An exploration of the role that expert knowledge plays in the assessment of undergraduate clinical competence: registered nurses' experiences

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Introduction and purpose

In the late 1980s and early 1990s, two important changes impacted on nursing in Australia. First, nursing education was transferred from the hospital environment to the university sector; second, national nursing competency standards were developed and implemented. The development of competency-based standards for nurses in Australia was consistent with a worldwide trend to adopt competencies in a wide variety of occupational groups^1,2. These changes meant that the traditional focus on assessing a student's ability to perform clinical skills was no longer sufficient evidence of the achievement of nursing competence³. Thus, nursing students are now assessed during their clinical placements in a way fundamentally different from that same assessment when nursing education was hospital based.

Competencies are an articulation of what it takes to function as a competent nurse; they describe the outcome of competent performance including the knowledge, skills, behaviors, attitudes and values consistent with competent nursing care³. Therefore, assessing competence is more complex than only assessing a student's ability to perform clinical tasks. In the context of this article it is important to note that the use of the word 'competent' when referring to student nurses' clinical performance does not mean competent as a stage of nursing knowledge described by Benner, rather it refers to the ability of student nurses to demonstrate achievement of the Australian Nursing Council (ANC) competency standards.

The adoption of competency standards for nursing in Australia has remained controversial. The ongoing debate reflects conflicting opinion regarding how nurses should use competency standards in the assessment process. For example, some authors believe that competency standards are merely a description of the level of performance required to function effectively as a nurse, therefore competent nurses need no further preparation in the use of these standards for assessing student performance^4-7. In contrast, other authors believe that nurses who assess competence require a comprehensive educational program focusing on the use of competency based assessment tools^8,9. However, none of these authors make any specific mention of the vital role that registered nurses play in the assessment of competence in rural health-care facilities, nor do they advocate any teaching programs to prepare rural nurses to assume this additional responsibility.

Most undergraduate nursing programs in Australian universities base their student assessments on the ANC Standards³ despite some recent questioning of the validity of using these as the basis for the assessment process¹⁰. Schools of nursing based at regional universities are sometimes more reliant on hospital-based registered nurses to supervise and assess the clinical performance of nursing students while on clinical placement than are metropolitan based universities. The reason for this is simple. Regional university nursing departments often place students in small health-care facilities spread over large geographical areas, because this is the nature of rural practice in Australia. Furthermore, it is not always practical or financially viable for regional universities to provide academic staff or clinical facilitators to supervise student placements, because distances are great and student numbers may be small. Thus, each student works closely with a registered nurse employed in the facility, and regional universities rely on these nurses who act as preceptors/mentors to provide an accurate assessment of the students' clinical performance. Preceptor workshops are often provided by the universities and following the workshops the preceptors are required to apply their professional judgement and expertise to the assessment of student competence^11-12. However, it is often the case that these nurses lack formal training in assessment techniques, and anecdotal evidence indicates that they often rely on their own understanding of nursing competence as a guide. Earlier studies that investigated registered nurses' experiences of mentoring or precepting students have not addressed the unique factors that impact on rural and remote nurses who supervise students, such as geographical remoteness and limited opportunities for contact with the relevant university^11,12.

Thus, the purpose of this study was to gain insight into the experiences of a group of rural registered nurses who assessed student competence by exploring how this group of nurses performed the assessment process. Furthermore, because competency standards have now been utilised in nursing practice and nursing education in many countries for a number of years, one further aim of this study was to explore whether the assessors perceived a link between expert nursing knowledge and the assessment of competency standards.

Background

The perceived link between the development of competency standards and expert nursing knowledge in Australia is well documented. For example, Anderson⁵ and Cameron⁶ both believe that nursing competencies were designed to enable nurses to use professional judgement based on expert nursing knowledge as the basis for assessment. Other authors also clearly link the development of competency standards with the use of expert knowledge as a means of assessing competence^13-15. In order to further explain this link between expert knowledge and competency-based standards, the present study draws on the work of Benner^16,17.

According to Benner, expert nurses have an 'intuitive' grasp of the situation and do not waste time going through vast lists of possible problems and alternative solutions, because they have a depth of knowledge and appear to 'just know' what to do^16,17. Expert knowledge or 'intuition', as it is often labelled, is not a magical ability. As Paul and Heaslip caution, intuition is not 'mysterious or arcane' (p.40), nor is it something extrasensory. It consists of extensive theoretical and practical knowledge, which the expert nurse is able to adjust to meet the requirements of particular situations¹⁸.

The value of expert knowledge was described in an evaluation report of the original ANC Competency Standards³ in which it was stated that 'tacit knowledge enables experts to judge quality' (p.1)⁷. However, the evaluation added that the major concern with this assumption is that to assess competence reliably and validly using competency-based standards, assessors are required to constantly bear in mind that they need a thorough understanding of the competency standards. This belief is also shared by Anderson⁵ who notes that nurses should not only be aware of the ANC Competency Standards, but should also learn how to apply them to the assessment process. This view is not shared by all nursing authors. Benner¹⁶ and Chambers¹³ believe that expert nurses already have sufficient knowledge about what constitutes competence and they apply this to the assessment of student clinical performance.

In 1994, Anderson identified that expert nursing knowledge is what enables the assessor to make sound judgements about the competence of others⁵. Other examples of the perceived link between expert nursing knowledge and nursing competencies can be found in the British and American literature. For example, Neary stated that 'students need the opportunity to learn from skilled practitioners who are experts in responding and reacting effectively to the unintended and unexpected' (p.35)¹⁹. Girot²⁰ and Hird²¹ link expert nursing knowledge with competencies by explaining that expert nurses demonstrate an integration of all the attributes of competence. This integration makes practice seem easy and effortless and it is this expert knowledge that enables practitioners to judge the competence of novices. A review of the nursing literature regarding the assessment of clinical performance found terms such as 'professional judgement', 'intuition', 'gut feeling' and 'expert knowledge' to be used repeatedly^20,22,23. A British study by Girot²⁰ described the use of 'gut feeling' and 'intuition' in the assessment of British student nurses and further explained that clinicians have tacit knowledge regarding the skills, knowledge, attitudes and values that are needed to function as a competent nurse. Thompson believes that tacit or expert knowledge of nursing and the context of nursing is what gives the assessor the ability to conduct valid and reliable assessments⁹. However, according to Chambers, many nurses are unable to explain how they decide if a student has reached an acceptable level of competency¹³. This would appear to reinforce Benner's view that tacit knowledge is used unconsciously by assessors of clinical performance and is therefore difficult to articulate¹⁶.

While the findings of these previous studies indicate that intuition, professional judgement and expert clinical knowledge can contribute to the assessment process, the literature demonstrates conflicting views about the value and applicability of these concepts in the assessment of competence. Thus, questions remain about their proven connection to the assessment process. First, although the literature has demonstrated that expert knowledge is used in clinical practice to assess student performance, there is no conclusive evidence to show the use of expert knowledge during the assessment process is valid or reliable. Further, while the use of intuition in clinical practice may be useful, there is no evidence to show that intuition transfers to the assessing process. Finally, there is no proven link between possessing and using expert clinical knowledge in a clinical setting, and possessing and using expert assessment knowledge with students. One aim of this small study was to contribute, from a rural perspective, to this ongoing debate and to pave the way for further research.

Methods

Research design

A qualitative design was chosen because this study sought to understand registered nurses' experiences of assessing the clinical competence of undergraduate nursing students. The design was based on hermeneutic phenomenology. The reasons for choosing this interpretive design were twofold. First, hermeneutic phenomenology is both a philosophical framework and a methodology for conducting interpretive research (p.66)²⁴. Second, hermeneutics is the ability to bring something to understanding by depicting everyday situations and experiences^24,25. Therefore, the chosen design provided a philosophical basis to guide the researchers to gain insight into the participants' experiences by using the complexity of participants' historical understandings of the world to uncover deeper meanings.

Setting and sampling

The population of interest in this study consisted of registered nurses who assessed the clinical competence of undergraduate nursing students studying at a regional university in New South Wales (NSW), Australia. Interviews were conducted with 10 participants who were selected using purposive sampling. This method was chosen because phenomenological investigations require the selection of particular participants who are known to have experience of the phenomenon being studied. The 10 participants were chosen because they had a range of years of experience as registered nurses and as assessors of student performance.

Data collection procedure

Individual unstructured interviews were conducted and audiotaped with participant permission. Each interview lasted between 45-60 min. The researcher transcribed the interview tapes as soon as possible after each interview. At the commencement of each interview, the participant was asked a broad, open-ended question such as, 'Could you tell me about your experience of assessing the clinical competence of undergraduate nursing students?' Depending on their response, the researcher either asked further open-ended questions such as, 'What skills do you use to assess a student's clinical performance?' or prompted the participant to continue with the narrative. Crotty points out that phenomenological data collection requires the interview to yield a conversation, not a question and answer session²⁶.

Analysis of data

A thematic analysis was conducted to analyse the verbatim transcripts. Great care was taken to transcribe each audiotape verbatim and the transcripts were then checked against the audiotapes. By reading and re-reading the transcripts, significant statements were obtained and these were categorised into themes in order to provide a clear description of the experiences of the clinicians as assessors of clinical competence.

Rigour and trustworthiness of the data were evaluated using the criteria of credibility, dependability, and confirmability²⁷. Three methods were used to strengthen the data's credibility. First, the researchers obtained feedback about the quality of the data and initial interpretations from an experienced researcher. Second, member checks were conducted whereby participants were invited to provide feedback on the analysed data and to suggest changes at points where the data did not reflect their experiences. Third, the researchers maintained a reflective journal to facilitate the interpretive process. Dependability and confirmability were achieved by the researchers diary-keeping that documented all methodological issues and decisions.

Ethical issues

Potential participants were approached by the researchers who provided an information sheet and consent form for those who indicated a willingness to participate. Consent was given for the interviews to be audiotaped. Pseudonyms were used for all respondents' quotes. Approval to conduct the research was obtained from the relevant university human research ethics committee.

Results and Discussion

'You just kinda know': Expert knowledge as the basis for decisions about clinical competence

Four themes emerged from the data, these are:

1. 'It's all about what we know': Notions of clinical competence.
   
2. 'Making the grade': The ANC Competency Standards and decisions about clinical competence.
   
3. 'You just kinda know': Expert knowledge as the basis for decisions about clinical competence.
   
4. 'Getting through the day': Factors that impact on the assessment of clinical competence.

The major theme 'You just kinda know' described the clinicians' use of expert knowledge in the assessment of undergraduate clinical competence and was used as the focus for the present article. The theme's title was a direct quote from a participant's narrative.

The theme emerged from the respondents' comments regarding how they actually assessed competence. In all cases the participants described the use of expert nursing knowledge as important when assessing students' clinical performance. One respondent commented:

...the gut feeling comes from years of experience, ...I mean they'll [students] get it eventually.

This quote is consistent with Benner's theory of the acquisition of nursing knowledge as a series of stages from novice to expert¹⁶. Overwhelmingly, the respondents endorsed Benner's notion that nursing knowledge is embedded in practice and intuitive in nature. The use of intuition in clinical practice is, according to Benner, one of the criteria for identifying an expert nurse¹⁶. Most of the respondents in this study talked about 'knowing', 'intuition' and 'gut feeling' when making decisions about competence. Similarly, Girot also found that British nurses spoke of 'gut feeling' and 'intuition' when asked about assessing student nurses²⁰. This theme clearly identified the way in which the respondents were guided when assessing student performance and the examples given indicated that all the respondents used their expert clinical knowledge to assist them when assessing students.

The following comments highlighted the respondents' use of expert knowledge when assessing student performance:

You just kinda know, you know what I mean? [Sam]

You have a gut feeling from your own experience as a nurse. [Bobby]

Well I judge whether I think that person is competent, I mean you get a feeling about somebody. [Kim]

Am I allowed to say I think it becomes instinct, that's what I like about nursing, I probably have got them summed up in the first hour, as to how interested they are, and if they really want to be there. [Steven]

I use the papers they bring as a guide, OK, but ...I still believe that nursing is very much an intuitive... an intuitive science. [Susan]

These comments are examples of the respondents' descriptions of the way expert clinical knowledge was used during the assessment process. All the respondents talked about the use of intuition, 'gut feeling' or, as described by Steven, 'instinct' when making decisions about a student's performance. While it is well documented that expert nursing knowledge is used every day to assist in the assessment of patients^16,17, little is written about its use in the assessment of novice nurses. However, in the present study the researchers found that experienced nurses do use their expert knowledge to assist them in assessing both patient care and nursing skills. One of the respondents, Bobby, commented '...a lot of nursing is gut feeling, you look at a patient and you know'.

The respondents all indicated that they just 'know' what is required to function as a competent registered nurse. This is certainly consistent with the literature, which indicates that some authors believe that nursing knowledge is intuitive and embedded in practice^16,28. Furthermore, these authors indicate that expert knowledge is used unconsciously and is not easily defined. The respondents' quotes reflect the use of expert knowledge, but it is interesting to note that none of the participants attempted to define it. Anderson describes the inability to clearly define expert knowledge as the reason why nurses and other health-care professionals undervalue this form of knowledge⁵. However, King and Appleton believe that experienced nurses often remain unaware of the link between their expertise and their appropriate responses to clinical situations (p.194)²⁹.

The findings from the present study also indicate a lack of awareness or underestimation of the value of expert clinical knowledge. The researchers found it surprising that the majority of participants failed to highlight the importance of expert knowledge in assisting them during student assessment. One of the respondents seemed almost apologetic about the use of intuition when he asked 'Am I allowed to say that I think it [assessment of competence] becomes instinct?' [Steven]. This apologetic tone was mirrored in other narratives, for example, Bobby described the use of tacit knowledge added 'I probably do use them [competency standards] unconsciously, that's what we have to use ..right?' These comments reinforce the researchers' belief that while expert knowledge is commonly used in nursing practice it is rarely acknowledged. These examples highlight the respondents' doubts about whether they should be using expert knowledge to assist them when assessing student performance although some authors believe that expert knowledge is a reliable tool for use in the assessment of performance and that it should be acknowledged as a valid means of assessing competence^7,17.

Limitations of the study

While it is acknowledged that the results of the present qualitative study cannot be generalised to the wider population of nurses, the aim of phenomenological research is not to produce generalisable results, but to understand and interpret the experiences of the participants¹⁶. This research was not designed to make predictions from the findings. The participants came from one NSW health-care region only, so the findings are not indicative of the experiences of other clinicians in Australia. Furthermore, the purpose of the study was not to make inferences, but rather to qualitatively gain rich data via in-depth interviews. It is hoped that the findings will resonate with registered nurses who are responsible for the assessment of student performance, specifically registered nurses employed in small rural health-care facilities.

Implications

The major finding that emerged from this study was that expert knowledge is used by a group of rurally based registered nurses to assist them in the student nurse assessment process. This finding was not unexpected because it was consistent with a substantive amount of literature which indicates that intuitive knowledge is used when judging competence and safe practice. However, while the participants in this study overwhelmingly agreed that expert clinical knowledge could assist them when assessing clinical competence, no conclusive evidence was drawn that expert knowledge is a valid and reliable tool in the assessment process, nor was it found to form the basis of the assessment process. Furthermore, a number of respondents seemed to apologise for the way in which they assessed clinical competence, and their comments indicated that they were not aware of the significance of using their expert knowledge as an assessment aid or of the perceived link between expert knowledge and the assessment process. Thus, while the results of this study support the belief expressed in the literature that nurses do use intuition, expert knowledge and professional judgement when assessing clinical competence, further research is required to confirm the perceived link between these concepts and the assessment process. Until further research is conducted and empirical evidence demonstrates a proven link, theoretical assumptions will continue to surround expert knowledge and the assessment process.

A recommendation from the present study is that nurses be encouraged to value their expert knowledge and professional judgement in their clinical practice. Both Manley and Garbutt (p.256)²⁶ and King and Appleton (p. 198)²⁷ stress that it is up to health professionals to promote the use of expert knowledge by making it more explicit in practice. This is especially important for rural nurses who have less access to specialist personnel and resources and therefore must rely on their own expert knowledge to manage whatever situation confronts them in the clinical setting.

Conclusion

The findings of this study clearly indicated that the participants do unconsciously draw on their expert knowledge to assist them when making assessment decisions; however the participants did not see this as overly important. It would be beneficial to assure registered nurses that the use of intuitive knowledge is valuable in all aspects of their clinical practice. The findings also provided an insight into how a group of rural nurses perceive the assessment process and the strategies utilised during the process. It has been shown that further research is required to determine the role of expert nursing knowledge in the clinical competency assessment process. Finally, it is hoped that the findings of this study will provide further insight into the concept of expert knowledge and stimulate further research to determine if there is a proven link between expert nursing knowledge and expert assessment knowledge.

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