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Struggling With the Notion of Competency

Zubin Austin, BSc.Phm, PhD

Originally published in Volume 22, Number 1 of the Federation Forum Magazine.

Note: The following article was written from a keynote speech by Zubin Austin at the 2006 FSBPT Annual Meeting in Portland, Oregon.

As a pharmacist, as unlikely as it may seem, I see similarities between pharmacy and physiotherapy. They include manpower shortages, integration of foreign trained professionals into the profession and possibly most importantly of all, struggling with the notion of competency. 

Defining Competency
I do not actually know what competency is; probably most of us do not. It is a lot like love - we know what it is not, but we do not actually know what it is. For example, is a Vietnamese language-speaking pharmacist who works with Vietnamese language- speaking clients and physicians who cannot communicate effectively in English, but provides wonderful patient care to that population incompetent? It is a tough question. And here are some more questions to throw into the mix.

Competency is defined by Webster as the quality of being adequately or well-qualified physically or intellectually. This is of absolutely no help in trying to define competency. Competency means very different things to very different people. Different stakeholders hold different perceptions of competencies and those views are very much shaped by the needs of each individual constituency group. For example, if you are that Vietnamese-speaking patient who has a hard time accessing English-language healthcare, that Vietnamese-speaking pharmacist is a godsend; the question of competency would never arise. Yet if you happen to be a tourist wandering around that neighborhood and need to access a pharmacist’s services, you may start to question the pharmacist’s competency. It is a problem to define one standard for competency, and if the mere definition is a problem, you can imagine what issues we have with measurement. 

Competency from a Patient/Client Perspective
The issue of actually defining competency and then trying to measure it is problematic. First and foremost, one must look at what competency means from a patient’s perspective. What do patients want from their healthcare professionals? Many studies in a variety of different fields have shown that what clients want are basically three things: accessibility, affability and acknowledgement.

You may notice that conspicuously absent from that list is knowledge or actual skill or ability. What that suggests is that you can be a very nice person but entirely devoid of any skills or knowledge and perhaps meet a patient’s healthcare needs. Flip that around and what it also says is you can be a very knowledgeable and skilled person but if you are not accessible, affable, and do not acknowledge patients, you will not be deemed competent in their eyes. 

If competency in the context of public protection is what we are trying to define and measure, perhaps we can argue that what we ought to do is undertake a standardized test of niceness because at the end of the day this is what patients want from professionals, and this is how patients define competency. This can be very frustrating. Entire complaints are often driven in the discipline process by impoliteness, not being acknowledged, not being heard, and not being accessible and affable. 

Competency from a Practitioner’s Perspective
From the perspective of any healthcare profession, day-to-day professional practice is tough and it is getting tougher. We all know that problems associated with increasing demands, human resources shortages and the expectation of doing more with less make it difficult to continue to like what you are doing. The idea of making a mistake and consequently being labeled by your regulatory body as incompetent is not a question of fundamental personality traits but simply a case of “Oh! There but for the grace of God, go I.” 

As a young pharmacist I had finished school, completed my internship requirements, completed national licensing exam requirements, got the letter saying I was now a licensed pharmacist, started to work and dispensed my first set of prescriptions as an independent licensed practitioner. The first three prescriptions I dispensed as a pharmacist I got wrong – I put them in the wrong bottles. Fortunately because I am generally affable and accessible, the patient said, “You know, normally the big white tablets are in the one that is labeled this and the little green tablets are in those.” I immediately apologized and nothing more happened. Does that mean that I am incompetent? Does an isolated error equal incompetence? Does the fact that I was very apologetic make the error better? If I came from a different country or culture or had been educated or trained in a different system as many internationally-educated professionals are, I might have been trained not to apologize for errors. So that exact same set of facts played out with a person from a different culture may have resulted in a discipline hearing and a finding of incompetence. 

Practitioners recognize that competence is a slippery slope. Competence from a practitioner’s perspective is not like citizenship. Once you get a stamp that says you are competent, you are only as good as your next interaction. It is stress, I believe, that sometimes plays out in a somewhat fearful or antagonistic relationship with regulators. There is a sense that regulators may have to impose a very strict definition of competence that does not allow for wiggle room. 

Competency from a Regulator’s Perspective 
From a regulator’s perspective, competency consumes a lot of time and resources. First and foremost is safety of the public, but if it’s already established that what the public wants is somewhat different than what we may think, that premise can be called into question. Regulators must be accountable to multiple stakeholders and they also need to have methods that all members can understand, accept, and, most importantly, buy into. 

Easier to Define Incompetence than Competence
I would suggest that in most professions and certainly in pharmacy we discover that it is often easier to define incompetence than to define competence. I have the distinct privilege of being able to view competency from an educator’s perspective and I think it is a privilege for a variety of different reasons. I get to view competency as a developmental process. I get to say that if you are a new pharmacist, you should not be held to the same standards as someone who has been in practice for ten years. There is some value to ten years of experience in a profession and you expect young practitioners to do certain things that older practitioners would not. From that perspective as an educator, standards are not fixed. Standards can evolve over time and there are actually some interesting implications for all of this. Each person is unique and a standard definition of competency makes little sense. 

Of course, the fact is that the Vietnamese pharmacist will not be able to meet standards that were set for me in my setting. They are doing their own thing and we should be working towards helping them to do their own thing as best as they possibly can. I am not trying to fit them into a box that does not necessarily work for them. 

As an educator, my job is not to prepare people to pass a test tomorrow but to prepare them for a lifetime of practice - not simply meeting some minimal standard today but wherever that standard is going to evolve over time. 

Competence from a Legal Perspective
A final important perspective to consider is a legal perspective. Standards end up being litigated. Standards are constantly evolving and are being interpreted in the light of changes in professional practice and expectations. For example, 30 years ago pharmacists were not allowed to actually educate patients about side effects associated with their drugs because it was thought that you should not put ideas into their heads. Things have evolved considerably and in the United States today, pharmacists are obligated to educate patients about side effects. If you graduated 30 years ago, all of a sudden your world is upside down. What you learned, what you valued, how you were supposed to practice is now wrong. 

Making sure that people have a way of adapting to a whole new world order is something that we need to take seriously. I would suggest that competency has multiple definitions depending on what hat you are wearing and what perspective you need to take. However, as regulators, this is not necessarily something that gives you a lot of solace because you have to take a very sophisticated look at how to actually measure competency. 

What the Literature Says
What competency literature in fields like medicine, nursing and pharmacy suggest are a couple of very key findings. First, attendance at compulsory continuing education events does not translate into change or enhancement of practice. Completion of continuing education through other means - for instance, home study units - does not predict whether an individual will meet objectively-defined competency standards.

Higher Risk of Not Being Defined Competent
Data we have from a pharmacy in Ontario suggest that there are three cohorts in particular that are at highest risk for not being defined competent in terms of objective standards of competency set by a regulatory body. 
  • Practitioners who are older (25 years or more post-graduation). 
  • Those who work by themselves. 
  • Those who are internationally educated - people who did not get their formative education and training in either Canada or the United States.
There are a lot of multiplication effects here so if you happen to be an older, internationally-educated person, your risks are compounded significantly. If you work by yourself and are internationally educated, your risks compound significantly. 

Most Likely to be Deemed Competent
Those most likely to be deemed competent are those who are connected and working professionally. The fact that you attend a continuing education event is not the reason you stay competent. 
  • Interacting with other people in your field, sharing war stories and networking professionally.
  • Those who like what they do.
  • Those who express satisfaction with their personal lives.
As an example, a woman was brought before her disciplinary board concerning her competency to practice. What emerged was that during this whole time - during the time she made the error - she was suffering significant physical and verbal abuse from her husband. This issue of satisfaction and stability in personal life moving into professional life is very important particularly because we all have this belief that we can check our feelings at the door. 

Peer Referencing as a Motivator for Learning
Peer referencing is probably the most powerful motivator and re-enforcer for learning. How do teenagers know what is right in their world? It is not what their parents say, it is not what the teachers say, and it is not what the experts say. Teenagers focus on is what their friends say – peer referencing. There is a growing volume of literature that suggests that all of us do peer referencing, and this starts to explain some of the earlier findings concerning competency. Practitioners have a hard time meeting competency standards if they are peer referencing older practitioners. This is a concept called “learn worthiness” (who is worthy to learn from) and it is a phenomenon that occurs from childhood to adulthood and suggests that in a complicated world where information is coming to you from a lot of different sources, humans develop a filtering system through peer referencing. 

About 15 years ago, there was a real movement to try to get pharmacists to spend more time talking to patients. It was difficult. At the end of the day, pharmacists were checking what other people in their field were doing and what they were doing bore no resemblance to this idealistic model of practice that was being put forward. It took decades to try to get pharmacists to move forward. Learn worthiness and peer referencing are absolutely the best predictor of how behavior is going to evolve. 

Internationally-educated professionals, simply by virtue of the facts that (1) English may not be their first language, (2) they did not go to the same schools you did and (3) they do not have the same professional and personal networks you do, are generally disconnected from their professional community. If they do not have a chance to see how other people do their own job, how do they know what is right? 

Four Approaches to Defining, Assessing and Measuring Competency
It is worthwhile looking at different approaches to measurements of competency. Competency literature suggests there are four major approaches to defining, assessing, and measuring competency. They are behaviorist, cognitivist, developmental, and psychoanalytic. 

Behaviorism involves the use of rewards and punishment to motivate and encourage a particular kind of performance. This is the entire basis of education and probably the entire basis of regulation as well. If you do not do this, you will be punished. Rewards and punishments are effective ways of teaching if you want to toilet-train a child or a pet. The question of how effective it is if you actually want to develop behavior in a competent adult professional is questionable, particularly in the context of a phenomenon known as code shifting. 

Every parent knows that you do not know what your children do when they are not with you. You can talk until you are blue in the face and give all the rewards and punishments that are appropriate, but the minute you are not around, who knows if Johnny is smoking with his friends or actually staying at home and doing his homework? Code shifting refers to the behavior of people when the person who provides the rewards and punishments is no longer there. If all we use are behavioral tactics, rewarding good behavior and punishing bad behavior, then the likelihood of developing some sort of long-term sustainable pattern of behavior is probably quite low. 

What we tend to do in the competency field is punish good behavior. In the name of being fair, we expect everybody to do certain things to prove their competency. The person who is competent, who is diligent, who is doing the right things now has to waste time and effort proving that competency and this starts to look like a punishment. Punishing good behavior is completely problematic if you are trying to encourage a certain kind of behavior.

Cognitivist Approach
Unlike behaviorist approaches, cognitivist approaches tend to favor learning as a vehicle for sustaining competency. It begins with the fundamental assumption that no one chooses to be incompetent. One is incompetent because he simply does not know how to be competent. He or she drifts away from competency. The person who has been out of school for a long time, the internationally-educated professional and the sole practitioner do not know what competent means anymore. It is one thing to read something in a journal and quite another to watch somebody doing your job. From a cognitivist perspective, education is the focus. But do we just wait for our Vietnamese pharmacist to learn English so that we do not have to worry about her competency? 

Developmental Approach 
Developmental approaches suggest that competency means different things at different stages of life. The needs and wants of a 23-year-old practitioner are different from a 42-year-old or a 62-year-old. A group at the University of Toronto did some research on the experience of pharmacists during a time of civic crisis. A few years ago, Toronto had the SARS outbreak and the healthcare system literally shut down. Hospitals closed and physicians were unavailable. Pharmacies were really among the only healthcare providers out there. The second major crisis that occurred in Toronto was in 2004 when a blackout affected the eastern seaboard. There was no electricity to run a healthcare system. With no electricity, the definition of competency changed. Suddenly these bright, new graduates who could search a database for drug information questions did not have computers and did not know what to do. Who became competent during that time? The 62-year-old practitioner who knew how to type, knew how to keep a manual inventory system, knew how to track narcotics by hand, and knew how to educate patients without benefit of those fancy little sheets that pharmacies always produce. For a three- or four-day period, the definition of competency in pharmacy changed.

During different stages, at different times and in different places, competency starts to shift. From a developmental perspective, we need all of those skills. If somehow we had found a way to dismiss all of those 62-year-olds who did not like using computers, who did not like to do electronic order inputting and all of those kinds of things, we would have had a very big problem. This suggests we need to be a little bit more humble in terms of what we define as competency and acknowledge the contributions of everybody in our field.

The approach that I tend to favor as an educator is the psychoanalytic approach. It does not try to make the case of incompetent versus competent. The opposite of competency is not incompetence; it is disengagement. If you look at it from that kind of a psychoanalytic approach, the focus on the root cause of competency drifts. No one wants to be incompetent. But why do some practitioners allow their skills to deteriorate vis-à-vis their peers? This approach is also based on the assumption that professional practice is really only an extension of an individual practitioner’s own personality in day-to-day life. 

What the literature points to again is that if there is competency drift at a professional level, there is probably some sort of drift at a personal level as well. The two are surprisingly correlated. We need to find out what disengagement from a profession really means. We use the word competency when perhaps what we really want to say is engagement. We want people who actually like what they do because if you like what you do, you are going to keep up, you are going to see what your peers are doing, you are going to be interested in your field, and you are going to be interested in your patients or your clients. From a psychoanalytic perspective, therefore, our goal is not to create competent practitioners but engaged practitioners - people who are interested in their profession, their patients and their practice. The concept of flow is a way of describing engagement. It is the experience you have when you feel at one with what you are doing. It might come when you are playing the piano, when you are jogging, in the middle of cooking. There is a very basic human ability to entirely engage in an activity and during that time of engagement there are a couple of specific attributes including timelessness (no worry about how many more days until retirement), an experience of productivity that you are engaged in doing something that is meaningful and a subjective sense of well being, constructiveness and purposefulness. 

In every health professional field today, we have lost this notion of flow. Occupational service from a variety of fields suggests that most practitioners who only work as practitioners are doing it for the money, for the status, for the pension plan, for the benefits. They are not doing it for purposes of flow. That disengagement is the first step towards what I believe becomes competency drift. 

Are these practitioners met with low challenges that actually do not require a lot of skills? If so, that breeds apathy - the first step towards disengagement. We have often thought of competency as the fault of the practitioner. But at least one important contributor to competency drift may be the environment in which practitioners in all fields find themselves. This helps to start to explain a lot of other phenomena that we are experiencing in the healthcare system. 

Do you really think we have a human resources shortage in any healthcare profession? Is there really a shortage of people or is there a shortage of high-skill, high-challenge environments in which people can experience flow so that they do not start to become disengaged? An argument that I would make is that the reason competency drift occurs is because those with the highest skills leave most professions. Those who cannot for a variety of reasons leave their profession end up being in this low-skill, low-challenge environment in all fields. 

A competency drift is worsened by many systems now in place to measure competency. Most competency assessment measurements are very behaviorist in orientation. They try to use rewards and punishments to produce a certain kind of behavior. From this perspective, measuring competency in this environment is, pure and simple, kicking someone when they are down.