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Nursing Levels of Competency Theory

(from Ignorance to Mastery) Introduction The image of nursing is changing. Images of angels in starched skirts and nursing caps eagerly awaiting guidance from physicians has long since been replaced by images of competent, independent men and women of diverse backgrounds. Gordon (2005) described the historical, stereotypical (iconic) view of the nurse as that of a physicians handmaiden, dependent on the physician for direction. She explained that the nursing profession has been negligent in sharing with the public the importance of nurses critical thinking, problem-solving, and research skills. Nurses have failed to help the public understand that nurses actions involve more than nurturing; they also include assessing, surveying for risks, identifying client goals, planning independent actions, and prioritizing care. Gordon (2006) has stated that in order to gain and maintain the respect of the public and other healthcare professionals, nurses must emphasize and communicate the knowledge and skills required for professional nursing. It is also imperative that those responsible for reimbursement of nursing care understand that nurses save lives, prevent complications, prevent suffering, and save money (para. 5). OMara (1999) has argued that in order to assure reimbursement and access to needed resources nurses need to articulate the cognitive abilities nurses need in order to provide competent care. Benner, Sutphen, Leonard, and Day (2010), too, have written that nurses must learn to emphasize the tangible benefits of nurses, beyond that of caring. Nursing education plays a central role in the ability to practice effectively. It follows that an optimally educated nursing workforce begets optimal patient care. But the learning process, wherein the nurses acquire skills and knowledge, has often become more difficult than necessary because of the bad feelings nurses get when they make mistakes in learning. The bad feelings come from judgments like, "not doing it right," "not good enough," "can never learn this," etc. Ironically, not doing it right and making mistakes are vital steps in the learning process. Yet too often our attention goes to trying to avoid the bad feelings, rather than to the learning at hand. Understanding the stages of learning a skill can help keep the learning process focused on learning to do something, and not feeling bad about ourselves for not already knowing how. Nurses must overwhelmingly acknowledged Learning as a major factor in nursing competence. The importance of the Learning process in nursing indicates that knowledge and Skills are required to prevent untoward patient outcomes. It also identified competence as

prerequisite to establishing trust with others. Competence is important because, it makes patients want you to take care of them and patients and health professionals trust competent nurses. And competence addresses patients holistically - in all dimensions.

Philosophical/ Theoretical Underpinnings This theory was originally acquired and attributed to Abraham Maslow, The Four Stages of Learning, provides a model for learning. It suggests that individuals are initially unaware of how little they know, or unconscious of their incompetence. As they recognize their incompetence, they consciously acquire a skill then consciously use it. Eventually, the skill can be utilized without it being consciously thought through: the individual is said to have then acquired unconscious competence.

Major Assumptions, Concepts and Relationships

Learning and practice partnerships are key to developing an effective model.


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An integrated practice/learning competency model will positively impact patient safety and improve patient care Nursing practice should be differentiated according to the nurses educational preparation and level of practice and further defined by the role of the nurse and the work setting Practice environments that support and enhance professional competence are essential

The nurse of the future will be proficient in a core set of competencies.


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There is a differentiation in competencies among practicing nurses at various levels Competence is developed over a continuum and can be measured

Conceptual Model

Unconscious Incompetence Nursing Unconscious Competence

Conscious Incompetence

Conscious Incompetence

The Nursing Competency Model

Explanation of the Model Four Levels of Competence: Stage 1 Unconsciously Incompetence (Novice) the nurse is not aware of the existence or relevance of the skill area the nurse is not aware that they have a particular deficiency in the area concerned the nurse might deny the relevance or usefulness of the new skill the nurse must become conscious of their incompetence before development of the new skill or learning can begin; the aim of the learner and the trainer is to move the person into the 'conscious competence' stage, by demonstrating the skill or ability and the benefit that it will bring to the nurse's effectiveness Stage 2 Consciously Incompetence (Apprentice) the nurse becomes aware of the existence and relevance of the skill

the nurse is therefore also aware of their deficiency in this area, ideally by attempting or trying to use the skill the nurse realizes that by improving their skill or ability in this area their effectiveness will improve ideally the nurse has a measure of the extent of their deficiency in the relevant skill, and a measure of what level of skill is required for their own competence the nurse ideally makes a commitment to learn and practice the new skill, and to move to the 'conscious competence' stage Stage 3 Consciously competence (Journeyman) the nurse achieves 'conscious competence' in a skill when they can perform it reliably at will the nurse will need to concentrate and think in order to perform the skill the nurse can perform the skill without assistance the nurse will not reliably perform the skill unless thinking about it - the skill is not yet 'second nature' or 'automatic' the nurse should be able to demonstrate the skill to another, but is unlikely to be able to teach it well to another person the nurse should ideally continue to practice the new skill, and if appropriate commit to becoming 'unconsciously competent' at the new skill Practice is the single most effective way to move from stage 3 to 4 Stage 4 Unconsciously competence (Master) You're so successful it's "automatic" -- you do it well, without thinking about it. the skill becomes so practiced that it enters the unconscious parts of the brain - it becomes 'second nature' It becomes possible for certain skills to be performed while doing something else, for example, assessing the pulse rate and respiratory rate at the same time. the nurse might now be able to teach others in the skill concerned, although after some time of being unconsciously competent the nurse might actually have difficulty in explaining exactly how they do it - the skill has become largely instinctual this arguably gives rise to the need for long-standing unconscious competence to be checked periodically against new standards. The four-stage model is intriguingly simple, describing a nurse's path from ignorance to mastery.

Concepts and Definitions Competence - addresses patients holistically - in all dimensions. Incompetence- without adequate skill or knowledge Practice- repeated performance or systematic exercise for the purpose of acquiring skill or proficiency Conscious- individual sense of recognition or awareness of competence within oneself Unconscious- unaware or insensitive of skills and knowledge one lacks Learning- the act or process of acquiring knowledge or skill through practice, training, or experience Meta-paradigms / Theory Assertions Person- one receiving therapeutic levels of care Health- inner and outer state of wellness, integrity, and wholeness; illness and disease from an individual Nursing- situated caring shaped by ones level of development (e.g., training and experience; psychological development; moral-ethical development) and the context of the situation. Environment- internal and external environments of both the nurse and the patient/client; Internal environments include the individuals state of mind, intention and personal beliefs (including personal philosophy of nursing or what nurses do); their level of relevant skill, training, and experience relevant to the care situation; societal and professional norms, values, and worldviews; and External environment, embedded in social, political, and economic systems, also referring to available resources. Usefulness (Application of Theory)

Each step builds on the previous one as abstract principles are refined and expanded by experience and the learner gains clinical expertise. It developed nursing competency that requires practice and clinical simulation which provides a safe, structured learning experience. This theory changed the profession's understanding of what it means to be an expert, placing this designation not on the nurse with the most highly paid or most prestigious position, but on the nurse who provided the most exquisite nursing care. It introduced the revolutionary assumption that the practice itself could and should inform theory.

Background of the Theorist My beginning as a legally recognized individual occurred on May 26, 1991 in Santa Maria District Hospital, and I was given the name, Elaisa Mae Celada delos Santos. My parents are Jessie and Myra delos Santos, I am the eldest of their three offsprings. We live a prudent life but sometimes what we have was not enough to support our daily living. With the motivation to improve the kind of life that we lived, my mother went to work abroad. My father was a former PUJ driver and currently has no source of income. I got my primary education at a public school, Sta. Cruz- Manggahan Elementary School, wherein I graduated with honors and awards. In high school, I was granted a scholarship because of my academic achievements. I was given the privilege to study at Grace of Shekinah School, a private school where doors of opportunity were opened for me. I have to maintain my high grades for my scholarship and eventually it paved off and I became one of the top students and graduated with honors and awards. By the time I went to college, wherein my mom chose my line of profession- NURSING, I studied in one of the nursing schools in Manila. But due to financial stability, I went to Eastern Samar to continue my second year with the same course. It was my last year when I got impregnated by my long-time boyfriend, who eventually left me. I have no choice but to stop schooling and went back here in Santa Maria, Bulacan. At the age of 19, I gave birth to a healthy baby boy. I am a single parent, and it was difficult and very depressing. But God is still good and blessed me with a loving family who supported me and my baby financially and emotionally. And as if by cue, our life got better. My moms visa t o work in Canada was approved. She got a high-paid salary job that was able to support us. I hope with my continued pursuance, hard work and hope for a brighter future for me and my baby; and coupled by my mother's words of wisdom, I will be able to gain or achieve certain goals as a student of this institution. Statistically, it would seem improbable that any student of my age would be able to go through such sacrifices and endeavor. However I am still making the effort which is conceivable, that I will do my best to accomplish my goals and finish my studies. Thus I have high hopes that I will achieve something of value through my current studies or with any new ideas that come in the future to help my family and my aspirations for my childs future with God's grace and guidance.

References OMara, A. (1999). Communicating with other health professionals. In E. Arnold, & K . U. Boggs, Interpersonal relationships: Professional communication skills for nurses (3rd ed., pp. 496-523). Philadelphia, PA: Saunders. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Gordon, S. (2005). Nursing against the odds: How health care cost cutting, media stereotypes, and medical hubris undermine nurses and patient care. Ithica, NY: Cornell University. Gordon, S. (2006). What do nurses really do? Topics in Advanced Practice Nursing eJournal, 6. Retrieved from http://www.medscape.com/viewarticle/520714 Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, Calif: Addison-Wesley; 1984. Olga F. Jarrin, PhD, RN (2012. The Integrality of Situated Caring in Nursing and the Environment, Center for Health Policy and Outcomes Research, School of Nursing, University of Pennsylvania, Philadelphia; Rhodes MK, Morris AH, Lazenby RB (2011). Nursing at its best: competent and caring; Auburn University Montgomery School of Nursing, Montgomery, AL, USA. Sawatzky JA, Enns CL, Ashcroft TJ, Davis PL, Harder BN (2009). Teaching excellence in nursing education: a caring framework; Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada. Pullen RL Jr, Murray PH, McGee KS (2001). Care Groups: a model to mentor novice nursing students; Nursing Resource Center, Computer Testing Center, Amarillo College, TX 79178, USA. Octaviano, E.F. & Balita, C.E. (2008). Theoretical Foundations of Nursing: The Philippine Perspective. Philippines: Ultimate Learning Series http://www.gordontraining.com/free-workplace-articles/learning-a-new-skill-is-easier-saidthan-done/ http://en.wikipedia.org/wiki/Four_stages_of_competence http://www.scribd.com/doc/27103958/Benner-Theory-Novice-to-Expert http://www.scribd.com/doc/18624149/Theoretical-Foundations-of-Nursing

In partial fulfillment of the requirements in

Theoretical Foundations of Nursing

NURSING COMPETENCY THEORY (from Ignorance to Mastery)

Submitted by: Elaisa Mae C. delos Santos

Submitted to: Prof. Regie P. de Jesus, RN, MAN

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