Aim, design and setting of the study
This descriptive study was conducted to compare the clinical competence of emergency nurses using two methods of self-assessment and assessment by the head nurse in the emergency department of hospitals affiliated to Dezfoul University of Medical Sciences in Iran. The research environment was the emergency departments of hospitals including Dezful Ganjouyan hospital, Karun Gatond hospital, and Nezam-Mafi hospital.
Sample size and sampling procedure
The statistical population included all staff nurses working in Emergency departments of three hospitals affiliated to Dezful University of Medical Sciences, which were studied for 3 months from July to September 2017. Generally, from 90 nurses working in all emergency departments of affiliated hospitals, 70 nurses were selected using census method based on entrance conditions after explaining the goals of the study, obtaining informed consent, and ensuring the confidentiality of personal information. The entry requirements for the study were as follows: 1) providing written consent to participate in the study, 2) employment in the emergency department as Official recruitment, contractual recruitment, nursing graduate, and 3) having a bachelor’s and master’s degree in nursing and 4) having at least two years of work experience
Study Instrument
The data collection tool was a two-part questionnaire. The first part was related to respondents’ demographic information, such as their age, gender, degree, marital status, field of study, employment status, work experience in an emergency department, type of university attended, and passed education courses. The second part of the questionnaire was a nurse competence scale (NCS), which assessed the nurses’ clinical competency. The NCS is based on Benner’s (2002) theory as provided by Meretoja et al. (2004) and consists of 73 items that measure nurses’ self-perceived competence in seven domains.
Self-perceived competence was measured through a visual analog scale (from 0-100, with 0 being a very low level of competence and 100 being a very high level of competence). Frequency of use was measured through a 4-point Likert-type scale (0 = not applicable in my work, 1 = used very seldom, 2 = used occasionally, 3 = used very often in my work). The original NCS methodology breaks the self-assessed level of competence into four overlapping integer groups: 0 to 25 is low, 25 to 50 is quite good, 50 to 75 is good, and 75 to 100 is very good.
This scale has high validity and reliability and is easy to use. The reliability of this tool was estimated by Meretoja et al. (2004) as having a Cronbach’s alpha of 0.79 to 0.99. Furthermore, its internal consistency was reported as being between 0.79 and 0.91 [14,15]. Because there were no special checklists for assessing Iranian nurses’ competencies in emergency departments, this questionnaire was distributed to 11 members of the nursing faculty and reduced to 63 items, which confirmed its content validity. The tool’s reliability was calculated using Cronbach’s alpha. Likewise, the questionnaire was distributed among 30 nurses, and its reliability was calculated as 0.96. The mentioned questionnaire includes items related to 63 clinical skills in seven general areas. These seven areas include the fields of patient support and assistance (four skills), education and guidance (14 skills), diagnostic actions (seven skills), managing clinical situations (eight skills), therapeutic measures (10 skills), quality assurance (four skills), and occupational and organizational tasks (16 skills). To compensate for the nurse's lack of English language knowledge, we used a translated form of the questionnaire. In a pilot study, the reliability of the translated questionnaire was between 0.70 and 0.85 in all seven areas, which is an acceptable level.
In this study, each nurse was asked to identify their level of competence on a visual analogue scale (VAS) (0-100), on which values 0-25, 26-50, 51-75, and 76-100 represent weak, moderate, good, and excellent levels of competence, respectively. Moreover, nurses’ clinical competence was ranked in four levels based on the frequency of actual use in clinical practice (0 = not applicable in my work, 1 = used very seldom, 2 = used occasionally, 3 = used very often in my work).
Data collection
First, a formal letter of permission was obtained from the Dezful of Medical Sciences University Ethics Committee. Then, this letter of permission was submitted to each hospital’s nursing directors. After receiving acceptance of our request, we coordinated with head nurses to prepare a list of permanent nurses in their department. Nurses from all emergency departments in each hospital who fulfilled the inclusion criteria were included in the study. In the next step, two supervisors from nursing faculties with an MSc degree in nursing held an introductory meeting for participants to discuss the study with them, explain the study’s objectives, assure the confidentiality of information (to comply with ethical considerations, the questionnaires were anonymous and encoded), obtain written informed consent, and describe how to complete the questionnaires in each of three work shifts (in the morning, evening, and night).
After the questionnaires were distributed among the nurses with the help of an assistant, the questionnaires were sent to head nurses. The participants were given one week to fill out and return the questionnaires. Two weeks were given to return the questionnaire in case of sick or other leaves, problems, and being unusually busy. If the questionnaire was not returned after the specified period, the subject was excluded from the study.
Ethics approval and consent to participate
This study was approved by the Ethics Committee affiliated to Dezful University of Medical Sciences (Ethics Code: IR.DUMS.REC1396.5). In this study, researchers were committed to ethical issues of obtaining informed written consent from the participants prior to data collection, respect for voluntary participation and inform the participants about the purpose of the study.
Data analysis
The data were analyzed using SPSS software version 16. Additionally, the descriptive statistics including frequency, mean, and standard deviation were used to describe the demographic characteristics of the subjects and evaluate the clinical competencies. Furthermore, the inferential statistics including Kolmogorov-Smirnov test for normality of competence score in two assessment methods and independent t-test was employed to compare clinical competency by self-assessment and assessment by the head nurse. The level of significance was considered at 5%.