This study aimed to model the relationship between knowledge, attitude, and performance with the competence of nurses caring for patients with COVID-19 using structural equations. The results of this study showed that the mean knowledge score of more than 50% of the participants was at an average level. The results of Ghezeljeh et al.’s study (2019) are in line with the present study, stating that nurses play an imperative role in helping people deal with disasters, which requires sufficient knowledge [5]. In another study, it was reported that the mean score of nurses’ preparedness to cope with disasters was at a low level; consequently, they concluded that due to the significant role that nurses play in crisis preparedness, such as educating people to reduce vulnerability to disasters and work in a crisis, it is necessary for them to enjoy sufficient preparedness for disaster management upon the occurrence of the specific event. Therefore, continuous education is one of the outstanding strategies for preparing nurses for crisis [30]. The results of another systematic review indicate that in some developing countries, nurses have low to moderate preparedness concerning crisis management, while nurses in developed countries have an optimal level of preparedness and knowledge [17].
Another study result showed that the mean attitude score was at an acceptable level in more than two-thirds of the participants. These results are in line with several studies, and it is believed that the education provided by the Hospital Incident Management team has improved nurses’ attitudes, and this positive attitude is probably due to Iran’s proneness to disaster [5]. The nurses’ mean attitude scores in Ibrahim’s study in Saudi Arabia were also at an acceptable level [16]. Those results are not in line with the results of Soltani et al.’s study (2016), and increasing crisis management training courses for nurses as the largest providers of information and health services to people in times of crisis has been emphasized [7].
Another result was that the mean performance score of more than half of the participants was at a high level. In a study, the participants’ performance mean score was below moderate and at a low level, and it was stated that, according to the learning/teaching preferences, the integration of training courses related to disasters and preparedness for the crisis, both theoretically and practically was essential and vital in nursing curricula [16]. In another study, participants’ performance mean score was reported to be weak, and participation in training courses was highlighted [6]. Hence, the Organization for Economic Co-operation and Development specifically notes that when designing nursing curricula, it is of particular importance to ensure that future generations of nurses will have the appropriate competencies to be “fit for practice” [31], and nursing graduates will need education and training conforming to critical changes in the field of health, such as epidemics [27].
Another result indicated that the mean competence score of more than two-thirds of the participants was at an acceptable level. Labrague et al.’s (2018) systematic review indicated that nurses’ competence in responding to crises was below the optimal level [17]. In another study, the mean score of nurses’ perceived competence was below the moderate level, and it was stated that most nurses were not confident in their abilities to respond to major crises [32]. Therefore, acquiring competence to provide care in critical conditions is one of the crucial issues in the nursing profession, and technical, managerial, ethical, and personal competencies are essential for all nurses to effectively provide care when a disaster occurs [33]. Consequently, it is required to include training in nurses’ university curricula and in-service courses. One of the reasons for the participants’ acceptable mean scores of knowledge, attitude, and performance in the present study for crisis management during the COVID-19 pandemic seems to be the use of successful crisis management models since crisis management is considered a long-term, complex, and technical process, the success of which requires scientific knowledge, attitude, and performance. Some studies in this field have shown that transforming hospitals into COVID-19 centers has improved the managerial performance and control of the situation, helped to organize the conditions, and improved health team members’ preparedness [34].
The other result was that 88% of nurses were responsible for taking care of patients in crisis, and only ten percent were not exposed to critical situations. The results of a study indicate that the positive correlation between previous experience and higher scores in emergency preparedness confirms that receiving education or participating in actual events increase nurses’ perceived and, thus, actual preparedness abilities. Therefore, creating opportunities for nurses to participate in disaster planning and actual exercises and events will increases competence in disasters, confidence in abilities, and familiarity with disaster preparedness and will be a beneficial investment in case of a disaster at a local level [32]. Moreover, while more than 80% of the participants of this study participated in crisis management exercises, only about 28% received an official crisis management certificate. More than 80% felt the need to receive training, and more than half received face-to-face training. Over 60% considered the need for maneuvers and exercises, and more than 70% considered nursing schools and the hospital’s education department responsible for training. Although more than 50% of the participants participated in a course related to crisis management during their studies, they felt they had received inadequate training in this field. Some researchers believe that disaster-related and continuous training is an imperative strategy for nurses’ better preparedness against a crisis, which improves their capacity in all stages of the crisis, including preparedness, response, recovery, and assessment of disasters. To this end, training sufficient nursing staff in this field is required [30]. In another study, it was reported that although most health science specialists had participated in the training courses, few had received regular and systematic training about disasters. Consequently, the curriculum and training programs were suggested to be revised for crisis management [35]. In addition, the role of education as an effective method to improve nurses’ knowledge and skills, holding maneuvers and exercises in the actual environment, participating in institutions’ disaster planning, and providing learning opportunities such as simulation methods and models to prepare nurses to respond to the critical situation must not be neglected [17].
Another result was that the principal obstacles to the development of nurses’ main competencies in crisis management from the nurses’ perspective included inadequate specialist personnel in crisis nursing and the lack of organizational support, educational materials, studies, and research in the field of crisis management, training courses in the workplace, ineffective training courses and formal training resources and nurses’ limited role in crisis management. In another study, factors affecting the nurses’ main competencies in crisis management included mental and emotional stress, human resource management, legal and ethical performance in disaster situations, teamwork ability, organizational hierarchy, individual ability (knowledge and skill), meta-competency, critical thinking ability, and communication and caring skills [33]. The results of another study introduced some of these obstacles: insufficient time and space for educational programs and curricula developed for disaster management, inadequate attendance in training courses, lack of budget, and satisfaction with the current educational level. In order to eliminate these obstacles, developing competencies, focusing on the differences in the training content, which is based on improving competencies, knowledge, skills, and attitudes, standardization of education according to the demands and requirements of each professional group, and emphasis on teamwork and the unique role of nurses are proposed. It is also believed that competencies can be improved through training and development [36].
Spearman’s correlation matrix showed a positive and significant relationship between knowledge, attitude, and performance with nurses’ competencies. Considering the path coefficients, the final model showed that knowledge, attitude, and performance could predict the changes in nurses’ competencies and positively affect them. Almost no study was found that addressed a similar model; however, in some studies, the significant relationship between knowledge, attitude, and performance and their determining role in nurses’ competencies has been pointed out [37–39]. A study also stated that to achieve an acceptable level of competence, an adequate level of proficiency in knowledge, skills, and attitude must be achieved, which is possible through practical courses [36].
The results related to the relationship between the demographic variables and the study’s main variables indicated that the mean score of knowledge, attitude, and performance of nurses above 37 years of age was better than that of younger-age nurses, which is consistent with the results of the study by Rastogi et al. This result seems rational since experience and knowledge develop with age [17, 38]. However, it is inconsistent with some studies [40–42], probably because younger nurses have acquired more knowledge due to more awareness and broader access to the media [35]. In contrast to the mean attitude score that was higher in women, men outscored women in knowledge, which was consistent with the results of several studies [7, 38, 42] and inconsistent with others [40, 41]. The mean performance score of nurses with a postgraduate degree was better than that of undergraduate students. A similar result was found in other studies [38, 41, 43]. Since the number of nurses with a bachelor’s degree is higher in the ward for patients with COVID-19, this can be a warning for managers and requires more focus on training these nurses. The supervisors’ mean knowledge, attitude, and performance score was higher than other nurses. No study with similar results was found. Since supervisors are selected from among nurses with work experience or higher education, these results seem rational. The nurses’ knowledge, attitude, performance, and competence levels were higher as their work experience increased. These results were consistent with the results of numerous studies [19, 32, 42]. In conclusion, there was a variety of correlations between the demographic variables and the main variables of the study that could be influenced by various context-related factors that require nurse managers to address these differences locally and nationally and focus on them intensely.