The development of a competency framework

With the need to deliver efficient and effective care and the increased emphasis on evidence based medicine, all healthcare workers involved in providing diabetes care need to ensure that their knowledge and practical skills are appropriate and up to date. Patients now expect to receive the highest quality care, whoever it is delivered by. The Clinical Standards Board for Scotland (CSBS, 2002) identifies the need for multidisciplinary working. The Scottish Diabetes Framework (NHS Scotland, 2002) and Management of Diabetes (SIGN, 2001) documents both stress the importance of multidisciplinary education programmes.

There has been no standardisation of diabetes education in Scotland. A diploma course for nurses was delivered in the West of Scotland during the 1990s. With the change of delivery of nurse training from hospital-based schools of nursing to further education colleges and then universities, the course had not survived. The Certificate in Diabetes Care through Warwick University and the Diabetes Management Course delivered by the primary care training centre in Bradford have been subscribed to by some health boards and individuals, and there has been a development of multidisciplinary university-based courses in Glasgow and Dundee. However, there is no consistency in either their content or their assessment methods.

In October 2001, two DSNs approached the NBS with a request to develop a Scottish national course in diabetes. However, with the need to promote multidisciplinary education, it was felt to be more appropriate to develop a nationally agreed framework for diabetes education using sets of professional competencies. Combining the competencies with a continuing professional development portfolio would enable practitioners to measure their existing level of competence and identify what further skills and knowledge they would require to deliver safe and effective care. This would help to ensure consistency in care while allowing for customised provision of training and education depending on local need.

Methodology
Initially, only the two nurses (in consultation with a professional officer from the NBS) decided to proceed with the initiative. However, it was felt more appropriate that the multidisciplinary team be involved from the outset, and a core group of colleagues representing five professions involved in diabetes care met to discuss the feasibility of the approach. It was agreed that multidisciplinary work would be strengthened through the provision of the framework. It was also agreed that the competencies would not be aimed at specialists in diabetes care, who require a different level of knowledge and skills, nor would be it be aimed at those providing care to children and adolescents; their competencies would be developed separately. 

The development work for the production of the competencies was carried out in three stages:

Stage 1:
A workshop, supported by the pharmaceutical industry, was organised. Five representatives from each of dietetics, medicine, nursing, pharmacy and podiatry, with a broad geographical spread covering the Scottish mainland were present, giving 25 delegates in all. Both specialists and generalists from each discipline were involved, representing primary and secondary care. Each discipline selected its own representatives. It was agreed that the ten CSBS clinical standards for diabetes (CSBS, 2002) would form the template for the work, in conjunction with the provision of care described in the Scottish Diabetes Framework (2002) and the evidence in SIGN 55 (2001).

The evening session was designed to facilitate networking. Short presentations introduced the background to the project and how it would be taken forward.

During the first part of the morning session the next day, five groups (each comprising one member of a discipline) were invited to concentrate on two of the ten standards. Each group identified the general skills and knowledge required by people involved in diabetes healthcare. In the afternoon, all representatives from each discipline worked together to identify discipline-specific skills and knowledge. Each group was supported by a facilitator to guide the discussion, and a recorder to document the outcome.

Stage 2:
Following the collation and editing of the draft competencies, a consultation document was produced. This raw document comprised generic and discipline-specific statements and was circulated to the workshop groups. It was also circulated to large representative samples of the relevant professions throughout Scotland and to patients and carers. A 6-week consultation period encouraged as much involvement as possible. Constructive comments were received and fed back to the core group.

Stage 3:
In response to the comments received from Stage 2, the core group revised the competencies further. Overlap between disciplines was eliminated and the core and discipline-specific statements were refined. The final document (NES, 2003) comprised:

• An introduction to diabetes in Scotland and to existing routes of professional education.
• A description of the background and methodology used.
• A list of attitudes and values fundamental to diabetes care.
• Six competency descriptors (see Table 1) each accompanied by key content.
• A description of lifelong learning.
• An explanation and outline of the portfolio route to achieving competence.

Each key content is a statement that describes in detail the areas of practice covered by each competency. Each of the competency descriptors was linked to its relevant CSBS diabetes standard.

Attitudes and values fundamental to diabetes care were identified in association with the competency descriptors. They represent a set of desirable behaviours that healthcare professionals should display when caring for people with diabetes and should be used in conjunction with each individual competency. Included in the final document is space to record:

• Identification of required knowledge and skills.
• Analysis of personal learning need.
• Action plan.

This space allows the healthcare professional to document their own competence, the knowledge and skills they possess, identify areas where professional development is needed and develop a plan of action to improve knowledge and skills. It may also be used as part of an appraisal system to enable discussion with managers about achieving identified goals.

As well as being used to identify personal learning needs, the competency framework document could play a part in helping diabetes teams work together to analyse the care they provide and identify strategies for improvement.

Lifelong learning
The Scottish Executive has shown its commitment to lifelong learning. In its strategy document for education, training and lifelong learning for staff in NHS Scotland (Scottish Executive, 1999), it commits to encouraging the development of national occupational standards and to promoting the use of personal development plans. It is recognised that knowledge and skills can be acquired from a wide range of formal and informal learning experiences, many of which complement more formal training activities. Enabling these experiences to be valued is an important step in assessing competence to practice. The use of the competency framework document will enable healthcare professionals to identify these experiences and their own needs and develop an action plan to meet those needs.

Launch
The final document was introduced at the Diabetes UK Annual Professional Conference in March, 2003 (see Figure 1). Following three short presentations about the background to the development, the development itself and multidisciplinary working, there was wide ranging discussion about the role of the competency framework document. Groups were formed to discuss four areas:

• Application in practice. The discussions revolved round the multidisciplinary team, recognising that multidisciplinary teams do not always exist, and the possibility of developing a local educational competency sub-group.
• Engaging the team and facilitating the process of participating in multidisciplinary education. This discussion included the need to break down barriers and ensure that healthcare professionals were kept up to date. The need to avoid duplication of effort, but to include other professions such as optometrists, retinal photographers, clerical staff and information management teams was stressed.
• The support required to implement the document. The place the pharmaceutical industry plays in professional education was acknowledged, but also it was recognised that there is a need for involvement by the Scottish Executive. Financial implications were discussed and the need for managerial support and enabling healthcare professionals to have paid study leave. Finally, the need to involve the educational establishments was highlighted.
• For whom the competencies might be appropriate. It was recognised that they would apply to many different groups, including paramedics and care staff, and that there would be different levels of involvement. There was discussion around local needs and wider learning needs, involving local courses and in house training.

Keen interest was shown in the document itself and requests for copies have been received from all over the UK and beyond.

Conclusion
The competency framework document has been developed by clinicians working within the field of diabetes. It can be used by all healthcare professionals to enable them to reflect on their skills and knowledge and to identify shortfalls in both. It should not be viewed as a threat, but rather as an aid to enhance delivery of the care offered to those with diabetes. They should expect no less.