Accident and Emergency Nursing (2007) 15, 2026

Accident and
Emergency
Nursing
www.elsevierhealth.com/journals/aaen

Competence in nursing practice: A controversial

concept A focused review of literature
David T. Cowan Dip Health & Social Welfare, BSc, PhD (Senior Research
Fellow) *, Ian Norman RN, BA, MSc, PhD (Professor of Nursing),
Vinoda P. Coopamah RN, BA, Dip Nursing Ed. MSc (Lecturer/Researcher)
Florence Nightingale School of Nursing & Midwifery, Ageing and Health Section, Kings College London,
James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK

KEYWORDS

Summary The competency-based approach to education, training and assessment

has surfaced as a key policy in industrialised nations. Following the transition of
nurse preparation to the higher education sector the need to attenuate the tension
of interests between employer and educator arose. While the competency-based
approach has the potential to fulfil this, the application of competence to nursing
is controversial and little consensus exists on definition. This paper synthesises a significant volume of literature relating to the acceptability and definition of the concept of competence with regard to nursing practice. Subsequent to a focused review
of literature, problems inherent to the definition and utilisation of the concept of
nursing competence are discussed. Because nursing requires complex combinations
of knowledge, performance, skills and attitudes, a holistic definition of competence
needs to be agreed upon and operationalised. This could facilitate greater acceptance of the concept and also underpin the development of competency standards
and the tools required for the assessment of such.
c 2006 This article was originally published in Nurse Education Today, 2005 25(5)
355362. This article is republished with permissions from Elsevier Ltd. Published
by Elsevier Ltd. All rights reserved.

Competence;
Competency;
Definition;
Utilisation;
Nursing practice

Introduction
The competency-based approach to education,
training and assessment has surfaced as a key pol* Corresponding author. Tel.: +44 20 7848 3215; fax: +44 20
7848 3634.
E-mail address: david.t.cowan@kcl.ac.uk (D.T. Cowan).

icy in industrialised nations (Gonczi, 1994).

According to Gonczi (1994) this approach has
the potential to provide a coherent framework
for uniting a range of policies concerning skills,
industrial relations and social equity. Similarly,
McAllister (1998) noted a world-wide preoccupation with competencies and competency

0965-2302/$ - see front matter c 2006 This article was originally published in Nurse Education Today, 2005 25(5) 355362. This
article is republished with permissions from Elsevier Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.aaen.2006.11.002

Competence in nursing practice: A controversial concept A focused review of literature

standards, which are variations of credentialing
the establishment by professions of self-regulatory processes to determine and acknowledge an
individual has demonstrated competence to
practice. Accordingly, a project (EHTAN, 2005)
to develop a competence matrix for nurses employed within the European Union (EU) has been
funded by the Leonardo da Vinci organisation
(Leonardo, 2005). In operationalising terms for
the purpose of this project it was necessary to
develop a working definition of the concept of
competence as applied to the nursing profession.
The development of this definition was not entirely straightforward and this paper discusses
some of the issues encountered along the way,
concluding with a suggested conceptualisation.

Background
In the UK, until the 1980s the majority of nursing
students were prepared for practice through the
apprenticeship system, based on that initially
developed by Florence Nightingale in the late
19th Century (Bradshaw, 2000a,b; Watkins, 2000).
Nurse competence was tested through observation
in clinical settings, complimented with practical
and written examinations. Hospital-based schools
of nursing relied on standardised, explicit syllabi,
listing biomedical subjects and specific practical
skills (Bradshaw, 2000b). Nurse preparation involved acquiring theoretical knowledge pertaining
to the care of patients and involved an assessment
of the personal qualities of the nurse, including
their moral character and how well they related
to patients and colleagues alike (Bradshaw,
2000b). This system was designed to ensure that
in addition to merely passing an exam, nurses acquired competence and possessed adequate personal attributes (Bradshaw, 2000b).
Following the Project 2000 report (UKCC, 1986)
it was determined that nursing students would benefit from preparation based in institutions of higher
education. It was envisaged that moving away from
the perceived ritualistic aspects of the apprenticeship system would lead to research-based practice,
undertaken by nurses who have been prepared to
either diploma or degree level and who would
adopt a more critical, analytical approach (Watkins, 2000). This was intended to facilitate the
highest possible achievement, advancing nursing
past simplistic levels such as meeting minimum
standards (Chapman, 1999). Similar developments
have occurred in other parts of the world, including
the United States (US), Canada, Australia and New
Zealand (Watkins, 2000).

21

However, Chapman (1999) observed that the

transfer of responsibility for nurse education to universities had created a complex environment with
contentious issues. For example, the health care
sector, as an employer, wants diplomates or graduates who can enter employment with minimal need
for further training. However, training in this context may be perceived as a short-term undertaking,
intended to do nothing more than preparing nurses
for a particular set of tasks to be performed in a given situation (McAllister, 1998). Such training
would not necessarily equip nurses to think laterally, for example, in transferring or modifying such
skills to an unforeseen situation. Conversely, universities aim to equip graduates with broad generic,
transferable skills in preparation for embarkation
upon a path of lifelong learning and self-reflection.
Indeed, as reflected in Melias (1987) work on
the occupational socialisation of student nurses,
the structure of nurse training has long been a compromise between the education of nurses and the
provision of a nursing workforce. During the days
of the apprenticeship system the compromise was
represented in the employment of large numbers
of student nurses who, under the supervision of a
small number of qualified nurses, would undertake
much of the staffing of hospital wards (Melia,
1987). In a more recent attempt to arrive at a compromise over this tension of interests between
nurse employment and nurse education, the competence-based approach to nurse preparation for
practice was adopted in order that nursing regulatory authorities could convey to universities the
requirements for nursing students in the form of
stated competencies (Chapman, 1999).
However, the competence-based approach to
curricula design has been criticised. In warning that
this strategy was faulty and ill-conceived, Ashworth and Morrison (1991) argued that in addition
to skills and knowledge, the notion of competence
was broad and involved a diverse set of qualities
including: attitudes, motives, personal interests,
perceptiveness, receptivity, maturity and aspects
of personal identity. Therefore, was it appropriate
to label these different qualities as competencies
and to what extent would this facilitate learning
that would influence nursing practice (Ashworth
and Morrison, 1991)? Similarly, Bradshaw (2000a)
noted that since 1983 the United Kingdom Central
Council for Nursing (UKCC) had defined preparation
for practice in terms of broad competencies, for
example, being able to assess, plan, implement
and evaluate care. Bradshaw (2000a) argued that
institutions of higher education interpreted
and broadened such general terms further, to
encompass aspects of academic and personal

22
development, while practical procedures specified
under the apprenticeship system were excluded at
the expense of unmet service needs (Bradshaw,
2000a).
A new strategy for nursing, midwifery and health
visiting, Making a Difference (DoH, 1999), was
launched by the UK government in 1999. Among
other things, Making a Difference (DoH, 1999)
sought to strengthen education and training and
counter the argument that nurse training had become too academic, which had, according to Watson (2002) led to a misguided public and political
perception that nurses were too clever to care.
Following the subsequent review of pre-registration nursing curricula that was prompted by Making a Difference (DoH, 1999), the UKCC
developed a set of competencies expected at the
end of the common foundation programme and another set that students would be expected to have
achieved at the end of their three year branch programme. However, these competencies are often
still very broad. Following the dissolution of the
UKCC and transfer of responsibility to the Nursing
and Midwifery Council (NMC), these broad UKCC
competencies are still quoted in the NMC requirements for nursing programmes (NMC, 2002). For
example, under the heading of Competencies required for entry to the register Care delivery,
in engaging in, developing and disengaging from
therapeutic relationships through the use of appropriate communication and interpersonal skills,
nurses must be able to utilise a range of effective
and appropriate communication and engagement
skills (NMC, 2002). In addition, the UK Quality
Assurance Agency for Higher Education (QAAHE,
2001) published benchmark statements describing
the nature and characteristics of study and training
in nursing. While these statements articulated the
standards, attributes and capabilities that those
possessing nursing qualifications should be able to
demonstrate, they are also very broad (QAAHE,
2001).
Bradshaw (2000a) argued that there was now
too much professional freedom in defining nursing
competence. For example, nurses, in creating
and utilising opportunities to promote the health
and well-being of patients, are left to decide
when to seek specialist/expert advice as appropriate (NMC, 2002). Accordingly, Bradshaw
(2000a) argued further that there is no agreed
consensus by which nurses can judge what they
know, what they should know and what they do
not know. Indeed, Watson (2002) observed that
competence is a poorly defined concept and the
measurement of such is even more problematic.
However, despite noting a possible prejudice

D.T. Cowan et al.

against the concept of competence on philosophical grounds, Watson (2002) conceded that competence has currency and could not be avoided
in nurse education. Therefore, we have to make
serious efforts to find, define and measure it
(Watson, 2002).
Reflective of the above issues, Bradshaw (2000a)
rightly predicted that defining criteria for nursing
competence would be a major issue for the 21st
century. In view of recent developments it appears
that the need to do this is now more pressing than
ever. A consultation document titled Post Registration Development a framework for planning,
commissioning and delivering learning beyond registration for nurses and midwives chaired by the
Chief Nursing Officer, was published in August
2004 (DoH, 2004). The document reports on the
work undertaken by a task force which was asked
to examine and make recommendations on the current approach to the education and development
of nurses and midwives beyond registration, with
particular regard to several issues including
terminology and levels of practice (DoH, 2004).
The document acknowledges the development of
an NHS-wide knowledge and skills framework to
underpin the new pay scheme and how this may also
help to standardise the many competency frameworks in existence (DoH, 2004). If terminology is
to be an area of particular focus and if the group
recognises a need to standardise different competency frameworks, then clearly, the first logical
step is to have agreement on the definition of what
competence in nursing practice actually means.
Accordingly, this paper synthesises and discusses a
significant volume of literature relating to the definition and subsequent utilisation of the concept of
competence with regard to nursing practice.

Methods
Searches for English language publications on nursing competence were made of Medline, The British
Nursing Index, journals, books, abstracts, letters,
conference proceedings, papers from meetings,
theses, newspaper/newsletter reports, national
and international nursing organisations and any
other relevant references that were encountered.
For the Medline and British Nursing Index searches
the following terms were entered: competenc$
and nurs$. Specific subject headings under which
searches were made were: nursing competence
and nursing profession. In order to extract literature with contemporary relevance, the initial
search of electronic databases was from 1995 onwards. It became apparent though that material

Competence in nursing practice: A controversial concept A focused review of literature

produced prior to this would also be of relevance.
The last electronic search was undertaken on
26th March 2003. Of the publications retrieved,
only those which in the opinion of the authors,
had relevance to the generalist hospital nurse,
were considered for review. Thus, this was deemed
to be a focused review of literature on competence
in nursing practice.

Findings
Literature on defining nursing competence was
found to lack consensus, being replete with controversy, ambiguity, confusion and contradiction (Ashworth and Morrison, 1991; Girot, 1993; While,
1994; Bradshaw, 1997; Goorapah, 1997; Milligan,
1998; Eraut and du Boulay, 1999; Bradshaw,
2000a; Mustard, 2002; Watson et al., 2002; McMullan et al., 2003; Dolan, 2003).
These findings are examined in some detail
below.

Definitions
Benner (1982) defined nursing competency as the
ability to perform a task with desirable outcomes
under the varied circumstances of the real world.
Benner (1984) placed competence in the middle
of a continuum, ranging from: novice, to advanced
beginner, to competent, to proficient, to expert.
Competent practitioners are consciously able to
plan their actions, but lack flexibility and speed
(Benner, 1984).
Girot (1993) noted that definitions of nursing
competence were divided between behaviour, this
equating with the ability to actually perform tasks
and a psychological construct, this equating with
cognitive, affective and psychomotor skills,
although these two senses were not mutually
exclusive, as for example, psychomotor skills
determine the ability to perform tasks. Eraut and
du Boulay (1999) noted the distinction between
competence as the ability to perform tasks and
roles to the expected standard of a particular job
and competence as an individualised set of personal capabilities or characteristics. Eraut and du
Boulay (1999) favoured the former definition and
suggested that capability describes what a person
can actually think or do. However, Eraut and du
Boulay (1999) conceded that knowing precisely
what constitutes the expected standard by which
competence can be defined could be problematic.
Chapman (1999) defined competence as being
more concerned with what people can do rather

23

than with what they know, focussing on doing

things to people as opposed to being with people.
Similarly, Winskill (2000) described competencybased training and education as focussing on what
people can do as opposed to what they know and
not on the learning process itself, emphasis being
on observable and measurable outcomes, requiring
a consistent standard of practice. According to Locsin (1998) competence could be described as an
intrinsic quality but could also be concerned with
performance, nurses able to portray both of these
aspects through utilisation of their knowledge of
theory (intrinsic quality) and provision of care (performance). Bechtel et al. (1999) advocated that forgoing the temptation to place an emphasis on either
philosophical approach may initially be difficult for
educators but that balanced learning would result
in a more proficient, insightful practitioner and that
the concept of skill competency was an essential
component of undergraduate nursing education
(Bechtel et al., 1999). Pearson et al. (2002) advocated that while competence has no singular definable meaning and may not be an observable
quality, competence could describe a set of characteristics or attributes that underlie competent performance in an occupation. This includes having the
insight to be aware of ones own expertise or limitations (Pearson et al., 2002).

Competence or Competency?
There appears to be particular confusion over the
distinction between competence and competency.
Woodruffe (1993), conceding that there could be a
blurring of distinction between the two, defined
competence as the aspect of a job that an individual could perform, while competency is the behaviour underpinning such performance. Similarly,
McMullan et al. (2003) noted that the terms competence, competency, capability and performance
are still used inconsistently and interchangeably.
McMullan et al. (2003) suggested that competence
and competences are job-related, are descriptive
of action, behaviour or outcome of performance.
Alternatively, according to McMullan et al. (2003)
competency and competencies are person-orientated, referring to underlying characteristics and
qualities that are indicative of effective and or
superior performance in a job. Conversely, Nolan
(1998) and McConnell (2001) defined competence
as a capacity, knowledge, the potential to perform
skills and competency as actual performance
according to established policies in a particular situation. In apparent agreement with McConnell
(2001), Mustard (2002) defined competence as a

24
potential capability for undertaking a job and competency as the actual performance in complying
with standards of care.
The NMC uses the term competence simply to
describe the skills and ability to practice safely
and effectively without the need for being supervised directly (NMC, 2002). Redfern et al. (2002)
endorsed Benners (1982) definition of competence, that is, the ability to perform the job with
desirable outcomes in the real world, incorporating
both capability and performance. However, While
(1994), regarded competence to be what a person
knows and performance as a more feasible outcome measure, performance being actual situated
behaviour, which, Nolan (1998), McConnell (2001)
and Mustard (2002) defined as competency.
Unfortunately, minimal guidance in this matter
is available from dictionaries. The Oxford Dictionary of English (2003) merely defines competence
as the ability to do and competent as adequately qualified for a task, to do, effective, adequate, appropriate. The Encarta Reference
Library (2002) defines competent (adjective)
and competently (adverb), as being able, skilful,
properly qualified, proper, due, legitimate, suitable, sufficient and competence/competency
(noun) as the state of being fit or capable, fitness,
adequacy, sufficiency.

Utilisation
In addition to making attempts at definition, several authors discussed actual utilisation of the concept of competence. McAllister (1998) argued that
the concept of nursing competence became favoured not because of what is understood about
it, but rather what is understood about its antithesis, incompetence. McAllister (1998) argued further
that if one is against incompetence, therefore, one
must be for competence. Similarly, Watson (2002)
expressed concern that competence was often
seen as no more than a lack of incompetence,
which may not be competence of a very high standard. Seen in this context, according to Eraut and
du Boulay (1999) one usage of the concept may
determine a person as either competent or incompetent. Another usage, with similarities to Benner
(1984) situates competence somewhere on a continuum that runs from novice to expert. In this case
being competent would situate one around the
middle of the continuum, thus implying that one
is rather less than excellent (Eraut and du Boulay,
1999). Thus, being referred to as competent may
have different connotations, the opposite to
incompetent being perceived as positive, or

D.T. Cowan et al.

conversely, being less than excellent and therefore
having the potential to be perceived as negative
(Eraut and du Boulay, 1999).

Holistic conceptualisation
Milligan (1998) argued that to successfully operationalise the concept of competence it needed to
be defined within the two key fields of nurse education and nurse training but warned that the meaning may be interpreted differently within the fields
of training and education. Way (2002), citing
Blooms (1956) taxonomy, suggested that knowledge, skills, attitudes, cognitive, psychomotor
and affective attributes should all be viewed as
crucial components in developing competence.
Bechtel et al. (1999) emphasised that critical thinking skills and mechanical skills are each an integral
aspect of nursing, one without the other being
inadequate or even dangerous. Indeed, these more
holistic definitions appear to have currency.
Short (1984) argued that competence in the
form of behaviours or performance has a narrow
range of use and applicability. Short (1984) defined
competence in the form of knowledge and skills as
having a broader application, but still lacking
dimension with regard to what constitutes enough
for a declaration of competence to be made. Short
(1984) perceived competence in the form of judgment about an adequate level of capability as more
applicable, as it incorporates values and evaluation, dimensions which could be applicable
whether the entities being judged are behaviours,
knowledge, objectives or outcomes. However,
Short (1984) believed that competence in the form
of a quality or a state of being is the most comprehensive definition, dependent as it is on holistic
concepts that include all dimensions, norms actions and intentions. According to Short (1984), if
one is concerned with all forms of competence,
then this holistic definition should be applied. However, Short (1984) predicted, quite accurately it
transpires, that confusion over the meaning of
competence would continue.
Acknowledging that competency-based approaches to assessment had been attacked by many
as invalid, unreliable and only capable of dealing
with superficial and trivial aspects, Gonczi (1994)
argued that this was due to the different ways of
conceptualising competence which led to inappropriate definitions. Elaborating on Shorts (1984)
earlier taxonomy, Gonczi (1994) perceived the first
conceptualisation of competence as being
task-based or behaviourist, conceived of in terms
of discrete behaviours associated with undertaking

Competence in nursing practice: A controversial concept A focused review of literature

atomised tasks. In this way, the task becomes synonymous with the competency. There is no concern
with connections between tasks and this form is
concerned only with the transparency of
occupational competency standards. Gonczi
(1994) believed that this form is conservative,
reductionist, atheoretical, ignores the complexity
of performing in real world situations and ignores
the role of professional judgement in intelligent
performance. According to Gonczi (1994) this form
is inappropriate for conceptualising professional
practice because the relevance to work at any level
is in doubt. Gonczi (1994) viewed the second conceptualisation as being independent of context
and concerned with the general attributes of the
practitioner that are crucial to effective performance. These include: underlying-knowledge, critical thinking capacity and attributes that are
transferable to different situations.
Gonczi (1994) described the third conceptualisation as the integrated, holistic approach. This marries the general attributes approach to the context
in which they will be employed. Thus, complex
combinations of knowledge, skills, values and attitudes are utilised to understand particular situations in which professionals may find themselves.
This notion of competence incorporates professional judgement, is relational and involves complex structuring, bringing together disparate
attributes and tasks required for intelligent performance in specific situations. According to Gonczi
(1994), the third, holistic conceptualisation overcomes objections to the competency movement.
It allows for the incorporation of ethics and values
as elements of competence, recognises the need
for reflective practice, the importance of context
and the possibility that there may be more than
one way of practicing competently.
Gonczi (1994) claimed that if the holistic conception of competence underpinned assessment
strategies, they were likely to be more valid than
traditional methods, enabling the assessment of
the capacity of the professional to integrate knowledge, skills, values and attitudes into their practice. However, while endorsing the holistic
approach, McMullan et al. (2003) still warned that
because this approach indicates the importance
of context and that there are different ways of
practicing competently, assessment of such may
not be as straightforward as was hoped for.

25

fusion over the meaning of competence has continued. The main distinction between definitions of
nursing competence remains between that of a
behavioural objective (Girot, 1993; Chapman,
1999; Eraut and du Boulay, 1999; Winskill, 2000),
which is also perceived as performance (While,
1994) and that of a psychological construct including
cognitive and affective skills, the latter being less
easy to measure (McAllister, 1998; Chapman, 1999).
Doubts have been raised as to whether competency standards are appropriate to nursing practice, as they may have the potential to be
reductionist, positivist and focussing on outcome
orientated technical procedures (McAllister, 1998;
Chapman, 1999). There are concerns over the artistic and humanistic aspects of nursing such as empathy and attentive listening becoming deemphasized, because it is easier to value and measure scientific and technical aspects that can be
repeatedly demonstrated (McAllister, 1998; Chapman, 1999). There are also concerns that the drive
for competence may lead to nurses being merely
trained to meet minimum competency levels (Watson, 2002). Indeed, maintaining minimum standards may level down the quality of nursing care,
may not encourage expert nurses and would no
longer represent pushing boundaries further but
merely guarding existing ones (McAllister, 1998).
Despite arguing that nurses should exercise caution before embracing competency standards,
McAllister (1998) stated that competencies could
offer greater precision in assessing workers performance and could provide clarity and clearer role
boundaries regarding the nature of nursing work
and professional accountability. Clearly, a balancing act needs to be performed whereby competency standards do not become so narrow that
they merely represent endless task lists, but that
they are not so broad as to become meaningless.
It is also clear, for example, as reflected in the consultation document on Post Registration Development (DoH, 2004) and funding of the EHTAN
(2005), project that the concept of competence
with regard to nursing practice, both in the UK
and other parts of the world, is not going to go
away in the near future. Therefore, as Watson
(2002) notes, serious efforts need to be made to
define it and to measure it.

Conclusion
Discussion
Girot (2000) observed that regardless of attempts at
resolution throughout the 1980s and 1990s, the con-

There has been little consensus on the definition of

competence with regard to nursing practice. Despite this, a possible solution, in the form of the
holistic conception of competence (Short, 1984;

26
Gonczi, 1994) appears to have been largely
overlooked. Clearly, nursing practice requires the
application of complex combinations of knowledge, performance, skills, values and attitudes.
Thus, the authors conclude by suggesting that the
dichotomy between nursing competence perceived
as either a behavioural objective or a psychological
construct is redundant and a definition drawing on
the holistic conception of competence should be
agreed upon and utilised. This could facilitate
greater acceptance of the concept and underpin
the research needed for the development of precise competency standards and the tools required
for the measurement and assessment of such.

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