Clinical Competence and Clinical Performance of Nurses: A Cross-sectional Study

Healthcare quality is a challenge for health service delivery systems worldwide, including those in Iran (1, 2). Since nurses constitute the most significant professional group in the healthcare system, their clinical performance (CP) can significantly impact the quality of provided care (2). Performance evaluation compares actual performance to the expected performance following objectives or subjective elements (3, 4). The CP refers to how nurses provide nursing care for their patients, including their methods and process. Therefore, CP involves performing duties and responsibilities related to direct patient care that affect treatment, recovery, and patient satisfaction. Any decrease in nurse performance will result in the treatment system being unable to achieve its main objectives (5), leading to a decrease in productivity, costs, and patient satisfaction and an increase in the nursing workforce’s needs (6).

Nurses must understand their current situation and comply with the standards by studying their CP from two perspectives, namely determining their level of performance and identifying the factors affecting it. In addition to improving professional activities (7), strengthening relationships among nurses, determining the best method of education and their educational needs, and increasing their efficiency (8), nurses can improve their professional activities. As a result, they could identify and strengthen positive practices and improve working conditions (9, 10).

Various studies have been conducted to measure the CP of nurses in different areas and wards. Several studies have indicated that nurses are less effective at teaching, communicating, collaborating, conducting clinical research, and resolving conflicts than treating, providing critical care, and coordinating care (1, 11-13).

The results of a study by Toulideh et al. examining the correlation between the type of hospital and the performance of nurses showed that the CP of nurses in teaching hospitals is more unfavorable than in non-teaching hospitals. Additionally, the level of CP of nurses in emergency departments has been lower than in critical care departments (14). The results of a study by Khoeiniha et al. comparing the performance of nurses in critical care units, which was conducted in the form of self-reporting, showed that nurses in critical care units of intensive care units in teaching and non-teaching hospitals of Qazvin, Iran, in the field of clinical examination, have lower CP than in emergency departments (15). According to Alizadeh et al.’s study, nurses in emergency wards perform well in terms of clinical outcomes (16). Moreover, the results of Ghamari Zareh et al.’s study have reported the quality of nurses’ CP as 64%, 28%, and 8% as average, poor, and good, respectively (13). The above-mentioned studies were conducted in the form of self-reporting; therefore, the results could be affected by reporting bias.

In the 21st century, the role of nurses has increased significantly (17), making the concept of clinical competence (CC) one of the primary topics in nursing education (18) and an essential component of quality care (19). The CC is the central issue in nursing. The CC is a continuous process of obtaining knowledge, values, attitudes, and skills, such as critical thinking skills, bringing creativity and innovation to nursing practice (20). The CC is considered the use of knowledge, skills, abilities, behaviors, and characteristics to successfully perform important work tasks in the field of nursing (21). One definition of CC is the efficient utilization of technical and communicational skills, knowledge, clinical reasoning, emotions, and values in a clinical environment (22).

Decreasing the level of nurses’ competence can lead to patient dissatisfaction, work mistakes, endangering the patient’s life and the staff’s health, loss of productivity, and incompleteness of a department’s activities (21). The CC is the effective use of technology and communication skills, knowledge, clinical reasoning, emotions, and values in the clinical environment (22). Concerning the current high pace of changes in the health monitoring system, the necessity of the provision of safe and cost-effective services, the increase of public information about health and hygiene, the general expectation for quality health services, and the tendency in health providers to recruit skillful workforces, it is essential to pay more attention to the CC of the professions pertinent to health services (23). It is important to note that CC is a necessary condition for the transfer and acceptance of professional responsibility (24) and is one of the performance indicators and performance requirements for providing quality nursing care (25).

Various studies have been conducted to examine the CC of nurses in Iran, and their results are based on the context of the research community and are different. Therefore, the comparison of clinical settings revealed differences in the levels of nurses’ CC (19). For example, the results of a study by Bahreini et al. in Shiraz showed that nurses’ competence in both the level and frequency of using competencies is excellent in the clinical settings of this hospital (19); nevertheless, another study by Bahreini et al. in Bushehr showed that nurses’ CC was unfavorable in education/guidance and quality assurance (26). Additionally, the results of evaluating the CC of nursing personnel in Bojnord showed that the CC of this personnel is in good condition (21).

Various factors also affect CC in any organization. The results of a study showed that CC has a significant relationship with increasing years of service, nurses’ gender, and the university where they study (21). According to Ebadi et al.’s study regarding the CC of critical care nursing master’s students, female students have higher levels of CC than male students (27).

As a result of the above-mentioned studies, the assessment of competence and performance is essential in ensuring the quality of provided care (19). A significant lack of information exists in this field, and there is a lack of awareness of nursing educational needs, CC, and practical application of care skills in a variety of wards of teaching-therapeutic hospitals (28).

This study aimed to determine the competence of nurses from their point of view and their CP.

This cross-sectional study was conducted in a teaching hospital in Kashan, Iran, from December to March 2020. The study was conducted in two parts: Self-report and observation. In the first stage, samples were selected based on the quota assigned to each ward through a table of random numbers to assess nurses’ CC. Then, in the second stage, samples were selected to observe the CP of the nurses selected in the first stage according to the quota assigned to each ward, using a table of random numbers.

Based on the results of a similar study (29) and the research community (n = 460, the entire nursing community of the hospital), P = 0.48, d = 0.05, and z = 1.96, 209 individuals were calculated in the formula for calculating the sample size, and 220 subjects were considered with a 5% chance of dropping out.

Considering the difficulty of observing 220 subjects, the researchers tried to select several samples to observe the performance based on the results of a pilot study. An initial pilot study was conducted on eight nurses selected by the convenience sampling method to calculate the sample size based on CP, whose CP mean scores were 64.21 ± 10.27. The sample size was calculated using a formula. Considering z = 1.96, s = 10.27, and d = 3, 46 subjects were estimated to be the necessary sample size, and 50 subjects were considered for further certainty. Pilot study samples were not included in the main sample.

The inclusion criteria were consent to participate in the study, at least a bachelor’s degree in nursing, employment in the clinical care field (nurses were not included in the study due to their managerial positions), a minimum of 3 months of work experience (to gain experience), and willingness to participate in the study. A personal information questionnaire containing seven items on gender, age, marital status, ward, employment status, work experience, and work experience in the current ward was used to determine demographic characteristics.

The CC of nurses was measured using a questionnaire prepared by Meretoja et al. based on the theory of “from beginner to expert”. Seventy-three items are included in the original version of this questionnaire (30). The questionnaire was previously translated by Bahreini et al. (19), and its content validity and reliability coefficient were evaluated within the range of 0.70 - 0.85. Participants are asked to rate each item on a scale of 0 to 100. Accordingly, overall scores of 25 ≥, 26 - 50, 51 - 75, and 76 ≤ are regarded as weak, average, sound, and excellent CC, respectively. The CC questionnaire was approved with 25 items and a content validity ratio (CVR) and content validity index (CVI) of 0.86 and 0.98, respectively. To determine the reliability of the questionnaire, 10 nurses (not included in the final sample) completed the questionnaire on two occasions for 2 weeks, and its reliability coefficient was calculated at 0.83 (31).

Observational checklists consisting of 29 items were developed to assess nurses’ performance based on their duties and capabilities. In addition to the existing tools, the researchers decided to develop a more comprehensive tool. When the nurse observes the performance, the option “yes” is selected; if the option is not performed, the option “no” is selected. The option “no item” is considered if there is no item. Moreover, 1 point, 0 point, and no point are considered for “yes”, “no”, and “no item” options, respectively. As a result, the total score is calculated; the numerator is the number of functions the nurse must perform. The nurse receives a score based on her performance. For example, a nurse only completes 15 of the 29 items on the checklist, although 20 items are required. After answering 15 yes questions out of 20, she/he will receive a score of 0.75. The resulting score is then multiplied by 100 to determine the basis for the score of 100. Accordingly, the nurse’s performance is evaluated based on the score of this checklist, which ranges from 0 (minimum score) to 100 (maximum score). The corresponding checklist was provided to 10 Faculty of Nursing and Midwifery professors to determine the necessity and clarity of the CVR and CVI. Nine professors confirmed the content validity of the checklist with a CVR and CVI of 0.89. The reliability coefficient was calculated using two observers as sole observers.

For the collection of data related to CC, a self-report questionnaire was provided for the nurses. The researcher first gathered a list of nurses working in clinical wards from the nursing office. According to the ward’s quota, a random number table online was used to assign numbers to the names of nurses in each ward based on their quota. Afterward, the selected nurses of each ward were approached, and after explaining the purpose of the study and obtaining written consent from them, they were invited to complete a questionnaire. The nurses were given the CC assessment questionnaire to complete on their own in a quiet and peaceful environment where they had more free time.

To investigate nurses’ CP, the first researcher visited internal, surgical, critical care, and emergency wards, observed their activity from the beginning of their shift to the end and evaluated their performance based on an observational checklist. The observation was made indirectly. A few days before data collection began, the observer (first author) was continuously present in each ward during different work shifts to prevent the researcher’s presence from affecting the nurses’ performance and behavior. This was performed to normalize and reduce the effect of his presence on nurses’ actual performance as much as possible.

The Ethics Committee of Kashan University of Medical Sciences approved this study (ethics code: IR.KAUMS.NUHEPM.REC.1397.35). The study participants were provided with explanations about the project’s objectives, voluntary participation in the study, no need to enter their names and surnames, the confidentiality of the information, and its non-impact on occupational status, salary, benefits, and the annual evaluation of the organization. A t-test, analysis of variance (ANOVA), Pearson correlations, and Spearman correlations were used to analyze the data using SPSS software (version 16).

According to the study results, 80% of the nurses were female, and 74% were married (Table 1). The mean age of the participants in the study was 31.15 ± 6.26 years. Furthermore, the participants’ mean scores of work experience in the current ward and work experience were 4.07 ± 3.88 and 7.57 ± 5.73 years, respectively.

The results revealed that the nurses’ mean CP score was 70.30 ± 11.94 (Table 2). The ANOVA showed a statistically significant difference between the mean scores of nurses’ CP in different wards (P = 0.001). In addition, this study’s results indicated a statistically significant difference between the mean nurses’ CP scores based on their age and work experience (P = 0.001; Table 1).

According to the Spearman correlation coefficient, there was a significant positive relationship between the mean CP score with marital status, ward type, and employment status (P < 0.05). Additionally, the Pearson correlation coefficient results revealed a positive and significant relationship between the mean CP score with age, work experience, and work experience in the current ward (P = 0.001; Table 3).

As determined by the independent t-test, the mean CC scores of female nurses (81.44 ± 11.25) were significantly higher than male nurses (77.13 ± 15.63; P = 0.006). Furthermore, ANOVA showed that the mean scores of nurses with different work experiences differed (P = 0.001); therefore, the mean scores increased significantly with increasing work experience (Table 3).

The Spearman correlation coefficient results revealed a positive and significant relationship between the mean CC score with marital status, ward type, and employment status (P < 0.05). Additionally, the Pearson correlation coefficient results showed a significant relationship between the mean CP score with age, work experience, and work experience within the current ward (P = 0.001; Table 4).

Nurses received a higher CP score than the average, indicating that nurses received a favorable evaluation. As a result, Shannon et al. (32) and Zaman Zadeh et al. (33) showed that nurses were performing at optimal CP. Furthermore, Ghamari Zareh et al.’s study showed that nurses perform better than other professions in care, treatment, and support (13). As one of the reasons for this result, it can be stated that nurses’ sense of responsibility and organizational commitment have led them to pay attention to performing their duties in patient care. According to some studies, nurses are more likely to focus on their clinical activities when they fear they will be reprimanded (2), which might be a factor among the nurses in the hospital under study.

In the present study, a significant difference was observed between the CP scores of nurses in different wards, where nurses in critical care wards and emergency wards scored the highest and lowest, respectively. In this regard, the results of other studies also showed that the CP of emergency department nurses is at a lower level than critical care department nurses (14). The lower CP score of emergency ward nurses is attributed to patients staying in the emergency ward for a short period and to the high turnover of nurses in this ward. Whenever nurses are required to perform tasks outside the scope of their nursing responsibilities, as directed by their managers, they are prevented from focusing on their primary duties (21).

A significant difference was also observed between the mean CP score based on some variables, such as employment status, age, and work experience. No similar study has been conducted in this field, as nurses with trial employment status had the highest performance scores, and those with designated employment status had the lowest. It was found that nurses with trial, definitive, contractual, and designated employment had the best CP. Due to their recent graduation, the nurses appear to lack the skills and confidence necessary for proper clinical practice (21). Meanwhile, nurses are trying to show their best CP with trial employment in the best conditions in terms of preparation and hope to have their permanent position. Following confirmation of employment, the nurses might feel more secure in their jobs, and their motivation to perform their best might decrease somewhat (14).

Furthermore, other studies indicated that nurses’ performance scores increased with age and experience. Age, employment status, and work experience affect nurses’ CP. Therefore, older nurses typically have more excellent clinical experience and knowledge. The employment status of these nurses is usually more stable. Nurses with more experience are more confident in using their clinical skills and qualifications and perform clinically better.

The results of the present study showed that the CC of the nurses in the present study is in good condition, which is in line with the results of other studies in Iran (26). According to the results of another study, the nurses’ scores of CC from their viewpoint were at a good level in surgical, critical, and emergency wards (31). In Goliroshan et al.’s study in Babol, Iran, the total score for CC was high (34). In the explanation of this finding, it can be said that the good and desirable CC of nurses in this study can be attributed to the presence of good and effective in-service clinical training. However, Jaffari Golestan et al. showed the low clinical activity of novice nurses working in Tehran medical centers, Iran, which is not consistent with the results of the present study (35). In expressing this difference, it might be possible to point to the inefficiency of the university education system, especially in the last year of clinical education, which could not familiarize students with professional tasks in the clinical environment. Additionally, it is possible to point out, based on Banner’s theory, that the lack of CC of new nurses can be caused by their limited clinical experience.

A further finding of the present study was that the mean overall score of the CC of female nurses was significantly higher than the mean score of male nurses, and the mean overall score of CC was higher in married nurses than in single nurses. In this regard, the results of Khorashadizade et al.’s study also showed that there is a significant relationship between the nurses’ CC score and the two genders; accordingly, the score of women was higher than men, which is in line with the results of the present study (21). However, the results of other studies did not show a relationship between gender and CC (31). Therefore, the higher mean scores of female nurses can be attributed to the greater number of female nurses participating in the present study. At the same time, considering the reported differences between studies, conducting further studies in this regard can help clarify this issue.

Karami et al.’s study also revealed that married nurses had higher CC scores than single nurses (36). In the studies conducted in Iran, there was no relationship between marital status and nurses’ CC (19, 29, 31); nevertheless, in a study by Kim and Kim in Korea, a relationship was observed between CC and marital status (37). It seems that CC is a variable of several factors (19) that might be affected in societies and organizations with different educational approaches, which needs to be investigated more carefully. In this regard, some studies also state that CC and related contextual factors have controversial and sometimes unexpected results (31).

According to Lakanmaa et al., nurses in critical care wards evaluated their competence in caring for patients well, which is consistent with the results of the present study (38). A review study shows a direct correlation between nurses’ CC and the ward and hospital where they work (39). It seems that nurses working in critical care wards, due to facing patients with worse conditions and having more power than other wards, while also having clinical skills, seem to have greater self-confidence, which has resulted in assessing their clinical qualifications higher than their peers.

There was a significant difference in the average overall score of CC between nurses with different levels of work experience in the present study. As a result, nurses of different ages significantly differed in average overall CC scores. In particular, nurses with a median age of 27 years or less scored the lowest; nonetheless, nurses with a median age of 34 years or more scored the highest. Additionally, the relation test revealed a direct and significant relationship between the nurses’ CC scores and variables, such as general work experience, work experience in the current ward, and age. Previously, a study showed that nurses’ age and work experience were significantly correlated with CC scores (31). In some previous studies, researchers have observed a direct relationship between nurses’ CC with their age and work experience (37, 40). There is also a significant relationship between work experience and nurses’ CC observed in the study of Kim and Kim in Korea (37) and the review study of Rizany et al. (39). In expressing this finding, it can be said that the existence of retraining programs and increasing the individual’s experience in the department can be a factor in increasing CC.