Healthcare and Medicine Reference
Tim Nutbeam 1 and Ron Daniels 2
1 West Midlands School of Emergency Medicine, Birmingham, UK
2 Heart of England NHS Foundation Trust, Birmingham, UK
or incompetently performed. Those responsible for the training
and supervision of the HCPs performing these procedures are
under increasing pressure to ensure the skills required to perform
these procedures are adequately taught and maintained. To do this
a learning and assessment process must be demonstrated.
Becoming adept at the practical procedures expected of you within
your role is a key step in achieving overall clinical competence.
A competency relates to performing a single skill or procedure,
but also includes the underlying knowledge, abilities and attitudes
necessary for optimal performance. In order to assess competency
in a procedure it must be performed to a specifi c standard under
specifi c conditions - standards and conditions this text attempts to
outline. Competence also implies a minimum level of profi ciency
which must be attained and maintained; in the United Kingdom,
case law dictates that an individual must perform a procedure to
the standard which can reasonably be expected of others with a
similar level of training and experience.
By the end of this chapter you should be able to understand:
the importance of becoming profi cient at practical procedures
the principle of 'competency'
how to learn and maintain these skills
the principles and purpose of a logbook.
The importance of practical procedures and of performing them
safely cannot be underestimated. Healthcare professionals (HCPs)
will be expected to perform a wide range of practical procedures
with competence and confi dence. Some of these procedures will
be diagnostic, some therapeutic and others life-saving. The struc-
ture of healthcare organisations dictates that even the most junior
trainees will on occasion have to undertake some of the procedures
described in this topic without supervision.
This topic contains procedures that are a part of medical, nursing
and allied health curriculi throughout the world. The focus is on
understanding not just the practical aspects of how to do a particu-
lar procedure but also why, when and where to do it.
Learning practical procedures: attaining
The days of 'see one, do one, teach one' are over. Experts estimate
that each new practical competency (e.g. intravenous cannulation)
must be performed a minimum of 30 times to be 'learned' as a new
psychomotor process; it is more diffi cult to estimate how frequently
the process must be performed to be retained.
More complex procedures (e.g. insertion of a central venous
catheter) must be performed on 50-80 occasions before an 'accept-
able' level of failure/complication (5%) is reached. However, health-
care now strives to achieve an adverse event rate of fewer than 1 in
100 episodes, and in anaesthesia and blood transfusion fewer than
1 in 1000 episodes result in adverse events. A failure rate of 5%,
therefore, may become unacceptable to patients in the foreseeable
It is impossible to generalise competency to a certain number of
procedures for all individuals; the number needed to become and
remain competent will vary vastly depending on the experience and
dexterity of the practitioner, the procedure, how regularly it is per-
formed, who it is performed upon and the environment in which
it is performed.
There are a number of essential preconditions that a practitioner
must satisfy before embarking upon a practical procedure.
Throughout healthcare education, 'competency-based training'
has evolved to address gaps between theory and practice. The pur-
pose is to demonstrate that an individual has received training and
assessment in knowledge and skills relevant to all aspects of their
clinical practice. Perhaps most importantly, maintaining a portfolio
of competencies stimulates the trainee and their clinical supervi-
sor to refl ect on their professional development and training needs
frequently to help direct future learning goals and strategies. An
additional benefi t may be to limit the susceptibility of practitioners,
trainers and organisations to successful litigation should complica-
tions occur. Up to 50% of incidents where patients come to physical
harm in hospital are due to practical procedures being inadequately