Core Competencies of South African Healthcare Professionals
7.2 Key findings from the literature
7.2.1 Competence and competency
In broad terms, competence is commonly understood as a holistic concept that refers to the judicious use of an integrated body of knowledge, skill (behavioural and technical), attitude and values, in an authentic practice context (Bruce and klopper, 2011; Epstein, 2007; kilminster, 2007). Competency is a narrower but more dynamic concept that entails an individual’s performance in a particular work role, specifying domains of ability and context (Bezuidenhoudt, 2014). Competency thus focuses on an individual’s ability to perform activities related to their area of work, practice or learning.
Core competencies are those essential competencies that a HCP is expected to possess upon entering the profession. It is described as a level of expertise that is essential or fundamental to a particular profession. In nursing, core competencies frame the entry-level practice expectations of registered nurses that require them to utilise depth and breadth of knowledge, skill and judgement for safe and competent practice and adaptation to a changing healthcare environment (College of Nurses of Ontario, 2014). when these competencies are common to a range of HCPs, roles or job contexts they are referred to as generic competencies.
Increasingly, employers and workplaces seek employees who possess not only job or profession-specific competencies, but also generic, high-level competencies (young and Chapman, 2010). Examples of these include communication, interpersonal relations, problem-solving and conflict management. globalisation, societal change and technological advances have forced organisations to employ graduates who, additionally, possess a global mindset, are socially accountable and IT-savvy. As a result, higher education institutions strive more and more towards engendering such generic competencies in their graduates.
In the South African education system, critical cross-field outcomes (CCFOs) set by the South African Qualifications Authority (SAQA) determine the generic competencies for all graduates. They describe the knowledge, skills and attributes that educators must develop in individuals for the social and economic development of the broader society (Bruce and klopper, 2011). These CCFOs (Table 7.1) serve as a guide for designing HCP curricula and qualifications.
Table 7.1: Critical cross-field outcomes (Adapted from SAQA, 2000) Critical cross-field outcomes Domain Critical outcomes • Identify and solve problems using
critical and creative thinking
• work effectively as member of a team or group
• Organise and manage oneself and one’s activities responsibly and effectively
• Collect, analyse and critical evaluate information
• Communicate effectively using a range of skills in oral and written communication
• use science and technology critically and effectively showing responsibility to the environment and the health of others
• Demonstrate understanding of the world as a set of related systems
Problem-solving; critical thinking
Teamwork
Self-management
Research; scholarship Communication
Scientific and technological literacy
global and systems thinking Developmental
outcomes • Explore and apply various and appropriate learning and development strategies, and evaluate their effectiveness
• Participate responsibly in local, national and global communities
• Be culturally and aesthetically sensitive across a range of social contexts
• Explore education and career opportunities
• Develop entrepreneurial opportunities
Learning and development
Responsible citizenship Sociocultural understanding
Education; career directedness Entrepreneurship
7.2.2 Competency-based education
Competency-based education can be traced back to developments in teacher education programmes in the late 1960s in the USA. It has its theoretical origins in the behavioural-objectives movement, which has also been a major point of criticism against competency-based education. In the 1980s William Spady coined the term outcomes-based education (OBE), declaring that competency-based education (CBE) and mastery learning share an orientation in which learning outcomes rather than time and routinised scheduling constitute the basic operating principle of instructional delivery and student progress. All these approaches including criterion- referenced assessment, according to Van der Horst and McDonald (1997), form the theoretical foundation of OBE. Today the terms competency-based education and outcomes-based education are used interchangeably in the health professional education literature. Morcke et al. (2013) conclude that whilst the two concepts differ in detail, the differences are subtle. Both describe educational models based on the premise that teaching, learning and assessment should be guided by predetermined outcomes, and both focus on the end-product, as opposed to the
process of the curriculum. Harden (2015), who prefers the term OBE, concurs that OBE has a distinct focus on the “outcome or product and specifies the expected learning outcomes and competences that healthcare professionals need to develop in order to progress to the next stage of their training programme or be accredited as independent healthcare professionals” (Harden, 2015:27).
CBE refers to a teaching and learning approach that emphasises explicit learning outcomes that can be assessed in a flexible environment and timeframe. It focuses on the mastery of learning outcomes, rather than on academic achievement through fixed time structures (Burke, 2005). De-emphasising time in a competency- based curriculum is a major discussion point in the competency-based medical education (CBME) discourse. given the fact that most HPE systems are time-based often linked to a specified number of ’blocks’ or a prescribed number of weeks for clinical rotation, serious concerns are raised about the logistical chaos and disruption of services that might ensue if students are allowed to progress through their training at different rates in a ‘pure’ CBE system (Taber et al., 2010; Touchie and Ten Cate, 2016). Hybrid versions of competency-based education are proposed and are currently being explored in CBME. Suggestions by the royal College of Physicians and Surgeons of Canada (Frank et al., 2014) include the option of having credit-bearing timed rotations, where progression to the next phase would not depend on completing the set number of rotations and a log book of procedures, for example, but instead on whether all relevant competencies were acquired at the specified level for the current phase of the curriculum. CBE is experiencing renewed interest due to the increasing demands for a new type of HCP and notions around new professionalism.
Developing HCPs with core and generic competencies requires an approach to HPE that, at most, is competency-based. Members of the CBME Collaborators4 group (Frenk et al., 2010: 641) describe CBME as “an outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programmes, using an organising framework of competencies”. They stress four overarching themes: curricula planning linked to the needs of those served; an emphasis on abilities and prior learning, not just knowledge; a de-emphasis on time- based learning; and the promotion of learner centredness – with learners reaching milestones at their own pace. In the context of nurse education, Anema and McCoy (2010: 32) emphasise how different CBE is from traditional education approaches.
They posit that competencies are developed according to the expectations of what graduates should be able to do; processes are important and are put in place for students to demonstrate competency and for when they do not demonstrate competency; assessments are specifically linked to competencies; and, results are used to adjust student experiences and assist them to become competent.
A generic CBE model asks four essential questions that guide curriculum and course development (Anema and McCoy, 2010). This is illustrated in Figure 7.1.
4 The International Competency-based Medical Education Collaborators group was formed to examine conceptual issues and current debates in CBME identifying areas needing clarification, proposing definitions and concepts, and exploring future directions.
Figure 7.1: Essential elements of a competency-based education model
Criticisms against a competency-based approach are mostly about its conventional task-orientated and technical nature at the expense of subjective, humanistic outcomes associated with HPE (Chapman, 1999; Mulder et al., 2009; Wheelahan, 2009). Humanistic outcomes such as caring, empathy and compassion that are difficult to define and measure are either omitted or neglected in a competency- based approach (Chapman, 1999; Hills and watson, 2011). Such criticism has led to the inclusion of other domains such as the interpersonal, social and (critical) thinking domains. The dominance of ‘outcomes’ over ‘process’ in CBE, has also enjoyed a fair amount of criticism where learning outcomes are seen to be divorced from the processes of learning (Wheelahan, 2009). It may be argued that a competency-based approach that optimises both the product and process of learning is best described as competency-based learning. In coining this phrase it means that student learning as process is central to achieving the outcome.
Within the South African education context an ‘applied competence’ approach tempers such criticism and informs the type of competence that a graduate must demonstrate, in an authentic context, as a result of the learning process. It therefore takes into account not only skills but knowledge, thinking, reasoning, justifying, prioritising and adapting as part of learning. Applied competence includes:
a Practical competence: demonstrated ability to distinguish between a range of possibilities for action/intervention, to make decisions about such actions and to perform the action/ intervention.
b Foundational competence: demonstrated understanding of the knowledge and thinking that informs action/intervention.
c reflexive competence: demonstrated ability to integrate actions and What are
the outcomes competenciesand
for practice?
What indicators dene the competencies?
What are the most effective ways to learn the compet- encies?
What are the most effective ways to assess whether competencies have been achieved?
1
2
3
4
decision-making with understanding; it includes justification for actions/
decisions and adaptability to changed circumstances.
Despite the prevailing contestations university acceptance of the usefulness of CBE is on the increase, but with due acknowledgement that further research is needed into, among others, the societal effects of its integration into programmes (Mulder et al., 2009).
7.2.3 Perspectives of core and generic competencies
The literature is replete with writings on core competencies for HCPs in specific categories and, more recently, on cross-disciplinary competencies such as collaboration and teamwork. Core competencies have been developed mainly by international organisations and within a variety of country contexts.
Canada and other developed countries such as the united States and the united kingdomhave predominated in this area and, more recently, there has been increased involvement in some developing countries. Cross-country collaboration in medical curriculum review, described by kiguli-Malwadde et al. (2014), has led to the development of a competency-based approach in two sub-Saharan African medical schools, taking into account the health and education systems of each country.
The most comprehensive competency framework identified appears to CanMEDS.
Figure 7.2 illustrates the roles embodied by competent physicians within the CanMEDS framework. Competencies are detailed and outlined within the roles of: medical expert (the central role); communicator; collaborator; leader; health advocate; scholar and professional (CanMEDS 2005; Frank et al., 2010; 2014). In this framework various specific competencies are identified with different milestones across the levels of medical school, residency and learning in practice. Within these categories there is further differentiation: for medical school these are medical school fundamentals and early clinical activity; for residency they comprise transition to discipline, foundations of discipline, core of discipline, and transition to practice. The milestones are generic across specialties and represent “the progression of competence from the start of medical training through advanced practice” (p. 4).
Figure 7.2: CanMEDS roles framework for physician competencies (Frank et al., 2014)
7.2.4 Current competencies and standards in South Africa
South Africa has three main professional registration bodies for HCPs – the HPCSA, SANC and SAPC. In 2014 the Medical and Dental Professions Board published an updated version of the Core competencies for undergraduate students in clinical associate, dentistry and medical teaching and learning programmes in South Africa (HPCSA, 2014). This document, originally published in 2012, represents an adapted and contextualised version of the CanMEDS 2005 framework that was agreed upon between the Medical and Dental Professions Board and the training institutions (Van Heerden, 2013). graduates from these programmes are expected to fulfil seven distinct roles. The HCP role is identified as the central role interlinked with that of professional, communicator, collaborator, leader and manager, health advocate and scholar. The medical expert role (espoused by CanMEDS) was replaced by HCP to encourage its adoption outside of medicine. Furthermore, this competency framework includes leadership and management competencies, which are considered essential for change management and for organisational efficiency and effectiveness. For each role key competencies are identified along with enabling competencies, referring to the means to achieve key competencies that involve others and a range of actions, decisions and values. Throughout
Professional Communicator
Scholar Collaborator
Health
advocate Leader