One key distinction to make when designing a clinical skills assessment programme is the difference between a competency and a capability.
Being clear on this distinction is helpful in understanding the different assessment frameworks out there, and also to think about how you assessment appropriate skills for any particular role. It can also help set clear expectations of both those assessing and being assessed.
Why the need for a distinction
We all intuitively understand that there are certain skills that are clear cut and specific – you can define exactly what is meant, the circumstances under which this applies, and even criteria that can clearly be applied. Take as an example:
Able to change the wheel on a Ford Focus.
That can be pretty universally understood and scoped – we can even define performance criteria which we can use to agree on whether a person has achieved it (1. Old wheel remove 2. New wheel put on 3. Bolts tightened to the value in the manual). Of course there will be elements that we don’t bother documenting (didn’t lose a finger while changing the wheel) or rely on some professional judgement (didn’t take five hours to do it), but in almost all cases we would easily have a common understanding of the skill and what successful achievement of it looks like. In this regard it is largely objective. We can also fairly clearly define the boundaries – as stated, this competency means I can change the wheel on a Ford Focus, but it doesn’t necessarily say that I can also change the wheel on a Scania HGV.
But there are other skills where this isn’t possible. Compare with a skill that is stated as:
Understands how an engine works
This is much harder to understand and define – and definitely harder to assess. It is a much broader skill. Even if we try to narrow it down:
Understands how a 2022 Ford Focus 2.0 petrol engine works
It’s still difficult to pin down. Am I talking about the broadest principles of how pistons and crank shafts work, or do I need to go all the way down to the biochemistry of hydrocarbon combustion? Do I just need the theoretical knowledge, or do I have to take the engine apart and show you? Whose interpretation of “understand” are we using – you may be much tougher on this than me. And how rigorously are we testing knowledge – written answers or just chat through? It is hard for this not to be subjective.
Boundaries are harder to define too; do I need to cover the normal functioning of an engine, how it works in different climates, how wear and tear may change this?
And yet both types of skills serves a different purpose. Being able to change the wheel on a Ford Focus is a relevant competency for the owner of a Ford Focus. But I would want my AA mechanic to have a good understanding of how an engine works.
Defining Competencies and Capabilities
Therefore we can identify two types of skill – which are increasingly termed Competencies and Capabilities.
Competencies are defined standards of performance, focused on the outputs of work and observable performance.
- The requirements and scope of a competency are specific, and performance of the task can be clearly described
- Achievement can be measured and assessed against objective, agreed criteria
- These are well suited to stable environments and familiar, repeatable problems, but offer limited applicability outside of those environments
Capabilities are the attributes (skills, knowledge and behaviours) which individuals bring to the workplace.
- These are broad, directional statements that are open to interpretation and professional judgement
- This makes them much hard to measure and assess, and inherently brings subjective judgement into any assessment
- But they are well suited to handling unpredictable environments and unfamiliar problems, where broader adaptability and creativity are required
Note: the terms here are not universally agreed or applied
I think it will be impossible to ever get agreement on a definition of “competent” and “capable”. These are words in general usage that have their own meanings beyond any attempt to co-opt them into technical terminology – and they both mean much the same thing (”able to do something”) anyway, with capable somewhat implying greater skill than competent:
adjective. able to do something well
adjective. able to do things effectively and skilfully, and to achieve results
One option is to refer to “clinical competencies” and “clinical capabilities”. This is clunkier and still doesn’t remove all ambiguity between the two terms, but it at least draws a distinction between general competence and a clinical competency.
Other important differences
Different tools to assess
Because of their objective nature, competencies lend themselves well to checklist-style assessments. These are made up of simple steps with clear performance criteria at each stage that allow any assessor familiar with the topic to give a consistent assessment of competence. There may still be debate as to the level of rigour required (how many errors are allowed) or weight of evidence required (how many times must the skill be successfully demonstrated) – but once agreed this can be consistently applied.
Capabilities are different. The varied and flexible nature means that clear performance criteria cannot so easily be applied. Therefore they rely more upon the subjective judgement of a qualified expert in that field. Ideally this is also backed up by material that helps support and explain that judgement:
- Justification of an assessor’s subjective judgement, including examples and rationale
- Potentially corroborating views – whilst the plural of “subjective” is not “objective”, at least having multiple subjective views avoids the potential extremes of a single subjective view
- Attendance at training course relevant to the topic
- Passing examinations or other tests of knowledge
- Portfolio of evidence that supports a judgement
- Logs of sufficient practice to have (most likely) gained capability
Note that the above may also form part of a judgement on competency, but in that case it is usually only part of the journey to being assessed with a specific competency assessment (e.g. a training course ahead of the skills assessment).
Competencies are better suited to portability
The objective nature of competencies makes them far better suited to portability between organisations.
If two organisations can agree on objective performance standards that need to be achieved, then it becomes much easier to accept competence from outside. These don’t even need to be exactly the same performance criteria – as long as both are satisfied that they meet the requirement of competence in that skill. Once this is agreed it is easy to accept someone has achieved competence in that skill at another organisation – that competency is portable. Of course suitable evidence and protection against fraud are still required, but the fundamental trust is there.
The lack of clear, objective performance criteria means this approach isn’t possible with capabilities. That’s not to say that capabilities can never be portable across organisations – it’s just that the evidence needs to be rigorous and transparent, and even still it may be treated far more sceptically outside of the original organisation. This may even be a matter of cultural pride (or arrogance) – we’ve all heard some version of “well, they might say he understands how an engine works, but the standard over there at Jones’ garage is not what we would accept here at Smith’s garage”.
As careers progress
Very loosely, early on in people’s careers they will have a greater proportion of competencies to develop, and as they progress they will increasingly rely on a greater proportion of capabilities. Sometimes this may be that more senior roles rely on management skills that are inherently capabilities (”able to recognise an individual’s strengths and weaknesses”), and sometimes its because the foundation of competencies is achieved and only needs to be maintained through routine practice whilst broader capabilities are developed over time.
It can be more of a spectrum than a distinction
Going back to our car example – there may be elements of car maintenance that are somewhere between this view of a competency and a capability. My dad is pretty good at fixing a lot of common problems on a car – and that skill can be applied across a range of different makes and models, based on a broad understanding of car mechanics. But this is also made up of some specific competencies (able to change the spark plugs on a Ford Cortina, Sierra and Focus) that he developed over the years, and it definitely has its limit on applicability too.
And so it can be for clinical skills – there may be elements that we would recognise as competencies (able to insert a cannula) that sit alongside capabilities (able to understand and address patient concerns) or even are part of the same single skill (able to safely and sympathetically insert a cannula in a distressed patient).
- See page 32 of https://www.hee.nhs.uk/sites/default/files/documents/Paramedic Specialist in Primary and Urgent Care Core Capabilities Framework.pdf for a good explanation
- https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.695.7600&rep=rep1&type=pdf for an academic discussion in the International Journal of Management
- https://www.linkedin.com/pulse/20141123155439-7430899-capabilities-versus-competence-how-are-they-different/ for a related online discussion
A note on external terminology
Whilst we have drawn up these definitions based on the sources above and this is increasingly being used across healthcare, that is far from universally accepted. Many respected professional bodies do not draw a distinction between competencies and capabilities, often using “competency” as a collective term to cover both. Capability and competency may be used interchangeably, and in some cases,”competency” and “competence” are also used interchangeably.