Competency as a concept used within training and education was introduced in 1973. It is now used in many spheres, not simply health. A recent review (here) has investigated its use. As one might expect, there are quite wide variations in meaning, which they illustrate. The review extracts main features and recommends a uniform terminology. This blog discusses the review and how to use the ideas as we develop the UK rehabilitation syllabus. The blog is summarised in a graphic accessed here. A later blog, stimulated by the World Health Organisation’s Rehabilitation Competency Framework (here and here) but not yet written, will consider specific rehabilitation competencies.

The review is impressive, reviewing 70 papers from a wide variety of sources and relates to a wide variety different types of activity and different roles. The review demonstrated a “lack of consistency in definitions and use of key terms even within a single organisation.” The paper gives much evidence, and many examples, but I will focus upon some findings.

This first is interesting. The United States generally has a different approach from the United Kingdom. Forty three of the 70 publications came from these two countries. Most other countries had one or two publications. However this difference highlights one of the main conceptual problems.

In the US, the idea of competency developed from 1973 in an educational context, which led to a concept of a “continuous and evolving” competence. In the UK, starting in the 1980s, the idea of competency developed in an employment context, which led to a concept of competence as a state. A person with was, or was not, competent. In two clear figures, the difference is illustrated.

Both approaches start with a development process, encompassing education, training, learning, and practice. Both approaches also have a set of four attributes (their preferred term): knowledge, skills, attitudes, and behaviours. In the educational model, the competency is set at this level. Both approaches also consider three aspects of the occupation: the role, the activity, and the tasks that make up the activity. In the employer model, competence is set at this level.

The review also found that that the eight attributes (their word) above – education through to behaviours – and the three occupational descriptors were also defined, if at all, in differing ways and to differing level of detail.

Although they only (?!) reviewed 70 papers, there were 623 papers about competency frameworks, most (425) published between 2010 and 2019. Twenty-four of the 70 papers reviewed concerned health organisations. These publications peaked between 2010 and 2014. They also showed inconsistent and often differing use of terms, even within a single publication.

The authors put forwards four important distinctions that underlie a new framework put forward.

Competency v. Activity.
Competence applies everywhere, across roles, activities and tasks. It lasts over time and applies in different settings and contexts; if you were competent last Tuesday on the ward with someone who has had a stroke, you should be competent next Friday in the out-patient department with someone who has motor neurone disease. Performance of a competence is difficult to measure.

An activity, on the other hand, has a beginning and an end and an instance will occur in one context. Moreover, as an activity is simply a collection of tasks, performance is reasonably measurable.

The authors consider that both an activity and a competency can be broken down. An activity is a series of task. They consider that a competency is evidenced by a collection of behaviours.

They also make the important distinction that a competency relates specifically and only to a person, whereas an activity relates to a role. I could not find a further explanation. I think they mean that someone with the competence can do the activity in any context, whereas some with role-based ability can only undertake the activity in a restricted, role-based context.

For example, both a suitably trained acute stroke nurse and a speech and language therapist could safely assess swallowing in a person shortly after a stroke, but only the speech and language therapist has the competence to “assess whether swallowing is safe‘, because he or she can do it with any patient, anywhere with any disorder, whereas the nurse could not. In the case of the nurse, the ability to undertake the activity is related to the role of ‘acute stroke nurse’, and cannot be generalised to other contexts. However the competence is independent of context for the speech and language therapist.

Attributes v activities and competencies.
Knowledge and skills are attributes, and they are the foundations upon which activities and competencies are based. Knowledge and skills are conceptually different from activities and competencies. They are a necessary, but not sufficient condition for performance of an activity. Moreover there is probably only a weak and indirect relationship between having knowledge and skills, and being competent.

Although not specifically stated, the extent of knowledge and skill required to undertake an activity in a limited context will be less than the amount needed to be competent.

The direct relevance of attitudes is unclear to me. They are described as “A person’s feelings, values and beliefs, which influence their behaviour and performance of tasks.“. These would seem to be more closely related to behaving in a professionally appropriate manner, or something similar, and to relate to making decisions about the wisdom and appropriateness of undertaking an activity in a specific context.

Proficient v competent.
This is an interesting distinction, and really relates to the grading of competence, and the the distinction between role-based and competence-based ability to undertake an activity. Taking the example of the assessment of swallowing, the nurse would be considered or described as being proficient in one circumstance, whereas the speech and language therapist could be considered proficient in all contexts. The proficiency might also extend to using instrumented tests of swallowing, for example.

This leaves open the question of setting a standard or criterion that changes someone from being very proficient to being competent because, even for people deemed competent, it is inevitable that some patients are at the limit of or beyond their proficiency.

The types of criteria that could be used to judge the extent of someone’s proficiency, and ultimately their competence, include:

• complexity. Someone who is competent can take on more difficult examples of the activity.
• adversity. Someone who is competent is more able to manage in the presence of unexpected events or challenges arising during the activity.
• settings. Someone who is competent can undertake the activity in a wider range of circumstances.
• conditions. In rehabilitation, someone who is competent can undertake an activity in patients with a wider range of diseases and/or accompanying impairments or disabilities.

Ability to translate into other languages.
A last feature of the proposed model is that the concepts can be translated into other languages, and do not depend upon nuances in the use of English. This is really a matter of making the distinctions between different concepts explicit, rather than using particular words. Even among people writing and familiar with English, there was obviously a wide range of meanings attached to single words.

The paper provides a glossary of the meaning of the terms used, and useful figures showing the concepts.

There are several important conclusions. When reading about competencies, be very aware that the words used may not mean what you think. Even within a document, a single word may carry different meanings in different places. The process of becoming competent at an activity depends upon having adequate and appropriate knowledge and skill. An activity is comprised of smaller tasks which have to be learned and used to undertake an activity. How well an activity is performed by someone can be described as their proficiency. At a lower level, someone may be proficient in a very specific context associated with their specific role. As a person increases their proficiency, on the basis of more knowledge, skill, and practice, they can manage situations that are more complex, they can adapt to unforeseen changes, they can manage in more and different settings, and they can manage patients with a wider range of associated problems. At some point their proficiency is sufficiently great that they are deemed competent. Setting the criterion for this is not within the scope of any framework; it is a judgement made externally.