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Nursing Care ContinuumFramework and Competencies

ICN Regulation Series

Pre-publication copy

ICN Regulation Series

Nursing Care Continuum Framework and Competencies

International Council of Nurses

2

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be reproduced in print, by photostatic means or in any other manner, or stored in a retrieval

system, or transmitted in any form, or sold without the express written permission of the

International Council of Nurses. Short excerpts (under 300 words) may be reproduced

without authorisation, on condition that the source is indicated.

Copyright © 2008 by ICN - International Council of Nurses,

3, place Jean-Marteau, 1201 Geneva, Switzerland

ISBN: 978-92-95065-25-3

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Table of contents Introduction 4

ICN Framework of Competencies 9

Accountability 12

Ethical Practice 14

Legal Practice 16

Principles of Care Provision 18

Promotion of Health 22

Assessment 23

Planning 24

Implementation 26

Evaluation 27

Therapeutic Communication and Interpersonal Relationships 28

Leadership and Management 30

Safe Environment 32

Delegation and Supervision 34

Inter-Professional Health Care 35

Enhancement of the Profession 36

Quality Improvement 38

Continuing Education 39

Glossary 40

References 42

4

Introduction

For over a century, the International Council of Nurses (ICN) has

acted as a global leader and advocate for improved nursing and

health care services. One of the traditional approaches used has

been international standard-setting. In addition, within the context of

increased migration, ICN more recently began using its global

resources to identify international frameworks and core

competencies for the levels of nursing personnel most commonly

recognised across countries.

Unfortunately, an increasing number of countries are experiencing a

nursing shortage.1 These shortages are intensifying against a

background of growing and changing health needs, health service

reform and expansion, advances in knowledge and technology and

new avenues for treatment and service. Within this environment ICN

is convinced of the need to complete work on defining the range of

knowledge, skills and competencies expected of those providing

care that falls within the Nursing Care Continuum Framework. (The

ICN Nursing Care Continuum Framework and Competencies will

henceforth be referred to as “the Continuum”).

In the context of health care, the term continuum is multi-

dimensional and describes a relationship between the health care

delivery system and those using its services. It is often used to

relate to the setting of care and seamless transitions from one

setting to another, such as from hospital to home to nursing home,

etc.2 It is also used to denote care needs, such as being fully

independent, partially dependent or fully dependent. Finally, it can

relate to roles (e.g. aide, enrolled nurse, registered nurse, etc.). This

paper addresses the care continuum from the perspective of

nursing roles.

In today’s highly paced, high cost health care environment, there is

much overlap of health and social care roles as well as increased

demand for value for money services. This is bound to grow as the

elderly make up an increasing proportion of the population and as

chronic disease increasingly takes its toll. The response, seen

already in the midst of the global health human resources crisis, is a

call for less skilled workers and for task shifting from the more

educated to the less educated, and from specialists to generalists.

At the same time, in some countries, the emphasis on education is

creating a range of baccalaureate prepared practitioners in low skill

level jobs which do not fully utilise their potential. All in all, there is

much pressure on nursing to define the profession, share

competencies, task shift, and delegate. Although some countries

are now starting to look at parts of the Continuum, nursing lacks a

coherent global framework within which to respond, let alone be

proactive.

The nursing profession has historically refused to define nursing’s

parameters, aside from the role of the professional nurse. This may

have been acceptable in the past but will not work in current or

future environments.

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ICN is challenged to better define the range of capabilities,

responsibilities, authority and relationships occurring among nursing

personnel for, as the ICN report on global shortages, points out:

Achieving a balance of skill mix, with the optimum proportion of

registered nurses and midwives, other health professionals,

support workers, and nursing assistants is one of the main

staffing challenges facing management.3

The need to undertake this work has been widely supported,

including through the Triad Communiqué

(www.icn.ch/triad/inaugural/2006TRiadCommunique.pdf) issued

after the May 2006 WHO/ICN/ICM meeting of government chief

nursing and midwifery officers and representatives of national

nursing and midwifery associations and regulatory bodies from 101

countries. The Communiqué articulated international nursing

leaders’ concerns for patient safety if skill mix changes are

introduced without effective controls and a clear understanding of

accountability, delegation and supervisory responsibilities within the

nursing personnel category.

The work has been endorsed by the ICN Credentialing Forum and

the ICN Observatory on Licensure and Registration. Both agreed

that it is imperative to turn attention to defining the roles and skill

base of the diverse group of health care workers, who are, and will

be, engaged in the delivery of nursing care. In doing so ICN will

contribute to:

• providing better tools for more coherent decision-making about

the nature of the nursing work force;

• supporting sound skill mix decisions; and

• managing the current re-configurations occurring within the

health workforce.

Purpose of the ICN Nursing Care Continuum Framework

The Continuum serves several purposes. It:

1. Communicates to nursing and others outside the profession

the range of roles and incremental complexity of the

competencies required to fulfil increasing levels of

responsibility.

2. Clarifies relationships and accountability among the different

levels within the Continuum.

3. Provide a tool to interpret levels of responsibilities and

accountability across health systems and jurisdictions.

4. Assist in a variety of situations such as deciding on curriculum

content, negotiating skill mix and developing job descriptions.

5. Help evaluate and manage the introduction of new or

changing nursing roles and responsibilities.

6. Guide formulation or revision of competencies at a national or

jurisdictional level.

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Approach

Using the Continuum Framework, competencies are identified for

the range of personnel most commonly found in the 129 ICN

member countries. The Continuum does not claim to address all the

possible levels that may exist in a particular country or jurisdiction

(e.g. Advanced Enrolled Nurse, Registered Psychiatric Nurse, etc.).

Countries are encouraged to make the necessary adaptation to

include other categories important to them. Additionally, the

Continuum does not seek to describe progression of competencies

within a particular level associated with the development of practice

from that of the newly qualified to the expert practitioner. However,

the support worker is included as this category is widely used and

does carry out nursing care in many countries. Moreover, nurses

have accountability and supervisory relationships for this group.

In the Continuum the following categories are addressed:

1. Support or assistive worker

2. Enrolled nurse/ Registered Nurse Assistant/Licensed Practical Nurse

3. Registered/Licensed Nurse

4. Specialist Nurse

5. Advanced Practice Nurse

For clarity it is important to state that the competencies are those

associated with a person who is newly qualified in the particular

role.

The development of the Continuum is a result of a two step process.

First, a small steering group was invited to comment on the

attached competency matrix and encouraged to consult widely,

particularly with educators and directors of nursing services. After

making modifications based on feedback from this consultation, the

document was circulated widely for comment to all ICN members

and others such as regulators, nurses in government and ICN’s

affiliates.

Definition of Categories within the Continuum

The Nursing Care Continuum is derived from the definition of

nursing4 adopted by ICN. The Continuum:

encompasses nursing care delivered through autonomous

and collaborative practise targeted towards individuals of all

ages, families, groups and communities, sick or well and in all

settings. Within this context, nursing includes the promotion of

health, prevention of illness, and the care of ill, disabled and

dying people. Additionally, advocacy, promotion of a safe

environment, research, participation in shaping health policy

and in patient and health systems management, and

education are also key aspects of nursing.

! Nursing support worker (SW) is the term applied to the

auxiliary category that assists directly in nursing care in

institutional or community settings under the standards and the

direct or indirect supervision of nurses.5 They are paid providers

who are neither registered nor licensed by a regulatory body.

They have no legally defined scope of practice or mandatory

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education or practice standards. Diverse titles are applied to this

health care worker such as nursing assistant, auxiliary, support

worker, orderly, aide, home support workers, personal care

worker, health care assistant, and community health worker.

! An enrolled, registered or licensed practical nurse (EN) is a

person authorised to practise within the limits of a defined scope

of practice and under the supervision (direct or indirect) of a

registered nurse. Titles that may be applied to this category

include licensed or trained practical nurse, and registered

assistant nurse.

! A registered or licensed nurse (RN) is a self-regulated health

care professional who works autonomously and in collaboration

with others and (a) has successfully completed a programme of

education approved by the nursing board/council, (b) has

passed the required assessments established by the nursing

board/council for entry into the profession and (c) continues to

meet the standards of the nursing board/council.6 The terms

licensed, professional or qualified nurse are used in a similar

sense.

! The nurse specialist (NS) is a nurse prepared beyond the level

of a nurse generalist and authorised to practice as a specialist

with advanced expertise in a branch of the nursing field.

Specialist practice includes clinical, teaching, administration,

research and consultant roles.7

! The advanced practice nurse (APN) is a registered nurse who

has acquired an expert knowledge base, complex decision

making skills and clinical competencies for expanded practice;

the characteristics of which are shaped by the context and/or

country in which s/he is credentialed to practice. Titles in this

category vary from country to country and are applied

inconsistently, even with the same country. Titles such as nurse

practitioners, clinical nurse specialist, and consultant nurse are

used in conjunction with this category.

For other definitions, refer to the glossary.

Assumptions

The following assumptions have been and should be kept in mind

when interpreting the links and progression of competence levels

across the Continuum:

1. Health care delivery requires a range of personnel providing nursing services.

2. There will be variability across countries and jurisdictions in the

definition of scope of nursing practice and, therefore, in the way

nursing and non-nursing functions are interpreted.

3. Regulation of roles is in the public interest, but needs to be

sufficiently permissive to encourage innovation and

development to meet changing and new care needs.

Lars

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4. Roles are described in terms of competencies needed to deliver the service.

5. Each set of competencies provides a unique and distinctive contribution to health care. In their differentiation (into separate levels), the spectrum of health needs are addressed and are articulated at the level required for the individual entering that level.

6. The Registered Nurse role is pivotal in the Continuum of nursing care delivery.

7. Nursing competencies and associated tasks and activities that

may be performed by other nursing personnel are consistent

with the legal scope of nursing practice and legal requirements

as defined within a country or as part of an international trade

agreement.

8. Although the responsibility for the performance of a nursing task

or activity may be transferred to a nursing support worker,

accountability rests with the professional (registered/licensed)

nurse who remains answerable for the outcome.

9. Although certain competencies can be shared across two or

more levels of the Continuum, in general they are progressive in

terms of complexity from support worker to advanced practice

nurse.

10. While competencies are described in terms of practice and do

not include a statement of the associated academic levels,

progress in the Continuum from support worker to advanced

practice nurse is contingent on acquiring the knowledge,

mastery of skills, and experience required to fulfil that role

completely. In some jurisdictions that may require undertaking a

formal programme of study and achieving a specific

qualification.

11. The three major domains in the Continuum Framework overlap

since the management and provision of care are underpinned

by professional, ethical and legal practice and, due to changing

needs, require the individual to continue to develop and remain

competent as practice evolves.

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ICN Framework of Competencies

Initially, the ICN Framework of Competencies for the Generalist

Nurse was developed to identify competencies expected of a

generalist nurse at the point of entry into professional practice.8 It

has been used in various ways internationally. For example, the

regulatory bodies of the concerned countries used it to identify

common competencies for registered nurses in South East Asia and

the Western Pacific.9 Another application was as a guide to the

development of a competency inventory for registered nurses in the

People’s Republic of China.10 In the King Faisal Specialist Hospital

and Research Centre in Saudi Arabia, the ICN Framework formed

the basis for a clinical practice assessment portfolio for new

graduates undertaking a period of internship.11

As a result of the consultation for the Continuum the major domains

and some of the sub-domains of the Framework have been revised

(Figure 1). The competencies under three domains are:

1. Professional, ethical and legal practice

2. Care provision and management

3. Professional, personal, and quality development

In undertaking work on the Continuum the ICN competencies for the

registered (generalist) nurse were used as the initial benchmark

against which all other competencies in the Continuum have been

set. As the registered nurse competencies were five years old ICN

took the opportunity to review and revise them as part of the

Continuum development process. The specialist nurse

competencies were based on those developed as part of work

undertaken in collaboration with the European Parkinson’s Disease

Association. The advanced practice competencies have been

developed in collaboration with the ICN International Nurse

Practitioner and Advanced Nursing Network.

In some cases an individual practitioner may develop competencies

in one or more of the areas beyond those set as the initial

benchmarks. This can occur as a result of progress from novice to

expert in their role, as part of preparation for moving to more

developed roles, or as part of a particular demand of the position to

which they have been appointed. Any individual who functions at a

level beyond the initial benchmark in one or more areas is not

considered competent or recognised as functioning at the higher

level unless all requirements are met and any additional formal

preparation or assessment have been completed.

Finally, in developing the Nursing Care Continuum Framework and

Competencies ICN consulted widely in order to arrive at

international consensus. However, these competencies should not

be regarded as prescriptive. Those utilizing the Continuum need to

refer to their particular context and make revisions accordingly.

Some areas may need further expansion and others may be

inappropriate, while areas that are important to practice in their

country may have been omitted. Additionally, some countries may

wish to use the competencies as the basis for developing more

detailed guidance that can inform curriculum development by

identifying the underpinning knowledge and skills required to

achieve the competencies. Figure 2 provides an example of how

this may be developed.

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ICN FRAMEWORK OF COMPETENCIES

PROFESSIONAL, ETHICAL, LEGAL PRACTICE

CARE PROVISION AND MANAGEMENT

PROFESSIONAL, PERSONAL & QUALITY DEVELOPMENT

Accountability Ethical Practice

Legal Practice

Enhancement of the Profession Quality Improvement Continuing Education

Key Principles of Care

Leadership and Management

Health Promotion Assessment

Planning Implementation

Evaluation Therapeutic Communication & Relationships

Inter-professional Health Care Delegation & Supervision

Safe Environment

Figure 1: Revised ICN Competency Framework

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Figure 2: Example of knowledge and skills required to achieve competencies associated with delegation and supervision

Delegation and Supervision

Knowledge & Skills SW EN RN NS APN

Definition and principles of effective delegation (5 rights of delegation)

Forms of delegation including the use of protocols, guidelines, standing orders

Relation of delegation to professional role, scope of practice and personal accountability/responsibilities,

statutory and regulatory authority for delegation

!!!!

!!!!

!!!!

Organisational responsibilities, policies and procedures to support delegation decisions and supervisory

activities

!!!!

Definition and principles of supervision of individuals

Types and methods of supervision (direct and indirect)

How delegation/supervision contributes to effective use of health resources and the continuum of care

!!!!

!!!!

!!!!

Role as receiver of delegation/supervision: Concept of delegation/supervision

How/when to request additional instruction, training and

support

Right to decline a delegated activity

!!!!

!!!!

!!!!

Skills: 1. Formulating organisational policies/procedures and creating adequate structures and resources

to support delegation and supervisory responsibilities

2. Communicating delegated task

3. Monitoring and providing feedback delegated tasks

4. Using a variety of methods for guidance, instruction, support

!!!!

!!!!

!!!!

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!!!! Denotes level at which initial knowledge and/or skill is obtained. Knowledge in that area may be further expanded in breadth and depth as a

person progresses in experience and the Continuum.

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Accountability

Support Worker Enrolled Nurse Registered Nurse Specialist Nurse Advanced Practice Nurse

1

Accepts accountability to client, employer and registered nurse.

Accepts accountability for own professional judgement, actions, outcomes of care and continued competence in accordance with scope of practice, legislative acts and regulations.

Accepts accountability for own professional judgement, actions, outcomes of care and continued competence in accordance with scope of practice, increased responsibility, legislative acts and regulations.

Accepts accountability for increased responsibility, for own professional judgement, actions, outcomes of care and continued competence in accordance with scope of practice, legislative acts and regulations.

Accepts accountability for increased role responsibilities, own professional judgement, actions, outcomes of care and continued competence in accordance with changing scope of practice, legislative acts and regulations.

2

Undertakes functions as directed. Knows and communicates own limits of knowledge and skill when accepting assignments.

Recognizes the limits of scope of practice and own competence.



Sets boundaries that acknowledge practice changes and developments as well as conform to legal requirements, policies and own level of competence.

3

Seeks assistance and guidance from a registered nurse when encountering situations beyond training and/or when undertaking a delegated task.

Seeks guidance from a registered nurse with the required knowledge, skills and when encountering situations that fall beyond own knowledge, competence or scope of practice.

Seeks guidance from the appropriate others when encountering situations beyond own knowledge, competence or scope of practice.

Consults with or refers to the appropriate others when encountering situations beyond own knowledge, competence or scope of practice.

Consults with or refers to the appropriate others when encountering situations beyond own knowledge, competence or scope of practice.

4

Understands different levels of accountability for the range of available personnel.

Recognizes and respects different levels of accountability for the range of available personnel.

Recognizes and respects the different levels of accountability for the range of available personnel.



5

Participates in activities related to improving the access to the range of services required for effective health services.

Participates in activities related to improving the access to the range of services required for effective specialist services.

Works collaboratively with other health care professionals, planners, policy makers and community leaders to improve service access, clinical efficacy and quality of care.

14

Ethical Practice


6

Conforms to employer’s code of conduct.

Practises in a manner that conforms to the ICN Code of Ethics, the professional code in force in the jurisdiction and employer’s code of conduct.




7

Recognizes ethical issues as they relate to own role, and seeks guidance in dealing with situations with ethical implications.

Engages in effective ethical decision-making in collaboration and consultation with other team members.

Engages in effective ethical decision-making with respect to own professional responsibilities or where ethical issues affect the broader health care team.

Engages in effective ethical decision-making with respect to own professional practice areas or where ethical issues affect the broader health care team.

Engages in effective ethical decision-making and contributes to resolution and the positive promotion of ethical practice in the health system.

8

Upholds right for the client to be cared for in circumstances that sustain human and patient rights, and report violations.

Acts in an advocacy role to protect human rights and questions violations of client in accordance with jurisdictional and the ICN Codes of Ethics.




9

Maintains confidentiality and security of written and verbal information acquired during the course of work.

Maintains confidentiality and security of written, verbal and electronic information acquired in a professional capacity.



Participates in policy and system development to increase the levels of confidentiality and security of written verbal and electronic information acquired in a professional capacity.

10

Respects the client’s right to privacy and dignity.





11

Respects the client’s right to choice and self-determination in nursing and health care.

Respects the client’s right to choice and self-determination in nursing and health care.

Respects the client’s right to information, choice and self-determination in nursing and health care.

Respects the client’s right to information, choice and self-determination in nursing and health care.

Participates in establishing policies that confirm the client’s right to information, choice and self-determination in nursing and health care and applies these in practice.

15

Ethical Practice (cont.)


12

Follows organisational procedures to report observed behaviour, actions or situations that could compromise client safety, privacy or dignity.

Challenges behaviour and health care practice that could compromise client safety, privacy or dignity.



Participates in creating mechanisms to monitor and respond to situations where behaviour or health care practice may compromise client safety, privacy or dignity.

13

Demonstrates professional integrity, probity and ethical conduct in response to industry marketing strategies when prescribing drugs and other products.

Demonstrates professional integrity, probity and ethical conduct in response to industry marketing strategies when prescribing drugs and other products.

16

Legal Practice


14

Works within existing legal and organisational framework.

Practices in accordance with professional, relevant civil legislation and regulations.

Practices in accordance with professional, relevant civil legislation and regulations.

Practices in accordance with professional, relevant civil legislation and regulations including those specific to area of specialty practice.

Practices independently in accordance with professional, relevant civil legislation and regulations including those specific to the advanced practice role.

15

Adheres to organisational policies and procedural guidelines.

Practices in accordance with jurisdictional and local policies and procedural guidelines.



Practices in accordance with jurisdictional and local policies and procedural guidelines pertaining to the advanced practice nursing role.

16

Raises concerns to direct supervisor or those in authority, in cases of harm or abuse of clients.

Recognizes and acts upon breaches of law relating to the professional role and/or professional code of conduct/code of practice.




18

Principles of Care Provision


17

Can accurately describe activity or task.

Provides a rationale for the nursing care delivered.

Uses knowledge from nursing, health and other disciplines combined with best available evidence to explain nursing decisions and interventions.

Uses knowledge from nursing, health and other disciplines combined with best available evidence to explain nursing decisions and interventions.

Draws on knowledge within nursing and across other disciplines and best available evidence to provide a rationale for APN decisions and interventions.

18

Uses acquired knowledge and skills when fulfilling role requirements.

Uses current knowledge based on best practice when carrying out professional responsibilities.

Applies contemporary knowledge from different sources and the best available evidence to base professional decision-making and practice.

Applies contemporary knowledge from different sources and area for speciality and the best available evidence to base professional decision-making and practice.

Integrates scientific knowledge, best available evidence and expert judgement to guide and advance practice.

19

Recognizes and reports a problem when it occurs during the course of work.

Uses clinical problem solving skills to guide practice.

Applies critical thinking skills and a systems approach to problem solving and nursing decision-making across a range of professional and care delivery contexts.

Applies critical thinking skills and a systems approach to problem solving and nursing decision-making and speciality care delivery contexts.

Applies critical thinking, clinical reasoning and expert judgement to decision-making in complex areas of practice and across a range of professional and care delivery contexts.

20

Delivers care according to instructions of the supervisor, and in concordance with nursing and organisational standards and procedures.

Delivers care consistent with professional and organisational standards, policies, protocols and procedures.

Delivers care consistent with professional and organisational standards, policies, protocols and procedures.

Delivers care consistent with professional and organisational standards, policies, protocols and procedures applicable to specialist nursing practice.

Delivers care consistent with professional guidelines, standards, policies, protocols and procedures applicable to advanced nursing practice.

21

Understands that care may need to be modified to cultural needs.

Recognizes culturally sensitive needs and adapts practice accordingly.



Recognizes breaches and intervenes at the practice and system levels to ensure that care is sensitive to cultural needs.

19

Principles of Care Provision (cont.)


22

Is aware of clients’ beliefs and practices in traditional healing practices.

Understands the significance of traditional healing practices within a client’s health belief system.

Incorporates traditional healing practices valued by clients and with proven beneficial/or harmless effects into care activities.

Incorporates traditional healing practices valued by clients and with proven beneficial or harmless effects into care activities.

Searches for evidence to support claims for the beneficial effects of traditional healing practices and incorporates as appropriate.

23

Consults with supervisor before providing information about rights of a health service user.

Informs clients about rights of a health service user.

Applies advocacy skills to assist clients unable to represent or speak for themselves.

Applies advocacy skills to assist clients unable to represent or speak for themselves regarding speciality care requirements.

Uses advocacy skills to influence health policy and planning and service access on behalf of clients unable to represent or speak for themselves.

24

Demonstrates awareness of resources available for assisting clients with changes in health, disability and death.

Knows how to access and use resources available to assist clients deal with changes in health, disability and death.

Acts as an information and education resource and for clients seeking to improve life styles, adopt illness/injury prevention activities and cope with changes in health, disability and death.

Acts as an information and education resource in the speciality area for clients seeking healthier life styles, adopt illness/injury prevention activities and cope with changes in health, disability and death.

Develops resources, programmes and formulates implementation strategies designed to promote healthy life styles, and adoption of illness/injury prevention activities of individuals, families or communities.

25

Provides support in the development and/or maintenance of independent living skills.

Provides guidance/ instruction in the development and/or maintenance of independent living skills.



Contributes to planning and policy development designed to promote self sufficiency and independent living skills.

26

Under the guidance of a supervisor, gives simple instruction appropriate to level of knowledge and work responsibility.

Uses opportunities to introduce health-related instruction during the care process.

Recognizes opportunities and provides guidance/education to individuals, families and communities to encourage adoption of illness prevention activities and maintenance healthy lifestyles.

Recognizes opportunities and provides guidance/ education to individuals, families and communities to encourage adoption of illness prevention activities and maintenance of healthy lifestyles.

Identifies and responds creatively to new opportunities for health education/patient education based on client and community needs, and available resources, and using strategies based on the best evidence available.

20

Principles of Care Provision (cont.)


27

Contributes to the teaching plan established by the registered nurse.

Selects teaching/learning strategies appropriate to the needs and characteristics of the individual or group.

Selects teaching/learning strategies appropriate to the needs and characteristics of the individual or group.

Participates in creating, and establishing evidence-based implementation strategies for education programmes designed to encourage learning about health promotion and illness/injury prevention, and stimulate participation of clients to meet own health needs. Monitors educational programme implementation and evaluates outcomes and impact on behaviour.

28

Gives feedback to client and supervisor on results of instruction.

Evaluates learning outcomes and modifies teaching/learning approaches and content accordingly.

Evaluates learning outcomes and modifies teaching/learning approaches and content accordingly.

Uses evaluation data to improve educational programme outcomes.

29

. Demonstrates awareness of major developments and the potential application of current communication/health technologies in health care.

Keeps abreast of developments and potential applications of emerging communication/health technologies in health care.

Identifies opportunities for and participates in the assessments of new communication/health technologies to practice prior to introduction into the practice context.

22

Promotion of Health


30

Maintains own health and personal fitness for/at work.





31

Seeks involvement in activities designed to reduce illness and promote healthy life styles and environments.

Participates with nurses, other professionals and community groups in activities to reduce illness and promote healthy life styles and environments.

Cooperates with nurses, other professionals and community groups in activities to reduce illness and promote healthy life styles and environments.

Cooperates with other professionals and community and speciality interest groups in activities to reduce illness and promote healthy life styles and environments in areas important to speciality practice.

Engages actively with other health professionals, planners, policymakers, advocacy and community groups to formulate strategies and mobilize resources for improving the health status of the community.

32

Demonstrates an understanding of how health and disease are affected by basic hygiene, sanitation and nutrition.

Demonstrates an understanding of how health and disease are affected by multiple and interconnected factors.

Incorporates into practice a perspective that takes account of the multiple determinants of health.

Incorporates into practice a perspective that takes account of the multiple determinants of health.

Incorporates a perspective that takes account the multiple determinants of health when developing illness prevention, health promotion and capacity building strategies for individuals, families and communities.

23

Assessment


33

Undertakes delegated aspects of health data collection within sphere of competence.

Undertakes delegated aspects of health data collection within sphere of competence and contributes data and information to the assessment made by the registered nurse.

Gathers accurate and relevant objective and subjective data through systematic health and nursing assessments-

Gathers accurate and relevant objective and subjective data required for practice in specialty area through systematic health and nursing assessments, ordering diagnostic tests and procedures as permitted in the scope of specialist practice and legislation.

Gathers accurate and relevant objective and subjective data for client assessment using multiple data collection strategies and information sources, ordering diagnostic tests and procedures as permitted in the scope of advanced nursing practice and legislation.

34

Reports changes that may affect health and well being.

Identifies common and overt actual and potential health problems and notes findings that lie outside the norm.

Organises, synthesizes, analyses, and interprets data from different sources to derive a nursing diagnosis and determine a care plan.

Organises, synthesizes, analyses, and interprets data from different sources to derive nursing diagnoses and determine a care plan.

Applies advanced clinical reasoning judgement and in-depth knowledge to derive a differential diagnosis and determine a comprehensive care plan.

35

Reports observations and complies with organisational policy.

Reports and keeps accurate, timely records of findings complying with professional standards and organisational policies.

Shares and documents findings accurately and in a timely manner complying with professional standards and organisational policies.



24

Planning


36

Contributes information to assist with care planning.

Assists the registered nurse to formulate a care plan for clients based on assessment results.

Formulates a comprehensive care plan with identified care outcomes based on nursing diagnoses, findings from a nursing and health assessment, inputs from other health team members, and nursing practice standards. .

Formulates a compre-hensive care plan with identified care outcomes based on nursing diagnoses, findings from a nursing and health assessment, inputs from other health team members, and nursing practice standards.

Formulates and mobilizes resources for a coordinated comprehensive care plan with identified care outcomes and based on advanced nursing practice standards, and informed decisions about preventive, diagnostic and therapeutic interventions.

37

Uses relevant knowledge from nursing and other disciplines to contribute to care planning.

Applies critical thinking and clinical reasoning skills underpinned by knowledge of nursing and other disciplines to the care planning process.

Applies critical thinking and clinical reasoning skills underpinned by knowledge of the area of specialist practice and other disciplines to the care planning process.

Applies critical thinking and complex clinical reasoning underpinned by in depth theoretical, scientific and contemporary clinical and health system knowledge to the care planning process.

38

Establishes priorities for care with nurse supervisor.

Establishes priorities for care in collaboration with other care providers and clients.

Establishes priorities for care in collaboration with other care providers and clients.

Negotiates to meet priorities for care within available health resources and the system capabilities.

39

Directs questions from clients about care plan to the nurse supervisor.

Provides accurate information to clients about aspects of care plan that fall within own responsibility.

Involves clients where possible in care planning ensuring that they receive accurate, understandable information on which to base consent for care.

Involves clients where possible in care planning ensuring that they receive accurate, understandable information on which to base consent for care

Involves clients where possible in care planning ensuring that they receive accurate, understandable information on which to base consent for care.

25

Planning (cont.)


40

Reports concerns regarding clients’ ability to understand and make decisions.

Reports and requests an advocate when clients and/or carers ask for support, have limited abilities in decision-making, giving informed consent, or where there is a language barrier.

Involves an advocate when clients, families or carers request support or have limited abilities in decision-making, giving informed consent, or where there is a language barrier.

Involves an advocate when clients, families or carers request support or have limited abilities in decision-making, giving informed consent, or where there is a language barrier.

Implements a mechanism to assure the presence of an advocate when clients, families or carers request support or have limited abilities in decision-making, giving informed consent or where there is a language barrier.

41

Contributes to care plan review and revision.

In collaboration with a registered nurse, regularly reviews and revises the care plan.

Regularly reviews and revises the care plan, where possible in collaboration with other members of the health/social health team, and clients.

Regularly reviews and revises the care plan, where possible in collaboration with other members of the health/social health team, and clients.

Regularly reviews and revises the care plan, where possible in collaboration with other members of the health/social health team, clients and/or carers.

42

Keeps records of activities.

Under the supervision of a registered nurse maintains a current, accurate care plan and related records.

Maintains a current, accurate care plan and related records.



26

Implementation


43

Assists with care under the direction of an enrolled or registered nurse.

Under the supervision of the registered nurse, implements planned nursing interventions in accordance with nursing and best practice standards.

Implements a range of procedures, treatments and interventions that fall within scope of practice for the registered nurse and are in accordance with nursing and best practice standards.

Implements a range of procedures, treatments and interventions that fall within scope of specialist practice and are in accordance with specialist nursing and best practice standards.

Implements procedures, treatments and interventions that fall within the legal authority, scope of extended practice and are in accordance with nursing and best practice standards.

44

Records task undertaken and observations accurately and in a timely fashion according to organisational procedures.

Documents interventions and client responses accurately and in a timely manner.




45

Identifies and reports unexpected changing situations.

Identifies and reports unexpected changing situations.

Responds appropriately and in time to unexpected or rapidly changing situations.

Responds appropriately and in time to unexpected or rapidly changing situations.

Adapts interventions to the needs of the client and/or the environment in unexpected or rapidly changing situations.

Summons immediate assistance in an emergency/ disaster situation.

Summons immediate and appropriate assistance to the emergency/disaster situation.

46

Applies life support skills until assistance arrives.

Applies life support skills until assistance arrives.

Responds immediately and appropriately to emergency and disaster situations, including launching life support procedures when necessary, and other emergency/disaster procedures.

Responds immediately and appropriately to emergency and disaster situations taking a leadership role in triage and coordination of care for clients with specialty care needs.

Mobilizes and coordinates resources and assumes leadership in emergency and/or disaster situations.

27

Evaluation


47

Contributes information to the evaluation of progress toward expected care outcome.

Monitors and documents progress toward expected outcomes accurately and completely.




48

Contributes to team evaluation of progress towards planned outcomes.

In consultation with clients, families and/or carers, and health team members, evaluates progress towards planned outcomes.

In consultation with clients, families and/or carers, and health team members, evaluates progress towards planned outcomes.

In consultation with clients, families and/or carers, participates in interdisciplinary evaluation of progress towards planned outcomes.

49

Contributes evaluation data and suggests modifications in the care plan to the registered nurse.

Uses evaluation data to modify the care plan.

Uses evaluation data to modify the care plan.

Uses evaluation data to influence care strategies and inform future practice trends.

28

Therapeutic Communication and Interpersonal Relationships


50

Operates within scope of work to initiate, develop and discontinue interpersonal relationships with patients/clients and/or carers.

Initiates, develops and discontinues therapeutic relationships through the use of appropriate communication and interpersonal skills.

Initiates, develops and discontinues therapeutic relationships through the use of appropriate communication and interpersonal skills.

Initiates, develops and discontinues therapeutic relationships using a range of advanced communication and interpersonal skills.

Initiates, develops and discontinues therapeutic relationships through the use of advanced communication and interpersonal skills.

51

Maintains a relationship that respects the boundary between clients and self.





52

Listens to others in an unbiased manner, respects points of view of others.

Listens to others in an unbiased manner, respects points of view of others.

Listens to others in an unbiased manner, respects points of view of others, and promotes the expression of diverse opinions and perspectives.



53

Communicates clear, consistent and accurate information about client status that falls within scope of work and maintains confidence in care.

Communicates clear, consistent and accurate information verbally, or in written and electronic forms, that falls within professional responsibility and maintains confidence in care.


Communicates clear, consistent and accurate information verbally, or in written and electronic forms, that falls within professional responsibility.


54

Interacts in a manner that is respectful and culturally appropriate to the clients, family and/or carers from diverse cultural backgrounds.





55

Facilitates access to information or refers request to the appropriate person.

Facilitates access to information or refers request to the registered nurse.



Advocates for and assists with establishing policies that facilitate access for clients to information relevant to their situation.

29

Therapeutic Communication and Interpersonal Relationships (contd.)


56

Communicates activities carried out to other team members, providing sufficient information for their needs.

Communicates and shares relevant information, including views of clients, families and/or carers with other health team members involved in providing services.

Communicates and shares relevant information including views of clients, families and/or carers with other health team members involved in providing services.

Communicates and shares information including views of clients, families and/or carers with other health team members involved in providing services.

Takes measures to create effective mechanisms for communicating and sharing information with other health team members involved in providing services.

30

Leadership and Management


57

Understands factors that contribute to creating a positive workplace environment.

Advocates for and contributes to creating a positive working environment.

Advocates for and acts within span of control to create a positive working environment.

Advocates for and acts within span of control to create a positive working environment.

Advocates for and implements policies and strategies within the health system to establish positive practice environments, including the use of best practices in recruiting, retaining and developing human resources.

58

Understands the need for different leadership styles and approaches in different situations.

Adapts leadership style and approaches to different situations.

Adapts leadership style and approaches to situations specific to the speciality practice area.

Engages in succession planning and active preparation of future leaders through education, coaching and mentoring.

59

Recognizes conflicts and uses interpersonal skills and available organisational mechanisms to achieve resolution.

Recognizes conflicts and uses interpersonal skills and available organisational mechanisms to achieve resolution.

Confronts conflict in a non-judgemental fashion, making effective use of communication skills and existing mechanisms to achieve resolution.

Confronts conflict in a non-judgemental fashion, making effective use of communication skills and existing mechanisms to achieve resolution.

Addresses conflicts promptly and creatively, recognizing the potential for opportunities for new solutions.

60

Supports leader in a consistent manner that promotes respect and confidence amongst the team.

Contributes to team leadership by reinforcing goals so as to promote respect and confidence amongst the team.

Leads in a manner to inspire respect and confidence from others.

Creates confidence in self and in the organisation to inspire others by tailoring leadership behaviours to maximise the contribution of others.

61

Able to articulate own leadership contributions and support expectations of other team members.

As team leader and in line with current job description, clearly defines contributions and expectations required of team members

Creates a vision and acts to provide all members of the team with a sense of ownership and control over their work.

62

Manages assigned work within agreed timeline.

Prioritizes workload and manages time effectively.

Prioritizes workload and manages time effectively.

Prioritizes workload, manages time effectively and allocates resources to optimise outcomes.

Prioritizes caseload, manages time effectively and allocates resources to optimise outcomes.

31

Leadership and Management (cont.)


63

Demonstrates awareness of the role of policies and procedures in the management of the organisation.

Demonstrates understanding of how policies and procedures are developed and contributes to feedback to review committees.

Contributes to the review and modification of current organisational and practice policies and procedures currently in force.

Contributes to the review and modification of current organisational and practice policies and procedures currently in force and provides leadership in developing and implementing organisational and practice policies and procedures specific to the specialty area.

Develops and implements mechanisms for periodic monitoring and evaluation of policies that impact on nursing services and translates these into health plans, structures, and programmes.

64

Participates in unit based teaching/ learning activities.

Participates in unit based teaching/ learning activities.

Contributes to education and professional development of students and colleagues in the work place.

Contributes to the development and implementation of specialist education and professional development of students and colleagues in the work place.

Promotes policies and advocates for resources to support education and professional development in the work setting.

65

Offers suggestions and provide feedback for changes in own sphere of work.

Provides feedback and offers suggestions for changes in own sphere of practice and deals effectively with the impact of change on own practice.

Provides feedback, offers suggestions for changes and deals effectively with the impact of change in own practice or on the organisation.

Uses the change process to influence the introduction of innovations and adaptations to specialist practice and service organisation.

Introduces, evaluates and manages innovation and change in the health system through encouraging creativity.

32

Safe Environment


66

Identifies and reports situations that may impact on the safety of patients/clients or staff.

Identifies and reports situations that may impact on the safety of patients/clients or staff.

Uses appropriate assessment tools to identify actual and potential risks to safety and reports concerns to the relevant authority.

Uses appropriate assessment tools to identify actual and potential risks to safety and security and reports concerns to the relevant authority.

Uses regular assessments to identify actual and potential environmental, patient, personnel safety and security risks and reports concerns to the relevant authority.

67

Contributes to safety and security measures through timely action and adherence to national legislation and workplace health and safety measures.

Maintains a safe care environment through timely action and adherence to national legislation and workplace health and safety requirements, policies and procedures.

Takes timely action through the use of quality improvement risk management strategies to create and maintain safe care environment and meet national legislation and workplace health and safety requirements, policies and procedures.

Takes timely action through the use of quality improvement risk management strategies to create and maintain safe care environment and meet national legislation and workplace health and safety requirements, policies and procedures.

Uses multiple interventions and risk management strategies to initiate change and maintain safe environments within the system and that meet national legislation and health and safety requirements.

68

Stores therapeutic substances safely and securely.

Ensures the safe and proper storage, administration and recording of therapeutic substances.

Ensures the safe and proper storage, administration and recording of therapeutic substances.

Ensure that policies and procedures are in place for the safe and proper storage, administration and recording of therapeutic substances.

69

Administers and records medication under the supervision of a registered nurse when legally permitted.

Administers and records medication, assesses side-effects and titrates dosages in accordance with authorised prescriptions.

In accordance with prescriptive authority selects/ prescribes/ administers medication, including accurate dosage, routes and frequency pattern, based upon accurate knowledge of the pharmacological effect, patient characteristics and concurrent therapies.

In accordance with prescriptive authority selects/prescribes/ administers medication, including accurate dosage, routes and frequency pattern, based upon accurate knowledge of the pharmacological effect, patient characteristics and concurrent therapies.

33

Safe Environment (cont.)


70

Complies with infection prevention procedures.

Complies with infection prevention procedures.

Complies with infection prevention procedures and challenges breaches in other practitioners’ practice.

Complies with infection prevention procedures and challenges breaches in other practitioners’ practice.

Is proactive in highlighting and proposing improvements to infection control strategies for all practice sites.

71

Knows actions to take in the event a disaster is declared.

Knows actions to take in the event a disaster is declared.

Knows responsibilities’ and procedures to follow in the event a disaster is declared.

Identifies and plans for specific measures necessary to deal with patients/clients in area of specialty practice in the event of a disaster.

Contributes to the formulation of service disaster and recovery plans.

34

Delegation and Supervision


Delegates to others, activities according to ability, level of preparation, proficiency and legal scope of practice.


72

Accepts delegated/ assigned activities for which preparation has been provided and proficiency has been assessed.

Accepts delegated activities in line with personal level of proficiency and legal scope of practice.




73

Provides feedback to persons delegating/ assigning activities and supervising work.

Provides feedback to persons delegating/assigning activities and supervising work.

Monitors and uses a range of supportive strategies including precepting when supervising and/or monitoring delegated care.

Monitors and uses a range of supportive strategies including precepting and mentoring when supervising and/or monitoring delegated care.

Offers supportive strategies including mentoring, coaching and precepting as part of supervisory responsibilities.

74

Accepts responsibility for delegated activity.

Maintains accountability for outcomes of delegated activity.

Maintains accountability and responsibility when delegating aspects of care to others.



75

Contributes to policy and protocol development that relates to delegation of clinical responsibilities.

Contributes to policy and protocol development that relates to delegation of clinical responsibilities specific to speciality practice.

Contributes to policy and protocol development that relates to delegation of clinical responsibilities within nursing and across the health professions.

35

Inter-Professional Health Care


76

Understands some roles and skills of other care providers in relation to own responsibilities.

Understands and values the roles, knowledge and skills of members of the health care team in relation to own responsibilities.

Understands and values the roles, knowledge and skills of members of the health team in relation to own responsibilities.

Understands and values the roles, knowledge and skills of members of the health team in relation to own responsibilities.

Creates an environment that fosters trust among health care providers, and familiarity of the knowledge and skills that different professions and disciplines bring to health service delivery.

77

Cooperates to maintain effective multidisciplinary teamwork.

Cooperates to maintain effective multidisciplinary teamwork.

Works collaboratively with other professionals in health care to enhance nursing and other health services being accessed by clients.

Works collaboratively with other professionals in health care to enhance nursing and other services offered in specialty area.

Utilizes leadership, team building, negotiation and conflict resolution skills to build intra-/inter-professional, agency and community partnerships to improve quality of care and address gaps/barriers to access.

78

Uses basic knowledge of effective inter- and intra-professional working practices.

Uses knowledge of effective inter- and intra-professional working practices.

Uses knowledge of effective inter- and intra-professional working practices.

Engages in active promotion of inter- and intra-professional collaborative working practices within the practice environment.

79

Communicates views of patients/clients and/or carers to assist with decision-making by the inter-professional team.

Presents and supports the views of clients, families and/or carers during decision-making by the inter-professional team.

Presents the views of clients, families and/or carers in decision-making by the inter-professional team and assists with negotiation of mutually agreed decisions.

Presents the views of /clients, families and/or carers in inter- and intra-professional team decisions and assists and/or leads in the negotiation of mutually agreed decisions.

80

Refers clients to a registered nurse to ensure patients/clients have access to best available interventions.

Refers clients to ensure patients/clients have access to best available interventions.

Refers clients and accepts referrals from other health care providers to ensure clients have access to best available intervention.

Makes referrals to and receives referrals from other health care providers to promote continuity of care and ensure offer best available intervention.

81

Accepts accountability and responsibility for caseload management.

36

Enhancement of the Profession


82

Understands how professional standards contribute to the safety and quality of care.

Knows and follows professional standards and best practices applicable to professional responsibilities.

Promotes dissemination, use, monitoring and review of professional standards and best practice guidelines.

Promotes dissemination, use, monitoring and review of professional specialist standards and best practice guidelines and participates in developing and adapting standards to the practice context.

Provides leadership in developing the evidence base for professional standards and best practice and leads in developing and adapting standards to the practice context.

83

Promotes and maintains a positive image of nursing.

Promotes and maintains a positive image of nursing.

Promotes specialist nursing practice as an essential part of health service delivery.

Articulates and promotes the advanced practice nursing role in the clinical, political and professional contexts.

84

Acts as an effective role model for enrolled nurse students and support staff.

Acts as an effective role model for students and within the care team.



85

Acts as a resource for enrolled nursing students and support staff.

Acts as a resource for students, other members of the health team and the public.

Acts as a resource in speciality area for students, other members of health team, health planners and the public

Acts as a resource on advanced nursing practice for students, other members of the health team, health planners and the public.

86

Values research in contributing to developments in nursing and uses findings as a means to improving standards of care.

Contributes to knowledge and practice development of the clinical nursing speciality through identifying and conducting research in areas of need.

Contributes new knowledge to practice development by conducting research, dissemination and incorporating findings into practice.

37

Enhancement of the Profession (cont.)


87

Advocates for and participates in obtaining public, legal and employer recognition of specialist qualifications, title protection and related scope of practice.

Advocates for and participates in obtaining public, legal and employer recognition of advanced practice nursing qualifications, title protection and scope of practice.

88

Scans practice environment and nursing literature to identify emerging trends and issues.

Scans practice environment and specialist nursing literature to identify emerging trends and issues.

Scans the global environment for emerging trends in advanced practice and health care.

89

Engages in advocacy activities through the professional organisation to influence health and social care service policies and access to services.

Engages in advocacy activities through the professional organisation to influence health and social care service policies and access to services.

Engages in advocacy activities through professional organisations to influence health and social care service policies and service provision important to the area of speciality practice.

Leads advocacy activities through professional organisation to influence health and social care service policies that impact on the availability and access to advanced nursing practice services.

38

Quality Improvement


90

Undertakes tasks as directed and in line with policies, procedures, quality measures and with level of training.

Undertakes tasks as directed and in line with policies, procedures, quality measures and with level of training.

Follows evidence-based and best practice guidelines in the delivery of nursing practice.

Uses and contributes to research into the evidence base for safe, effective, efficient practice in speciality area.

Translates and integrates research to produce evidence based practice to improve safety, efficiency and effectiveness of care.

91

Suggests ideas to the appropriate person for services improvement.

Participates in quality improvement and quality assurance procedures.

Participates in quality improvement and quality assurance procedures.

Uses systematic review to improve client experience and outcomes in area of speciality.

Participates in intra- and inter-disciplinary peer supervision and review to improve client experience and outcomes.

39

Continuing Education


92

Identifies gaps between current work requirements and current knowledge, understanding and skills.

Undertakes regular review of own practice by engaging in reflection and peer review.

Undertakes regular review of own practice by engaging in reflection, critical examination and evaluation and seeking peer review.



93

Routinely attends up-date sessions relevant to developments on own and associated areas of work.

Assumes responsibility for lifelong learning, own professional development and maintenance of competence.




94

Takes opportunities to learn together with others contributing to health.

Takes opportunities to learn with others contributing to health care.

Takes opportunities to learn with others contributing to health care.

Participates in uni- and multidisciplinary teaching learning.

Promotes and encourages programmes that support interdisciplinary health care education.

40

GLOSSARY

Accountability: The readiness or preparedness to give an explanation or justification to relevant others (for one's judgements, intentions, acts and omissions) when appropriately called upon to do so.

Competence: The effective application of a combination of knowledge, skill and judgement demonstrated by an individual in daily practice or job performance. In nursing definitions, there is wide ranging agreement that, in the performance of nursing roles to the standards required in employment, competence reflects the following:

" Knowledge, understanding and judgement;

" A range of skills cognitive, technical or psychomotor and interpersonal; and

" A range of personal attributes and attitudes.12

Clinical Judgement: The process of arriving at a clinical decision after assessment of alternatives.

Clinical Reasoning: The cognitive process that informs and underpins autonomous clinical practice, involving the gathering and interpretation of data, generation of hypotheses and making of decisions regarding patient care.

Critical Thinking: Critical thinking is essential as a tool of inquiry. It is a purposeful, results-oriented process that focuses on information seeking, decision making and problem solving and involves a process of interpretation, analysis, inference and evaluation of information.

Delegation: Delegation involves the transfer of responsibility for the performance of a task from one individual to another while the person whose task is being delegated retains accountability for the outcome.13 It involves assessment of the needs of the client and the abilities of the person being assigned the delegated activities and includes the responsibility of the person whose task is being delegated for the ongoing direct or indirect supervision and monitoring of patient outcome and performance of the individual undertaking the delegated activities.

Scope of Practice: The range of roles, functions, responsibilities and activities, which a registered/licensed professional is educated for, competent in, and is authorised to perform. It defines the accountability and limits of practice.14

41

Skill Mix: The mix of posts in the establishment; the mix of employees in a post; the combination of skills available at a specific time; or the combination of activities that comprise each role, rather than the combination of different job titles.15

Supervision: The active process of directing, guiding and influencing the outcome of an individual’s performance of a task.16 Direct supervision refers to the situation when the supervisor is physically present when the task is being done. Indirect supervision occurs when the supervisor is not physically present but communicates instruction, directions and guidelines through various forms of communication – written, verbal or electronic.

Task: A set of activities aimed at reaching a specific goal or objective. It involves a number of skills. It is at a lower level than a competency, stipulating what is done but not indicating why it is done.17

42

REFERENCES

1 Buchan J & Calman L (2004). The Global Shortage of Registered Nurses: An Overview of Issues and Actions, International Council of Nurses. 2 Center to Improve Care of the Dying, Continuity of Care. Retrieved 17 May, 2006 from www.gwu.edu/~cicd/toolkit/contin.htm. 3 Buchan J & Calman L. (2004). Op. Cit., p41 4 Adapted from the ICN Definition of Nursing. Available on www.icn.ch/definition.htm 5 International Council of Nurses (1993). Nursing Support Workers: Position Statement and Guidelines. No longer in print. 6 Adapted from Regulation Terminology, International Council of Nurses (2005), p21. Available on icn.ch/regterms.htm. 7 Affara FA & Styles MM (1992). Nursing Regulation Guidebook: From Principle to Power. 8 Alexander MF & Runciman PJ (2003). ICN Framework of Competencies for the Generalist Nurse, International Council of Nurses. 9 Australian Nursing and Midwifery Council (2004-2005). 13th Annual Report. 10 Lui M, Kunaiktikul W, Tonmukayakul O and Eriksen L (2006). Development of Competency Inventory for Registered Nurses in the People’s Republic of China: Scale Development. Int. J. Nurs. Stud.: 4, 2006. 11 King Faisal Specialist Hospital & Research Centre, Nursing Saudization Department, Clinical Practice Assessment Portfolio. Retrieved 17 May 2007 from www.kfshrc.edu.sa/saudization/files/Clinical%20Practice%20Assessement%20Portfolio.doc 12Adapted from Regulation Terminology, International Council of Nurses (2005), Op. Cit. p9. 13 American Nurses Association (2005). Principles for Delegation. Retrieved 17 May 2007 from www.indiananurses.org/education/principles_for_delegation.pdf, p4. 14 Adapted from Regulation Terminology, International Council of Nurses (2005), Op. Cit. p33.

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15 Buchan J, Ball J and O’May F (2000). Determining skill mix in the health workforce: guidelines for managers and health professionals. Issues in health services delivery paper no. 3. Department of Organisation of Health Services Delivery. World Health Organisation. Retrieved 17 May 2007 from www.who.int/mipfiles/2361/Disc.3-Determiningskillmix.pdf#search='Determining%20skill%20mix%20in%20the%20health%20workforce%3A%20guidelines%20for%20managers%20and%20health%20professionals 16 American Nurses Association (2005). Op. Cit, p4. 17 Uys LR (2004). Competency in Nursing. World Health Organization. Retrieved 17 May 2006 from www.rsdesigns.com/extranet/IMG/pdf/Competency_in_Nursing.pdf#search='Competency%20in%20Nursing%20uys', p3.