Construction of An Index System of Core Competence Assessment For Infectious Disease Specialist Nurse: A Delphi Study

Aim and objective: To establish an index system for the evaluation of infectious disease specialist nurse core competence. Background: An index system for the evaluation of infectious disease specialist nurse core competence has not been established. Design: A two-round Delphi survey sought opinions from experts about the index system for the evaluation of infectious disease specialist nurse core competence. Methods: Based on the methods of literature retrieval, theoretical analysis and qualitative research, the draft of core competence evaluation index system of infectious disease specialist nurses was constructed. A Delphi survey was used for the study of 30 infectious disease experts from 8 provinces and cities around China. A modied recommendation for the Conducting and Reporting of Delphi studies (CREDES) was used to guide this study. A STROBE checklist was used. Results: The evaluation index system of core competence of diseases specialist nurses is composed of 6 primary indicators which includes Nursing Abilities for infectious diseases, Infection Prevention and Control Capabilities, Capabilities in Response to Infectious Disease, Professional Development Capabilities, Communication and Management Capabilities and Professionalism and Humanistic Accomplishment, 16 secondary indicators and 47 tertiary indicators. The authority coecient, judgment coecient and familiarity degree of Delphi experts were 0.923, 0.933 and 0.913 respectively. Conclusions: The evaluation index system of core competence of diseases specialist nurses is scientic and reliable. It can be reference for future training and assessment of infectious disease specialist nurses. Relevance to clinical practice: Infectious disease specialist nurses are the main force for infectious disease nursing. Their core competence is related to the quality of infectious disease nursing and treatment. The core competence of the nurses is important for identication of training strategies and can be regarded as reference for nurse assessment and promotion. The construction of the index system is based on the consensus of infectious disease experts, which is helpful to standardize the training strategies and selection standards of infectious disease specialist nurses in the future and meet the needs of clinical infectious disease nursing.


Introduction
Infectious diseases have existed in human life for a very long time. In recent years, under the background of globalization and economic and cultural exchanges, public health emergencies of infectious diseases occur from time to time (Pitrelli & Sturloni, 2007). Especially after the outbreak of Corona Virus Disease 2019 (COVID- 19), the pandemic spreads rapidly all over the world in a short period of time, which poses great threats to the health and property safety of all human beings (Rauch, Jasny, Schmidt, & Petsch, 2018; Triggle, Bansal, Farag, Ding, & Sultan, 2020). The importance of medical treatment and nursing of infectious diseases has become increasingly prominent (Jump et al., 2018). The medical staff of infectious diseases department play a critical role in containing the spread of infectious diseases and treating infected patients (Houghton et al., 2020).
In clinical nursing work, specialist nurses are the leading gures in specialist nursing team, and their core competence level concerns the quality of the nursing and the development of the nursing career (Jokiniemi, Pietilä, & Mikkonen, 2020;Rauch et al., 2018). Infectious disease specialist nurses are registered nurses who are are able to undertake and guide clinical infectious diseases nursing work since they have undergone systematic and standardized training with professional knowledge and specialist practical skills of infectious disease, communication and management capabilities and teaching and coaching skills.
Core competence was rst applied in the eld of enterprise management (Chiu, Chu, & Kuo, 2019). It refers to the technology and knowledge that employees need to possess in the process of enterprise development. This concept was later applied to the eld of nursing, which refers to the knowledge, skills and attitude that a nurse must possess in clinical nursing work (Taskiran & Baykal, 2019;Wei, Niu, & Ge, 2019). In respond to the growing complexity and rapid change of infectious diseases, the core competence of infectious disease specialist nurses should also be constantly enriched and improved. A competent infectious disease specialist nurse should not only need to acquire the professional knowledge and skills to provide systematic, safe and ethical holistic care for infectious disease patients, but also have the capabilities of safety protection and be able to respond to infectious disease emergencies.

Background
At present, there are some researches on the core competencies of diabetes specialist nurses (Xing et  In consideration of the complexity and uncertainty of infectious diseases and the increasing of the incidence of transfusion transmitted diseases, the incidence of occupational exposure and injury among nursing personnel maintained an upward trend. This put forward higher requirements for the abilities of nurses in infectious diseases department. The aim of this study was to establish an index system for evaluation of infectious disease specialist nurse core competence.

Methods
A Delphi study was conducted with 30 participants from 12 hospitals in 8 different provinces and cities in China to explore their altitude to the index system for the core competence of infectious disease specialist nurses. A modi ed recommendation for the Conducting and Reporting of Delphi studies (CREDES) was used to guide the study (Heuzenroeder,

3.1Design
Delphi survey is a feedback anonymous inquiry method. Its involves multiple rounds of consultation by using questionnaires to collect and summarize the questions to be asked after obtaining the opinions of experts until a consensus is reached (Campos-Luna, Miller, Beard, & Leach, 2019). This independent way of consultation can ensure that there is no interference between experts (Black, Matthews, & Millington, 2018). Therefore, it is a very effective method to set goals, items, etc. We set up a research group which is composed of one professor, one associate professor, two lecturers, one supervisor nurse and one postgraduate. The research group is responsible for literature review, theoretical analysis, selection of inquiry experts, compilation and distribution of inquiry questionnaires, sorting out and analyzing suggestions and data.

Inclusion criteria
The inclusion criteria of consultation experts participating in the investigation were as follows: (a) engaged in clinical nursing or medical work of infectious diseases, and working years in this eld are more than 15 years; (b) worked with Medium-grade professional title and above; (c) should have bachelor degree or above; (d) voluntarily participate in the investigation, and ensure to participate in two rounds of consultation.

Construction an evaluation index system
We looked up literature about specialist nurses, infectious diseases, core competence and other related aspects ( On the basis of the above literature review after discussion, our research group carried out qualitative interviews with infectious disease experts, specialist nurses and patients. We nally set up 6 primary indicators (namely, disease management ability, infection prevention and control ability, emergency response ability, professional development ability, communication management ability and professional humanistic quality), 17 secondary indicators and 48 tertiary indicators.

The rst draft of the expert consultation questionnaire
The questionnaire consists of three parts: (a) general information of experts: age, working years, education background, professional title, etc.; (b) evaluation index system of core competence of infectious disease specialist nurses expert consultation form: the importance of the index was evaluated by way of Likert 5-level scoring method, 5 = very important, 4 = important, 3 = general, 2 = unimportant, 1 = completely unimportant, and the column for suggestions was provided; (c) expert familiarity with the content of the survey, and index judgment.

Delphi consulting and feedback cycle
Firstly, after introducing the subject to experts and obtaining informed consent, we sent the questionnaire to experts in the eld of infectious diseases by email. Experts scored and modi ed the index items, and then returned the evaluation by email. Delphi method ensured the independence of opinions. We sorted out and summarized the experts' opinions and designed the questionnaire for the second round. The index inclusion criterion: Mean value assignment >4.5; coe cient of variation<3. If the importance score is between 3.5 and 4.5, the research team needed to discuss and decide whether the indicator items needed to be retained or deleted (Shen et al., 2019). In the second round of Delphi expert consultation, the opinions of all experts tended to be the same, the evaluation index system was con rmed.

Ethical consideration
Our research was approved by the ethics committee and was conducted under ethical guidelines described in the Helsinki Declaration (World Medical Association 2013). Before the investigation, we explained the purpose to the experts, and asked for their verbal consent before conducting the survey. During the investigation, participants could terminate and withdraw from the investigation at any time and the questionnaire was completed anonymously.

Quality Control
In order to ensure the research results were representative and reliable, we had proposed some basic requirements in selecting appraisal expert, and selected 30 infectious disease experts from 8 different provinces and cities in China. The research group collated and summarized the experts' opinions. In the data analysis, we made use of Kendall coordination coe cient and chi square value to test the signi cance of the expert's opinions, so as to ensure the reliability of the results.

Statistical analysis
SPSS 24.0 statistical software were used for data analysis. Measurement data and counting data were expressed in the form of mean ± standard deviation and frequency, percentage respectively. The positive degree of experts was expressed in the form of questionnaire recovery rate. The expert authority coe cient (Cr) was the average value of expert familiarity with the indicators (Cs) and judgment criteria for the indicators (Sutherland, Yeung, Mak, & Levesque, 2020). The coordination degree of expert opinions was expressed by Kendall harmony coe cient.

Basic information of experts
Among the experts participating in the consultation, 23 (76.67%) were infectious disease nursing experts, and 7 (23.33%) were infectious disease medical experts. Their age ranged from 36 to 56 years old, with an average age of 46.27 (SD 5.99). Their working years ranged from 15 to 38 years, with an average working time of 25.27 (SD 5.92) years. There were 8 (26.67%) with bachelor's degree, 16 (53.33%) with master's degree and 6 (20%) with doctor's degree (Table 1).

4.2Experts' enthusiasm
The enthusiasm of the experts was assessed on the basis of the rate of the recovery rate of questionnaires. In the rst round, 32 questionnaires were distributed and 30 effective questionnaires were received, with a recovery rate of 93.75%; in the second round, 30 questionnaires were distributed and all of them were recovered, with a recovery rate of 100% (Table 2).

Expert authority coe cient and opinion coordination degree
The judgment coe cient, familiarity coe cient and authority coe cient are 0.933, 0.913 and 0.923 respectively, which meet the standard of expert consultation authority coe cient > 0.7. In the rst round of expert consultation, the Kendall's concordance coe cients of the rst, second and third level indicators were 0.156, 0.262 and 0.318 respectively. In the second round of expert consultation, the Kendall's concordance coe cients of the rst, second and third level indicators were 0.177, 0.236 and 0.324 respectively. And the Kendall's W test had statistical signi cance (all p < 0.01) ( Table 3).

The index system of core competence assessment for infectious disease specialist nurse
In this study, we adopted two rounds of consultation with the use of the Delphi method, involving a total of 30 experts from 8 provinces and cities including Shaanxi, Chongqing, Beijing, Zhejiang, Yunnan, Shandong, Hubei and Shanxi. In round 1, the research team modi ed 12 index, deleted 3 index, merged 3 index, added 2 index, adjusted 2 index based on the exclusion criterion and experts' opinions. In round 2, the research team modi ed 2 index. Finally, the index system of core competence assessment for infectious disease specialist nurse was established and it included 6 rst level indexes, 16 Table 4).

Reliability of Delphi expert consultation results
In this study, a total of 30 experts engaged in clinical infectious disease treatment and nursing work participated in Delphi consultation who came from 8 different provinces and cities in China, which ensured the results were objective and would not be affected by the region. The consulting experts had been engaged in infectious diseases for more than 15 years, who had rich experience in clinical infectious diseases, and were familiar with the research contents. The authority coe cient of this research was 0.923, which showed that it had good authority. The response rates of the two rounds of expert consultation were 93.75% and 100% respectively, indicating that they had high enthusiasm. The Kendall's concordance coe cient of the two rounds of consultation were statistically signi cant, and the results of the evaluation index system of core competence of infectious disease specialist nurses were reliable.

5.2Importance of evaluation index system of core competence of infectious disease specialist nurses
Infectious disease specialist nurses are the backbone of infectious disease nursing. Their core competence is related to the work quality, service level and team development of infectious disease nursing. At present, there is no research on the core competence index system of infectious disease specialist nurses, so the de nition of the core competence of infectious disease specialist nurses is not clear. In the context of the New Coronavirus disease and the increasing number of new infectious diseases (Tanzi, Alquati, Martucci, & De Pan lis, 2020; Xue, Cao, & Wan, 2021), speeding up the training of infectious disease specialist nurses and clarifying their core competencies will help standardize the work of infectious disease nursing, improve the quality of nursing services, and prevent the spread of infectious diseases. Therefore, it is of great practical signi cance to construct the evaluation index system of core competence of infectious disease specialist nurses. 5.3Comprehensiveness of evaluation index system of core competence of infectious disease specialist nurses

Nursing Abilities for infectious diseases
Infectious diseases are susceptible, transmissible, widespread and harmful (Keesing et al., 2010;Kiely et al., 2017). The management of infectious diseases is the basic responsibility of specialist nurses, and also one of the most important core competencies. In this study, the weight coe cient of infectious disease nursing ability was 0.169, ranking second in the rst level indicators, only to the ability of infection prevention and control capabilities, indicating that this ability is highly recognized by experts and very important. Infectious disease specialist nurses should be familiar with the knowledge of infectious diseases and commonly used drugs. They should be able to formulate corresponding nursing plans in response to different infectious disease patients and implement different nursing measures accordingly. At the same time, specialist nurses should also master rst-aid nursing methods for patients with infectious diseases, make clear the requirements of specimen collection and the terminal treatment methods for patients with infectious diseases.

Infection Prevention and Control Capabilities
Infection prevention and control ability is the most important core ability of infectious disease specialist nurses, and it is an important guarantee of continuous work (Cho & Chung, 2017; Fadare, Akpor, Ifechukwude, Richard, & Bello, 2020; Tschudin-Sutter et al., 2018). It is reported that the risk of infectious diseases of nurses in infectious diseases department is much higher than that of ordinary clinical nurses (Fadare et al., 2020). The importance of infection prevention and control ability in this study ranked the rst, with the weight coe cient of 0.172. The secondary indexes were safety protection capabilities and disinfection and quarantine skills, with safety protection capabilities as the largest weight. In the clinical infectious disease nursing work, nurses in the infectious disease department should put self-protection in the rst place.

Capabilities in Response to Infectious Disease
The capabilities in response to infectious disease of infectious disease specialist nurses refers to the ability of emergency rescue and nursing in public health emergencies. Public health emergencies of infectious diseases spread widely, spread rapidly and do great harm (Morens & Fauci, 2020). Therefore, as a specialist nurse of infectious diseases, it is necessary to have the ability of emergency response and the ability to predict the emergency of infectious diseases. In their daily work, they need to master the reporting time limit of legal infectious diseases, and be familiar with the reporting and drilling process and relevant regulations of public health emergencies of infectious diseases. In the clinical nursing work of New Coronavirus disease, infectious disease specialist nurses played an important role in the outbreak of disease (Lee & Lee, 2020).

Professional Development Capabilities
Infectious disease nursing is a profession that keeps pace with the times. Facing the continuous variation and evolution of the virus, the specialist nurse needs to have the ability of professional development. The ability 'to train other nurses in face of emerging infectious diseases emergencies' and 'to improve and innovate on infectious disease nursing process and protective articles' accounted for the largest weight, which were 0.022. In public health emergencies of infectious diseases, it is of great signi cance for infectious disease specialist nurses to help ordinary nurses to work quickly according to the standardized training process, so as to enhance and expand the nursing reserve force (Lam, Kwong, Hung, & Chien, 2020; Tan et al., 2020) and innovation is an important driving force to promote clinical nursing work (Albert, 2018). At the same time, as a specialist nurse of infectious diseases, it is also necessary to master the frontier dynamic knowledge, have the ability of further teaching and learning, and promote the professional development and the improvement of their own ability.

Communication and Management Capabilities
In clinical nursing work, good communication and management skills are essential (Curtis et al., 2013;Grubaugh & Flynn, 2018). Due to the particularity of patients with infectious diseases, they are more sensitive, so in the process of communication with patients with infectious diseases or their families, nurses should pay attention to the skills, contents and methods of communication (Gaur et al., 2020). In the second level indicators, the score of management ability accounts the highest. Specialist nurses are different from ordinary nurses. They need not only master basic nursing skills, but also assume the role of a manager.

Professionalism and Humanistic Accomplishment
Since infectious disease nursing work confronted with infectious diseases patients, the work is of a certain degree of risks. Therefore, infectious disease specialist nurses should have good professional humanistic accomplishment. They must recognize the occupation identity of infectious disease nursing work. Infectious disease nursing work is a high-risk occupation (Maltezou et al., 2020), so the nurses should have good self-adjusting ability to release the pressure of infectious disease nursing work. In the process of communication with infectious diseases patients, they should respect and treat everyone equally.

Conclusion
Through two rounds of Delphi expert consultation, the core competence index system of infectious disease specialist nurses was established, which entailed good authority, reliability and comprehensiveness. It can provide reference for the training and assessment of infectious disease specialist nurses in the future.

Relevance to Clinical Practice
In the context of the global New Coronavirus pneumonia pandemic, the importance of infectious disease nursing is increasing. As the backbone of nursing work, specialist nurses play an important role in nursing work. To clarify their core competence requirements is helpful to specify the content for the development of infectious disease specialist nurses and provide reference for their training and assessment.

Consent for publication
Written informed consent for publication was obtained from all participants.

Availability of data and materials
The datasets generated and analysed during the current study are not publicly available due to protect the privacy of consulting experts but are available from the corresponding author (906963251@qq.com) on reasonable request.

Competing interests
No potential con ict of interest was reported by the authors.

Funding
No Funding.

Authors' contributions
Chao Wu wrote the main manuscript text. Ping Wu distributed questionnaires to experts. Pei Li contributed to the analysis and processing of data. Feixia Cheng contributed to the writing and revision of articles. Yanling Du contributed to the design of index system. Shizhe He contributed to the distribution and collection of questionnaires. Hongjuan Lang contributed to the design of index system.

Acknowledgements
We would like to express gratitude to the infectious disease specialist for participating in this survey during the time out of their busy schedule.