Competency Development for Military Nursing: Developing the Competency Framework for Global Health

Background: As military nurses are required to maintain high level of clinical expertise and currency for short-notice deployments of global health missions, competency assessment and capability building is a basic paradigm of military nursing. However, research focusing on the competencies of military nurses is limited. Methods: A two-phased procedure was implemented. In phase 1, the competency framework was developed by scoping review and crosschecking the common used competency framework of nurses. During phase 2, two rounds of a Delphi process were carried out and a penal of experts used a 5-point Likert scale to rate their level of agreement with the competency statement. Results: Experts of military nursing and military medicine responded to the rst round (n = 19), and the second round (n = 19). The nal competency framework consisted of 67 competencies and was classied into ve domains: clinical nursing knowledge and skills, military nursing knowledge and skills, professional ability, management ability, and comprehensive quality. Conclusion: The competency framework developed in this study lays solid foundation for competency-based education of a competent nursing team to play a signicant role in the global health.


Background
Competency is de ned as a personal trait or set of habits that lead to more effective or superior job performance, and competencies can be used for translating strategy into job-related performance and individual behaviours [1][2][3]. Competency-based education (CBE) has been used in the graduate, postgraduate and continuing education to improve the education quality and teaching effect, which is an outcomes-based approach to design, implement, assess and evaluate education programs through a well de ned framework of competencies [4]. Therefore, developing a competency framework could be considered as a key step toward CBE [5].
Military nurses are frequently deployed by the governments for global health [6]. Compared with civilian nurses, military nurses have dual roles, including role of clinical nurse and military personnel. They normally shoulder diverse responsibilities, including providing nursing care in hospital and being deployed to war and public emergencies at short notice [7]. During deployment, the working environment is often dynamic and demanding, and this pose challenge to military nurses. When transit from routine work in hospital to an uncertain environment and from deployment environment to informal family chores, they experienced professionally, physically, mentally and personally challenge [8]. Besides, military nurses normally play an important part in management and leadership positions, such as company commander, head nurse, executive o cer [9]. Due to diverse responsibilities indicating comprehensive competencies, along with the competencies of civilian nurses, military nurses also should meet the requirements of providing care during military deployment.
Several competency frameworks and assessment tools of nurses have been developed in past decades, such as, Nurse Competency Scale (NCS), Self Evaluated Core Competencies (SECC) Scale, Competence Inventory for Registered Nurses (CIRN) [10][11][12]. However, research focusing on the competencies of military nurses is limited. In UK military, the ve pillars of advanced level practice within the military nursing care were adapted, including tactical military competence, management and leadership, education, research, advanced clinical practice [13]. In USA military, the Readiness Estimate and Deployability Index (READI) was developed to assess deployment readiness competencies [14]. As military nurses are required to maintain high level of clinical expertise and currency for short-notice deployments, competency assessment and capability building is a basic paradigm of military nursing. A set of competency will aid in CBE of military nurses, therefore, we conducted a Delphi study to develop a competency framework of military nurses in the Chinese context.

Methods
The Delphi method was used in this study, which is considered as an effective way to achieve consensus by a group of experts on a given topic [15][16]. A panel of experts was consulted electronically and asked to identify and prioritize competency statements speci c to military nurses. In this study, consensus was achieved by the end of the twice round. ve-step procedure of scoping review proposed by Levac and his colleague was taken [17]. The search terms " military", "army", "air force", "navy", "warrior", "combat", "armed force", "defense", "nurse", "nursing", "head", "mid-level", "manager", "leadership", "executive", "leader", "competence", "competency", and "competencies" were used to search from PubMed, CINAHL, EMBASE, PsycINFO, Cochrane Library and Chinese databases including CNKI and Wanfang. After following the PRISMA ow chart, a total of nine studies were included in this review. The competencies identi ed in the above nine studies were developed into a framework of military nurse manager's competencies and summarized into six domains, which included clinical expertise, role model, leadership competencies, human competencies, nancial competencies, and deployment competencies.

Constructing the initial framework
After the scoping review of military nurse manager's competencies, a literature review of competency assessment tools for nurses was also carried out. NCS and CIRN were identi ed to cross check with the framework of military nurse manager's competencies in the above scoping review. The nal framework of nurses in military hospitals was developed after several group meetings between the research group, which consisted of ve domains and 76 statements.

2.2
The Delphi process 2.2.1 Selection of expert A panel of experts was selected from military nursing and military medicine. The following inclusion criteria were used in this process: (1) bachelor degree or higher degree; (2) professional experience exceeding 10 years and engaged in the eld of military nursing and medicine with a solid theoretical foundation; (3) consent to participate. Purposive sampling was taken to make sure that a national panel with diverse expertise. A list of 24 potential participants was prepared by the researchers. The target experts were contacted to know their willingness to participate in this study, and twenty experts who met the eligibility criteria consented.

Data collection
Each expert who was consent to participate in this study received the questionnaire. They were asked to give feedback within two weeks, and they would be reminded if they did not give feedback in the given time. After receiving all the feedback from the expert panel, the data collected would be analyzed to develop the questionnaire for the next round. When the consensus achieved among the panel, the data collection process would be stopped.
In the rst round, the questionnaire the expert received included the demographic information questionnaire and the competency framework of 76 statements regarding to military nurses. The statement with less than 70% consensus rate were deleted from the framework. The suggestions collected in the rst round were discussed among the research team, and were utilized to re ne the framework. In the second round, the questionnaire containing the re ned framework were sent to the expert panel.

Data analysis
Data analysis was performed with IBM SPSS Statistics for Windows 22.0. The following variables were included in this study: demographics, approval rate (the percentage of statement rated as 4 or 5 by 1 to 5 signi cance Likert scale), coe cient of variation (CV). The statement would be selected if the mean value of signi cance score was more than 3.5, the approve rate was more than 705 and CV was less than 0.25.

Ethical consideration
The study protocol was submitted to the Medical Ethics Committee of Army Medical University in Chongqing, China. The research was approved by the Medical Ethics Committee and determined to be exempt. Prior to the Delphi process, the expert would receive the introduction of this study and the informed consent form. The Delphi study was carried out among the expert who singed the informed consent form under willingness.

The rst round
Initially, 20 experts consented to participate, of whom 19 (95%) nished the questionnaire among the rst round. The demographic characteristics are presented in Table 1 criteria. From the panel comments, three competencies were deleted because of duplicate. See Fig. 1.
The nal framework of competencies for military nurses consisted of 67 items and ve domains. These ve domains were clinical nursing knowledge and skills, military nursing knowledge and skills, professional ability, management, and comprehensive quality (see Fig. 2). This framework can be used to develop nurses from novice to expert at hospital and during deployment. The nal list of competencies and their ratings can be seen in Table 2.    As shown in Fig. 2, military nurses should possess clinical/military nursing knowledge and skills, which is corresponding to two different kinds of work environment. Military nurses not only provide care to patients in hospitals, but also care for diverse patients during deployment [7]. Military nurses should also possess professional ability and management ability, and this is in line with the diverse responsibilities military nurses shoulder, including playing an important part in management and leadership position [9].
The inner layer of the competency framework was comprehensive quality, which are composed by military quality, professional quality, and personality characteristics.
To some extent, the competency framework of military nurses in this study is different from the competency framework of civilian nurses in the past research, such as 6-D Scale, NCS, SECC. Firstly, the competency framework in this study was designed for military nurses, and this framework re ected their dual roles and diverse responsibilities. Secondly, the competency framework in this study was developed based on the Onion Model of competency theory, which not only facilitate to include all the elements of competency model, but also help to clarify different elements of competency model [2]. When compared with the advanced nursing practice pillars for UK military and READI in USA military, it can be found out that the competency framework in this study covered most domains of the above two, such as clinical practice, operational nursing, management, research, education, soldier/survival skills [9,13].
Past research showed that deployment is challenge to military nurses, and they are likely to feel insu ciently prepared during deployment [18]. A full preparation plays an crucial role for military nurses to successfully complete their duties [8]. As shown in Fig. 2, the competency framework in this study was leveled by Patricia Benner's ve levels of competency: novice, advanced beginner, competent, pro cient and expert [19]. This framework can be used to guide the CBE for different level of military nurses.
Trustworthiness of the Delphi study was ensured by credibility, transferability, con rmability, and dependability [20][21]. In this study, experts with different background within military nursing and medicine were selected to assure credibility. Transferability was assured by developing a competency framework which was generalizable to military hospitals throughout China. Con rmability was con rmed through providing the expert penal with detailed results of each round and feedback of each experts. Dependability was assured by inviting more experts to review the nal framework. Furthermore, high response rate was achieved during two rounds. This review has strengths and limitations. This study aimed to develop a robust competency framework of military nurses which can be used in competency assessment, competency building and personnel recruitment. However, This study has its limitations. Firstly, the methodological of the Delphi study has its own limitations, such as the di culty of generalising the results to a wider population due to the sample size and the uneven spread of expertise among cultural location [22]. Secondly, we only invited Chinese experts on military medicine and nursing to participate in this study. Before conducting the Delphi study, the competency framework initially was developed through the scoping review to maximize the generalization of results in China to the worldwide. This competency framework may be more suitable for Chinese military nurses, however, it can also can provide a a reference for military nursing in other countries.

Conclusion
This study developed a competency framework of military nurses through two-phased procedure, which can be a crucial step in implementing CBE among military nurses. This framework can also be used to develop a competency measurement tool to assist the regular capacity building and readiness training of this population. Subsequent research should include to develop a valid instrument to measure the competency and design CBE curricula for military nurses. These ndings supports the delivery of professional nursing care to promote patient safety in hospitals and assure the fast and scienti c rescue during deployment. Figure 1 Flowchart of Delphi process Competency framework for CBE among military nurses