QUT Digital Repository:
Gardner, Anne and Hase, Stewart and Gardner, Glenn E. and Carryer, Jenny and Dunn,
Sandra (2008) From competence to capability: a study of nurse practitioners in clinical
practice. Journal of Clinical Nursing, 17(2). pp. 250-258.
© Copyright 2008 Blackwell Publishing
The definitive version is available at www.blackwell-synergy.com
FROM COMPETENCE TO CAPABILITY: A STUDY OF NURSE
PRACTITIONERS IN CLINICAL PRACTICE
Anne Gardner RN BA MPH PhD MRCNA
Associate Professor, Cabrini-Deakin Centre for Nursing Research
Deakin University Burwood
Victoria 3125, Australia.
Phone: +61 39508 1366, Fax: +61 39508 1908, E-mail: firstname.lastname@example.org
Stewart Hase Dip Nurs Ed BA Dip Psych MA(Hons) PhD MAPS
Associate Professor, Graduate College of Management
Southern Cross University
PO Box 157, LISMORE 2480, NSW
Phone +61 266203166, Fax +61 66269170, Email: email@example.com
Glenn Gardner RN PhD FRCNA
Professor of Clinical Nursing
School of Nursing
Queensland University of Technology
Victoria Park Road, Kelvin Grove, Queensland 4059
E-mail: firstname.lastname@example.org, Phone: +61 73636 5395, Fax: +61 73636 1557
Sandra V. Dunn RN PhD FRCNA
Chair in Nursing Practice
Flinders University/Flinders Medical Centre
Level 7, Flinders Medical Centre
Bedford Park SA 5042, Australia
Ph: +61 88204 4227, Fax: +61 88204 5907, E-mail: email@example.com
Dr. Jenny Carryer RN, PhD, FCNA(NZ), MNZM
Professor of Nursing
School of Health Sciences
PB 11-222, Palmerston North, New Zealand
Phone +64 6 3569099, Fax +64 6 3505668, Email: J.B.Carryer@massey.ac.nz
This project was sponsored by the Australian Nursing and Midwifery Council and the
Nursing Council New Zealand. We also wish to acknowledge the contribution of the
nurse practitioners who generously gave of their time to participate in the study.
FROM COMPETENCE TO CAPABILITY: A STUDY OF NURSE
PRACTITIONERS IN CLINICAL PRACTICE
Aims and Objectives
This research aimed to further understand the level and scope of practice of the nurse
practitioner in Australia and New Zealand using a capability framework.
The original study, from which the present paper was developed, sought to identify
competency standards for the extended role of the nurse practitioner in Australia and
New Zealand. In doing so the researchers became aware that while competencies
described many of the characteristics of the nurse practitioner they did manage to tell
the whole story. In a search of the literature the concept of capability appeared to
provide a potentially useful construct to describe the attributes of the nurse practitioner
that went beyond competence.
A secondary analysis of data obtained from interviews with nurse practitioners working
in Australia and New Zealand was undertaken. This data had previously been obtained
in a study to identify nurse practitioner competencies. The analysis described in this
paper investigated whether or not the components of capability would adequately
explain the characteristics of the nurse practitioner.
Fifteen nurse practitioners were interviewed from Australia and New Zealand. A
secondary (deductive) analysis of interview data using capability as a theoretical
framework was conducted.
The analysis showed that capability and its dimensions is a useful model for describing
the advanced level attributes of nurse practitioners. Thus, nurse practitioners described
elements of their practice that involved: using their competences in novel and complex
situations as well as the familiar; being creative and innovative; knowing how to learn;
having a high level of self-efficacy; and working well in teams.
This study suggests that both competence and capability need to be considered in
understanding the complex role of the nurse practitioner.
Relevance to clinical practice
The dimensions of capability need to be considered in the education and evaluation of
FROM COMPETENCE TO CAPABILITY: A STUDY OF NURSE
PRACTITIONERS IN CLINICAL PRACTICE
Nurse practitioners (NPs) have had a presence in healthcare delivery in some
countries since the 1960s. The role originated in the United States (US) to improve
primary healthcare to under-serviced communities. Currently NPs exist in many
countries in primary and acute healthcare settings in rural and urban settings. Broadly,
NPs are registered nurses with advanced and extended clinical roles. They provide
comprehensive nursing management of clients that include referral to other healthcare
professionals, prescription of medications, and ordering of diagnostic investigations.
A NP level of service is currently being developed in Australia and New Zealand. The
title of NP is now protected by legislation in New Zealand. In Australia, authorization
processes for the title are controlled by state and territory nurse registration authorities
and formal processes are currently underway in most jurisdictions. Trans-Tasman
mutual recognition legislation necessitates a comparable standard of practice between
New Zealand and Australia. However, there have been considerable discrepancies in
the requirements for registration being developed across Australian jurisdictions and
none were entirely consistent with New Zealand requirements. Consequently a study
was commissioned to develop a single set of Australian and New Zealand competency
standards for NPs.
One of the key findings from the study was the apparent limitation of the use of a
competency based assessment framework for the practice of NPs. Our thematic
analysis indicated that there was an additional feature needed that adequately
described the method and contexts of practice, which must be captured and defined in
any approach to evaluation, education and licensing of the NP (Gardner et al, 2004;
Gardner et al, 2006) Thus, we explored the literature for other frameworks and
identified the concept of capability as a useful construct. There is an emergent body of
literature exploring capability that has had very limited empirical testing. In the
original project we reported our inductive findings as consistent with the existing
capability literature. The Nurse Practitioner Standards Project (hereafter referred to as
the Project) provided an exciting opportunity to further test the capability framework
deductively. Here we report a secondary analysis of NP interview data using
capability as the theoretical framework.
Nurse Practitioner Standards Project
In 2003, the then Australian Nursing Council and the New Zealand Nursing Council
jointly sponsored a research project to develop NP competency standards (the Project).
The aims were to describe the core role of the NP; to develop core competency
standards for NPs in Australia and New Zealand and to develop standards for
education and program accreditation for NP preparation leading to
registration/authorisation. The primary source of data was in-depth interviews with
NPs who were authorised and practising in either Australia or New Zealand. Each
interview included a report of a NP case study. Further data were derived from NP
education program materials obtained with permission from tertiary institutions and
interviews conducted with the academics coordinating these programs. An extensive
literature review relating to NP authorisation, legislation and roles was undertaken.
Data were analysed according to the requirements of each data set and then
triangulated. Based on the research findings, a competency assessment framework
was developed which outlined the knowledge, skills and attitudes required of NPs
(Gardner et al, 2004;Gardner et al., 2006).
Nurse practitioners described a scope of practice that is located at the extended level
of nursing service. There was strong evidence that the role of the NP was qualitatively
different from other roles and levels of nursing in Australia and New Zealand. Nurse
practitioners were accommodated in a range of practice environments, dealt with
complexity and used non-linear reasoning in healthcare, and drew upon innovative
and non-standard solutions to achieve optimal outcomes for clients. This finding has a
number of implications for how we construe and, hence, evaluate the NP in clinical
The constraints of competencies
Whilst some suggest that competency standards are a necessary balance against an over
intellectual approach to education and practice in nursing (Eraut, 1998), we argue, as
have others, that there are limitations in the use of competencies to assess clinical skills.
In a systematic review of clinical competency assessment in nursing, Watson and others
claim that competence is a nebulous concept that is defined in different ways by
different people (Watson et al, 2002). Moreover, they conclude that while there is
almost universal acceptance of the need for assessment of clinical nursing competence,
evidence of the reliability and validity of assessment methods is absent in the published
Distinguishing between different levels of competence has been identified as a
particular problem when it comes to assessment of clinical skills (Girot, 2000).
Perhaps because of this, there is also a reported move away from a total reliance on
competencies as a way of benchmarking practice standards (Storey, 1998) in
postgraduate nursing. With a history based in manual occupations competency
assessment in nursing practice primarily focuses on the technical and procedural
elements. Implicit in this form of assessment is an opposition to the relevance of
academic or intellectual abilities and, as such, has been argued as being a double-
edged sword (Goldsmith, 1999). Competency-based practice is also inherently
reductionist, providing a limited view of professional practice and impeding
professional development (Goldsmith, 1999, McAllister, 1998).
Recent vocational education and training literature acknowledges that competencies
may be just the beginning of our understanding about requirements for developing an
effective workforce (Hase & Saenger, 2005). Furthermore, reductionism may in fact
provide inappropriately simple solutions to highly complex phenomena. For example,
when evaluating ability to function in a complex clinical situation the interaction of
several competencies may be much more important than a series of separate
assessments of task specific competencies (Watson et al, 2002). All this evidence
points to an unavoidable tension in the use of competencies to measure the
performance of a Masters prepared nurse. Nonetheless, without a superior alternative,
regulatory authorities must seek to demonstrate safe standards for NP practice by use
of competency standards.
Our conclusion from the Project was that, in addition to a competency framework, NP
standards should be informed by an evaluation approach that accommodates
additional characteristics. We identified the notion of capability as a useful model to
achieve this orientation (e.g., Cairns, 1996, Stephenson, 1992, Stephenson, 1996,
Hase & Kenyon, 2000). We have recently extended the research to conduct a
secondary (deductive) analysis (Szazbo & Strang, 1997) using capability as a
There is a nascent literature and limited but growing empirical evidence for the
concept of capability. It has been used largely in the context of understanding
teaching and learning and to inform evaluation methodologies for practice in range of
professional occupations Graves, 1993, Hase & Davis, 2002, Phelps, Hase & Ellis,
2005). Capability has been described as a holistic attribute with capable people more
likely to deal effectively with the turbulent environment in which they live (or work)
by possessing an all-round capacity to manage continual change (Hase & Kenyon,
2000). Cairns (2000, p. 1) has defined capability as: ‘Having justified confidence in
your ability to take appropriate and effective action to formulate and solve problems
in both familiar and unfamiliar and changing settings’.
Capable people have high levels of self-efficacy, they know how to learn, they work
well with others, they are creative and, most importantly, they are able to use their
competencies in novel as well as familiar circumstances (Davis & Hase, 1999). Thus,
demonstration of competence is an important attribute of capability but is not
sufficient to enable people to take effective and appropriate action. Capable people are
more likely to be able to manage complex and non-linear challenges (Phelps & Hase,
2002, Phelps, Hase & Ellis, 2005)
We thought that applying the concept of capability might orientate NP competencies
towards the dynamic clinical environments in which NPs are likely to practice
(Gardner et al, 2004). To confirm this notion we undertook a secondary (deductive)
analysis of the data informing the core role of the NP.
This secondary analysis sought to answer the question:
Does the concept of capability provide a relevant and useful theoretical framework to
explain the characteristics of nurse practitioner practice?
Population and sample
The population of authorised and practising NPs was used for the primary study. All
NPs in New Zealand and each state in Australia where NPs were both legitimised and
practising were invited to participate in the study. Through the nursing regulatory
authority in each jurisdiction, these NPs were sent a letter, an information sheet, a
consent form and contact details. They were invited to contact the investigator in their
area if they were interested in participating in the interviews.
A purposeful sample of NPs was used for an interpretive approach. There were 64
NPs registered in Australia and 11 in New Zealand at the time the research was
conducted. Of those authorized, an unknown percentage were actually practicising
because many were still in the process of obtaining approval for clinical protocols
including prescribing rights. At the time of initial contact only those who were both
authorized and practicing were recruited into the study. The sample size was
determined by theoretical sampling. After fifteen interviews sampling was ceased as
data saturation through identification of themes was achieved.
Fifteen NPs employed in acute services, primary health care, mental health and
primary health care were interviewed. There were 11 women and four men ranging in
age from 29 to 56 years. Participants had been registered as NPs for a period ranging
from three years to three months.
As the number of NPs in Australia and New Zealand is small, a breakdown of
demographic data was not reported. Very little information with regard to respondent
characteristics was collected to preserve anonymity. This method was designed so that
no individual or institution could be identifiable through the data.
Data collection and analysis
Interviews with consenting NPs lasted for between one and two hours. The structure
of the interviews included two distinct components. A semi-structured format was
used to collect data relating to the NPs’ employment, education, and authorisation
experiences. An additional in-depth component elicited information on the
experiential dimensions of NP work. This latter part included a report of a de-
identified case study that represented for that participant an exemplar of NP service.
These interviews were audio recorded and transcribed.
All four investigators were involved in the collection and analysis of the data from
nurse practitioner interviews. Two investigators conducted initial analysis and themes
were discussed and reconciled with the other two researchers in face to face meetings.
The secondary data analysis was structured by the defining characteristics of
capability. That is, an analytical framework was established from the five attributes of
capable people as defined by Davis and Hase (1999) and data were deductively coded
according to this framework (see Table 1).
Table 1 Analytical framework
Attributes of capability
Knows how to
Works well with
Has a high degree
both novel and
The following section describes how the data obtained from NPs supported the
attributes of capability in Table 1 above.
Knows how to learn
Knowing how to learn has been shown to be a more powerful indicator of capability
than simple technical knowledge (Phelps, Hase & Ellis, 2005). Acquisition of a
technical skill arises through repetition but with ongoing learning the capacity to
discover and to deduce from experience is a higher order activity. Competency
concerns acquiring a certain level of skill and then being assessed on what is
essentially past knowledge and ability. However, the ongoing development and
progressing of that skill into more refined and sophisticated practice is a function of
knowing how to learn and is largely self-determined (Hase & Kenyon, 2000).
As we analysed the data for competency indicators we consistently noted NP
narratives which suggested that these clinicians were not only ready to utilize the
knowledge they had accumulated through education and experience but were also
committed to a process of building their practice knowledge. That is, NPs identified
what they did and did not know, and from this were able to identify what they needed
to know. As one NP asserted:
(I ask) what are my weaknesses, what are my strengths? So I can focus. Well, if I’m
a bit weak in these areas, and this is what is really expected of me as a nurse
practitioner, I can identify those and do something about it.
In addition to identifying the practice environment as the trigger for learning, NPs
identified the need to know where to find information. They emphasized that
information was accessed from a range of sources both formal and informal including
the ability to search the literature effectively. When asked about types of knowledge
needed one NP responded:
… being able to research the vast amount of knowledge that is available to us. It is
probably critical … because there is so much out there. I think having the ability to
be able to effectively search through things to find what you need to find.
Another responded to the same question by claiming that NPs required the skills and
confidence to select what is good evidence:
(being) able to critique (the literature) appropriately, that what you are using isn’t
These excerpts illustrate commitment to continuous reflection and ongoing learning.
These behaviours are consistent with the characteristics of life long learning as
described by and, significantly, for the objectives of this study, conform to the
capability attribute of knowing how to learn. Hase, Cairns & Malloch, 1998) proposed
that capable people self-manage their learning potential. They understand the
processes and strategies needed to implement self-managed learning.
Works well with others
While capability includes elements of independent action, capable people have, as a
core value, recognition of the importance of working with others to achieve outcomes.
Nurses of all levels work in teams. However, the nature of teamwork that the NPs
described was both precise and qualitatively different from many previously
published accounts of nurses as team members. The interview data indicated that
these clinicians viewed teamwork and collaboration as central to their practice.
The NPs regarded teamwork in all its forms as best practice. Working in
multidisciplinary teams was the best way to work, the most efficient for both staff and
patients. A remote area NP illustrated this:
We are more autonomous …but we’re doing teamwork to get the best possible
outcomes for the patient. That obviously means you would still have good
relationships, with their GP and the clinical nurse consultant ... even though we’re
we’re not working in isolation.
Furthermore, the NP tended to express a sophisticated and inclusive notion of team
configuration. Membership of the team was related to the clinical problem or situation
at any given time. For example:
And they (the baby’s family) asked me whether I thought a decision needed to be
made. So we talked about withdrawing treatment, about what happens when
treatment is withdrawn, about how we make those decisions about how we walk
with the families and its not actually a family decision it’s a decision with the entire
health care team of which they are part of, and that we really listen to what they say
so if that’s what they wanted to happen in this situation that we would talk about that.
The NP used the notion of teamwork as a therapeutic intervention. Responsibility for
a difficult decision is ameliorated when the NP positions the parents as part of the
Communication was a concept that came up repeatedly in the context of teamwork.
Nurse practitioners talked about communication across and within levels of healthcare
demonstrating another dimension to the capacity to work with others. As another NP
You have got to be able to liaise and talk across all care boundaries and to everybody
from the care assistants particularly in rest homes up to consultant level. We have
got to be able to communicate across all those pathways.
As stated earlier, working with others was an essential part of NP practice. In the
following excerpt, the role of education and information sharing is one dimension of
Having the ability to teach others, being willing to teach others, to impart your
knowledge and skills and not keep it to yourself. That’s really important, that
building capacity in the work force, being willing to do that is important. Not
feeling that you own anything necessarily, that you’re just a cog in the wheel and
you’re meant to work as part of a team.
The facility to work well with others was probably the most strongly supported aspect
of capability in this study. These excerpts from the data clearly articulate both the