The purpose of this chapter is to illuminate the versatility of the main concept in the focus of this research and its close relatives. With reference to Ruohotie and Honka (2003) such concepts as competence, skill, qualification, ability, capacity, performance and proficiency are tied to each other. They are a mixture of knowledge, behaviour, attitudes and values, and they all refer to mastery of some skill. Furthermore, they are related to creativity, innovativeness, flexibility, accuracy and preciseness.
2.1.1 Clinical skill
When trying to define the concept of clinical skill it seems unavoidable to talk also about skill, competence and knowledge. For a start, the researcher defines clinical skill as skill applied in clinical settings. The following longish citation of Ruohotie and Honka (2003) aims at building more profoundly the underpinnings of the concept of clinical skill applied in this study. Attewell (1990) regards skill as a synonym of competence, albeit his definition generates a notion of expertise, mastery and excellence. Ability to do something skilfully is found to be characteristic to the concept of skill, which, in turn, is always associated with knowledge and understanding. Application of any knowledge into practice takes skill. It seems appropriate to refer to Ruohotie and Honka (2003) due to their claim that the emphasis, put on the cognitive aspect associated with skills, has resulted in the valuation of mental and physical capability. On the other hand the physical aspect as dexterity and manual skills have often been left in the shadow.
With reference to Webster’s Dictionary, (1996)clinical stands for something that pertains to a clinic or ispertaining to orused in a sickroom. Moreover,clinical is concerned with or based on actual observation and treatment of disease in patients rather than on artificial experimentation or theory.
In this study, based on the aforementioned quotations and definitions, clinical skill is regarded as mastery of such a combination of knowledge, skills and attitudes that enables an ED nurse to master the assessment and diagnostic functions, to possess the attributes required in responding adequately to any clinical incident that may occur, and to master the evaluation of the patient’ s response to the care that has been provided, and reassessment of both the patient
as well as the situation at hand. Even though clinical skills definitely are at the core of any nurse’ s professional practice (Nicol and Freeth 1998), clinical skill turned out to be an ill-defined concept. Such an impression was formed that clinical skill is a concept taken for granted and not necessarily needing an accurate definition, like anyone should self-evidently perceive the concept in the right way. This claim was based on rather extensive review of the literature, e.g. Hilton (1996), Nicol and Freeth (1998), Boxer and Kluge (2000), Spunt et al.
(2004), Morgan (2006), and Roxburgh et al. (2008).
The Institute of Medicine of the National Academies, USA (2004), refers to Goethe, when stating ‘Knowing is not enough; we must apply. Willing is not enough; we must do‘. The everyday non-scientific observation of the researcher is in concordance with the preceding statement, i.e. increased knowledge is not a synonym for increased understanding.
Furthermore, time has not been able to refute the Aristotelian intuition, according to which such a skill that aims merely at indefinitely promoting one’s own objectives will not be capable of solving solve any of our problems. The application of skill is decisive, and that in turn, also requires ethical consideration deriving from practical sense (Sihvola 1992). It seems reasonable to postulate that clinically skillful ED nursing deals with all of these factors:
knowing, applying, willing and doing, skilfully and with ethical consideration (ENA 2003).
Correspondingly, the key-concept of this study, clinical skill, arises from and is built upon those preceding components.
2.1.2 Skill as a concept
Skill is a complicated and multi-faceted concept. According to Webster’s Encyclopedic Unabridged Dictionary of the English language (1996, 1335), skill stands for ‘the ability, coming from one’ s knowledge, practice, aptitude etc., to do something well’, ‘competent excellence in performance; expertness; dexterity’ ‘a craft, trade or job requiring manual dexterity or special training in which a person has competence and experience’. One of the several obsolete meanings is ‘understanding’. Similarly, skilled stands for ‘having skill;
trained or experienced in work that requires skill’; ‘showing, involving or requiring skill, as certain work’. Skilled labormeaning‘labor that requires special training for its satisfactory performance’. Furthermore, it is hardly possible to ignore the fact that the conceptartstands, among other meanings, for ‘exceptional skill in conducting any human activity’ (Webster’ s Encyclopedic Unabridged Dictionary of the English language (1996, 84). The synonyms for skill in greece (tekhne), in latin (ars), in german (Kunst) and in swedish (konst) also indicate
that the concept of skill carries with it interest-arousing connections with several domains of human action (Niiniluoto 1992).
With reference to the aforementioned evidence, it seems clear and necessary that the conceptual basis of this study is built on the fundamental idea that the concept of skill is not synonymous with something that is merely technically competent performance. Nevertheless, everyday, non-scientific, experience of the researcher is that within the discipline of nursing there may sometimes have emerged a slight undervaluation or even misunderstanding concerning the non-superficial meanings of the concept of skill, see e.g. Kaskinen (2006).
Reducing the concept of skill to merely technical performance, or even a form of playing tricks, is not in concordance with the original, traditional and multi-faceted meanings of this concept (Halonen et al. 1992).
2.1.3 A retrospective review of skill
In order to enable the reader to catch the approach the researcher has had in terms of the concept of skill as a combination of theoretical knowledge and practical mastery a historical view is provided. The originally Greek word technique along with its derivatives can be used more widely to describe any action requiring skilfulness or magic, even though the action would belong to the domain of Aristotelian praxis (sports, dance, circus acrobatics) rather than that of productive work. Here skill (poiesis) does not, in the first place, refer to a productive ability to achieve certain results (e.g. skill to make iron), but a skilled way of performing the action (e.g. figure skating). (Niiniluoto 1992.)
During the Middle Ages, a system of so-called liberal arts (grammar, dialectic, rhetoric, geometry, arithmetic, astronomy, music) rose to be the core of the educational system (Figure 4). From the philosophical faculties, acting as heirs of the Middle Ages’ universities, ‘Masters of Arts’ are still graduated.
FIGURE 4. The system of liberal arts according to Niiniluoto (1992, modified by the researcher).
During the fifth century, the most advanced skill was medical skill, which can be said to have, already in that early phase, developed to be a certain kind of practical science. According to the Hippocratic physicians, only such competence as is based on well reasoned theoretical knowledge could be regarded as real skill (Sihvola 1992). Aristotle specified the concept of skill, emphasising the distinction between skill and merely mechanical skilfulness. Real skill requires, in addition to functional competence, intellectual comprehension of the principles upon which the execution of the skill is based on. Aristotle adhered to the Greek tradition when combining together the concepts of skill and knowledge (Sihvola 1992).
In Finnish, the concepts of skill and knowledge have as originating from the sixteenth century had approximately the same meaning. Skill could refer to person’s mind, consciousness, soul, sense or knowledge. The concepts of knowledge and skill have gradually achieved stable meanings, and skill is now understood to be composed of the mastery of performance and the knowledge related to that. (Vertanen 2002.)
2.1.4 Qualification, competence and vocational proficiency
The concepts of qualification, vocational competence and proficiency are used in miscellaneous ways. To some extent they are even regarded as synonyms. These concepts are related to each other and they have a mutual core, but each of them also has its own meaning.
Qualification can be defined as a specification of quality, eligibility, aptitude, and as fulfilling the conditions set. Qualification reveals an expression of quality and qualitative application.
Qualification also stands for the knowledge and skills required due of the technical content of the working process, the demands made on the motivation and compliance of the employee and their innovative attributes. Some of the qualifications are profession-specific, while others are general qualifications (Hilden 1999).
Hilden (1999) presents, with reference to Streumer (1993), that competence, i.e. the concept of vocational proficiency, has a close relationship with the concept of qualification. Compe-tence tends to be regarded as a more abstract concept than qualification. While qualification refers to ability to perform concrete actions, competence, in turn, refers to regulation of these actions. As far as competencies are concerned, they deal more with the structure of cognition, interpretation of schemes and operational models, than particular skills or solitary components of knowledge (Pelttari 1997). According to Söderström (1990) competence is conditional and means that competence does not exist as such, but it is always relational to a task or action. If these are not recognized, the concept is insignificant.
Vocational proficiency is difficult to describe, as in Finnish the term vocation carries different meanings. Vocational proficiency is something that is required by the vocation. In this way, the extent of vocational proficiency varies according to the definition and comprehension of the concept of vocation (Taalas and Venäläinen 1994). With reference to Ellström (1994) it would seem reasonable to postulate that proficiency may be regarded as a superordinate con-cept, below which can be differentiated, among others, vocational proficiency, and clinical skill in turn as one of its components.