Assessment of competencies in nursing midwifery education

INTRODUCTION TO THE REPORT

The issue of developing and implementing adequate assessment strategies for nursing and midwifery education programmes has challenged both state bodies and educators across the world for over fifty years. The ACE project was set up to report on current experiences of assessing competence in pre-registration nursing and post-registration midwifery programmes. Nursing and midwifery have undergone rapid and far reaching changes in recent years both in initial educational requirements and in the demands being made on professionals in their everyday work. It is intended that the report will contribute to current developments in educational programmes to shape the future of the professions to meet the increasing demands being made upon them.

Decisions are made at every level of the professions, at national, local and in face-to-face practice with clients that affect both the quality of educational processes and the delivery of care. This report intends to contribute to the quality of educational decision making at each of these levels. For this reason the report provides both general analyses of structures and processes directed towards policy interests and also concrete illustrations of the issues, problems met and the strategies employed by staff and students during assessment events.

CONTEXTUAL INFORMATION ABOUT THE RESEARCH PROJECT

The Setting Up and Operation of the Research

ACE was funded by the ENB during the period July 1991 to June 1993. It was conducted as a joint project between the School of Education of the University of East Anglia, the Suffolk and Great Yarmouth College of Nursing and Midwifery and the Suffolk College of Higher and Further Education.

The focus was on the assessment of competence of students on pre-registration nursing courses (Project 2000 (all branches) and non diploma) and 18 month post registration midwifery courses (diploma and non diploma). The project conducted fieldwork in nine colleges of nursing and midwifery and their associated student placement areas, in the three geographical regions of East Anglia, London and the North East. Appendix A 1 provides full details of the conduct of the fieldwork. In brief, there were two phases and through a process of progressive focusing the issues relevant to the current state of assessment of competence were explored.

During the first phase, data was collected in all nine approved institutions to identify issues of national importance operating in their local contexts. Issues related to the whole of the assessment process were explored including planning & design, assessment experiences and monitoring & development. At the end of this phase an interim report was written which provided a means of articulating initial findings and of firming up the research questions for the second phase which then directed the collection of relevant data in greater depth in a smaller number of fieldsites. This approach is generally known as 'theoretical sampling' which produces 'grounded theory' (Glaser and Strauss 1967;). [1]

Project Aims

The ACE proposal set out with the following aims:

1. To establish the effectiveness of current methods of assessing competencies and outcomes from education and training programmes for nurses and midwives.

2. To examine the relationship between knowledge, skills and attitudes in the achievement of competencies and outcomes.

3. To establish the extent to which profiles from the assessment of individual competencies adequately reflect the general perception of what counts as professional competence.

4. To investigate the feasibility of simultaneously assessing understanding, the application of knowledge and the delivery of skilled care.

5. To collect perceptions of the usefulness of the UKCC's interpretive principles in helping nurse and midwife educators to assess competencies and outcomes.

Upon inspection it soon becomes clear that there is an overlap between each aim. It is difficult to do one without also doing the others. However, they each have their individual stress.

Aim one stresses 'effectiveness'. If a mechanism is to be effective, then its intended event must occur. Thus to be effective, if an assessment procedure designates someone as being competent, then that person must actually be competent. This is quite different from concerns with say, cost efficiency. A system which produces 80 or 90 per cent of people as being competent may still be considered cost efficient. It is then a matter of the level of risk that is considered as being acceptable. In an effective system the level of tolerable risk is zero. However, this may not be accepted as cost-efficient. It is the aim then of this project to critique the assessment of competency from the point of view of effectiveness. This has the advantage of making both the risk and the cost or resource implications clear in any discussion that may then take place on the issue of 'effectiveness' as against 'cost efficiency'.

Aim two stresses the complex interrelations of knowledge, skills and attitudes. If the appropriate competencies and outcomes are to be achieved, then educational and assessment strategies must be attuned to the development of knowledge, skills and attitudes. None of these are simple categories for study. They resist the kind of observation that is appropriate for the study of minerals. Their observable dimensions are highly misleading and the situation is rather like the iceberg that has nine tenths of its bulk hidden. Human behaviour is managed behaviour. That is to say, it is not open to straightforward interpretation. Impressions are managed by individuals to produce not only unambiguous communications but also multi-levels of possible interpretations and deceptions. What counts as knowledge to one person may not be considered knowledge at all by another. This is as true for scientific communities as it is for lay people (Kuhn 1970 , Feyerabend 1975;). Again, there is no easy distinction to be made between 'knowledge' and 'skill'. Knowledge may initially be thought of as 'theoretical' as distinct from practical action or skills. Yet, in professional action, knowledge is expressed in action and developed through action. To analyse professional action into 'skills' and aggregate them into lists required to perform a particular action may well do violence to the knowledge that encompasses and is expressed in the whole action. To see professional action as an aggregate of skills may thus lead to an inappropriate professional attitude. Knowledge, skills, attitudes and the processes of everyday action may in this way be regarded as different faces of the same entity. It is the aim of this project to begin with the experience of professional action through which concepts of 'knowledge', 'skills' and 'attitudes' are expressed and defined in practice.

Aim three stresses the relationship between the assessment process and what it purports to assess. In short, are the assessment profiles that result from the assessment process fit for their purpose? In order to examine this question it is essential that 'what counts as competence' has been identified. It may not be that there is a single 'general perception'. Rather, there may be a range of acceptable variation in what is perceived to be 'competence'. This implies a debate of some kind. One prime intention of this project then is to describe the debate and discuss the extent to which assessment structures and processes fit the purposes that are currently being debated. This in turn refers the discussion back to questions of effectiveness and of the ways through which 'knowledge', 'skills' and 'attitudes' are being identified and defined.

Aim four stresses the feasibility of assessing understanding and the application of knowledge at the same time as delivering care. Effectiveness and feasibility are closely allied. It must be feasible for it to be effective. In short, the aim is directed towards the relationship between educational processes and care processes. This may be seen as presupposing a distinction between the two so that assessing would be an additional burden to be carried at the same time as delivering care. The aim of this project is to explore the professional process in terms of its dimensions of care and education: is the one aggregated to the other, or are they indissoluble faces of the same coin?

Aim five is different in kind to the preceding four. This aim has a survey dimension to it where the others are interpretive and analytic in orientation. For ease of reference the UKCC's interpretative guidelines are reproduced in appendix C 2. It is a straightforward matter of asking a range of individuals in the participant institutions whether the guidelines have been found to be useful. Whilst the UKCC's interpretive principles acted as a focus of this aim, it became apparent from interviewing that the inclusion of comments on the usefulness of national guidance in general ( i.e. including ENB guidance) provided a more comprehensive exploration of the issue. Consequently this wider perspective on the usefulness of national guidance was pursued.

METHODOLOGY

A Qualitative Approach for the Study of Qualitative Issues

The project aims define the kind of methodology which is appropriate to their achievement. For example, to identify what counts as an effective method of assessing competencies and outcomes, a structural analysis of cases considered to be effective is required. Before one can begin this, however, it is necessary to define what is to count as 'effectiveness'. This in turn requires the collection of views as to what is to count as competence and as outcomes that signify competence. The initial task then is to conduct a conceptual analysis of these key terms as they are expressed in the appropriate professions. Aim two equally demands a conceptual analysis of the relationship between the key terms 'knowledge', 'skills' and 'attitudes'. Once this has been established, then it becomes possible to analyse the structural relationships between assessment procedures and processes, and the real events in which competence is expressed as a professional quality. With some understanding of what is involved in the relationships between the performance of assessment and the delivery of care then aim four can be explored. The methodology appropriate to these aims is one which identifies those instances in which the necessary features of the key terms are exhibited. Through an analysis of those instances, the structures, mechanisms and procedures through which effective assessment takes place can be identified and described in order to facilitate future planning and design. This essentially fits the approach known as 'theoretical sampling' [2]. It is not a quantitative approach and thus does not result in percentages and tables which illustrates the distribution of variables. Rather it generates theoretical and practical understandings of systems.

The methodology of the ACE project then, is qualitative, focusing upon structures, processes and practices as these are revealed through documentation, interviews and observations. A full exploration of the methodology can be found in appendix B, but broadly, the task has been to generate an empirical data base. By a process of comparison and contrast, key groups of structures, processes and practices are identified as a basis for the more formal analysis of events.

Alongside the strategies for the gathering of data and their analysis have been strategies to ensure the 'robustness' of the data and their interpretation. These have included the use of an expert 'steering group', dialogue and feedback with participating staff and students, theoretical sampling, the application of the triangulation of perspectives and methods, and reference to research output from other projects. The sensitivity of the methodology, with its emphasis on communication and personal contact has been a feature, and attention to principles of procedure have facilitated fieldwork relationships.

In summary, methods of data collection were:

¥ In-depth interviews (individual and group) with students, clinical staff, educators and other key people in the assessment process. Recordings of interviews were transcribed for analysis

¥ Observation of assessment related events in clinical and classroom settings

¥ Creation of an archive of assessment related documentation from approved institutions

The result was a large text based archive constructed from interview transcriptions, observational notes and documentation of courses, planning groups and official bodies. The method of analysis involved various strategies of conceptual analysis employing discourse and semiotic approaches to try to pin down the meanings of particular key terms employed by professional and student discourse communities. This in turn provided a means of identifying the institutional, local and national structures necessary for the construction and delivery of assessment. Structural analyses could be made of particular approaches to identify the roles and associated mechanisms and procedures through which events (both intended and unintended) are effected. These events in turn were then analysed into their stages, phases and process features in order to identify what counts as professional competence in action, in situ.

Whilst gathering and analysing the data was clearly impossible to understand the experiences of professionals and students without having grasped the contemporary changes taking place in nursing and midwifery. There are thus discourses of reform, of innovation and of change (whether or not perceived as being innovations or reforms) which act as the context for the conceptual, structural and process analyses described above. This context is the subject of the next section.

THE CONTEXT OF REFORM

Professional and Educational Change in a Changing World

By 1991, when the ACE project started its work, a number of significant changes had taken place both within nursing and midwifery education and within the structures of the occupational settings of nursing and midwifery. These changes formed part of a relatively long term strategy for NHS reform which was to continue to develop and have impact throughout the life of the project. The field of study was and still is characterised by the complexity of wide variation with differential pace of change across both regional boundaries and local, internal boundaries. This complexity has been further compounded by the regularity with which new demands have been made on participating institutions as NHS reform gathered momentum and concepts such as the regulated internal market (DoH, 1989a;) were tested and reformulated in the light of experience. Not only has this climate had an impact on practice and education in nursing and midwifery, but it has also made particular demands on the research methodology. A field of study which is in constant state of flux and change demands the contextualisation of any account of the assessment of competence.

The move of nurse and midwife education towards full integration with Higher Education institutions has added further complexity to the situational aspects of the assessment of competence. Alongside the strategy for NHS reform there has been a parallel movement towards educational reform which has encompassed the organisation and funding mechanisms of all Higher and Further Education institutions (DES 1987, 1991;). Throughout the study therefore, the fields of nursing and midwifery education faced two challenges; firstly to prepare practitioners for workplace environments which were themselves experiencing major organisational and ideological change; and secondly, as they moved closed to Higher Education, to contend with the structural changes occurring within those institutions. Studying nursing and midwifery education during this period has therefore inevitably raised a number of issues which speak directly to the more general issues relating to both the impact of NHS reform and the impact of education reform.

It is the intention here to make explicit the main areas of change which were already having some impact at the start of the project and to describe those changes which occurred during the study period in an attempt to set the scene for the arguments and recommendations raised in this report. These areas of change will have inevitably shaped ideas about what midwives and nurses do, what is expected of them, their educational needs and the ways in which competence is defined and assessed.

NHS Reform

Since the publication of the government white paper ÔWorking for PatientsÕ (DoH, 1989a;), the pace of change within NHS service provision has been relentless, and the impact of the subsequent legislation inescapable. ÔWorking for PatientsÕ arose as part of a major review of NHS provision and was to provide the impetus for extensive NHS reform during the 1990Õs. The NHS and Community Care Act 1990 was the statutory instrument which finally placed firmly into legislation, reforms which were to have far reaching and on-going impact on virtually all aspects of health service provision.

One of the central stated arguments for reviewing NHS provision, structure and funding has been the need to find economic and ideological solutions to identified changes in health needs of the population. Demographic and epidemiological trends (HAS 1982, DoH, 1989b;) have created new demands on health provision and have influenced recent moves towards a demand-led rather than service-driven health care economy. ÔWorking for patientsÕ attempted to address the challenge of creating provision on the basis of population need rather than the presence of clinical expertise, by creating a regulated internal market where Health Authorities purchase services on behalf of their population from a range of potential service providers. The creation of this market has rearranged local provision from a single resource into several separate and semi autonomous units.

The period of fieldwork undertaken in this study spanned two years of intense activity in relation to the recommendations imbedded in ÔWorking for PatientsÕ. The first NHS Trusts were approved in 1990 and throughout the study many of the clinical areas served by colleges of nursing and midwifery had gained Trust status or had applications in progress. This separation of purchasing activity from services and the division of local provision not only presented challenges for the management of the research especially in terms of access to clinical areas, but was evidenced in the data in terms of concerns about availability of student placement areas, workload of clinical staff and the potential for even greater variation in the expectations about the outcomes of nursing and midwifery courses.

The Changing Roles of the Nurse and Midwife

Any change in the demands which are placed on nurses and midwives within their occupational roles will have an impact on what counts as professional competence and on the way in which competence is assessed.

The Strategy for Nursing (DoH, 1989b;) described a range of strategic targets for nursing and midwifery. These responded to changes which had already occurred in service provision and professional practice and anticipated the demands on nursing and midwifery into the next century.

Already nurses and midwives faced a number of initiatives over the previous decade which would have direct impact on their role and practice. For example the Griffiths Report (DHSS, 1983;) had introduced general management to the health service and the unquestionable right of nurses or midwives to hold senior generic management positions in hospitals and the like was gone. This left a major gap in opportunities for career advancement outside clinical practice. 1988 saw the achievement of two major initiatives which were intended to raise the value of clinical practice and provide opportunities for career progression through, on the one hand, a new clinical grading structure and on the other, Project 2000 and academic accreditation of nursing and midwifery courses. These suggest a trend towards a changing ideology and value base within nursing and midwifery and a re conceptualisation of professional role and status in relation to other health care workers. For midwives in particular the last decade has seen continuation of the strong movement away from their traditionally close identification with nurses and nursing practice. It is a clear reflection of the dynamic and changing nature of the field of study that by the time the ACE fieldwork was complete, a major revision of the Strategy for Nursing had taken place to take account of other fundamental changes within service provision (DoH, 1993).

Other ideological changes were taking root within nursing and midwifery practice. Throughout the 1980Õs increasing emphasis has been placed on community care (DHSS 1986, DoH, 1990;) based on the notion that care in the clients normal everyday surroundings is of greater benefit than institutionalised care. For many community midwives this has meant less emphasis on high technology births and more emphasis on the individual needs of women and their families. Changes in the location of care have had significant impact on nurses and nursing practice. Under The NHS and Community Care Act 1990, responsibility for community care was invested in Social Services rather than the Health Service (DoH, 1990;) and questions are being raised about both the role and competence of nurses in community settings, and the extent to which health care should, or indeed, could be separated from social care. This change in location of care has created different demands not just in relation to the skills required by nurses in community settings, but also in the demands on nurses in hospital settings where patients require acute care over shorter periods.

In similar vein there has been an increasing orientation within nursing towards holistic care, the prevention of ill health and health education. Midwives have always worked predominantly with healthy women and as a result have perhaps been better placed to reject a sickness oriented model of care and adopt an approach centred on health, normality and education. This trend towards a health orientation has mirrored a national concern for health and health promotion over recent years. The Health of the Nation (DoH, 1992;), described the governments policy and strategic targets in these areas, and reinforced the demand on nurses and midwives towards curricula which were firmly based within a framework of health as well as ill health.

Changes have also occurred in the delivery of care. For more than a decade the trend has been to move away from task-based routinised systems of care to more individualised, client centred approaches. Primary nursing and team nursing started to spread throughout the country and the publication of the Patients Charter (1991;) formally introduced the concept of the Ônamed nurseÕ for each patient. It can be argued that individualised care, primary nursing and the concept of the named nurse have contributed significantly to a shift towards a model of nursing and midwifery practice in which judgement, assessment, care planning and reflective critical analysis are becoming increasingly valued role components. Where role expectations and values shift, so too should ideas about what counts as competence and how that competence should be assured. A major question therefore must be, to what extent have role expectations and values embedded in those expectations, kept pace with changes in policy and legislation? To what extent do practitioners, managers and educators, hold onto role expectations which have not yet taken account of major policy shift? The implication here for the research is to uncover and explicate the relationships between role expectation and policy implementation in order to inform possible mismatches between the rhetoric of assessment documents and the realities of assessment experience.

Changes within Education

Although apparently less directly affected by the main thrust of NHS reform, professional education has been in the process of a fundamental transformation. Major changes were taking place within nurse and midwifery education both in terms of the nature and content of educational programmes and in the structure and organisation of institutions. A subsidiary paper of ÔWorking for PatientsÕ, ÔWorking Paper 10Õ, addressed the need to separate education provision from service units and purchasing authorities by investing the relationship between service and education with similar market processes. What followed was a wholesale review of nurse and midwife education across the country and consequent major reorganisation. At the beginning of the ACE project most education institutions had already undergone some form of rationalisation. All approved institutions involved with the study were the products of the amalgamations of several small schools of nursing and midwifery, which had traditionally been located on NHS hospital sites into much larger colleges of nursing and midwifery. Most were therefore multi-site institutions which were in various stages of incorporation.

Later, as the overall intention to embed nurse and midwife education into a HE framework took shape, colleges of nursing and midwifery were to begin the process of wholesale integration with HE institutions. During the period of study, colleges were in various stages of integration ranging from validation-only arrangements through to full integration.

Clearly, given the overall trend towards integration with HE, all fieldsites were experiencing major upheaval in terms of both organisational structures and working arrangements hard on the heels of one, if not more, previous periods of re-organisation. In one college, senior staff were facing the prospect of re applying for their jobs for the third time in a space of two years.

Concurrent with these various strands of organisational restructuring, fundamental changes were being implemented to the nature of courses. Project 2000 (UKCC 1986); and moves towards devolved continuous assessment were having a dramatic impact on the nature of pre registration nursing courses as were the increasing number of direct entry midwifery courses and the accreditation of midwifery courses to the level of Diploma in Higher Education.

Project 2000 represents a major move away from the apprenticeship style training of previous years. One of its fundamental and over-riding stated aims is to provide nurses with the type of preparation which will best meet the changing demands and expectations on qualified nurses in changing contexts of health care delivery. If nurses are to cope with a working environment characterised by its changeability and ideologically committed to the primacy of the individual, then nurses will need new skills to be flexible and adaptable enough to manage the unpredictability of individualised systems of care within a constantly changing professional context. These are the skills most frequently associated with HE. Colleges of nursing have therefore been required to form collaborative links with HE institutions in order to develop and validate Project 2000 courses. The process of conjoint validation between nursing professional bodies and HE institutions placed different and sometimes competing sets of demands in relation to course assessment strategies. On the one hand professional bodies were concerned that assessment strategies were sensitive to the demands of professional practice and on the other the HE institutions concerns focused on academic credibility and the extent to which the assessment design was adequately sensitive to intellectual competence.

Although midwifery education remains separate from Project 2000, a number of direct entry midwifery programmes share components with the Project 2000 Common Foundation Programmes. Even where Project 2000 has not had such a direct impact on midwifery education, there has been a parallel trend within midwifery to incorporate some of the more generic educational principles of Project 2000 within their own curricula.

Project 2000 and diploma level midwifery education are only one aspect of a broader set of educational initiatives which challenge traditional expectations of what nurses and midwives do, how they interpret their roles and how they should be prepared for practice. PREPP (UKCC, 1990); and the ENB framework and Higher Award (ENB, 1990;) address the increasing concern for opportunities for lifelong learning. They imply a distinct move away from a view that nursing or midwifery can draw on discrete, finite and stable sets of knowledge and understanding and move towards the notion that maintaining professional competence is more to do with providing skills for continual self development. Central to these initiatives is the need to demonstrate evidence of continual progression and learning in order to be considered fit and competent to practice.

Changes to the structure, content and philosophy of nurse and midwife education were not occurring in isolation from wider changes which were impinging on HE and FE throughout the period of study (DES, 1987, 1991);. Recent legislation, (DES, 1992;) has brought about a number of changes in the Higher Education institutions into which nurse and midwife education continues to integrate. These changes were heralded by the government as:

far reaching reforms designed to provide a better deal for young people and adults and to increase still further participation in further and higher education.

(Lord Belstead, Paymaster-General, Hansard, H.L. Vol. 532, col. 1022;)

Changes to HE included a new system of funding (DES, 1988);, which merged the functions of the old Polytechnics and Colleges Funding Council and the Universities Funding Council to form the Higher Education Funding Council. The intention behind this was to introduce greater competition between HE institutions for both students and funds in order to achieve greater cost effectiveness. The act also created opportunities for a wider range of HE institutions to award their own degrees and to include the term 'university' in their titles. The impact on some institutions was experienced as a series of priority changes as the pace of these changes gathered momentum throughout 1992. For institutions seeking to meet the criteria set by the Privy Council to gain university status, the main priority was experienced as a pressure to develop, market and deliver HE courses to increasing numbers of students. Once achieved, many 'new universities' faced new demands for increased research activity in order to benefit in any substantial way from the research assessment exercise which was to determine the allocation of university research moneys.

Although the effect of these changes on the project fieldwork was not as direct nor dramatic as the effect of NHS reform, several colleges involved with the study had HE partners who were undergoing fundamental changes as a direct consequence of the above legislation. Some colleges involved in the study started their integration process with polytechnics who have since gained university status. For colleges of nursing and midwifery these changes were not just about nomenclature but were also about the nature, structure and expectations of their relationships with HE validating body and partner.

In summary, during the period of study a number of pressures upon both understandings and administration of assessment of competence were in operation and which can be categorised into the following groups:

¥ changes in population health needs

¥ values about health care and service provision

¥ political/ideological changes (structural changes)

¥ educational reform

Each category exerts its own distinct range of changes and pressures upon individuals and groups involved in the assessment process on both personal and professional levels, affecting what counts as competence and the means by which it should be assessed. Consequently this section concludes with a selection of extracts from the data which articulate some experiences of the changing context. Further examples can be found throughout this report.

THE EFFECTS OF CHANGE ÔON THE GROUNDÕ

Individual Experiences of Change

The research examines the assessment of competence in nursing and midwifery education within the changing context described above. It does so from the perspective of the individuals who deliver the service, upon whom these changes impinge directly, but who also, as members of a body which has campaigned for a considerable time for the changes, the motivators of the continuing developments. As affectors and affected, people experience change with mixed feelings, which the research has set out to capture. For some, the effects of changes within educational and health care environments are experienced as a continual break on educational planning:

The Health Authority was in a state of flux and there was a lot of change going on. First we amalgamated with another Health Authority and then second we amalgamated as one college of nursing with other schools of nursing. So every time you thought, "Now we've got some ideas coming on paper," you had to stop and re-evaluate because you got new schools joining and then you had to look at what they were doing.

Organising and guaranteeing a range of clinical experience for students on placements is also difficult in some instances:

I find the clinical areas are changing their speciality month by month. You know you have one area that's doing so and so (...) and then you find that they're no longer doing that because some other consultant has actually gone in there and they're doing something else. It's a constant battle, it really is. (educator)

A prevailing climate of uncertainty makes long term planning difficult and unsettling in many instances:

The whole future's up for grabs. The college may become an independent (...) it may become completely separate, someone may take on a faculty of nursing in Middletown. The next six months should give some indication of...politically...of how things go. (educator)

The cumulative effect of change was highlighted by one educator:

I think it's...not just how it's changed, it's the speed of change. There is more coming on, you just get one set of initiatives finished and then there's another set going through, and another set. And on top of that there's changing the curriculum...there's changes, it's the speed of change. Change has always been there but there's been more time to assimilate it, to take it out there to work out there to change it. Now it's so hard to keep up with the change and take it out there. And a lot of people out there in the clinical field are not really sure what is going on.

Those involved in education are keen to ensure that colleagues in patient care are kept up to date with educational change. Likewise the need to share understandings about developments occurring in service is recognised, but remains a difficult task in a climate of competing demands:

...I think our staff here don't always recognise all the great changes that are happening in education, they see their own changes, changes in technology, the way we're pushing patients through, reducing patients' stays, the way we are changing our structures and our ways of working and contracting, and income comes in and goes out. We don't get a budget any more, we have to earn out income through so many patients we see, and they don't see that the college have got their own stresses and strains. What the college don't see is perhaps the speed at which we're moving forwards and the new language. I'm not convinced that my college friends really have an understanding and grasp of the new NHS. They have not got a grasp of contracts and earning income through numbers of patients. (nurse manager)

The report offers a detailed record of individual perceptions of change and provides an account of the manner in which these have affected, and are likely to continue to affect, the implementation and further development of structures, mechanisms, roles, and strategies for devolved continuous assessment.

CHAPTER ONE

ABSTRACT

Assessment in general has a range of purposes, including the formative ones of diagnosis, evaluation and guidance, and the summative ones of grading, selection and prediction. It is expected to be reliable, valid, fair and feasible, and to offer what is usually called, somewhat mechanistically, ÔfeedbackÕ. The assessment of professional competence has additionally to be able to evaluate practical competence in occupational settings, and to determine the extent that appropriate knowledge has been internalised by the student practitioner. Approaches to assessment which lie within the quantitative paradigm, including technicist and behaviourist approaches as well as quantitative approaches proper, are suitable for collecting information about outcomes within highly controllable contexts, and for collecting information which can be measured, or recorded as having been observed. Such approaches are inappropriate for assessing the degree to which the student professional has developed a suitably flexible and responsive set of cognitive conceptual schema that facilitates intelligent independent behaviour in dynamic practical situations. Neither do they take account of the fact that contexts of human work themselves continue to evolve and change, and that therefore the individualÕs ability to blend knowledge, skills and attitudes into a holistic construct that informs their practice, is crucial. Assessment from within the educative paradigm, on the other hand, does do these things, whilst also acknowledging that assessment itself is an essential element of the educative process. Educative assessment takes full account of institutional and occupational norms, and of the fact that there are actual individuals involved who are not automatons but people who interpret and make sense in terms of their experience; its structures are generated in response to those features rather than in contradiction of them. It offers structures, mechanisms, roles, and relationships that reflect interior processes and take into account the essential ÔmessinessÕ of the workplace. It does not attempt to impose a spurious logical order on what in practice is complex. In so doing it performs a formative function as it performs the summative one. The one does not follow the other, but happens in parallel. Assessment from the educative paradigm is integral to the learning process that generates individual development. Competency-based education stands provocatively on the bridge between the quantitative paradigm and the educative paradigm, still making up its mind about the direction in which it should move.

The ACE Project: The Assessment of Competence in Nursing and Midwifery