Mar 20, 2015 - The National Registry of Emergency Medical Technicians. (NREMT) was formed in 1970 by the Highway Traffic Safety. Committee set up by the ...
Competency standards, continuing professional development and implications for regulatory frameworks | Arab Health Magazine
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Year: 2012 - Show Issue Emergency and Trauma, Non Clinical
Competency standards, continuing professional development and implications for regulatory frameworks By: Mr Nathan Puckeridge, Education Manager, National Ambulance, Senior Lecturer, School of Medical Sciences, and Ms Vicki Cope, Nursing Pathways Coordinator, School or Nursing, Edith Cowan University, Joondalup, Australia
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The National Registry of Emergency Medical Technicians (NREMT) was formed in 1970 by the Highway Traffic Safety Committee set up by the then President of the United States of America, Mr. Lyndon Johnson. This committee recommended a
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national body be inaugurated to certify and register emergency medical technicians according to a standardised national curriculum framework. The national curriculum was pieced together in 1976, becoming the first benchmark for EMS education and competency standards within the states and territories of the United States. The NREMT is a private national certification body complimenting individual states and territories to license personnel through State EMS Offices conferring the right to practice within the public arena. In a similar manner, the Republic of South Africa, Ireland and the United Kingdom have regulatory bodies that register pre-hospital providers in accordance with a national competency framework, defined standards of practice and evidence based educational principles in order to provide public protection and adherence to clinical practice standards for patient safety. Registration confers the right to practice according to national clinical practice guidelines for practitioners, details the limitations of practice and defines the scope with which the community can be assured of service delivery and safety. The regulatory bodies fulfil the same functions of the individual US State EMS Offices to regulate, govern and oversee the clinical practice of pre-hospital providers. What is different for the NREMT, is that Ireland, South Africa and the United Kingdom provides rights to practice within a national framework and national standardised clinical practice whereas the NREMT provides certification of competence against a national education curriculum framework. Licensure in this case, relates to the authority to practice whereas certification confirms the appropriate level of competence to practice. At the present time, Australia and New Zealand do not have an independent certification body or a regulatory authority that governs pre-hospital providers because individual state and territory emergency ambulance service Medical Advisory Committee or Medical Director (whichever be the case) authorise the right to practice pre-hospital care. Authority to practice comes with completion of programmes of instruction referred to as a service familiarisation, http://arabhealthmagazine.com/competency-standards-continuing-professional-development-and-implications-for-regulatory-frameworks/#more-346[20/03/2015 3:36:42 PM]
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Competency standards, continuing professional development and implications for regulatory frameworks | Arab Health Magazine
orientation or re-training in organisational specific practice and culture. The United Arab Emirates has initiated health professions licensing for EMS that now involves the assessment of cognitive and psychomotor competency, necessitating the need to have a standard national EMS curriculum, an accepted standard scope of practice, an authorised regulation identifying the profession and a determined level of safe
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proficiency. This paper therefore, seeks to determine the evidence behind the assessment of practitioner competencies within a health profession for licensure to practice and recommend a strategy for implementing a quality education and assessment system that upholds public safety while ensuring the best clinicians are awarded authority to practice fairly
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and equitably. COMPETENCY STANDARDS The NREMT and Irish Pre-Hospital Emergency Care Council (PHECC) have a standardised approach to clinical assessment for registration of specific skill competencies that are identified as particular for a designated clinical grade. A search of CINAHL, PubMed, JEPHC and Google found no documented evidence supporting any method identifying the relevance of these skills being conducive to safe practice in pre-hospital care. The Convention of Ambulance Authorities (CAA) documents a list of core competency statements for graduate paramedics under the Australian tertiary and vocational education system however there are no clinical task specific items within these statements. The UK Health Professions Council, Canadian National Competency Occupational Profile and Australian Health Training Package give a more pointed reference to clinical capabilities and skill definitions however there is no detailed evidence basis for these specific clinical skills except reference to “local clinical practice guidelines”. The HPC-UK utilise a document trail to prove recognised qualifications and experience in awarding registration up to including a ‘Test of Competence’ against the Standards of Proficiency and the employing ambulance service subjects the applicant to a period of internship where competence is assured before independent practice occurs. In limited provinces of Canada as well as in Ireland and the United States, competence is determined by application of a written knowledge test and objective structured clinical examination (OSCE) after completion of a course of instruction that conforms to a standardised and approved curriculum. In a nursing context, competency does not necessarily refer to clinical skills requiring a checklist of observable tasks. Competence is something that is not necessarily visible or observable. Scientific knowledge, clinical skills and humanistic values and attitudes make up a holistic view of nursing practice whereby the individual procedural skill is seen as not only the physical element but also the care interaction, the care transference and client perceptions of care acknowledging safe clinical competence. The CAA and HPC-UK document competencies, which provide a rounded professional view for the expectations of a paramedic graduate in not only the clinical aspects but also the attitudinal, applied scientific cognition and community standards required of healthcare professionals. Nursing and paramedicine each have a distinct skill set and contextual application of competencies, which are documented and detailed within their respective educational programmes. Underpinning knowledge and attitudinal aspects of practice may well be very similar (although there are no studies which have determined this for fact), the practical application of nursing and paramedicine are distinctly different. It does not matter the context of the skills (be they medicine, nursing or paramedicine), what matters is that these required competency standards are clear, of benefit to the patient, and ensure that evidence is sufficiently collected from the candidate to confirm competence and ensure patient safety. Determining competency is a measure of observable behaviours and techniques where the candidate demonstrates a required set of actions for evidence-based patient outcomes. They should be objective, meaning they occur within a context that is applicable and verifiable by independent experts observing the competency. They should be structured, meaning they are detailed in the level of technique, process and principles of evidence based, quality care required for the candidate to demonstrate safe patient care. They must be clinically orientated and incorporate the clinical environment or similar simulation where the candidate is likely to be operating to conserve the realism of the competency assessment. Most importantly, they must be designed with the industry in mind ensuring employer expectations of practice are fulfilled. There is human interference to competency assessment and this involves elements of subjectivity leading to bias and http://arabhealthmagazine.com/competency-standards-continuing-professional-development-and-implications-for-regulatory-frameworks/#more-346[20/03/2015 3:36:42 PM]
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Competency standards, continuing professional development and implications for regulatory frameworks | Arab Health Magazine
inconsistent assessments of clinical behaviours and competence. When competency assessment is directly related to a course structure, there is uniform objectivity with which to base assessment judgements upon and attempts to remove any bias of subjectivity from the assessment. Standardising an assessment approach may have a negative impact on the education endeavour of programs in nursing. This may be true for the graduate expecting to be able to practice immediately in diverse and broad spectrums of circumstance, however a single scenario assessment may not cover sufficient affective aspects or relate to, for example, the process of inserting a nasopharyngeal airway upside down in a vehicle wreck in the dark. How does one assess competence in this particular skill fairly and equitably between candidates if there is no standardised approach to the scenario, clinical background or expected patient response to the intervention? If the assessment of a particular skill competence was standardised in its approach and there is a clear defined curriculum to reference the skill to, this should decrease subjectivity owing to a more consistent assessment process. Standardising the clinical skill assessment means assessors also need to be competent as assessors and clinicians to make judgements of clinical performance. This has a meaning that registered or licensed practitioners who have received training in assessment methodology are determined qualified to make judgments for safe clinical competence. ASSESSMENT OF COMPETENCE Finding incompetence is easier than identifying the attributes, knowledge base and tactile skills of competent practice. The ability of a candidate to transfer skill knowledge through simulation practice into the real world sense is one barrier to effective assessment of competence, subjectivity issues aside. In terms of regulatory compliance and application for licensure, candidates may not have undertaken classes, remediation, refresher or up-skilling training for some time leading to a degradation of skills and knowledge during this period. It has been shown that basic life support skills degrade at a rapid rate to almost pre-training level after 90 days. Candidates need to be afforded the opportunity to fully prepare prior to assessments. This can take the form of exam preparation courses, mandatory continuous professional development courses or rotational duties in high risk, high event skill centres to practice critical skills that are high risk and low event rates in clinical practice settings. Competence needs to encompass the whole role of the healthcare practitioner in a holistic manner and technical skills are best measured with standardised tools across the learning domains. By preparing for the assessment, a candidate who may not have been provided adequate, evidencebased and up-to-date education will be afforded the same equal opportunity at being found competent as a new graduate thereby retaining a wealth of experience and system know-how that can only be learnt with exposure and experience. Written paper exams consist of learning outcome elements taken from a curriculum framework or created on the basis of a particular skill method theory. It is less nerve-intensive than a practical demonstration and ensures the candidates have either developed or already have the required knowledge base for the position they occupy. Written paper tests have no measure for applicability of the knowledge or the ability to perform a skill, only that they can recite or remember written details. Practical skills exams consist of a defined static skill and assessors check off items as they are observed within the skill station. They are time-, and resource expensive and are only representative of a small function of paramedic clinical practice. Scenario OSCE simulation is where a sterile environment is created and a variety of skills combined to assess, a candidate’s ability to integrate knowledge, skills and attitudes. Close to the real thing but very far indeed from being life-like there is still minimal quality evidence that OSCE’s can effectively assure clinical competence. Observation is in essence on the job training where an experienced clinician observes in real time the clinical cognitive, affective and psychomotor competencies for safe and evidence based practice for a specified period of time in a range of situations and circumstances. It is here when real time assessment can be undertaken to ensure the candidate can initiate safe evidence based clinical care. Observation assessments can also be termed an internship depending on the assessment requirements for time and range of variables to be assessed. The only issue is the resource aspect, ensuring adequately qualified and suitable people are available to supervise clinical practice and the operational constraints of having students undertaking high risk skills in real time. The three domains of learning, cognitive, affective and psychomotor are capable of being assessed in distinct methods of ambulance education frameworks. These domains can be summarily linked to the elements of competency as stated http://arabhealthmagazine.com/competency-standards-continuing-professional-development-and-implications-for-regulatory-frameworks/#more-346[20/03/2015 3:36:42 PM]
Competency standards, continuing professional development and implications for regulatory frameworks | Arab Health Magazine
previously, namely scientific knowledge, clinical skills and humanistic attitudes however, not all are assessed in licensing or registration assessments. Written paper exams and an OSCE or simulation code would confirm the cognitive and psychomotor or scientific knowledge and clinical skills, but there lacks the humanistic attitude assessment where the first two domains are finally integrated into the clinical service delivery. Written paper exams test how much a person remembers from their readings, and psychomotor skills OSCE tests one’s ability to run off a skill checklist they have practiced multiple times in preparation for the exam day. The ability of the candidate to pull all the resources at the scene of a cardiac arrest where multiple clinical skills and drug calculations, algorithm protocols, policy/procedures and community interfacing initiated all at the same time is not assessed and remains largely ignored in the process of deeming one competent to practice in EMS. ENSURING CONTINUED PATIENT SAFETY As an evaluation tool, there is limited evidence documented for the use of simulation being utilised to identify continuing competence and patient safety in accordance with evidence based guidelines. One study identified the critical competencies required to be addressed in professional development programmes for paramedics, however these clinical skills are possibly the high-risk, low-event skill tasks already identified by previous authors as problematic competency areas. There is no surprise that advanced airway management, ventilatory support and medication administration for paediatric patients are seen as these critical areas, however, advanced airway management and basic life support are key skills that deteriorate in short periods of time after training. Being able to pass a cognitive and psychomotor assessment for certification does not mean the clinician is safe to practice at the bed or street side. Being certified or licenced assumes that conformance to standards of practice are applied, regulatory compliance is assured and independent regulators monitor the practitioner for quality performance indicators and clinical interventions shaped by current evidence based practice. Even in Nursing, there is no evidence of conformance across Western borders identifying the educational requirements of clinical practice, no single entry point for registration of healthcare practitioners and different regulatory systems who require different processes to determine competence. There needs to be a mapping of recognised qualifications to curriculum and competencies leading to protected titles as a standardised approach to regulation and the establishment of regulatory standards for clinical practice to assure confidence in paramedic competency. When such a regulatory system is established, initial and continuing professional standards would address performance indicators and quality controls for patient safety thereby fulfilling community expectations of the highest clinical care delivery possible. CONCLUSION For a curriculum and local context standpoint, five alternate international frameworks were reviewed detailing paramedic practice as part of this paper. PHECC and NREMT have very similar curriculum doctrines, Canada and Australia have almost identical vocational training outcomes and the CAA has begun accrediting Australian and New Zealand tertiary institution programmes against competency statements closely relating the HPC-UK’s Standards of Proficiency. Each curriculum can be mapped to a standard clinical practice, which is evidence-based and accepted by the regulator. This then develops the first step towards creating a United Arab Emirates Standard Pre-Hospital Care Curriculum document which is evidence based to clinical practice guidelines and is steeped in an international background covering the multinational workforce of EMS in the UAE. From here, curriculum standards can be implemented locally and assessment strategies developed with such combinations as pen and paper exams, static skill stations, simulation scenarios and observable clinical practice to determine definitive elements of competency for cognitive, affective and psychomotor skills. Maintaining that competency forms part of the reportable regulatory key performance indicators for each pre-hospital care service stating how they maintain high-risk, low-event skills and continue to maintain an organisational lifelong learning culture. Tweet
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Competency standards, continuing professional development and implications for regulatory frameworks | Arab Health Magazine ambulance, assessment, bodies, competency, curriculum, education, EMS, evaluation, evidence-based, framework, health, healthcare, middle east, national, organisation, patient, practice, qualified, regulation, regulatory, safety, standardised, standards, training, UAE
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