggesting that it may be a feature of disengagement with the process.

Discussion

It is five years since the last survey was administered and during this time it has become obligatory for all nurses to meet competency standards set by NCNZ and mandated by the HPCA Act (2003). This has added impetus to the PDRP programme as through NCNZ approval of PDRP programmes there can be a valuable link in the two processes.

A measure of knowledge and attitudes towards the study hospital's CCP was devised in 2001 and the same measure, with minor amendments to suit the current PDRP and its terminology, was again administered in 2006. At the time of administration of the first survey 19.7% of all eligible staff had completed a portfolio; at the time of this survey 53.4% have completed.

Results showed that PDRP knowledge levels were very similar across the two time periods, both in relation to the number of correct responses to individual questions and to the total knowledge scores. The mean scores obtained were not particularly high, with the average person achieving correct answers to about half of the questions. As before, knowledge was better amongst those nurses who had submitted a portfolio compared with those who had not, but the difference was not great. Secondly, results showed that attitudes were similar across the two study periods. A slight improvement was evident in the PDRP process scores, particularly in relation to the suitability of competencies to all areas of practice, and the ease with which a colleague can be found to validate personal statements. On average nurses who had already submitted a portfolio appeared to be slightly less positive about it than they had been in 2002, particularly with respect to the satisfaction in completing a portfolio being worth the effort required. This could reflect the "expected" nature of the PDRP in this organisation. At the time of the earlier study, submitting a portfolio was voluntary and it could be that only those nurses who were already cognisant of the advantages of the process were enrolled and consequently they felt relatively positive about it.

Having increased knowledge about the PDRP was found to be associated with more positive attitudes, which affirms the importance of good, positive education about the programme and the need to provide support for nurses currently working on portfolios.

In relation to concerns about the time spent on portfolio development expressed in the first survey, the organisation has addressed the "time issue" by developing a Clinical Practice Development Process (CPDP) in the last 12 months. This framework encourages the identification of skills and knowledge that the nurse needs for the specific practice setting. Presented as a system of levels, it facilitates nurses' learning in a systematic and targeted fashion. It also assists nurses with an education role to identify the clinical skills required for each level of practice and co-ordinate education to meet those specific needs. For each area of practice there is a CPDP which meets NCNZ competencies and can be "signed off" within areas of practice. Use of CPDP meets much of the PDRP requirements for that level and so reduces the amount of writing required as evidence for the PDRP portfolio.

The extent of persistent discomfort about the perceived excessive requirements of competency review remains a concern. The organisation surveyed attempts to address the knowledge deficits through education workshops and has developed a pamphlet to further explain the process. Comments made in the survey will be addressed at the two yearly review of the PDRP programme, but NCNZ competency requirements (NCNZ, 2005a; 2005b) and the national frameworks established by the working party report to National Nursing Organisations (National Professional Development & Recognition Programme Working Party, 2004) cannot be compromised. Perceptions expressed that the process changes frequently are partly accurate and partly not. Changes to the PDRP programme were made as a result of the HPCA (2003) as establishment of PDRP programmes preceded the Act. Further changes were made in response to the revised NCNZ competencies (NCNZ, 2005a; 2005b), hopefully no further significant changes will occur in the immediate future. The survey organisation's PDRP is however a working document and is reviewed every two years, with nurses given six months to complete portfolios using existing documents.

The need for national consistency and transportability featured strongly in the 2002 survey at which time there were no national guidelines or direction. In 2006 this was not reported as a large issue which is not surprising as there are now NCNZ competencies (NCNZ, 2005a; 2005b) and a national framework and standards (National Professional Development & Recognition Programme Working Party, 2004) which guide each organisation's PDRP. Some nurses would still like to see a national document, but participants did comment on the ease of transfer between organisations during transfer of their portfolio from another accredited organisation to the surveyed one. In both surveys nurses were positive about working on portfolio development in small groups of colleagues and acknowledged that support was readily available and useful when it was asked for. Some nurses in the 2006 survey suggested that the recertification process (every three years) should be modified and reduced if the nurse was working in the same clinical area and applying for the same level of practice.

This second survey more clearly identified the greatest resistance as coming from older and hospital trained nurses who continue to express considerable resentment towards the process of competency review. Essentially it is their view that the years of practice they have completed should and do guarantee competence, and that the portfolio process does not provide anything of additional value.

Conclusion

Administration of a PDRP to support competency review continues to be an exacting process for nursing. Two surveys have been completed showing that, despite a vigorous and inherently supportive process of administering the PDRP in the surveyed organisation, significant areas of concern and resistance persist amongst nurses surveyed. It remains a challenge to continue to meet regulatory and professional development requirements and at the same time support a profession working under considerable stress.

References

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlow Park, CA: Addison-Wesley.

Carryer, J. B., Budge, R. C., & Russell, A. (2002). Measuring perceptions of the Clinical Career Pathway in a New Zealand hospital. Nursing Praxis in New Zealand, 18(3), 18-29.

Health Practitioners Competence Assurance Act. (2003). National DHB MECA. (2004-2006). District Health Boards / NZNO Multi-employer Nursing / Midwifery Collective Agreement. Retrieved October 28, 2007, from http://www.nzno. org.nz/site/ campaigns/ fair play.asp.pdf

National Professional Development and Recognition Programme Working Party. (2004). National framework for nursing professional development & recognition programmes & designated title roles. Report to the National Nursing Organisations. Retrieved October 28, 2007, from http://www.nzno.org.nz/Site/Professional/Other/PDRP/PDRP.aspx. pdf

Nursing Council of New Zealand. (2005a). Competencies for the registered nurse scope of practice. Wellington: Author.

Nursing Council of New Zealand. (2005b). Competencies for the nurse assistant and enrolled nurse scope of practice. Wellington: Author.

Nursing Council of New Zealand. (2005c). Framework for the approval of professional development and recognition programmes to meet the continuing competence requirements for nurses. Wellington: Author.

Nursing Council of New Zealand. (2007). Approved professional development and recognition programmes. Retrieved October 28, 2007, from http://www.nursingcouncil.org.nz.

Jenny Carryer, RN, PhD, FCNA(NZ), MNZM, Professor of Nursing, MidCentral District Health Board & Massey University, Palmerston North

Anne Russell, RN, PG Dip., PDRP Co-ordinator, MidCentral Health, Palmerston North

Claire Budge, PhD (Psychology), Research Associate

Carryer, J., Russell, A., & Budge, C. (2007). Nurses' understanding of the professional development recognition programme. Nursing Praxis in New Zealand, 23(2), 5-13.
Table 1
Attitude subscale statistics for the 2002 and 2006 applications of
the measure

 Score range Mean

Subscales 2002 2006 2002 2006

Pro PDRP 5-25 5-25 16.39 16.99
PDRP Process 10-35 7-34 22.3 20.48
PDRP Benefits 7-19 4-20 14.43 13.59

 Standard Cronbach's
 deviation alpha

Subscales 2002 2006 2002 2006

Pro PDRP 4.45 4.14 .83 .77
PDRP Process 5.17 5.00 .78 .75
PDRP Benefits 2.92 3.56 .70 .79

Table 2
Pearson's r coefficients for correlations between attitude and
knowledge scores

 PDRP PDRP
 Pro PDRP Process Benefits Knowledge

Pro PDRP -- -.46 ** .77 ** .23 **
PDRP Process -- -.53 ** -.23 **
PDRP Benefits -- .24 *
Knowledge --

* p < .01 ** p < .001
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Author:Carryer, Jenny; Russell, Anne; Budge, Claire
Publication:Nursing Praxis in New Zealand
Geographic Code:8NEWZ
Date:Nov 1, 2007
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