1. Developing a Competence Framework & Evaluation Tool for Primary Care Nursing in South Africa SUSAN STRASSER 1, LESLIE LONDON 1 & ELMA KORTENBOUT 2 1 Department of Public Health and Primary Health Care, University of Cape Town, and 2 Department of Nursing, University of the Western Cape, South Africa

2. Objectives: To identify core competencies of clinic nurses Develop an evaluation tool for primary care nursing in South Africa.

3. Context: Nurses provide the bulk of primary care services in South Africa. Health legislation provides for the provision of comprehensive primary care services at public clinics Thus, the need for a cadre of primary care nurses able to render such services.

4. Table 1: Challenges facing primary care nursing IssueChallenges ________________________________________________________________ Professional developmentEmpowerment, Autonomy Prescriptive Authority Scope of Practice Education & TrainingHospital centric practice Practical supervision Biomedical versus community based approaches Training to meet PHC service needs Service deliveryWide and demanding scope of practice Inequity in distribution of trained staff (Inter and intra-provincial disparities) Inequitable distribution of resources Lack of orientation programs for new graduates and staff Structural issuesSupport systems including equipment Technical support and referral networks _________________________________________________________________

5. The National Qualifications Framework You show competence when you are able to combine the use of the skills, information and understanding necessary to a particular learning situation, and the essential outcomes at a required level of performance. [NQF] (1996) p.4.

6. Methods: Descriptive and exploratory Reference group meetings of South African primary care professionals, Consensus building using the Delphi technique

7. Findings: Reference groups 9 core competencies. Infrastructure issues, such as the supermarket (one-stop shopping) approach to service delivery Communication and transport systems, and the quality of supervision still cause concern. These issues underscore that competence cannot be measured in a vacuum

8. Nine core competencies for primary care nursing Able to problem solve: The consultation & health assessment skills Capable of managing common conditions Demonstrates effective communication and counseling skills Able to apply rational drug use Identifies when and where to refer Capable of accessing and using information Demonstrates a caring, confident approach Capable of providing general clinic management Demonstrates a community orientation

9. Delphi Study Questions Question 1: Can training around core competencies yield a safe practitioner more quickly than traditional methods? Question 2: Should a truncated training program look at both clinic and community-based needs? Question 3: In one sentence, define a competent primary care nurse. Question 4: Do you feel the competencies listed in figure 3 are core competencies? Please modify, add or delete as necessary. Question 5: Do you feel that the list of core competencies manifested in specific programs (e.g. maternal-child health) could be a helpful way of assessing competence?

10. Delphi Findings Delphi participants affirmed the nine core competencies discussed the need to assess the impact of core competency training. felt one possible way to measure the nine core competencies would be to use proxy indicators

11. Discussion/Conclusions: Identifying core competencies is a complex process. There is a need to process a wide range of views and ideas. Balancing academic concerns with service delivery needs and constraints is an ongoing challenge. A potential limitation of the Delphi technique is participant selection bias and fatigue. Although the process is cumbersome, providing experts with a venue to wrestle with these ideas can be fruitful. Future studies would help to assess the reliability of the findings.

12. Phase One: Identification of core competencies and assessment parameters Phase Two: Development and piloting of measurement tool Phase Three: Development, implementation and evaluation of core competency training Figure 1: Sequential exploratory study of primary care nurse competence 1 QUAL represents the use of qualitative methods of data collection and analysis QUAN represents the use of quantitative methods of data collection and analysis QUAL QUAL QUAN QUAL 2 Reference DELPHI Core Competence 2 Focus GroupsStudy Training Groups & Trainer Feedback 1Adapted from Research Design Qualitative, Quantitative and Mixed Methods Approaches by J.W. Creswell (2003). Thousand Oaks, California: SAGE. Interpretation of findings Summary analysis