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Continuing Competence Programs for Registered Nurses and Nurse

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					Continuing Competence Programs for
Registered Nurses and Nurse Practitioners




       Consultation Paper
       February 2008
Continuing Competence Programs for RNs and NPs: Consultation Paper




                 ii
     Continuing Competence Programs for RNs and NPs: Consultation Paper



               Table of Contents

Introduction .......................................................................................................... 1

Continuing Competence....................................................................................... 2

Beliefs and Guiding Principles ............................................................................ 3

Background: What is Driving the Shift Towards Continuing Competence
Programs .............................................................................................................. 4

Key Stakeholder Roles ......................................................................................... 4

Continuing Competence Programs ...................................................................... 5

Continuing Competence - Tool Box .................................................................... 6

Summary ............................................................................................................ 11

References .......................................................................................................... 13

Appendix A ........................................................................................................ 17

Appendix B ........................................................................................................ 19

Appendix C ........................................................................................................ 20




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  Continuing Competence Programs for RNs and NPs: Consultation Paper




Introduction                                 This paper will introduce members to
                                             the concept of continuing compe-
                                                                                        ARNNL is in the early
The Association of Registered Nurses         tence, highlight the views of our          stages of developing a
of Newfoundland and Labrador                 members, summarize the role of key         mandatory continuing
(ARNNL) is the regulatory authority          stakeholders, and present an overview      competence program
and professional organization govern-        of the selected tools and approaches       (CCP) for RNs and NPs.
ing registered nurse (RN) and nurse          commonly used in CCPs. The paper
practitioner (NP) practice in this prov-     will also serve as the basis for discus-
ince. The primary mandate of                 sion as the ARNNL considers its op-
ARNNL is public protection – ensur-          tions. As work continues on the
ing its members are safe, competent,         ARNNL CCP, the Association will
and ethical practitioners.                   also address issues such as (a) ensur-
                                             ing confidentiality of a nurse’s CCP
Through the RN Act ARNNL has the             records, (b) legislative protection of
authority to implement regulatory ac-        CCP documents from legal proceed-
tivities in the public interest, including   ing, c) an audit/verification process to
requirements for annual renewal of a         confirm compliance with CCP re-
RN and NP practicing license. Cur-           quirements, and (d) a process for
rently, RNs and NPs must submit              evaluation.
proof of ongoing maintenance of
competence, including having the re-         ARNNL values the input from its            ARNNL values the input
quired numbers of hours of practice                                                     from its members and key
                                             members and key stakeholder groups.
                                                                                        stakeholder groups. This
within a five-year period to qualify for     This consultation process therefore        consultation process there-
licensure renewal. The requirements          aims to seek input about the model         fore aims to seek input
for professionals to provide proof of        that would be most effective in meet-      about the model that would
ongoing maintenance of competence            ing the needs of our nurses, and those     be most effective in meet-
have changed, however, and practice          of our key stakeholders. The ARNNL         ing the needs of our
hours alone are no longer seen as a          is interested in developing a meaning-     nurses, and those of our
true measure. Regulatory bodies for          ful program for RNs and NPs in all         key stakeholders.
health professionals across Canada           practice domains, regardless of their
and internationally have moved, or are       role.
moving, towards more valid measures
of ongoing maintenance of compe-             The consultation paper will be posted
tence through implementation of con-         on the ARNNL website. We encour-
tinuing competence and/or assurance          age you to complete the questionnaire
programs.                                    found in Appendix A, or respond on-
                                             line. ARNNL will be conducting fo-
ARNNL is in the early stages of de-          cus groups and education sessions in
veloping a mandatory continuing              major areas of the province between
competence program (CCP) for RNs             February and April 2008, including a
and NPs. The primary impetus is to           teleconference presentation on April
ensure nurses are able to continue to        1, 2008. In addition, key nurses, nurs-
deliver quality nursing care during          ing groups, and stakeholders will be
their career based upon the most cur-        contacted by mail for their opinion. A
rent evidence. The ultimate goal of a        background paper on continuing com-
CCP is to improve client outcomes            petence was prepared for the ARNNL
and ensure public protection.                in May 2007. This document provides


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                                  Continuing Competence Programs for RNs and NPs: Consultation Paper




                               greater detail and can be accessed on      knowledges that RNs in this province
                               the ARNNL website.                         are already engaged in a variety of
                                                                          activities to enhance competence
                               Continuing Competence                      throughout their careers. Some nurses,
                                                                          for example, take university courses
                               Continuing competence is defined as        or participate in structured continuing
A CCP focuses on promot-       “the ongoing ability of a nurse to inte-   education programs. Others write cer-
ing the maintenance and        grate and apply the knowledge, skills,     tification exams, seek out learning
acquirement of the compe-      judgments and personal attributes re-      opportunities in their respective clini-
tence of RNs throughout        quired to practice safely and ethically    cal areas through in-services, nursing
their careers (CNA, 2000).                                                rounds, journal clubs, unit-level pres-
                               in a designated role and set-
                               ting” (CNA & CAUSN, 2004). A               entations, self-directed study and
                               CCP focuses on promoting the main-         mentoring colleagues. Still others par-
                               tenance and acquirement of the com-        ticipate in special interest groups and
                               petence of RNs throughout their ca-        Association committees. Surveys in-
                               reers (CNA, 2000). In addition to ad-      dicate that our members realize that
                               dressing the regulatory mandate of         continuing education is important in
                               public protection, a CCP plays an im-      the maintenance of competency. The
                               portant role in supporting RNs in their    majority receive support for continu-
                               professional commitment to life-long       ing education and professional devel-
                               learning and excellence. A mandatory       opment from their employers. Not-
                               CCP will establish a more formal           withstanding, the ARNNL is aware
                               structure for the assessment and docu-     that several issues remain that affect
                               mentation of competence. More im-          nurses’ ability to access continuing
                               portantly, participation in a CCP dem-     education (i.e., financial and human
                               onstrates accountability to the general    resource concerns), and it is our inten-
                               public, and contributes to the ARNNL       tion to work with employers through-
                               primary mandate of public protection.      out the province to address these is-
                                                                          sues and improve access.
                               The ARNNL’s Standards of Nursing
The ARNNL’s Standards of       Practice (2007) emphasize the impor-
Nursing Practice (2007)
emphasize the importance
                               tance of RNs maintaining and enhanc-
of RNs maintaining and         ing competencies. Standard 2 states
enhancing competencies.        that the RN “models commitment to
Standard 2 states that the     continuing competence through life-
RN “models commitment          long learning, reflective practice and
to continuing competence       integration of learning into practice.”
through life-long learning,    RNs in this province have already
reflective practice and        indicated their support for a CCP. In a
integration of learning into   2003 ARNNL Membership Survey,
practice.”                     over 88% of respondents agreed that a
                               program is necessary to enable RNs to
                               assess their competency and to iden-
                               tify needs for continuous learning
                               (ARNNL, 2003). The ARNNL ac-



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 Continuing Competence Programs for RNs and NPs: Consultation Paper




Beliefs/Guiding                          benchmark for RNs as they reflect on
                                         their current practice, consider their
Principles                               accountability to their clients, and
                                         work to strengthen their competence.
The CNA developed A National             Figure 1 outlines the continual proc-
Framework for Continuing Compe-          ess linking the code of ethics, stan-
tence Programs for Registered Nurses     dards of practice and life-long learn-   Figure 1 outlines the con-
to provide guidelines for a broad,       ing to continuing competence. The        tinual process linking the
flexible approach for nursing regula-    arrow and spiral in the diagram repre-   code of ethics, standards of
tory bodies in developing CCPs           sent a continual cycle over the course   practice and life-long
(CNA, 2000). The ARNNL partici-          of a nurse’s career.                     learning to continuing
pated in the development of this docu-                                            competence. The arrow
ment and supports its beliefs and                                                 and spiral in the diagram
guiding principles. Appendix B pro-                                               represent a continual cycle
vides a summary of the salient points.                                            over the course of a
                                                                                  nurse’s career.
The ARNNL’s Standards of Nursing
Practice (2007) and the CNA Code of
Ethics for Registered Nurses provide
a foundation for the development of a
CCP. These documents serve as the




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                                Continuing Competence Programs for RNs and NPs: Consultation Paper




How can the public be        Background: What is                        there is no formal mechanism to en-
assured that RNs are con-                                               sure that nurses remain competent
tinuously updating their     driving the shift towards                  throughout their careers. The main
knowledge on a regular       mandatory     continuing                   indicator for continuing competence is
basis, and incorporating                                                the annual reporting of practice hours.
what they have learned
                             competence programs?
                                                                        There is widespread agreement, how-
into their practice?
                             The health care system is undergoing       ever, that minimum practice hours
                             rapid change. A nurse’s practice envi-     should not be the sole indicator in
                             ronment is increasingly complex and        measuring ongoing competence.
                             challenging, and marked by new and
                             emerging knowledge, technologies,          The trend towards the development of
                             treatment modalities, and research.        CCPs is occurring in all health profes-
                             Client demographics have also al-          sions and in other non-health regula-
                             tered, and new skills are required to      tory professional bodies nationally
                             meet changing, more diverse, client        and internationally. This movement
                             needs. All of this is happening within     reflects the increased emphasis on
                             an environment of varying resource         public accountability. While the ma-
                             capacities. Over the past decade there     jority of health professionals welcome
                             has been increasing pressure from the      this move, there will always be a mi-
                             general public, government, and            nority who will question the need for
                             within the health care professions         a CCP. Some may argue that compe-
                             themselves to improve accountability       tence is assured by prolonged clinical
                             through more rigorous assessment of        experience. Research across the health
                             entry-level and continued compe-           professions, however, has demon-
                             tence. The quality assurance focus         strated that the length of time a pro-
                             within the health care system is also      fessional has been practicing is not a
                             driving the movement for more strin-       good indicator of competence (Aiken,
                             gent assessment of continuing compe-       Clarke, Cheung, Sloane & Silber
                             tence.     The hallmark of a self-         2003; Austin, Marini, Croteau & Vio-
                             regulating profession is the expecta-      lato, 2004; Choudry, Fletcher &
                             tion that the profession be responsible    Soumerai, 2005).
The trend towards the de-    for assuring the competence of its
velopment of CCPs is oc-
curring in all health pro-
                             members. In the past it was deemed         Key Stakeholder Roles
fessions and in other non-   acceptable for individual practitioners
health regulatory profes-    to renew annually based on their past      The focus on the RN’s responsibility
sional bodies nationally     achievement of entry-level license and     for life-long learning does not mini-
and internationally. This    their ability to assess their own com-     mize the importance of other stake-
movement reflects the in-    petence. This is no longer acceptable.     holders. Promoting continuing compe-
creased emphasis on pub-     How can the public be assured that         tence is a collaborative responsibility
lic accountability.          RNs are continuously updating their        involving the individual nurse, profes-
                             knowledge on a regular basis, and          sional and regulatory bodies, employ-
                             incorporating what they have learned       ers, educational institutions, and gov-
                             into their practice? While ARNNL           ernments. Because most RNs are em-
                             ensures candidates for initial registra-   ployees, employers have a responsi-
                             tion meet entry-level competencies,        bility to ensure that the practice envi-



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    Continuing Competence Programs for RNs and NPs: Consultation Paper




ronment has strong organizational                             learning plan. The evaluation compo-
attributes that support nurses in main-                       nent relates to the achievement of the
                                                                                                                               The concept of continuing
taining and acquiring competence                              objectives outlined in the learning                              competence is now well
(CNA, 2000). Nursing and other col-                           plan. Peer review/feedback is a com-                             integrated into the policy
leagues have a responsibility to sup-                         ponent of several programs. A self-                              agenda of all nursing juris-
port RNs in maintaining and acquiring                         declaration indicating that the member                           dictions.
competence through peer feedback                              has completed the continuing compe-
and mentoring. Educators must instill                         tence requirements is included on the
in students the importance of continu-                        annual renewal form. Random audits
ing competence, life-long learning                            or verification occur in several juris-
and reflective practice. Students must                        dictions.
realize that they will be required to
periodically demonstrate their compe-                         In addition to standards of practice,
tence throughout their careers. Clini-                        any assessment of competence must
cal educators also play a role in devel-                      also be relevant to the nurse’s scope
oping and implementing evidence-                              of practice. In this province, NPs have
based clinical education programs that                        a much broader scope of practice than
support and encourage nurses to                               RNs. NPs have legislative authority to
maintain and enhance their compe-                             autonomously diagnose, order, and
tence.                                                        interpret diagnostic tests, prescribe
                                                              pharmaceuticals and perform specific
Continuing Competence                                         procedures (CNPI, 2006). A number
                                                              of provincial regulatory bodies require
Programs                                                      more rigorous CCP components for
                                                              NPs because of the potential greater
As ARNNL moves forward in devel-                              risk to the public in regard to their
oping a CCP, ARNNL can benefit                                additional scope of practice require-
from the experiences of other nursing                         ments. During development of an
and health regulatory bodies. The Ca-                         ARNNL CCP, consideration will be
nadian nursing profession has clearly                         given to the need for additional re-
accepted the need for mandatory                               quirements for NPs in this province.
CCPs, and there has been consider-
able movement in this area over the                           Other professional bodies are also
                                                                                                                               Other professional bodies
past 10 years. The concept of continu-                                                                                         are also engaged, in vary-
                                                              engaged, in varying stages, in the de-                           ing stages, in the develop-
ing competence is now well integrated                         velopment of CCPs. These programs                                ment of CCPs. These pro-
into the policy agenda of all nursing                         have different levels of rigour in rela-                         grams have different levels
jurisdictions. While there are vari-                          tion to competency assessment1 ele-                              of rigour in relation to
ances, all of the programs are founded                        ments. In Ontario, British Columbia,                             competency assessment1
on the standards of practice and the                          and Alberta, the demonstration of                                elements.
code of ethics and stipulate a report of                      continuing competence is now a legis-
practice hours as a precondition for                          lative responsibility of all health regu-
renewal of licensure. Most programs                           latory bodies in these provinces. The
require reflective practice and self-                         colleges, therefore, must have a CCP
assessment based on the nursing stan-                         in place with quality assurance ele-
dards. All require the development,                           ments. Appendix C provides an over-
implementation, and evaluation of a
1
 Competence Assessment is an external evaluation of the RN’s ability to integrate and apply the knowledge, skills, judgment and personal attributes required to
practice safely and ethically in a designated role and setting (CNA, 2000)

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                                  Continuing Competence Programs for RNs and NPs: Consultation Paper




                               view of select programs and the varia-
                               tion in the types of approaches used to
                                                                         Tools
No standardized tools or       demonstrate or measure maintenance
approaches are capable of      of competence.                            Mandatory Continuing Edu-
meeting all of the require-                                              cation (CE) Hours
ments of validity, reliabil-
ity, cost effectiveness and    Continuing Competence
                                                                         However, there is sound evidence that
achievement of improved        – Tool Box                                mandatory CE hours is not an effec-
health care outcomes...
                                                                         tive method of ensuring competence
                               Tools and approaches for assessing        (Davis, et al., 1999; Lyon & Boland,
                               and documenting continuing compe-         2002; Vaughn, Rogers, & Freeman,
                               tence are discussed thoroughly in the     2006). Other studies have concluded
                               literature. No standardized tools or      that CE using traditional teaching
                               approaches are capable of meeting all     techniques has had minimal impact on
                               of the requirements of validity, reli-    practice performance. The problem
                               ability, cost effectiveness and           inherent in many CE-based programs
                               achievement of improved health care       is that there is no requirement for a
                               outcomes (De Vera Barredo, 2001;          needs assessment prior to participa-
                               Meretoja, & Leino-Kilpi, 2001;            tion, and no evaluation of the impact
                               Swankin, LeBrhn, & Morrison, 2006).       on professional practice. The basic
                               Cognitive knowledge is important, but     premise of a CE-based program is that
                               in measuring continuing competence,       the professional is able to self-identify
                               it may be more important to look at       what they need to learn, that they will
                               clinical performance or the profes-       participate fully in the program, and
                               sional’s competence in the practice       that they will apply what they have
                               setting. Clinical practice measurement    learned.
                               is certainly more difficult.
                                                                         While the limitations of traditional CE
                               The challenge for nursing associations    mandates are well documented, many
                               such as the ARNNL is to develop in-       health professionals argue that they
                               novative approaches capable of re-        would prefer mandatory CE credits as
                               flecting the variations in scope of       the basis of their program (Austin,
                               practice. Because of the lack of re-      Marini, Glover, & Croteau, 2005;
                               search to support the use of one tool     College of Registered Nurses of Brit-
Traditional approaches to      over another, most regulatory bodies      ish Columbia [CRNBC], 2005). The
professional development       offer several options to their mem-       main complaint about requiring man-
have often focused on man-     bers to meet their CCP requirements.      datory CE involves concerns about
datory continuing educa-       The tools discussed below are com-        inequities in access to quality educa-
tion (CE) hours and re-        monly used by nursing and other
porting of practice hours.                                               tional opportunities which are often
                               health regulatory bodies in CCPs.         more pronounced in rural and isolated
                               Some of the tools listed are used for     areas. This approach, however, takes a
                               promoting continuing competence,          narrow view of continuing education.
                               and others are used for more rigorous     Opportunities exist for individually
                               competence assessment and assurance       driven CE activities such as journal
                               programs.                                 clubs, clinical rounds, employer in-
                                                                         service, academic courses, profes-



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  Continuing Competence Programs for RNs and NPs: Consultation Paper




sional committee/interest groups, pre-     making a plan to address gaps. But is
ceptorship, on-line self-study mod-        self-assessment sufficient in determin-
ules, and research projects. In some       ing competence?
regulatory bodies, formal CE is one
feature of a program; however, a vari-     The main criticism of self-assessment
                                                                                      Self-assessment is the foun-
ety of other options are also offered to   is that it is subjective; therefore, the   dation of many CCPs in all
meet professional development needs.       same level of public accountability        professions.
Establishing a CE structure with more      does not exist. There is no external
formal documentation of learning plus      assessment or judgment to validate
evidence of how the learning is rele-      the professional’s observations. Evi-
vant to practice is recommended.           dence suggests that how health pro-
Standardized needs assessments and         fessionals rate their own strengths and
other strategies such as peer valida-      weaknesses in a self-assessment is not
tion of learning needs may enhance         reliable (Davis et al., 2006; Regehr &
the reliability of CE mandates. Insist-    Eva, 2006; Swankin et al., 2006; Vio-
ing that the CE tie in to the nurse’s      lato & Lockyear, 2006). Individuals
area of practice, be evidence-based,       may lack insight into their practice.
and include a validation or testing of     Even when adult learners identify
course material are ways to address        gaps or weaknesses in knowledge,
the limitations of this approach.          they still avoid learning in this area
                                           because the learning requires too
Self-assessment                            much energy and commitment
                                           (Regehr & Eva, 2006). These findings
                                           are consistent with other researchers
Self-assessment is the foundation of
                                           who found that nurses usually at-
many CCPs in all professions. It is
                                           tended CE they were interested in, not
widely used in nursing and recognizes
                                           necessarily those that they needed
that nurses are competent, self-
                                           (Hughes, 2005; Smith, 2004).
regulating professionals, who are
committed to life-long learning. All
Canadian nursing CCPs use self-            Peer Feedback
assessment as the primary tool to re-
flect on practice, identify learning       Peer feedback is recommended as an
needs, and develop a learning plan.        option in the majority of CCPs in
                                                                                      Peer feedback is recom-
Self-assessment tools are viewed as        Canada. There is, however, consider-       mended as an option in the
confidential, and are generally not        able trepidation about the concept. It     majority of CCPs in Can-
submitted for review to the regulatory     has generally not been well received,      ada.
body unless requested through an au-       and is often viewed in a negative
dit. From a regulatory perspective it is   light. The term “peer feedback” is
easy to see why self-assessment is         commonly misunderstood and viewed
widely used: it is easy to administer,     as “peer evaluation.” Research, how-
accessible, cost effective, and gener-     ever, indicates that the process of en-
ally acceptable to health profession-      gaging in peer feedback encourages
als. Self-assessment encourages the        participants to become more intro-
practitioner to be actively involved in    spective and reflective (Vuorinen,
identifying learning needs and in          Tarkka, & Meretoja, 2000). The inclu-




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                                 Continuing Competence Programs for RNs and NPs: Consultation Paper




                              sion of peer feedback in a program          vidual’s practice is reviewed in the
                              helps “to validate your self-               context of the case studies, using pre-
                              assessment and/or provide new infor-        determined questions. The reviewer(s)
Peer review is a more in-
tensive form of assessment.   mation” (CRNM, 2006). One limita-           provide feedback on excellence in
                              tion of peer feedback centers on the        practice, areas for improvement, and
                              notion that colleagues may lack in-         assists in guiding the peer in future
                              sight in identifying weaknesses in          professional development activities.
                              practice because they are part of the
                              same system. The views of one’s col-        The one drawback to peer review is
                              leagues, therefore, may not be an ac-       the cost, both financially and in hu-
                              curate reflection of a health profes-       man resources. Peer reviewers require
                              sional’s competence. Relationships          review and constructive feedback
                              among peers influence the reliability       training. Another drawback is that
                              of peer assessments (Noricini, 2003).       peer review does not evaluate non-
                              When peers are self-selected they may       cognitive skills such as communica-
                              find it difficult to be critical, and may   tion. When used in conjunction with
                              not provide objective information. In       other assessment tools, however, va-
                              some situations, an assessor may ad-        lidity may be improved. In a review of
                              just the feedback to avoid potential        the effectiveness of audit and feed-
                              conflict in the workplace.                  back on health professional practice,
                                                                          there were greater improvements
                              Peer Review                                 when the health professional’s adher-
                                                                          ence to standards was low and when
                              Peer review is a more intensive form        the feedback was delivered more in-
                              of assessment. Rout and Roberts             tensively (Jamtvedt, Young, Kristof-
                              (2007) describe peer review as “an          fersen, O’Brien, & Oxman, 2006).
                              organized effort whereby people criti-      Peer review is often regarded as an
                              cally appraise, systematically assess,      effective model for practitioners
                              monitor, make judgments, determine          working in either isolated practices or
                              their strengths and weakness and re-        in independent practices where there
                              view the quality of their practice, to      is considerable autonomy.
                              provide evidence to use as the basis of
                              recommendations by obtaining the            Performance Appraisals
                              opinion of their peers”. Several phar-
                              macy, medicine, physiotherapy and           Performance appraisal is also a form
                              midwifery programs use peer review          of peer review. A performance ap-
                              through on-site assessment, group           praisal is an evaluation of an em-
Performance appraisal is      practice peer feedback, or clinical         ployee’s performance by an employer
also a form of peer review.   case reviews. Some NP and mid-              or manager. Performance appraisal is
                              wifery CCPs in Canada require each          an ongoing, two-way process involv-
                              practitioner to participate in a mini-      ing reflection on an individual’s per-
                              mum of six peer case reviews each           formance, identification of education
                              year. The peer review is conducted as       needs and planning for personal de-
                              an interview and structured around the      velopment (British Medical Associa-
                              presentation of case studies. The indi-     tion, 2003). It is generally carried out



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    Continuing Competence Programs for RNs and NPs: Consultation Paper




regularly, at least annually. If the indi-                      practice settings. The main barrier
vidual’s practice is evaluated against                          identified in the literature, and in dis-
                                                                                                                                    The use of a professional
practice standards or other compe-                              cussion with colleagues who have                                    portfolio is gaining popu-
tency based-standards, the perform-                             used this process, is the considerable                              larity, both as an important
ance appraisal may be viewed as a                               time to complete and assess the port-                               tool for promoting and
valid and reasonable option for as-                             folio (Butler, 2006). The opportunity                               documenting life-long
sessing ongoing competence.                                     to be selective in content is also a                                learning, and as a tool for
                                                                drawback.                                                           assessing and demonstrat-
Professional Portfolios                                                                                                             ing continuing compe-
                                                                Certification/Recertification                                       tence...
The use of a professional portfolio is
gaining popularity, both as an impor-                           Certification programs and the main-
tant tool for promoting and document-                           tenance of certification, are recog-                                Certification programs and
ing life-long learning, and as a tool for                       nized and valued by the general public                              the maintenance of certifi-
assessing and demonstrating continu-                            as a sound indicator of health profes-                              cation, are recognized and
ing competence (Austin, Marini &                                sional competence (Troyen et al.,                                   valued by the general pub-
Desroches, 2005; Butler, 2006; Had-                             2004; Miller, 2005). There are rigor-                               lic as a sound indicator of
field, Murdoch, Smithers, Valoletti &                           ous guidelines for meeting certifica-                               health professional compe-
Patterson, 2007; McMullan et al.,                               tion eligibility and for maintaining                                tence ...
2003). A portfolio is an “organized                             certification. The CNA has a well-
collection of documents that chroni-                            established certification program in 17
cles your career and demonstrates the                           designated nursing specialties where
activities you have undertaken to as-                           members can apply to be certified
sess and maintain your competence to                            through a rigorous written exam. See
practice” (AARN, 2001). There are                               http://www.cna-ic.ca/CNA/nursing/
various formats. If a portfolio is to be                        certification/default_e.aspx for more
more rigorous in demonstrating con-                             information. The certification creden-
tinuing competence, specific criteria                           tial is an important indicator that the
and standards for content, documenta-                           certified nurse is qualified, competent
tion, and evaluation are needed to                              and current in a nursing specialty
minimize subjectivity.2                                         (CNA, 2007). Specialty certification
                                                                is a voluntary process for nurses who
Portfolios are self-directed and in-                            meet rigorous practice, continuous
clude a self-reflection component that                          learning and testing requirements.
reviews past accomplishments and
activities, identifies learning needs,                          CNA program recertification is re-
and develops a learning plan. The                               quired every five years, either through
portfolio serves to guide further edu-                          written examination or by compiling
cation and practice, acts as a record or                        100 hours of continuous learning ac-
archive of an individual’s professional                         tivities (CE units). While CNA has
career, education history and accom-                            stringent criteria for meeting recertifi-
plishments, or serves simply as a re-                           cation requirements, it offers a variety
pository of career documents and                                of professional development options
achievements. A portfolio is flexible                           such as:
and can be applied to a variety of                              • an academic course (e.g., Masters
2
 Health professional portfolios consist of a series of documents including records of certificates, awards, educational courses, degrees, activities, references, publi-
cations, samples of work, performance appraisals, and client feedback.


                                                                                   9
                                    Continuing Competence Programs for RNs and NPs: Consultation Paper




                                    or Ph.D.) applicable to the area of      counters. The OSCE can be effective
                                    specialization,                          in presenting a wide variety of real-
                                •   CNA exam development,                    life clinical situations. Compared to
                                •   independent study modules,               written exams, the OSCE format more
                                                                             closely reflects realistic clinical prob-
An Objective Structured         •   professional committee member-
                                                                             lems. There is evidence to support the
Clinical Examination                ship (applicable to specialty),
(OSCE) is a clinical skills                                                  reliability and validity of the OSCE as
assessment in which the
                                •   preceptorship, and                       a competency assessment tool
individual is assessed on       •   publication of articles, book chap-      (Adamo, 2003; Rushforth, 2007). It is
their clinical skills in re-        ters, or research projects.              viewed as objective because the ex-
sponse to a variety of clini-                                                aminers are trained, and follow a pre-
cal scenarios that use real     Notwithstanding the variety of op-           established checklist of expected
or simulated clients.           tions, CNA identifies a maximum              clinical behaviours. Each practitioner
                                number of hours a nurse can claim for        is evaluated on the same clinical situa-
                                continuous learning activities. In addi-     tion. The main limitation of the OSCE
                                tion, the CNA requires that a nurse          is that it is costly to develop and im-
                                identify three to five key competen-         plement. Examiners need to be
                                cies that relate specifically to the nurs-   trained, and the scenarios need to be
                                ing specialty to guide continuous            updated regularly and revised to re-
                                learning activities for the five-year        flect current practice. There is also the
                                certification term. Random audits are        added cost of travel to OSCE training
                                completed of 10% of candidates ap-           sites. The artificial testing environ-
                                plying for recertification. The value        ment presents a limitation in that the
                                of a certification program is that it        situations can not fully reflect real-life
                                provides a structured, credible means        situations. Student stress has also been
                                for nurses to demonstrate to col-            identified as a disadvantage.
                                leagues and the general public that
                                they have made a professional com-           Examinations
                                mitment to maintaining competence.
                                                                             Examinations (written or computer-
                                Objective Structured Clinical                ized) are common as tools in CCPs
Examinations (written or        Examination                                  implemented by pharmacy, medicine,
computerized) are common                                                     and selected nursing regulatory bod-
as tools in CCPs imple-
                                An Objective Structured Clinical Ex-         ies. There is value in using well-
mented by pharmacy,
medicine, and selected          amination (OSCE) is a clinical skills        established tests that provide reliable
nursing regulatory bodies.      assessment in which the individual is        and valid information, are relatively
                                assessed on their clinical skills in re-     cost effective, and can test large num-
                                sponse to a variety of clinical scenar-      bers. The main limitation is the inabil-
                                ios that use real or simulated clients.      ity to accurately assess clinical com-
                                The OSCE has been a popular method           petence. Furthermore, it is more chal-
                                of testing medical students, and, more       lenging to develop a test that reflects
                                recently RNs, NPs and allied health          the varying stages of individual ca-
                                students. The OSCE is usually devel-         reers, areas of expertise and types of
                                oped as a series of stations set up as       practice settings. It may also be more
                                standardized, fixed-time client en-          difficult to measure competence in



                                                         10
  Continuing Competence Programs for RNs and NPs: Consultation Paper




practice settings such as administra-      be required to participate in a Practice
tion and education. The issue of re-       Interview (CNO, 2007). If necessary,
testing, however, is contentious, as it    remediation is the final step.
is viewed by some professionals as
punitive and disempowering. More-
over, there are significant financial
                                           Summary                                    Practice interviews are
                                                                                      structured interviews with
and human resource implications, es-                                                  a pre-established set of
pecially when regulatory bodies have       This paper has presented background
                                                                                      questions, and/or scenar-
large numbers of members. As the           information on the development of a
                                                                                      ios, presented to the practi-
testing is more accessible and less        CCP, defined continuing competence,        tioner in a face-to-face
costly for participants, on-line options   identified key stakeholder roles, and      meeting with an inter-
are growing in popularity. Regulatory      highlighted a variety of tools and ap-     viewer.
bodies may also reserve testing for        proaches. There is little evidence that
specific target groups.                    one method or technique for demon-
                                           strating continuing competence is
Practice Interviews                        more valid and reliable than another.
                                           Therefore, researchers recommend           In developing a relevant
                                           using multiple approaches. In devel-       and meaningful CCP for
Practice interviews are structured in-                                                RNs and NPs in this prov-
                                           oping a relevant and meaningful CCP
terviews with a pre-established set of                                                ince, ARNNL will consider
                                           for RNs and NPs in this province,
questions, and/or scenarios, presented                                                the combination of tools
                                           ARNNL will consider the combina-
to the practitioner in a face-to-face                                                 that best reflect a true
                                           tion of tools that best reflect a true     measure of a nurse’s cur-
meeting with an interviewer. Practice
                                           measure of a nurse’s current mainte-       rent maintenance of com-
interviews may also be conducted by
                                           nance of competence for licensure          petence for licensure re-
a group of peers. The interview usu-
                                           renewal. It will also explore ap-          newal.
ally lasts one to two hours. Questions
                                           proaches that assist nurses in uphold-
and scenarios reflect standards of
                                           ing a professional commitment to life-
practice or competencies and the indi-
                                           long learning and continued mainte-
vidual’s ability to meet the standard.
                                           nance of competence.
The strength of a practice interview is
that it assists the interviewer in gain-
                                           Given that the ARNNL is mandated to
ing a deeper understanding of the in-
                                           ensure that its members deliver qual-
diviual’s practice environment; there
                                           ity, safe, ethical care to the general
are also opportunities to probe if a
                                           public, the way forward is clear. We
concern is identified about practice
                                           must develop a program that ensures
competency. From a regulatory per-
                                           that RNs and NPs in this province
spective the training and resources to
                                           meet requirements for professional
support the interviewers may be
                                           practice, including maintenance of
costly. Practice interviews are also
                                           competence, at all stages of their ca-
perceived as stressful for the RN. The
                                           reers.
College of Nurses of Ontario (CNO)
currently uses Practice Interview as a
                                           This paper has presented several op-
component in the Quality Assurance
                                           tions for your consideration. Through
Practice Review. As a first step, a ran-
                                           this consultation process, ARNNL
dom selection of nurses in clinical
                                           members have an opportunity to say
practice and administration are se-
                                           what is most meaningful to them in
lected to complete a written examina-
tion. Based on the results, a nurse may


                                                       11
   Continuing Competence Programs for RNs and NPs: Consultation Paper




meeting their standards for ongoing
maintenance of competence. We value
your input into the ARNNL decision
making process and look forward to
hearing your views.

Thank-you




                     12
  Continuing Competence Programs for RNs and NPs: Consultation Paper


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cal Teacher, (25)3, 262-270.

Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Siber, J.H. (2003). Educational levels of hospital nurses and
surgical patient mortality. Journal of the American Medical Association, 290, 1617-1623.

Alberta Association of Registered Nurses. (2001). Guidelines for Portfolio Development. Edmonton, AB: Author.

Association of Registered Nurses of Newfoundland and Labrador. (2007). ARNNL’s Standards of Nursing Practice.
St. John’s, NL: Author.

Association of Registered Nurses of Newfoundland and Labrador. (2003). ARNNL Membership Survey. St. John’s,
NL: Author.

Austin, Z., Marini, A., Glover, N. & Croteau, D. (2005). Continuous professional development: A qualitative study of
pharmacists’ attitudes, behaviours, and preferences in Ontario, Canada. American Journal of Pharmaceutical Educa-
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Austin, Z., Marini, A., Croteau, D. & Violato, C. (2004). Assessment of Pharmacists’ patient care competencies: Va-
lidity evidence from Ontario (Canada)’s quality assurance and peer review process. Pharmacy Education, 4(1), 23-32.

Austin, Z., Marini, A. & Desroches, B. (2005). Use of a learning portfolio for continuous professional development:
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British Medical Association (2003). Appraisal for medical practitioners. Retrieved January 3, 2008 from http://
www.bma.org.uk/ap.nsf/Content/Appraisal-ref#6

Butler, P. (2006). A review of the literature on portfolios and electronic portfolios. eCDF Portfolio Project. Massey
University College of Education, Palmerston North,NZ. Retrieved March 24, 2007 from https://eduforge.org/docman/
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Canadian Nurses Association. (2004). A National Framework for Continuing Competence Programs for Registered
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Canadian Nurses Association. (2006). Canadian Nurse Practitioner Initiative. Competence Assessment Framework
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Canadian Nurses Association. (2007). CNA 2008 Certification Requirements. Retrieved May 14, 2007 from http://
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Canadian Nurses Association & Canadian Association of Schools of Nursing. (2004). Joint Position Statement of
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Choudry, N.K., Fletcher, R.H., & Soumerai, S.B. (2005). Systematic Review: The Relationship between Clinical Ex-
perience and Quality of Health Care, Annals of Internal Medicine, 142(4), 260-273. Retrieved March 14, 2007 from
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College of Nurses of Ontario (2007). Quality Assurance Program Practice Review. Retrieved March 15, 2007 from
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College of Registered Nurses of British Columbia. (2005).Continuing Competence Program Evaluation:Phase III
Final Report. Vancouver, BC: Author.

College of Registered Nurses of Manitoba. (2006). Continuing Competence: A Strategy for Safe, Competent Practice
and Life Long Learning (Handbook). Winnipeg, MN: Author.

Davis, D.A., Thompson, M.A., O’Brien, A.D., Freemantle, N., Wolf, F., Mazmanian, P., & Taylor-Vaisey, A. (1999).
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De Vera Barredo, R. (2001). Identifying the gaps: reconsidering the issue of continued competence. Rehabilitation
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Hadfield, I., Murdoch, G., Smithers, J.,Valoletti, L. & Patterson, H. (2007). Is a professional portfolio, as a record of
continued professional development, the most effective method to assess a physiotherapist’s competence? NZ Journal
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Hughes, E. (2005). Nurses’ perceptions of continuing professional development. Nursing Standard, 19(43), 41-49.

Davis, D.A., Mazmanian, P.E., Fordis, M., Van Harrison, R., Thorpe, K.E., & Perrier, L. (2006). Accuracy of physi-
cian self-assessment compared with observed measures of competence: a systematic review. Journal of the American
Medical Association, 296:1094-1102.

Jamtvedt, G., Young, J.M., Kristoffersen, D.T., O’Brien, M.A. & Oxman, A.D. (2006). Audit and feedback: effects
on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 1998, Issue 1. Art. No.:
CD000259. DOI: 10.1002/14651858.CD000259.pub2

Lyon, B. L., & Boland, D. L. (2002). Demonstration of continued competence: A complex challenge. Clinical Nurse
Specialist, 16(3), 155-156.

McMullan, M., Endacott, R., Gray, M., Jasper, M.,Miller, C., Scholes, J. & Webb, C. (2003). Portfolios and assess-
ment of competence: A review of the literature. Journal of Advanced Nursing, 41(3), 283-294.

Meretoja, R. & Leino-Kilpi, H. (2001). Instruments for evaluating nurse competence. Journal of Nursing Administra-
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Miller, S.H. (2005). American Board of Medical Specialties and repositioning for excellence in life-long learning:
Maintenance of certification. The Journal of Continuing Education in the Health Profession. 25,51-156.

Norcini, J.J. (2003). Peer assessment of competence. Medical Education, 37(6), 539-543.

Regehr, G. & Eva, K.W. (2006). Self-assessment, self-direction, and the self-regulating professional. Clinical Ortho-
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Rushforth, H.E. (2007). Objective structured clinical examination (OSCE). Review of literature and implications for
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Smith, J. (2004). Exploring the efficacy of continuing education mandates. JONA’s Healthcare Law, Ethics, & Regu-
lation, 6(1), 22-31.

Swankin, D., LeBuhn, R.A., & Morrison, R. (2006). Implementing Continuing Competency Requirements for Health
Care Practitioners. AARP Public Policy Institute. Retrieved February 28, 2007 http://www.aarp.org/ppi

Troyen A., Brennan, M.D., Horwitz, R.I, Daniel-Duffy, F.D., Cassel, C.K., Goode, L.D., & Lipner, R.S. (2004). The
Role of Physician Specialty Board Certification Status in the Quality Movement. Journal of the American Medical
Association, 292, 1038-1043.

Vaughn, T.H. Rogers, J.L. & Freeman, J. K. (2006). Does requiring continuing education units for professional li-
censing renewal assure quality patient care? Health Care Manager, 25(1),78-84.

Violato, C. & Lockyer, J. M., (2006). Self and peer assessment of pediatricians, psychiatrists and medicine special-
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Continuing Competence Programs for RNs and NPs: Consultation Paper




                16
  Continuing Competence Programs for RNs and NPs: Consultation Paper


Appendix A
                                   Feedback Sheet
                   Continuing Competence Program: Consultation Paper
                                Reply by May 30th, 2008
This questionnaire provides an opportunity for you to respond to the continuing competence issues outlined in the
consultation paper. We are interested in hearing your views about what an effective continuing competence program
model should look like for nurses in this province.

This survey is anonymous and your responses will remain confidential.
We anticipate that it will take approximately 20 minutes to complete this survey.
Replies will be accepted up until May 30th, 2008.

Thank you for your time and interest!

1. Overall, how important is it for the ARNNL to develop a program to assist you in maintaining and enhancing
   your competence?
    Very Important              Somewhat Important          Not at All Important

    Please explain.

2. What do you currently do to maintain your competence?


3. What approaches to continuing competence do you think would meet your needs in your current role and work
   setting? (Check all that apply)
  Mandatory Continuing Education Hours               Professional Portfolio
  Self-Assessment                                    Certification/Recertification
 Peer Feedback                                            OSCE
 Peer Review                                              Examinations
 Performance Appraisal                                    Practice Reviews
 Other (please provide details below: )


4. Are there approaches to continuing competence that you would prefer to see excluded or are not of value in the
ARNNL       program?
  Yes                          No                          Don’t Know


If yes, please explain.


5. What supports might be helpful to you in meeting any continuing competence program requirements?




                                                          17
                                     Continuing Competence Programs for RNs and NPs: Consultation Paper




6. Various key stakeholders (e.g., employers, union, educational institutions, peers and colleagues) have roles and
   responsibilities in developing and implementing a continuing competence program. How do you see these groups
   supporting you in maintaining your competence?


7. Have you ever participated in a continuing competence program in another province or country?
  Yes                      No
    If yes, do you have any advice for the ARNNL as we move forward?


8. Do you have any additional feedback or advice?


Demographic Information

9. What is your current employment setting?
  Acute Care
  Long Term Care
 Community
 Other (please specify):

10. What is your current position?
  Direct-care Provider
 Educator
 Manager
 Other (please specify):


11. Number of years you have been nursing:
  < 1                                                   10-14
 1-4                                                    15-19
 5-9                                                    20 +


12. Are you a licensed Nurse Practitioner?


Yes                        No




                                                        18
     Continuing Competence Programs for RNs and NPs: Consultation Paper


Appendix B
Canadian Nurses Association Continuing Competence
Beliefs and Guiding Principles

Continuing Competence

1.      The nursing profession as a whole, through its professional and self-regulatory organizations, promotes the ad-
        vancement of nursing practice, identifies standards of practice and promotes professional development.

2.      Registered nurses are competent, self-regulating professionals and are committed to life-long learning.

3.      Continuing competence is essential to professional nursing practice. It promotes good nursing practice, assists
        in preventing poor practice, and contributes to the quality of nursing practice and best possible client outcomes.

4.      Competence is continually maintained and acquired through reflective practice, life-long learning, and integra-
        tion of learning into nursing practice.

5.       The individual registered nurse has a professional obligation and the primary responsibility for maintaining
         and continually acquiring competence.

6.      Professional and regulatory nursing organizations, employers, educators, and colleagues share the responsibility
        for continuing competence of registered nurses.

7.      An individual’s ability to continually maintain, acquire, or demonstrate competence is influenced by the prac-
        tice setting.

8.      Nursing colleagues, through their moral commitment to their profession and to one another, support each other
        in demonstrating, developing and maintaining competence

9.      The public has the right to expect that registered nurses demonstrate continuing competence throughout their
        careers.




                                                            19
Continuing Competence Programs for RNs and NPs: Consultation Paper




                20
 Continuing Competence Programs for RNs and NPs: Consultation Paper


Appendix C
Examples of Continuing Competence Programs
Note: This summary contains key points of select programs only. Please refer to the organizational website for more
detailed information.

     Jurisdiction                                Continuing Competence Requirements
British Columbia        Hours of Practice 1125 in last 5 yrs (RN)
CRNBC                   CCP called “Personal Practice Review”
                        •    Self-assessment/standards
                        •    Peer feedback
                        •    Develop, implement, & evaluate learning plan

                        At license renewal RN must be able to declare CCP requirements have been met. If not,
                        granted 3-month conditional registration. If after 3-months requirements are not met, noti-
                        fied registration converted to non-practicing status.

College of Pharma-      Professional Development and Assessment Program (PDAP)
cists of British Co-    Phase 1
lumbia                  •     Self-assessment Survey
                        •     Knowledge Assessment (KA) (open book exam)
                        •     Learning and Practice Portfolio (LPP)
                        Phase 2
                        •     Practice Audit (on-site assessment)
                        •     Objective Structured Clinical Examination (OSCE)
                        Phase 3
                        •     Peer Group Review
                        •     Professional Support
                        •     Reassessment


College of Nurses of    CCP is called “Reflective Practice” and it has 5 steps:
Ontario                 •     Self-assessment
                        •     Peer Feedback
                        •     Learning Plan
                        •     Implement Learning Program
                        •     Evaluate Learning
                        In addition to the CCP, the CNO is required by legislation to randomly assess RN compe-
                        tence or assure competence. This is achieved through the Practice Review component of the
                        QA program. In 2006, 400 direct care and 350 administrative RNs were randomly selected
                        for Practice Review:
                        •      Practice Review Written Assessment: proctor administered test that includes case-
                               based scenarios & multiple choice questions about CNO standards and ongoing
                               practice competencies.
                        •      Practice Review Behavior-Based Interview: referred to this step only if more infor-
                               mation is needed to test competence.
                        •      Remediation: Assists RN in meeting learning needs identified in steps 1 and/or 2.
                               In severe cases, registration may be limited.



                                                        21
                                   Continuing Competence Programs for RNs and NPs: Consultation Paper




                                                Continuing Competence Requirements
     Jurisdiction

North Carolina Board     •     Reflective practice approach-self-assessment
of Nursing               •     Practice hours
                         •     30 CE hours or 15CE hours and activity e.g., nursing project, research
                         •     Random audit


UK Central Council       Mandatory Post-registration Education and Practice (PREP) Standard
for Nursing Midwifery    •     450 hours in preceding three years
and Health Visiting      •     35 hours of relevant learning activity in past three years
                         •     Professional profile of learning activity
                         •     Comply with audit request
                         Note: Plans for changes in program to make it more relevant for nurses; to be renamed
                         “Revalidation”.


Kentucky Board of        Mandatory CE 14 contact hours/year
Nursing                  OR
                         •   National certification
                         •   Research project
                         •   Publication
                         •   Preceptor(120 hours)
                         •   Nursing education session
                         •   7 CE hours and performance appraisal


College of Family Phy-   MAINPRO®(maintenance of proficiency)
sicians of Canada        Reflective Practice Cycle
                         Continuous Professional Development
                         •     250 MAINPRO® credits every five years(125 from accredited CMEs)


Chartered Accountants    •     120 hours of CPD over a three year cycle, including 60 hours of verifiable learn-
Newfoundland and               ing
Labrador                 •     Random audit of worksheets
                         •     Practice inspection every 3-4 years


Professional Engineers   Professional Development Program
and Geoscientists of     •     240 professional development hours over a three year period
Newfoundland and         •     Activities include mentoring, professional association work, attending a confer-
Labrador                       ence
                         Random audits and audits of targeted individuals



                                                       22
 Continuing Competence Programs for RNs and NPs: Consultation Paper




                                         Continuing Competence Requirements
     Jurisdiction
Ontario College of      The Quality Management Framework
Physiotherapists
                        Competency Reflection and Integration
                             Professional Portfolio
                             Self-assessment
                        Competency Assessment
                             Peer on-site assessment
                             Random selection of 10% of registrants
                             Participate every 5-10 years
                        Competency Improvement
                             Participation as needed
                             Remediation-one-to-one work




                                                23
                             Continuing Competence Programs for RNs and NPs: Consultation Paper




NOTES:

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 Continuing Competence Programs for RNs and NPs: Consultation Paper




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                             Continuing Competence Programs for RNs and NPs: Consultation Paper




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Continuing Competence Programs for RNs and NPs: Consultation Paper




                                             27
ARNNL is the professional organization representing all Registered Nurses and Nurse Practitioners in the
 province. In pursuit of its vision, ARNNL exists so there will be excellence in nursing, public protection,
                               quality health care, and healthy public policy.




                            Association of Registered Nurses of Newfoundland and Labrador
                                      55 Military Road, St. John’s, NL. A1C 2C5
                                 Web Site: www.arnnl.nf.ca, Email: info@arnnl.nf.ca
                                  Telephone: 709-753-6040, Toll Free: 800-563-3200
                                                Facsimile: 709 753 4940

				
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