Growing professional competence in nutrition and dietetics

‘The real challenge… is to recognise the complexity of competence as a concept. Only then can [we] effectively delineate the knowledge, skills, and attitudes that learners must acquire to be able to perform within each domain at a predetermined level and to recognise that the expected level of performance within each domain will vary depending on the learner's stage of education and the speciality he or she is learning’.1 (p. xi) Health, disease and the health-care system are complex and ever changing domains of practice, requiring an adequately equipped health workforce. An area that offers perhaps the greatest potential for improving health is that of optimising the population's nutritional intake.2 Dietitians are experts in food, diet and nutrition, and they have a crucial role to play in addressing the problems of over- and under-nutrition that are currently observed within Australia. Creating an effective nutrition and dietetics workforce that practises safely will assist in maintaining and improving the health of the population. Competency-based education has developed as a movement to create a workforce equipped to deal with these challenges.3 The 1990s saw first the emergence, and then the dominance, of competency-based education in the health professions in Australia. Dietetics was one of the first of these to develop competency standards,4 which subsequently became drivers for the education of dietitians and for the content of the curriculum. In the early stages, competency standards were influence by the vocational sector and they have been accused of being an attempt to reduce the art of professional practice to a discrete set of technical skills.5 For dietetics in Australia, this may have led to an overemphasis on knowledge and clinical reasoning to justify the complexity of practice in the first versions of the standards. Equally, the standards themselves have influenced the nature of the profession: for example, including research as a key role has affected research skill development within the curriculum; identifying three areas of practice within the competency standards (food service, patient care, and community and public health nutrition) has meant that dietitians continue to graduate with a diverse, rather than limited, set of practice context skills. The dietetics profession internationally has also developed competency standards with Canada,6 the USA,7 New Zealand,8 the UK9 and Europe,10 each having a set of standards or capabilities to define their roles in their respective countries. This international movement is accompanied by ongoing reviews of the standards to reflect the changing expectations and work contexts of dietitians. This paper aims to explore professional competence and the strengths and limitations of competency standards in nutrition and dietetics. Through this exploration using narrative reviews of the literature, the intention is to broaden the reader's views and understandings of competence and to suggest a productive way forward for the profession in its future use of the concept of developing professional competence. Competency standards define the practice of a profession11 and provide a framework from which to accredit education programs and to prepare professionals for practice.12 Before discussing the development of professional competence, it is first important to define the terms ‘competency’ and ‘competence’, which are distinct. Competence is ‘the ability to make satisfactory and effective decisions or to perform a skill in a specific setting or situation’13 (p. 921) or ‘the bringing together of different components to perform, do something successfully or manage complex situations’14 (p. 361). It ‘is multi-dimensional and dynamic… developing or receding over time, and is grounded in the environment of practice’15 (p. 641). Competency, on the other hand, refers to ‘an observable ability… integrating… knowledge, skills, values and attitudes’15 (p. 641). Competency-based education uses the framework of competency standards to plan, implement and evaluate teaching and learning.15 Growing professional competence as a dietitian involves both an initial attainment of competence at the point at which a trainee is deemed ‘competent’ to enter the workforce, as well as a commitment to the continued development of new skills, and revision of previously mastered skills, to adapt to new contexts and changing work environments and challenges.15 Using competency standards as an entry point for a profession carries the risk of promotion of the flawed perception of performance as being something static. The complexity of skill acquisition is better understood as a continuum, whereby an individual develops additional abilities leading to expertise or mastery by practising the same skills in a continuing education environment with increasing complexity.13, 16 Competency-based education includes teaching and learning strategies that are directed towards the achievement of competency standards as outcomes, and that are accompanied by competency-based assessment. Assessment of competence is a key component of competency-based education and continued professional development.17 Competency-based assessment encompasses both the assessment of simulated performance and of actual observed performance in the workplace. Such assessment is used for certification, for entry into the workforce and for professional development. It is necessary to view assessment as a whole system, rather than focusing on individual tasks or observations.18 However, the importance of credible, dependable, feasible and acceptable individual assessment instruments that promote learning cannot be ignored.19 A ‘system of assessment’ is a program of learning and assessment activities that contribute to the development of competence, with these activities being intricately linked, interconnected and dependent on each other reflecting the multidimensional and dynamic nature of competence.19 A competency-based assessment system provides a body of evidence that illustrates an individual's competence to practice against competency standards. Defining professional competence within a framework of standards has several advantages and multiple uses. Competency standards support a shared understanding of acceptable entry-level performance relevant to the workplace and they focus on outcomes. They assist in designing education programs to meet the requirements for accreditation. This includes the implementation of judgment-based approaches to the assessment of the achievement of competence, so eliminating time as the main factor in determining readiness to practice.5 Competency standards can also be used to direct continuing learning and to guide the processes for credentialing overseas-trained dietitians and dietitians returning to practice. In addition, by describing the expected knowledge, skills and behaviours of dietitians and the minimum standards of safe and effective performance in the workplace, competency standards clarify the expectations of those outside the profession.20 In dietetics, competency standards have been used to describe the skills and practice of graduates from dietetics programs12 and to articulate the more advanced skills of practitioners in specialist fields.21, 22 There is little dispute about the key advantages of competency standards: they provide a descriptive account of observable performance; they focus on outcomes; and they support preparation for the current workplace.5 Competency standards frameworks also demark a profession describing what makes it unique and how it is distinct from other professions. However, notwithstanding these perceived benefits, there has been much criticism of the competency-based education movement. This paper will now discuss these debates and suggest ways of overcoming the limitations of the competency-based approach. In their work in the mid-1900s on competency standards, Gonczi and Hager23 describe the notion of ‘integrated competence’ which refers to a framework of written statements that describe both the major tasks and attributes (knowledge, skills and attitudes). They argue that integrated competence requires the ability to encapsulate the depth and breadth of professional practice, including complex clinical reasoning skills.23 Despite this intent, the theoretical foundation of competency-based education, whereby the development of professional practice can be described as a distinct set of measurable tasks, has been said to hinder the development of professional expertise.14, 24 Many competency-based assessment approaches are centred on individual competency elements or performance criteria, with the link to the whole picture of competence left unclear. Dietetic assessors have described their lack of faith in a ‘tick-box’ approach to competency-based assessment, acknowledging the risks of failing to see competence as being something more than just the sum of its parts.25 Measuring what is easily measurable. It is also argued that the comparative ease of measurement/assessment of knowledge and skills can lead to them dominating competency standards, with insufficient acknowledgement of complex (and more difficult to assess) attributes such as professionalism, advocacy and leadership, which are essential for effective practice.24 This is indeed the case for the competency standards for dietitians in Australia where the greatest emphasis has been on the nutrition care process (assessment and communication across patient care, food service, and community and public health nutrition), with less attention given to professional qualities.20 This contrasts with generic health professional standards, where there is a greater focus on the skills required to function effectively in a complex health system (such as values, collaboration, approach and commitment to lifelong learning), and less emphasis on the discipline-specific skills.26 To date, competency standards for dietitians have predominately emphasised the knowledge and skills (or ‘science’) of dietetics and devoted less attention to the attitudes and wisdom (or ‘art’) required for successful practice.20 For example, focusing on the process of nutrition assessment, planning and evaluation across all areas of practice instead of measuring the outcomes of practice or teamwork.20 This contrasts with generic health professional competency standards which emphasise the professional attributes and collaboration required for effective practice.26 The evidence suggests that professional skills are valued by the health professions, but they are inadequately taught and assessed.27 Recent health workforce movements have aimed to highlight the importance of professional qualities in the practice of delivering effective care as a health professional.26 As a profession, we should not be afraid to articulate the professional attributes that we expect and aspire to, even though measuring their achievement requires judgment and may be subjective. Within health professional education, there have been recent calls to acknowledge the limitations of traditional methods of competency-based assessment in a complex workplace setting, and to consider that it can be desirable to embrace subjectivity and expert judgment as a component of best practice assessment.28, 29 The challenge that lies ahead to become comfortable with a dialogue about what we expect of professional practice and to accept that judgment of these attributes needs to be made as descriptive words or criterion-referenced scales. The system will also be strengthened by an evolution of the roles of a range of different players, including other health professions and patients, in making judgments about competence. The focus on competence as something acquired by individuals brings its own limitations as we try to create a dynamic health workforce equipped to address the burden of disease and disability. While dietetic competency standards do highlight the role of the individual practitioner as part of a team to improve nutrition outcomes,20 these competencies are nevertheless constructed as behaviours that an individual can demonstrate. There is a failure to recognise the relationship between the competence of the individual and the shared competence of the teams within which that individual works.1 One reason for this may be a lack of validated instruments to assess teamwork.30 It is certainly a challenging task to make a judgment on the role of an individual learner as part of a complex system, where they participate in authentic situations and navigate a myriad of social process, political and individual factors that influence the system. Any such judgment must acknowledge that learning is achieved through shared interaction and knowledge generation and this is a way in which competence could be viewed more broadly.1 Acknowledging the dynamic nature of competence is essential for understanding competence in the context of teamwork. Competence is grounded in the environment of practice and developed through the application of knowledge to problem solving in differing situations and work contexts. Health professionals make decisions that are dependent on the environment in which the problem is situated. As such, competence is not static. Participation or situated learning is essential for the development of competence, and individuals and teams may be competent in one context but not another. Learning requires participation in the situation, and thus learning and competence development is a continuous process.1 Dietitians problem-solve food and nutrition issues in a range of environments, including patient care, food service and population health. A competent dietitian needs to show the ability to apply knowledge and skills within the complexity attendant to each of these unique environments. The application of knowledge in context is important, both for competence and for the development of expertise.31 There is a tendency to think of competence as a minimum performance standard. This has been criticised for supporting the development of mediocre professionals and prompted calls for thinking about ‘excellence’ rather than ‘competence’. Knowledge situated within practice enables the development of expertise.31 A community of practice, whereby people with a common issue or interest come together to discuss best practice, share resources and develop new knowledge to improve their individual and group professional practice,32 has been described as an example of situated learning. Through experiences, practitioners work with others to develop solutions, reflect on practice and recognise the role of the sociocultural environment of the workplace in shaping learning.33 Acknowledging the role of knowledge as a community resource can assist our understanding of individual competence, as well as the development of expertise.31 A more recent critique of competency is the lack of attention paid to emotion as a component of competence. McNaughton and LeBlanc argue that emotional competence is essential for health professions.34 In dietetics, as with other health professions, the term ‘emotion’ is notably absent from dietetics competencies internationally.6-9, 20 The most likely reasons for this stem from a fear that emotion interferes with a professional's ability to be objective, to make accurate assessments, and to devise appropriate management plans for the patients, groups and communities they serve.34 However, emotional intelligence, which has been defined as ‘the perception, processing, regulation and management of emotions’, has been shown to improve empathy, teamwork, communication skills and health outcomes.35 When defining and assessing professional competence, it is possible, although difficult, to articulate emotion as a part of an individual's values, attitudes and beliefs, and to make a judgment about their demonstration of this. At the crux of an unease about emotion is the discomfort assessors commonly feel when making judgments of learners' professional attributes. The challenge is to embrace this important attribute and assess it in our developing professionals. To my knowledge, the new Australian competency standards will be the first to acknowledge the role of emotional intelligence as central to the professional practice of dietitians. When conceptualising competency standards as a framework that can be understood by many, it has been essential to use words to document the specific competencies. However, written words have several limitations, as some elements of professional practice are tacit. It is difficult to fully capture in words alone the complex ways in which an individual practitioner navigates their delivery of health care between patients, groups, communities and the professional teams within which they work. Dietetics educators have expressed differences in expectations of competence.36 Competency standards should be thought of as a guide, rather than a rigid specification, due to the clear limitations of language to describe the reality of professional practice and its nuances.37 A range of methods has been used to develop competency standards for health professions internationally. In Australia, a diverse range of approaches has been used to develop competency standards for dietitians.12 Despite their differences, all these approaches have incorporated the views of experts as to what constitutes ‘competence’ notwithstanding the fact that the profession has expressed difficulties in defining competence.25, 38 Although patients' needs seem to have been a driver for the competency-based education movement, patients themselves have had little say in the development of standards of performance. While the role of experts is essential for the development and delineation of what constitutes competence, developers of competency standards may also wish to consider the views of others, in particular the people and communities in which the professional works. The discussion above highlights the challenges we face in developing and using competency standards, and the concept of competence, for the development and advancement of our profession. While we need to acknowledge its limitations, moving away from competency-based education is not the solution. We must move beyond the view of competence as a ‘tick-box’ approach, and with an awareness of its constraints, work to apply the development and advancement of professional competence into the future. To understand competence in this field, it is essential to have an understanding of health care as a complex system that an individual professional needs to navigate, utilise and appreciate to improve health outcomes. The development of professional competence is progressive over time and is dependent on the context of practice. ‘Competence is a point on the performance spectrum’.13 The degree of performance depends on the complexity of the practice setting and scenario, and the individual's skills, but also on factors such as the work environment, personality, emotional status and physical health.13 What is needed is to work towards a systems approach to assessment that utilises multiple methods, at multiple points in time, where assessors embrace subjectivity and judgment and acknowledge the importance of delineating and assessing professional attributes such as emotional intelligence.19 It is better to invest in developing the profession's ability to make judgments about both the ‘art’ and ‘science’ of dietetics than it is to sharpen the instruments used for assessment.39 In defining and assessing professional competence, the uniqueness of the environment in which competence is being developed or assessed must be considered as must the complexity of the social and political factors that need to be navigated in pursuit of the development of competence. It is important to recognise the role of the dietitian within communities of practice and to acknowledge that, together with individual competence, a dietitian must be part of the collective competence of other professionals. Assessors, managers and learners should reflect on the role of the multitude of factors that affect performance in workplace environments. Only then will we truly be able to understand the relationship between competence and performance. Rather than aim for minimum standards of ‘competence’, the profession is challenged to create mechanisms and policy within organisations and accreditation systems from which to strive for ‘excellence’. One way forward may be to embrace and acknowledge the subjectivity implicit in the language used to describe the standards. If we acknowledge the limitations of words to adequately describe aspirational performance in practice, we may be encouraged to explore the value of dialogue, illustrations and expert judgment in making decisions about what competence is and looks like. Work-based learning and assessment needs to be viewed as a ‘socially situated interpretive act’.28 Competency standards can be seen as providing a springboard to lifelong learning, rather than as reaching a plateau of attainment of skills and knowledge that do not need further development. The Advanced Accredited Practising Dietitian competency standards provide guidance on continued learning post-entry into the workplace and reinforce the idea that competence is a continuum of developing performance towards mastery.21 By broadening our profession's (including students') view and understanding of competence and competency standards, we will be better prepared as dietitians to make a difference to the nutritional health of the individuals, groups and communities with whom we work. This work received no funding but was completed at the time the author was completing research for DAA on revising the national competency standards for dietitians. The author has no conflicts of interest to declare. The author conceptualised the review, undertook literature review and analysis, drafted the manuscript and approved final contents. The comments by the anonymous reviewers were highly valued in an improved final product.

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