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Development and psychometric evaluation of the competency inventory for nursing students: A learning outcome perspective
Nurse Education Today 33 (2013) 492–497
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Development and psychometric evaluation of the competency inventory for nursing students: A learning outcome perspective Li-Ling Hsu a,⁎, Suh-Ing Hsieh b a b
Graduate Institute of Health Allied Education, National Taipei University of Nursing and Health Sciences, No. 365, Ming-Te Rd., Peitou, Taipei City 11219, Taiwan, ROC Department of Nursing, Chang Gung University of Science and Technology, Taiwan, ROC
a r t i c l e
i n f o
Article history: Accepted 31 May 2012 Keywords: Competency Inventory of Nursing Students Factor analysis Nursing students Learning outcome
s u m m a r y Deficiency in essential core competencies could jeopardize the safety of patients. Adopting the outcomebased approach, a set of minimally required core competencies for nursing students was developed to ensure the quality of nursing education. Determination of what point to measure competency is needed. Most importantly, competence indicators of nursing students can be used in curriculum development, planning, and learning outcome evaluation. The purpose of this study was to develop a competency inventory to measure learning outcomes of baccalaureate nursing students and to test its psychometric properties. Psychometric testing was conducted with a convenience sample of 599 nursing students in 2011. Principal axis factor analysis was performed on the 52-item scale to determine construct validity and Cronbach's alpha was used to measure the internal consistency. Principal axis factoring method identified six factors through the direct oblimin rotations including pattern matrix and structure matrix: ethical and responsibility, general clinical skills, lifelong learning, clinical biomedical science, caring and critical thinking reasoning. Exploratory factor analysis yielded an instrument with 43-items on six factors, accounting for 69.84% of the variance in scores. The Competency Inventory of Nursing Students (CINS) factors ranged from 0.91 to 0.98. This study shows that the Competency Inventory of Nursing Students has satisfactory psychometric properties and could be a useful instrument for measuring learning outcomes of nursing student. The competence indicators show merit for assessing learning outcomes for nursing students in nursing education. However, a cross-validation of the scale with another sample is also needed. © 2012 Elsevier Ltd. All rights reserved.
Introduction Most health care providers began their health profession education expecting to acquire the knowledge and skills needed to provide highquality care (Hall et al., 2008). Insufficient competencies in basic patient care are a source of stress for new graduates (Burch et al., 2005). Because of the rapid changes in health care delivery, an expansion of nursing services, and various population health needs, new graduates have difficulty critically thinking in clinical situations (Burns and Poster, 2008; Paganini and Egry, 2011). Competency in nursing has a direct influence on the health and safety of all patients (Axley, 2008). The role of competency in education has grown dramatically as health care employers and educators have identified the gap between education and practice (Scott-Tilley, 2008). Competence is the skill to develop knowledge and ability that enhances professional practice in multiple ways (Paganini and Egry, 2011). Adopting the outcome-based approach, a set of minimally required core competencies for nursing students was developed in 2005 by Taiwan ⁎ Corresponding author. Tel.: + 886 2 2822 7101x3169. E-mail addresses: [email protected] (L.-L. Hsu), [email protected] (S.-I. Hsieh). 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2012.05.028
Nursing Accreditation Council (TNAC). A clear and consistent definition of competency is an important step. Determination of what point to measure competency is needed (Scott-Tilley, 2008). Most importantly, competence indicators of nursing students can be used in curriculum development, planning, and learning outcome evaluation. Background The move to competency approaches to education has emerged from the apparent gap between what students learn in the classroom and what they need to know for work (Grealish, 2006). Several attempts have been made to develop scales that adequately assess nurses' competence level (Bartlett et al., 2000; Meretoja et al., 2004; Cowan et al., 2007; Liu et al., 2009; Takase, 2011) but few studies have been published on the subject of core competencies of nursing students (Lofmark et al., 2006; Berkow et al., 2009; Hsu and Hsieh, 2009). TNAC holds meetings on a regular basis to evaluate and reevaluate nursing schools and nursing programmes in Taiwan. TNAC sets up eight core competencies for BSN (Hsu and Hsieh, 2009). The definition of core competence is different in nursing schools, so no coherent tools can be used for accreditation schools. Therefore, a
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practical comprehensive assessment tool is required for assessing students' learning outcomes. Deficiency in essential core competencies could jeopardize the safety of patients (Tekian, 2002). Adopting the outcome-based approach, a set of minimally required core competencies for nursing students was developed to ensure the quality of nursing education. In outcome-based education, the learning outcome, such as (1) what the nurse is able to do, (2) how the nurse approaches his/her practice, and (3) the nurse as a professional, determine the curriculum contents, teaching methods, and assessments (Simpson et al., 2002; Shumway and Harden, 2003). Competence is seen as a series of integrated capabilities consisting of clusters of knowledge, skills and attitudes necessarily conditional for task performance and problem solving and for being able to function effectively in a certain profession, organization, job, role, and situation (Mulder et al., 2009). In addition, competence includes cognitive competence, functional competence, personal competence, and ethical competence. Competence relates to an overall job done well, as measured against a system of minimum standards, and as demonstrated by performance and outputs (Sultana, 2009). There is an international agreement that nursing competence must be viewed from a holistic perspective (Takase, 2011). Current holistic approaches to competencebased models seem to have successfully absorbed insights from the behaviouristic and functionalist approaches, and additionally integrated some of the most promising practices in education and training (Ramritu and Barnard, 2001; Sultana, 2009). The competence frameworks are generally developed for assessing performance in relation to set standards and providing programmes development (Sultana, 2009). The competence scales for nursing students have a few problems including operationalisation of term, conceptual framework, and reliability and validity. Some studies focused on newly-graduated nurses, for example, Lofmark et al. (2006) summed four factors (communication, patient care, personality characteristics, and knowledge utilisation) and Berkow et al. (2009) grouped six categories (clinical knowledge, technical skills, critical thinking, communication, professionalism, and management of responsibilities). Black et al. (2008), on the other hand, addressed five categories for entry-level registered nurses: professional responsibility and accountability, knowledge-based practice, ethical practice, service to the public, and self-regulation. Based on the 8-item SelfEvaluated Core Competencies (SECC) Scale we had developed for baccalaureate nursing students, we constructed a learning outcome scale which included definitions and attributes of core competence and psychometric testing.
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Instrument The initial 48 items were evaluated for content validity by a panel of seven experts who specialised in nursing education, medical education, clinical nursing, higher education and human resources. They have experience in competence assessment for university students. Using a 4-point rating scale (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = extremely relevant), the seven experts gave 48 items ratings of 3 or 4, resulting in a S-CVI (scale-content validity index) of 0.99. The I-CVI (item-content validity index) ranges from 0.83 to 1.00. The content validity index is taken as a barometer for item and instrument clarity, homogeneity and relevance. In addition, experts recommended addition of three items to this scale (“I collect as much information about the patient as possible to formulate the best nursing strategy”; “I assess a patient's needs for nursing intervention based on data available to me”; “I assess the outcome of my nursing interventions”). Therefore, 48 items were increased to 52 items. The Competency Inventory of Nursing Students (CINS) was designed based on eight core values (American Nurse Association (ANA), 2004; Lofmark et al., 2006; American Association of College of Nursing (AACN), 2008; Black et al., 2008; Hsu and Hsieh, 2009; Taiwan Nursing Accreditation Council (TNAC), 2009), literature reviews, and the learning outcomes of nursing schools in Taiwan. The final version of the scale was the result of fifteen times of revision of the original version. The CINS includes basic biomedical science (5 items), general clinical nursing skills (9 items), communication and cooperation (6 items), critical thinking (5 items), caring (6 items), ethics (9 items), accountability (7 items), and lifelong learning (5 items). In other words, there were in total 52 items divided into 8 categories in the scale. The students reviewed 52 statements and gave a score of one (clearly incompetent on this item) to seven (extremely competent) based on their situation, producing a total score in the range of 52–364 points. Each item is rated on a 7-point Likert scale (Wilkinson and Frampton, 2003). Higher score represents students' higher competencies. Measuring core competence requires the integration of cognitive, affective, and psychomotor skills (Mackenzie, 2009). The nursing students were undertaking a self assessment for evaluating their competence including knowledge, skills, communication, attitudes, values and professional judgment. It is essential that the reliability of a developing questionnaire can be established. A pilot study of 55 senior nursing students was administered for this purpose. Internal consistency of the scale registered an alpha coefficient of 0.96. The instrument had a Cronbach's alpha and split-half reliability coefficient of 0.98.
The Study Ethical Considerations Aim The aim of this study was to develop a competency inventory to measure learning outcomes of baccalaureate nursing students and to test its psychometric properties. Design A cross-sectional survey design was used.
The study was approved by the Institutional Review Board. Consent to participate was implied by voluntary completion and return of the questionnaire, and participants were informed that they would not be penalized for failure to participate or for quitting at any stage of the survey. The researcher did not have direct teaching responsibilities with all participants, and research assistants collected the data to avoid the possibility of coercion of students to participate. Participation was anonymous.
Sample
Data Analysis
A total of 652 senior baccalaureate nursing students selected from a university with two branches (northern and southern Taiwan) were asked to complete a questionnaire survey administered before and after their final clinical practicum in 2010. Completing the questionnaire took approximately 20 min. A gift card as an incentive was given to each participated student for increasing the proportion of returning questionnaires. Out of 652 questionnaires issued, 599 were answered in full (pretest and posttest) with a returning rate of 94.87%.
Statistical analyses were performed using the SPSS software package 17.0 (SPSS Inc., Chicago, IL, USA). PAF (Principal Axis Factoring) is an exploratory factor analytic technique used for the purpose of identifying the underlying dimensions or constructs of a particular scale (Floyd and Widaman, 1995). Oblique rotation (promax) was conducted in this study because of the assumption that the factors were correlated (Tigges, 2009). In order to evaluate sampling adequacy to perform a satisfactory factor analysis, Kaiser–Meyer–Olkin Measure of Sampling
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Adequacy (KMO), and Bartlett test was calculated. To determine the best structure, the eigenvalue greater than one and factor loading equal to or greater than 0.35 were applied (Hair et al., 2006). Correlation values of 0.40 or above were considered satisfactory (Nunnally and Bernstein, 1994; Polit and Beck, 2008). Results Participants' Demographics The majority of students (85.5%) graduated from private schools, while a small number (14.5%) graduated from public university (Table 1). Among them, 70.1% were enrolled in a 2-year programme leading to a bachelor's degree in nursing, whereas 29.9% were enrolled in a 4-year programme leading to the same degree. The participants had a mean age of 21.83 years (SD = 1.02). In addition, those on the 2-year programme had acquired some nursing knowledge from previous nursing programmes leading to Registered Nurse (RN) license at vocational junior colleges. Those on the 4-year programme, however, possessed relatively little nursing knowledge, since they had begun the programmes immediately after vocational or high schools. However, the outcome-based competences before graduation were the same between 2-year programme and 4-year programme. Construct Validity Exploratory factor analysis (EFA) using principal axis factoring with promax oblique rotation was performed to determine the underlying
Attributes of prior school attended Private school Public school Previous school attended High school Vocational Diploma None Type of programme 2-year college 4-year college Age (years) Mean (SD) Range Gender Male Female Marriage Single Married Divorced Nursing license No Yes Licensed practical nurse Registered nurse Missing Religion No Yes Taoist Buddhist Christian Others Missing Missing
Internal Consistency Cronbach's alphas of each factor and the overall scale are presented in Table 2. The Cronbach's alpha for the factors ranged from 0.91 to 0.98. The Cronbach alpha for the 43-item, six-factor scale was 0.98 indicating a high internal consistency of the items to represent the competence inventory of nursing students. Table 4 shows the correlation coefficients between the factors. As showed in Table 4, moderate to strong correlations were observed between the factors. Descriptive Statistics of the Inventory
Table 1 Participant demographics (n = 599). Variable
factor structure of the set of items. The calculated KMO was 0.977 and the Bartlett's test of sphericity was significant (χ2 =33127.55, degree of freedom=1326, Pb 0.0001). A six-factor solution with 52 items emerged based on the criteria of eigenvalues higher than 1 and loading level of 0.4 or above. A scree plot showed that six factors were retained. The factor loadings from the rotated factor structure matrix for the final CINS, as shown in Table 2, consists of 43 items and six factors. In addition, items not loaded are deleted (items 7, 12, 15, 16, 17, 18, 19, 20 and 24). While removing these not loaded items, evaluating and refining a set of factors to examine the rotated factor matrices for high or low loading (Pett et al., 2003), the factor analysis was rerun several times. In the final solution, a six-factor structure comprising 43 items was obtained through focusing first on the factor structure matrix for factor interpretability and then comparing factor pattern matrix (Pett et al., 2003). The six factors were named according to the underlying construct that related to the items: ethical practice and accountability, general clinical nursing skills, lifelong learning, clinical biomedical science, caring, and critical thinking and reasoning. Table 3 displays the total variance explained by the six extracted factors of the 43-item CINS. The initial cumulative variance explained by this solution was 73.99%, and final six-factor solution explained 69.84% of the total variance of the hypothesized model (Table 3).
n (%) 512 (85) 87 (15) 76 (13) 108 (18) 413 (69) 2 (0) 420 (70) 179 (30) 21.83 (1.02) 20–39 5 (1) 594 (99) 597 (100) 1 (0) 1 (0) 88 (15) 511 (85) 92 (15) 403 (67) 16 (3) 309 (52) 288 (48) 142 (24) 76 (13) 37 (6) 31 (5) 4 (0) 2 (0)
Table 5 presents the means and the standard deviations of the factors. The means of six factors ranged between 5.17 and 6.01, which indicated that the students assessed themselves as reasonably competent in nursing. The highest self-evaluation of CINS was observed in the ethics and accountability (Factor 1) , followed by caring (Factor 5), lifelong learning (Factor 3), general clinical skills (Factor 2), and critical thinking and reasoning (Factor 6). The lowest self-evaluated competence was identified in the clinical biomedical science (Factor 4). Discussion The purpose of this study was to develop a scale for assessing nursing students' competencies and to test its psychometric properties. This scale was developed based on TNAC, AACN, ANA and literature review. The conceptual framework for the competencies developed in this project contains eight categories: clinical biomedical science, critical thinking, communication and teamwork, ethics, caring, lifelong learning, accountability, and general clinical skills. Each of the eight categories includes a broad competence standard statement established through literature review and learning outcomes of nursing schools in Taiwan. Finally, the CINS is established after seven experts' content validity check, the pilot study, and the construct validity check. Six factors obtained accounted for 69.84% of the total variance and the strength of the intercorrelations was fully in line with the conceptualisation as a multifactorial construct. Factor analyses showed a variance ranging from 40 to 60%, which is considered sufficient (Wood and Haber, 2002). Factor 1 “ethical practice and accountability” composed of 15 items and their factor loadings ranged between 0.75 and 0.87 in the factor structure matrix. Factor 1 had a high Cronbach's alpha of 0.98 and an eigenvalue of 20.89 and explained 48.59% of the variance. These fifteen items were about professional responsibility and ethical action. A similar result
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Table 2 Results of exploratory factor analysis: factor loading using principal axis factoring with direct oblimin rotation(>.40). Factors and items (Cronbach's α)
Factor structure matrix
Factor pattern matrix
Item-to-total correlation
Factor 1. Ethics and accountability (α = 0.98) 40 I have full respect for the different beliefs and values held by patients. 35 I have full respect for the decisions and choices of patients. 36 I respect patients' request for confidentiality. 33 I try my best to keep patients from harm in providing medical care. 38 I provide patients with safe medical care. 34 I am always careful not to infringe upon patients' rights when making decisions concerning patients. 41 I abide by the code of nursing ethics. 39 I never judge patients based on my values. 32 I abide by the codes of nursing ethics and other related rules and regulations. 42 I actively fulfill my duties. 37 I give patients equal shares of medical resources. 43 I am accountable for my professional judgments and actions. 45 I consult other medical staffs when I come across a situation that is beyond my ability to handle. 44 I am fully aware of the limitations of my professional role and abilities. 46 I take my work seriously and conduct my work carefully.
.872 .886 .868 .883 .900 .865 .867 .825 .824 .857 .819 .818 .775 .799 .748
.960 .956 .940 .926 .911 .894 .888 .830 .826 .786 .743 .675 .633 .618 .542
.782 .785 .765 .797 .820 .803 .802 .783 .774 .797 .738 .789 .760 .792 .784
Factor 2. General clinical skills (α = 0.93) 09 I assess a patient's needs for nursing intervention based on data available to me. 10 I provide patients with nursing treatments that suit their needs. 08 I collect as much information about the patient as possible to formulate the best nursing strategy. 11 I assess the outcome of my nursing interventions. 13 I set priorities of nursing tasks based on the needs of patients. 14 I try to provide comprehensive follow-up medical care that suits the needs of patients. 06 I carry out doctor's instructions and nursing care routine accurately.
.863 .832 .804 .780 .776 .778 .735
.934 .911 .786 .765 .682 .641 .580
.708 .718 .707 .698 .710 .723 .679
Factor 3. Lifelong learning (α = 0.94) 51 I know where and how to look for resources for learning. 48 I am fully aware of what I need to learn. 49 I enjoy seeking answers to questions. 52 I make use of technology and other resources in learning. 50 I set goals for my learning. 47 I make effective use of my time at work.
.878 .837 .817 .822 .831 .699
.899 .885 .805 .789 .776 .465
.761 .734 .760 .752 .708 .712
Factor 4. Clinical biomedical science (α = 0.91) 02 I explain to patients the procedure and results of physical examinations. 04 I understand the purposes and normal values of clinical examination. 03 I understand the mechanism, side effects, and clinical applications of the medicine patients are taking. 01 I make use of pathological and biological knowledge to explain to patients their condition. 05 I understand the principles and logic of medical treatment.
.865 .801 .763 .765 .750
.860 .764 .713 .712 .525
.527 .555 .559 .553 .590
Factor 5. Caring (α = 0.95) 28 I provide timely emotional support for patients when necessary. 27 I encourage patients to express their feelings and I am attentive to their positive and negative feelings. 30 I try my best to provide patients with a comfortable and peaceful environment. 29 I pay attention to the psychological, social, and spiritual wellbeing of patients. 26 I try to empathize with patients in order to identify their needs for medical care. 31 I believe that each patient's life has its own meaning.
.902 .897 .852 .824 .816 .741
.870 .850 .744 .721 .650 .505
.758 .774 .794 .743 .750 .769
Factor 6. Critical thinking and reasoning (α = 0.93) 22 I try to look for the root cause of any changes in patients' condition. 23 I try to analyze the problems facing patients from different angles. 21 I carefully consider the condition of patients and make reasonable judgments and inferences. 25 I always think about whether there is ample empirical basis to support nursing actions.
.861 .847 .834 .790
.831 .769 .734 .596
.699 .694 .725 .711
appeared in a study conducted by Black et al. (2008), who developed five competencies for entry-level nurse in professional responsibility and accountability, and ethical practice dimension, which suggests that the primary responsibility of nurses is to provide competent, ethical, and safe care to clients. Karayurt et al. (2008) and Ramritu and Barnard (2001) noted that student nurses should be evaluated for ethical practice because ethical practice is an integral part of nursing competence. Paganini and Egry (2011) observed that professional ethics determines professional attitudes, values and behaviour, and professional competencies include the ability to undertake responsibilities concerning care. Ethics can be defined as a concern for doing the right thing and avoiding harm when related to nursing (Paganini and Egry, 2011). Ethical competence is a key factor in preventing or reducing moral
distress (Sporrong et al., 2007). Therefore, some key competencies related to ethics are to know and understand codes of ethics, to be able to recognize and analyze ethical situations, and try to resolve them. Factor 2 “nursing student clinical nursing skills” composed of seven items and their factor loadings ranged between 0.74 and 0.86 in the factor structure matrix. Factor 2 had a high Cronbach's alpha of 0.93 and an eigenvalue of 4.35 and explained 10.13% of the variance. Most of these seven items were identified by Karayurt et al. (2008) who noted that student nurses should be evaluated for their abilities to collect data, identify the needs of patients, prioritize tasks, and provide care. In addition, Ramritu and Barnard (2001) stated that competence is experienced as performance of clinical skills, which is another general requirement nurses are expected to meet. When students graduate from nursing school, they need to possess
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Table 3 Total variance explained by the six extracted factors of the 43-item competency inventory of nursing students scale. Initial eigenvalues
Extraction sums of squared loadings
Factor
Total
% of Variance
Cumulative%
Total
% of Variance
Cumulative%
1. 2. 3. 4. 5. 6.
21.19 4.66 2.05 1.57 1.29 1.06
49.27 10.84 4.77 3.65 3.00 2.46
49.27 60.11 64.88 68.53 71.53 73.99
20.89 4.35 1.76 1.29 0.97 0.77
48.59 10.13 4.09 3.01 2.26 1.78
48.59 58.72 62.81 65.82 68.08 69.84
Ethics and accountability General clinical skills Lifelong learning Clinical biomedical science Caring Critical thinking and reasoning
a certain level of clinical skills to stand a good chance of succeeding in their future role as nurses. Factor 3 contained six items concerning competence in enhancing one's own professional development. The factor loadings ranged from 0.70 to 0.88 in the factor structure matrix. It had a high Cronbach's alpha value of 0.94 and an eigenvalue of 4.09. The factor of lifelong learning tends to focus on professional learning, technology and resources use, and question inquiry. This factor is consistent with previous studies (Meretoja et al., 2004; Liu et al., 2009; Takase, 2011) showing that nursing students should be given learning opportunities to foster continuous development and improvement of the knowledge and skills needed for personal growth. The clinical biomedical science and caring factors explained 3.01 and 2.26% respectively, of the variance in the overall scale. Clinical biomedical science in this context includes all kinds of pathological, biological, and physical examinations and treatments administered to patients in clinical settings. Lastly, Factor 6 “critical thinking” explained 1.78% of the variance in the overall scale. Empirical studies have suggested that enhancing students' critical thinking is conducive to their preparation for practice in a complex healthcare environment (Toofany, 2008). It is important for nurses to be able to communicate clearly with patients and medical staffs (Karayurt et al., 2008). Assessing the competence of nursing students is critical to identifying areas for professional development and educational needs while ensuring that competencies are put to use for quality care (Marshburn et al., 2009). This study results were consistent with McEwen and Brown's (2002) definition of core nursing competencies as a combination of critical thinking, therapeutic nursing intervention, problem-solving, communication, caring, and values. Conclusion
Table 5 Means and standard deviations of six factors. Factor Factor Factor Factor Factor Factor Factor
1: Ethics and accountability 2: General clinical skills 3: Lifelong learning 4: Clinical biomedical science 5: Caring 6: Critical thinking and reasoning
Mean
Standard deviation
6.01 5.52 5.78 5.17 5.87 5.44
0.51 0.48 0.59 0.48 0.53 0.55
competencies vary across the globe, depending on the context of the region, resulting in differences in health care and nurse education (Paganini and Egry, 2011). Therefore, generalisability of this study's findings is limited because the sample came from a limited pool. A crossvalidation of the scale with another sample is also needed. Funding This research project was sponsored by the National Science Council (NSC-99-2516-S-227-002) In Taiwan. Conflict of interest No conflict of interest has been declared by the authors. Author contributions LLH, and SIH were responsible for the study conception and design. LLH collected the study data. SIH performed the data analysis. LLH drafted and revised the manuscript. Acknowledgment
This study shows that the CINS has satisfactory psychometric properties and could be a useful instrument for measuring learning outcomes of nursing student. “Ethics and accountability” was found to be the most important factor contributing to nursing student's competencies. A learning outcome perspective focuses on the learner's ability to perform a task rather than a simple possession of the knowledge required to perform the task. Competency is an ongoing process of initial development, maintenance of knowledge and skills, educational consultation, remediation, and re-development (Whelan, 2006). Nursing standards and Table 4 Correlation coefficients between six factors (n = 599). Factor
D1
D2
D3
D4
1. Ethics and accountability (D1) 2. General clinical skills (D2) 3. Lifelong learning (D3) 4. Clinical biomedical science (D4) 5. Caring (D5) 6. Critical thinking and reasoning (D6) 7. Total scale (TS)
1.00 .66 .75 .47 .77 .60 .90
D5
1.00 .66 .69 .67 .71 .84
1.00 .50 .67 .64 .84
1.00 .47 1.00 .56 .66 1.00 .68 .85 .79 1.00
Note. All correlation coefficients are statistically significant (**P b 0.001).
D6
TS
We would like to thank all the nursing students who participated in this study and the National Science Council who provided research funding for this study. References American Association of Colleges of Nursing, 2008. 2006–2007 Enrollment and graduations in baccalaureate and graduate programs in nursing. Author, Washington, DC. American Nurse Association, 2004. Nursing: Scope and Standards of Practice. Author, Washington, DC. Axley, L., 2008. Competency: a concept analysis. Nursing Forum 43 (4), 214–222. Bartlett, H.P., Simonite, V., Westcott, E., Taylor, H.R., 2000. A comparison of the nursing competence of graduates and diplomats from UK nursing programmes. Journal of Clinical Nursing 9 (3), 369–379. Berkow, S., Virkstis, K., Stewart, J., Conway, L., 2009. Assessing new graduate nurse performance. Nurse Educator 34 (1), 17–22. Black, J., Muzio, L., Balaki, B., Conlin-Saindon, K., Gautreau, G., Kelly, C., 2008. Competencies in the context of entry-level registered nurse practice: a collaborative project in Canada. International Nursing Review 55, 171–178. Burch, V.C., Nash, R.C., Zabow, T., 2005. A structured assessment of newly qualified medical graduates. Journal of Medical Education 39, 723–731. Burns, P., Poster, C., 2008. Competency development in new registered nurse graduates closing the gap between education and practice. Journal of Continuing Education in Nursing 39 (2), 67–73.
L.-L. Hsu, S.-I. Hsieh / Nurse Education Today 33 (2013) 492–497 Cowan, D.T., Wilson-Barnett, D.J., Norman, I.J., Murrells, T., 2007. Measuring nursing competence: development of a self-assessment tool for general nurses across Europe. International Journal of Nursing Studies 45, 902–913. Floyd, F.J., Widaman, K.F., 1995. Factor analysis in the development and refinement of clinical assessment instruments. Psychological Assessment 7, 286–299. Grealish, L., 2006. Learning to be a professional: two models of competence and related learning strategies. The Journal of Religion 18 (4), 207–225. Hair, J.F., Anderson, R., Tatham, R., Black, W., 2006. Multivariate Data Analysis. Upper Saddle River, New Jersey. Hall, L.W., Moore, S.M., Barnsteiner, J.H., 2008. Quality and nursing: moving from a concept to a core competency. Urologic Nursing 28 (6), 417–426. Hsu, L.L., Hsieh, S.I., 2009. Testing of a measurement model for baccalaureate nursing student's self-evaluation of core competencies. Journal of Advanced Nursing 65 (11), 2454–2463. Karayurt, O., Mert, H., Beser, A., 2008. A study on development of a scale to assess nursing student's performance in clinical settings. Journal of Clinical Nursing 18, 1123–1130. Liu, M., Huang, Y.S., Liu, K.M., 2009. Assessing core clinical competencies required of medical graduates in Taiwan. The Kaohsiung Journal of Medical Sciences 22 (10), 475–483. Lofmark, A., Smide, B., Wikblad, K., 2006. Competence of newly-graduated nurses — a comparison of the perceptions of qualified nurses and students. Journal of Advanced Nursing 53 (6), 721–728. Mackenzie, K.M., 2009. Who should teach clinical skills to nursing students? British Journal of Nursing 18 (17), 395–398. Marshburn, D.M., Engelke, M.K., Swanson, M.S., 2009. Relationships of new nurses' perceptions and measured performance-based clinical competence. Journal of Continuing Education in Nursing 40 (9), 426–432. McEwen, M., Brown, S.C., 2002. Conceptual frameworks in undergraduate nursing curricula: report of a national survey. Journal of Nursing Education 41 (1), 5–14. Meretoja, R., Isoaho, H., Kilpi, H.L., 2004. Nurse competence scale: development and psychometric testing. Journal of Advanced Nursing 47 (2), 124–133. Mulder, M., Gulikers, J., Biemans, H., Wesselink, R., 2009. The new competence concept in higher education: error or enrichment? Journal of European Industrial 33 (8), 755–770. Nunnally, J.C., Bernstein, I.H., 1994. Psychometric Theory. McGraw-Hill, New York. Paganini, M.C., Egry, E.Y., 2011. The ethical component of professional competence in nursing: an analysis. Nursing Ethics 18 (4), 571–582. Pett, M.A., Lackey, N.R., Sullivan, J.J., 2003. Making Sense of Factor Analysis: The Use of Factor Analysis for Instrument Development in Health Care Research. Sage Publications, Thousand Oaks, CA.
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Polit, D.F., Beck, C.T., 2008. Nursing Research: Generating and Assessing Evidence for Nursing Practice, Eighth Edition. Lippincott Williams &Wilkins, Philadelphia. Ramritu, P.L., Barnard, A., 2001. New nurse graduates' understanding of competence. International Nursing Review 48 (1), 47–57. Scott-Tilley, D.D., 2008. Competency in nursing: a concept analysis. Journal of Continuing Education in Nursing 39 (2), 58–64. Shumway, J.M., Harden, R.M., 2003. AMEE Guide No. 25: The Assessment of Learning Outcomes for the Competent and Reflective Physician. Medical Teacher 25 (6), 569–584. Simpson, J.G., Furnace, J., Crosby, J., Cumming, A.D., Evans, P.A., Friedman, M., et al., 2002. The Scottish doctor-learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners. Medical Teacher 24 (2), 136–143. Sporrong, S.K., Arnetz, B., Hansson, M.G., Westerholm, P., Höglund, A.T., 2007. Developing ethical competence in health care organizations. Nursing Ethics 14 (6), 825–837. Sultana, R.G., 2009. Competence and competence frameworks in career guidance: complex and contested concepts. International Journal for Educational and Vocational Guidance 9, 15–30. Taiwan Nursing Accreditation Council, 2009. The criteria of accreditation[www] http:// www.heeact.edu.tw/lp.asp? ctNode=352&CtUnit=118&BaseDSD=7&mp=52009accessed 12, 10, 11. Takase, M., 2011. Development of the holistic nursing competence scales. Nursing and Health Sciences 13, 396–403. Tekian, A., 2002. Have newly graduated physicians mastered essential clinical skills? Medical Education 36, 406–407. Tigges, B.B., 2009. Psychometric properties of the social comparison motives scale. Journal of Nursing Measurement 17 (1), 29–44. Toofany, S., 2008. Critical thinking among nurses. Nursing Management 14 (9), 28–31. Whelan, L., 2006. Competency assessment of nursing staff. Orthopaedic Nursing 25 (3), 198–202. Wilkinson, T.J., Frampton, C.M., 2003. Assessing performance in final year medical students. Can a postgraduate measure be used in an undergraduate setting? Medical Education 37, 233–240. Wood, G.L., Haber, J., 2002. Reliability and Validity. In: Wood, G.B., Haber, J. (Eds.), Nursing Research: Methods, Appraisal and Utilization. Mosby, St Louis, pp. 311–330.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Development and psychometric evaluation of the competency inventory for nursing students: A learning outcome perspective Li-Ling Hsu a,⁎, Suh-Ing Hsieh b a b
Graduate Institute of Health Allied Education, National Taipei University of Nursing and Health Sciences, No. 365, Ming-Te Rd., Peitou, Taipei City 11219, Taiwan, ROC Department of Nursing, Chang Gung University of Science and Technology, Taiwan, ROC
a r t i c l e
i n f o
Article history: Accepted 31 May 2012 Keywords: Competency Inventory of Nursing Students Factor analysis Nursing students Learning outcome
s u m m a r y Deficiency in essential core competencies could jeopardize the safety of patients. Adopting the outcomebased approach, a set of minimally required core competencies for nursing students was developed to ensure the quality of nursing education. Determination of what point to measure competency is needed. Most importantly, competence indicators of nursing students can be used in curriculum development, planning, and learning outcome evaluation. The purpose of this study was to develop a competency inventory to measure learning outcomes of baccalaureate nursing students and to test its psychometric properties. Psychometric testing was conducted with a convenience sample of 599 nursing students in 2011. Principal axis factor analysis was performed on the 52-item scale to determine construct validity and Cronbach's alpha was used to measure the internal consistency. Principal axis factoring method identified six factors through the direct oblimin rotations including pattern matrix and structure matrix: ethical and responsibility, general clinical skills, lifelong learning, clinical biomedical science, caring and critical thinking reasoning. Exploratory factor analysis yielded an instrument with 43-items on six factors, accounting for 69.84% of the variance in scores. The Competency Inventory of Nursing Students (CINS) factors ranged from 0.91 to 0.98. This study shows that the Competency Inventory of Nursing Students has satisfactory psychometric properties and could be a useful instrument for measuring learning outcomes of nursing student. The competence indicators show merit for assessing learning outcomes for nursing students in nursing education. However, a cross-validation of the scale with another sample is also needed. © 2012 Elsevier Ltd. All rights reserved.
Introduction Most health care providers began their health profession education expecting to acquire the knowledge and skills needed to provide highquality care (Hall et al., 2008). Insufficient competencies in basic patient care are a source of stress for new graduates (Burch et al., 2005). Because of the rapid changes in health care delivery, an expansion of nursing services, and various population health needs, new graduates have difficulty critically thinking in clinical situations (Burns and Poster, 2008; Paganini and Egry, 2011). Competency in nursing has a direct influence on the health and safety of all patients (Axley, 2008). The role of competency in education has grown dramatically as health care employers and educators have identified the gap between education and practice (Scott-Tilley, 2008). Competence is the skill to develop knowledge and ability that enhances professional practice in multiple ways (Paganini and Egry, 2011). Adopting the outcome-based approach, a set of minimally required core competencies for nursing students was developed in 2005 by Taiwan ⁎ Corresponding author. Tel.: + 886 2 2822 7101x3169. E-mail addresses: [email protected] (L.-L. Hsu), [email protected] (S.-I. Hsieh). 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2012.05.028
Nursing Accreditation Council (TNAC). A clear and consistent definition of competency is an important step. Determination of what point to measure competency is needed (Scott-Tilley, 2008). Most importantly, competence indicators of nursing students can be used in curriculum development, planning, and learning outcome evaluation. Background The move to competency approaches to education has emerged from the apparent gap between what students learn in the classroom and what they need to know for work (Grealish, 2006). Several attempts have been made to develop scales that adequately assess nurses' competence level (Bartlett et al., 2000; Meretoja et al., 2004; Cowan et al., 2007; Liu et al., 2009; Takase, 2011) but few studies have been published on the subject of core competencies of nursing students (Lofmark et al., 2006; Berkow et al., 2009; Hsu and Hsieh, 2009). TNAC holds meetings on a regular basis to evaluate and reevaluate nursing schools and nursing programmes in Taiwan. TNAC sets up eight core competencies for BSN (Hsu and Hsieh, 2009). The definition of core competence is different in nursing schools, so no coherent tools can be used for accreditation schools. Therefore, a
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practical comprehensive assessment tool is required for assessing students' learning outcomes. Deficiency in essential core competencies could jeopardize the safety of patients (Tekian, 2002). Adopting the outcome-based approach, a set of minimally required core competencies for nursing students was developed to ensure the quality of nursing education. In outcome-based education, the learning outcome, such as (1) what the nurse is able to do, (2) how the nurse approaches his/her practice, and (3) the nurse as a professional, determine the curriculum contents, teaching methods, and assessments (Simpson et al., 2002; Shumway and Harden, 2003). Competence is seen as a series of integrated capabilities consisting of clusters of knowledge, skills and attitudes necessarily conditional for task performance and problem solving and for being able to function effectively in a certain profession, organization, job, role, and situation (Mulder et al., 2009). In addition, competence includes cognitive competence, functional competence, personal competence, and ethical competence. Competence relates to an overall job done well, as measured against a system of minimum standards, and as demonstrated by performance and outputs (Sultana, 2009). There is an international agreement that nursing competence must be viewed from a holistic perspective (Takase, 2011). Current holistic approaches to competencebased models seem to have successfully absorbed insights from the behaviouristic and functionalist approaches, and additionally integrated some of the most promising practices in education and training (Ramritu and Barnard, 2001; Sultana, 2009). The competence frameworks are generally developed for assessing performance in relation to set standards and providing programmes development (Sultana, 2009). The competence scales for nursing students have a few problems including operationalisation of term, conceptual framework, and reliability and validity. Some studies focused on newly-graduated nurses, for example, Lofmark et al. (2006) summed four factors (communication, patient care, personality characteristics, and knowledge utilisation) and Berkow et al. (2009) grouped six categories (clinical knowledge, technical skills, critical thinking, communication, professionalism, and management of responsibilities). Black et al. (2008), on the other hand, addressed five categories for entry-level registered nurses: professional responsibility and accountability, knowledge-based practice, ethical practice, service to the public, and self-regulation. Based on the 8-item SelfEvaluated Core Competencies (SECC) Scale we had developed for baccalaureate nursing students, we constructed a learning outcome scale which included definitions and attributes of core competence and psychometric testing.
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Instrument The initial 48 items were evaluated for content validity by a panel of seven experts who specialised in nursing education, medical education, clinical nursing, higher education and human resources. They have experience in competence assessment for university students. Using a 4-point rating scale (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = extremely relevant), the seven experts gave 48 items ratings of 3 or 4, resulting in a S-CVI (scale-content validity index) of 0.99. The I-CVI (item-content validity index) ranges from 0.83 to 1.00. The content validity index is taken as a barometer for item and instrument clarity, homogeneity and relevance. In addition, experts recommended addition of three items to this scale (“I collect as much information about the patient as possible to formulate the best nursing strategy”; “I assess a patient's needs for nursing intervention based on data available to me”; “I assess the outcome of my nursing interventions”). Therefore, 48 items were increased to 52 items. The Competency Inventory of Nursing Students (CINS) was designed based on eight core values (American Nurse Association (ANA), 2004; Lofmark et al., 2006; American Association of College of Nursing (AACN), 2008; Black et al., 2008; Hsu and Hsieh, 2009; Taiwan Nursing Accreditation Council (TNAC), 2009), literature reviews, and the learning outcomes of nursing schools in Taiwan. The final version of the scale was the result of fifteen times of revision of the original version. The CINS includes basic biomedical science (5 items), general clinical nursing skills (9 items), communication and cooperation (6 items), critical thinking (5 items), caring (6 items), ethics (9 items), accountability (7 items), and lifelong learning (5 items). In other words, there were in total 52 items divided into 8 categories in the scale. The students reviewed 52 statements and gave a score of one (clearly incompetent on this item) to seven (extremely competent) based on their situation, producing a total score in the range of 52–364 points. Each item is rated on a 7-point Likert scale (Wilkinson and Frampton, 2003). Higher score represents students' higher competencies. Measuring core competence requires the integration of cognitive, affective, and psychomotor skills (Mackenzie, 2009). The nursing students were undertaking a self assessment for evaluating their competence including knowledge, skills, communication, attitudes, values and professional judgment. It is essential that the reliability of a developing questionnaire can be established. A pilot study of 55 senior nursing students was administered for this purpose. Internal consistency of the scale registered an alpha coefficient of 0.96. The instrument had a Cronbach's alpha and split-half reliability coefficient of 0.98.
The Study Ethical Considerations Aim The aim of this study was to develop a competency inventory to measure learning outcomes of baccalaureate nursing students and to test its psychometric properties. Design A cross-sectional survey design was used.
The study was approved by the Institutional Review Board. Consent to participate was implied by voluntary completion and return of the questionnaire, and participants were informed that they would not be penalized for failure to participate or for quitting at any stage of the survey. The researcher did not have direct teaching responsibilities with all participants, and research assistants collected the data to avoid the possibility of coercion of students to participate. Participation was anonymous.
Sample
Data Analysis
A total of 652 senior baccalaureate nursing students selected from a university with two branches (northern and southern Taiwan) were asked to complete a questionnaire survey administered before and after their final clinical practicum in 2010. Completing the questionnaire took approximately 20 min. A gift card as an incentive was given to each participated student for increasing the proportion of returning questionnaires. Out of 652 questionnaires issued, 599 were answered in full (pretest and posttest) with a returning rate of 94.87%.
Statistical analyses were performed using the SPSS software package 17.0 (SPSS Inc., Chicago, IL, USA). PAF (Principal Axis Factoring) is an exploratory factor analytic technique used for the purpose of identifying the underlying dimensions or constructs of a particular scale (Floyd and Widaman, 1995). Oblique rotation (promax) was conducted in this study because of the assumption that the factors were correlated (Tigges, 2009). In order to evaluate sampling adequacy to perform a satisfactory factor analysis, Kaiser–Meyer–Olkin Measure of Sampling
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Adequacy (KMO), and Bartlett test was calculated. To determine the best structure, the eigenvalue greater than one and factor loading equal to or greater than 0.35 were applied (Hair et al., 2006). Correlation values of 0.40 or above were considered satisfactory (Nunnally and Bernstein, 1994; Polit and Beck, 2008). Results Participants' Demographics The majority of students (85.5%) graduated from private schools, while a small number (14.5%) graduated from public university (Table 1). Among them, 70.1% were enrolled in a 2-year programme leading to a bachelor's degree in nursing, whereas 29.9% were enrolled in a 4-year programme leading to the same degree. The participants had a mean age of 21.83 years (SD = 1.02). In addition, those on the 2-year programme had acquired some nursing knowledge from previous nursing programmes leading to Registered Nurse (RN) license at vocational junior colleges. Those on the 4-year programme, however, possessed relatively little nursing knowledge, since they had begun the programmes immediately after vocational or high schools. However, the outcome-based competences before graduation were the same between 2-year programme and 4-year programme. Construct Validity Exploratory factor analysis (EFA) using principal axis factoring with promax oblique rotation was performed to determine the underlying
Attributes of prior school attended Private school Public school Previous school attended High school Vocational Diploma None Type of programme 2-year college 4-year college Age (years) Mean (SD) Range Gender Male Female Marriage Single Married Divorced Nursing license No Yes Licensed practical nurse Registered nurse Missing Religion No Yes Taoist Buddhist Christian Others Missing Missing
Internal Consistency Cronbach's alphas of each factor and the overall scale are presented in Table 2. The Cronbach's alpha for the factors ranged from 0.91 to 0.98. The Cronbach alpha for the 43-item, six-factor scale was 0.98 indicating a high internal consistency of the items to represent the competence inventory of nursing students. Table 4 shows the correlation coefficients between the factors. As showed in Table 4, moderate to strong correlations were observed between the factors. Descriptive Statistics of the Inventory
Table 1 Participant demographics (n = 599). Variable
factor structure of the set of items. The calculated KMO was 0.977 and the Bartlett's test of sphericity was significant (χ2 =33127.55, degree of freedom=1326, Pb 0.0001). A six-factor solution with 52 items emerged based on the criteria of eigenvalues higher than 1 and loading level of 0.4 or above. A scree plot showed that six factors were retained. The factor loadings from the rotated factor structure matrix for the final CINS, as shown in Table 2, consists of 43 items and six factors. In addition, items not loaded are deleted (items 7, 12, 15, 16, 17, 18, 19, 20 and 24). While removing these not loaded items, evaluating and refining a set of factors to examine the rotated factor matrices for high or low loading (Pett et al., 2003), the factor analysis was rerun several times. In the final solution, a six-factor structure comprising 43 items was obtained through focusing first on the factor structure matrix for factor interpretability and then comparing factor pattern matrix (Pett et al., 2003). The six factors were named according to the underlying construct that related to the items: ethical practice and accountability, general clinical nursing skills, lifelong learning, clinical biomedical science, caring, and critical thinking and reasoning. Table 3 displays the total variance explained by the six extracted factors of the 43-item CINS. The initial cumulative variance explained by this solution was 73.99%, and final six-factor solution explained 69.84% of the total variance of the hypothesized model (Table 3).
n (%) 512 (85) 87 (15) 76 (13) 108 (18) 413 (69) 2 (0) 420 (70) 179 (30) 21.83 (1.02) 20–39 5 (1) 594 (99) 597 (100) 1 (0) 1 (0) 88 (15) 511 (85) 92 (15) 403 (67) 16 (3) 309 (52) 288 (48) 142 (24) 76 (13) 37 (6) 31 (5) 4 (0) 2 (0)
Table 5 presents the means and the standard deviations of the factors. The means of six factors ranged between 5.17 and 6.01, which indicated that the students assessed themselves as reasonably competent in nursing. The highest self-evaluation of CINS was observed in the ethics and accountability (Factor 1) , followed by caring (Factor 5), lifelong learning (Factor 3), general clinical skills (Factor 2), and critical thinking and reasoning (Factor 6). The lowest self-evaluated competence was identified in the clinical biomedical science (Factor 4). Discussion The purpose of this study was to develop a scale for assessing nursing students' competencies and to test its psychometric properties. This scale was developed based on TNAC, AACN, ANA and literature review. The conceptual framework for the competencies developed in this project contains eight categories: clinical biomedical science, critical thinking, communication and teamwork, ethics, caring, lifelong learning, accountability, and general clinical skills. Each of the eight categories includes a broad competence standard statement established through literature review and learning outcomes of nursing schools in Taiwan. Finally, the CINS is established after seven experts' content validity check, the pilot study, and the construct validity check. Six factors obtained accounted for 69.84% of the total variance and the strength of the intercorrelations was fully in line with the conceptualisation as a multifactorial construct. Factor analyses showed a variance ranging from 40 to 60%, which is considered sufficient (Wood and Haber, 2002). Factor 1 “ethical practice and accountability” composed of 15 items and their factor loadings ranged between 0.75 and 0.87 in the factor structure matrix. Factor 1 had a high Cronbach's alpha of 0.98 and an eigenvalue of 20.89 and explained 48.59% of the variance. These fifteen items were about professional responsibility and ethical action. A similar result
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Table 2 Results of exploratory factor analysis: factor loading using principal axis factoring with direct oblimin rotation(>.40). Factors and items (Cronbach's α)
Factor structure matrix
Factor pattern matrix
Item-to-total correlation
Factor 1. Ethics and accountability (α = 0.98) 40 I have full respect for the different beliefs and values held by patients. 35 I have full respect for the decisions and choices of patients. 36 I respect patients' request for confidentiality. 33 I try my best to keep patients from harm in providing medical care. 38 I provide patients with safe medical care. 34 I am always careful not to infringe upon patients' rights when making decisions concerning patients. 41 I abide by the code of nursing ethics. 39 I never judge patients based on my values. 32 I abide by the codes of nursing ethics and other related rules and regulations. 42 I actively fulfill my duties. 37 I give patients equal shares of medical resources. 43 I am accountable for my professional judgments and actions. 45 I consult other medical staffs when I come across a situation that is beyond my ability to handle. 44 I am fully aware of the limitations of my professional role and abilities. 46 I take my work seriously and conduct my work carefully.
.872 .886 .868 .883 .900 .865 .867 .825 .824 .857 .819 .818 .775 .799 .748
.960 .956 .940 .926 .911 .894 .888 .830 .826 .786 .743 .675 .633 .618 .542
.782 .785 .765 .797 .820 .803 .802 .783 .774 .797 .738 .789 .760 .792 .784
Factor 2. General clinical skills (α = 0.93) 09 I assess a patient's needs for nursing intervention based on data available to me. 10 I provide patients with nursing treatments that suit their needs. 08 I collect as much information about the patient as possible to formulate the best nursing strategy. 11 I assess the outcome of my nursing interventions. 13 I set priorities of nursing tasks based on the needs of patients. 14 I try to provide comprehensive follow-up medical care that suits the needs of patients. 06 I carry out doctor's instructions and nursing care routine accurately.
.863 .832 .804 .780 .776 .778 .735
.934 .911 .786 .765 .682 .641 .580
.708 .718 .707 .698 .710 .723 .679
Factor 3. Lifelong learning (α = 0.94) 51 I know where and how to look for resources for learning. 48 I am fully aware of what I need to learn. 49 I enjoy seeking answers to questions. 52 I make use of technology and other resources in learning. 50 I set goals for my learning. 47 I make effective use of my time at work.
.878 .837 .817 .822 .831 .699
.899 .885 .805 .789 .776 .465
.761 .734 .760 .752 .708 .712
Factor 4. Clinical biomedical science (α = 0.91) 02 I explain to patients the procedure and results of physical examinations. 04 I understand the purposes and normal values of clinical examination. 03 I understand the mechanism, side effects, and clinical applications of the medicine patients are taking. 01 I make use of pathological and biological knowledge to explain to patients their condition. 05 I understand the principles and logic of medical treatment.
.865 .801 .763 .765 .750
.860 .764 .713 .712 .525
.527 .555 .559 .553 .590
Factor 5. Caring (α = 0.95) 28 I provide timely emotional support for patients when necessary. 27 I encourage patients to express their feelings and I am attentive to their positive and negative feelings. 30 I try my best to provide patients with a comfortable and peaceful environment. 29 I pay attention to the psychological, social, and spiritual wellbeing of patients. 26 I try to empathize with patients in order to identify their needs for medical care. 31 I believe that each patient's life has its own meaning.
.902 .897 .852 .824 .816 .741
.870 .850 .744 .721 .650 .505
.758 .774 .794 .743 .750 .769
Factor 6. Critical thinking and reasoning (α = 0.93) 22 I try to look for the root cause of any changes in patients' condition. 23 I try to analyze the problems facing patients from different angles. 21 I carefully consider the condition of patients and make reasonable judgments and inferences. 25 I always think about whether there is ample empirical basis to support nursing actions.
.861 .847 .834 .790
.831 .769 .734 .596
.699 .694 .725 .711
appeared in a study conducted by Black et al. (2008), who developed five competencies for entry-level nurse in professional responsibility and accountability, and ethical practice dimension, which suggests that the primary responsibility of nurses is to provide competent, ethical, and safe care to clients. Karayurt et al. (2008) and Ramritu and Barnard (2001) noted that student nurses should be evaluated for ethical practice because ethical practice is an integral part of nursing competence. Paganini and Egry (2011) observed that professional ethics determines professional attitudes, values and behaviour, and professional competencies include the ability to undertake responsibilities concerning care. Ethics can be defined as a concern for doing the right thing and avoiding harm when related to nursing (Paganini and Egry, 2011). Ethical competence is a key factor in preventing or reducing moral
distress (Sporrong et al., 2007). Therefore, some key competencies related to ethics are to know and understand codes of ethics, to be able to recognize and analyze ethical situations, and try to resolve them. Factor 2 “nursing student clinical nursing skills” composed of seven items and their factor loadings ranged between 0.74 and 0.86 in the factor structure matrix. Factor 2 had a high Cronbach's alpha of 0.93 and an eigenvalue of 4.35 and explained 10.13% of the variance. Most of these seven items were identified by Karayurt et al. (2008) who noted that student nurses should be evaluated for their abilities to collect data, identify the needs of patients, prioritize tasks, and provide care. In addition, Ramritu and Barnard (2001) stated that competence is experienced as performance of clinical skills, which is another general requirement nurses are expected to meet. When students graduate from nursing school, they need to possess
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Table 3 Total variance explained by the six extracted factors of the 43-item competency inventory of nursing students scale. Initial eigenvalues
Extraction sums of squared loadings
Factor
Total
% of Variance
Cumulative%
Total
% of Variance
Cumulative%
1. 2. 3. 4. 5. 6.
21.19 4.66 2.05 1.57 1.29 1.06
49.27 10.84 4.77 3.65 3.00 2.46
49.27 60.11 64.88 68.53 71.53 73.99
20.89 4.35 1.76 1.29 0.97 0.77
48.59 10.13 4.09 3.01 2.26 1.78
48.59 58.72 62.81 65.82 68.08 69.84
Ethics and accountability General clinical skills Lifelong learning Clinical biomedical science Caring Critical thinking and reasoning
a certain level of clinical skills to stand a good chance of succeeding in their future role as nurses. Factor 3 contained six items concerning competence in enhancing one's own professional development. The factor loadings ranged from 0.70 to 0.88 in the factor structure matrix. It had a high Cronbach's alpha value of 0.94 and an eigenvalue of 4.09. The factor of lifelong learning tends to focus on professional learning, technology and resources use, and question inquiry. This factor is consistent with previous studies (Meretoja et al., 2004; Liu et al., 2009; Takase, 2011) showing that nursing students should be given learning opportunities to foster continuous development and improvement of the knowledge and skills needed for personal growth. The clinical biomedical science and caring factors explained 3.01 and 2.26% respectively, of the variance in the overall scale. Clinical biomedical science in this context includes all kinds of pathological, biological, and physical examinations and treatments administered to patients in clinical settings. Lastly, Factor 6 “critical thinking” explained 1.78% of the variance in the overall scale. Empirical studies have suggested that enhancing students' critical thinking is conducive to their preparation for practice in a complex healthcare environment (Toofany, 2008). It is important for nurses to be able to communicate clearly with patients and medical staffs (Karayurt et al., 2008). Assessing the competence of nursing students is critical to identifying areas for professional development and educational needs while ensuring that competencies are put to use for quality care (Marshburn et al., 2009). This study results were consistent with McEwen and Brown's (2002) definition of core nursing competencies as a combination of critical thinking, therapeutic nursing intervention, problem-solving, communication, caring, and values. Conclusion
Table 5 Means and standard deviations of six factors. Factor Factor Factor Factor Factor Factor Factor
1: Ethics and accountability 2: General clinical skills 3: Lifelong learning 4: Clinical biomedical science 5: Caring 6: Critical thinking and reasoning
Mean
Standard deviation
6.01 5.52 5.78 5.17 5.87 5.44
0.51 0.48 0.59 0.48 0.53 0.55
competencies vary across the globe, depending on the context of the region, resulting in differences in health care and nurse education (Paganini and Egry, 2011). Therefore, generalisability of this study's findings is limited because the sample came from a limited pool. A crossvalidation of the scale with another sample is also needed. Funding This research project was sponsored by the National Science Council (NSC-99-2516-S-227-002) In Taiwan. Conflict of interest No conflict of interest has been declared by the authors. Author contributions LLH, and SIH were responsible for the study conception and design. LLH collected the study data. SIH performed the data analysis. LLH drafted and revised the manuscript. Acknowledgment
This study shows that the CINS has satisfactory psychometric properties and could be a useful instrument for measuring learning outcomes of nursing student. “Ethics and accountability” was found to be the most important factor contributing to nursing student's competencies. A learning outcome perspective focuses on the learner's ability to perform a task rather than a simple possession of the knowledge required to perform the task. Competency is an ongoing process of initial development, maintenance of knowledge and skills, educational consultation, remediation, and re-development (Whelan, 2006). Nursing standards and Table 4 Correlation coefficients between six factors (n = 599). Factor
D1
D2
D3
D4
1. Ethics and accountability (D1) 2. General clinical skills (D2) 3. Lifelong learning (D3) 4. Clinical biomedical science (D4) 5. Caring (D5) 6. Critical thinking and reasoning (D6) 7. Total scale (TS)
1.00 .66 .75 .47 .77 .60 .90
D5
1.00 .66 .69 .67 .71 .84
1.00 .50 .67 .64 .84
1.00 .47 1.00 .56 .66 1.00 .68 .85 .79 1.00
Note. All correlation coefficients are statistically significant (**P b 0.001).
D6
TS
We would like to thank all the nursing students who participated in this study and the National Science Council who provided research funding for this study. References American Association of Colleges of Nursing, 2008. 2006–2007 Enrollment and graduations in baccalaureate and graduate programs in nursing. Author, Washington, DC. American Nurse Association, 2004. Nursing: Scope and Standards of Practice. Author, Washington, DC. Axley, L., 2008. Competency: a concept analysis. Nursing Forum 43 (4), 214–222. Bartlett, H.P., Simonite, V., Westcott, E., Taylor, H.R., 2000. A comparison of the nursing competence of graduates and diplomats from UK nursing programmes. Journal of Clinical Nursing 9 (3), 369–379. Berkow, S., Virkstis, K., Stewart, J., Conway, L., 2009. Assessing new graduate nurse performance. Nurse Educator 34 (1), 17–22. Black, J., Muzio, L., Balaki, B., Conlin-Saindon, K., Gautreau, G., Kelly, C., 2008. Competencies in the context of entry-level registered nurse practice: a collaborative project in Canada. International Nursing Review 55, 171–178. Burch, V.C., Nash, R.C., Zabow, T., 2005. A structured assessment of newly qualified medical graduates. Journal of Medical Education 39, 723–731. Burns, P., Poster, C., 2008. Competency development in new registered nurse graduates closing the gap between education and practice. Journal of Continuing Education in Nursing 39 (2), 67–73.
L.-L. Hsu, S.-I. Hsieh / Nurse Education Today 33 (2013) 492–497 Cowan, D.T., Wilson-Barnett, D.J., Norman, I.J., Murrells, T., 2007. Measuring nursing competence: development of a self-assessment tool for general nurses across Europe. International Journal of Nursing Studies 45, 902–913. Floyd, F.J., Widaman, K.F., 1995. Factor analysis in the development and refinement of clinical assessment instruments. Psychological Assessment 7, 286–299. Grealish, L., 2006. Learning to be a professional: two models of competence and related learning strategies. The Journal of Religion 18 (4), 207–225. Hair, J.F., Anderson, R., Tatham, R., Black, W., 2006. Multivariate Data Analysis. Upper Saddle River, New Jersey. Hall, L.W., Moore, S.M., Barnsteiner, J.H., 2008. Quality and nursing: moving from a concept to a core competency. Urologic Nursing 28 (6), 417–426. Hsu, L.L., Hsieh, S.I., 2009. Testing of a measurement model for baccalaureate nursing student's self-evaluation of core competencies. Journal of Advanced Nursing 65 (11), 2454–2463. Karayurt, O., Mert, H., Beser, A., 2008. A study on development of a scale to assess nursing student's performance in clinical settings. Journal of Clinical Nursing 18, 1123–1130. Liu, M., Huang, Y.S., Liu, K.M., 2009. Assessing core clinical competencies required of medical graduates in Taiwan. The Kaohsiung Journal of Medical Sciences 22 (10), 475–483. Lofmark, A., Smide, B., Wikblad, K., 2006. Competence of newly-graduated nurses — a comparison of the perceptions of qualified nurses and students. Journal of Advanced Nursing 53 (6), 721–728. Mackenzie, K.M., 2009. Who should teach clinical skills to nursing students? British Journal of Nursing 18 (17), 395–398. Marshburn, D.M., Engelke, M.K., Swanson, M.S., 2009. Relationships of new nurses' perceptions and measured performance-based clinical competence. Journal of Continuing Education in Nursing 40 (9), 426–432. McEwen, M., Brown, S.C., 2002. Conceptual frameworks in undergraduate nursing curricula: report of a national survey. Journal of Nursing Education 41 (1), 5–14. Meretoja, R., Isoaho, H., Kilpi, H.L., 2004. Nurse competence scale: development and psychometric testing. Journal of Advanced Nursing 47 (2), 124–133. Mulder, M., Gulikers, J., Biemans, H., Wesselink, R., 2009. The new competence concept in higher education: error or enrichment? Journal of European Industrial 33 (8), 755–770. Nunnally, J.C., Bernstein, I.H., 1994. Psychometric Theory. McGraw-Hill, New York. Paganini, M.C., Egry, E.Y., 2011. The ethical component of professional competence in nursing: an analysis. Nursing Ethics 18 (4), 571–582. Pett, M.A., Lackey, N.R., Sullivan, J.J., 2003. Making Sense of Factor Analysis: The Use of Factor Analysis for Instrument Development in Health Care Research. Sage Publications, Thousand Oaks, CA.
497
Polit, D.F., Beck, C.T., 2008. Nursing Research: Generating and Assessing Evidence for Nursing Practice, Eighth Edition. Lippincott Williams &Wilkins, Philadelphia. Ramritu, P.L., Barnard, A., 2001. New nurse graduates' understanding of competence. International Nursing Review 48 (1), 47–57. Scott-Tilley, D.D., 2008. Competency in nursing: a concept analysis. Journal of Continuing Education in Nursing 39 (2), 58–64. Shumway, J.M., Harden, R.M., 2003. AMEE Guide No. 25: The Assessment of Learning Outcomes for the Competent and Reflective Physician. Medical Teacher 25 (6), 569–584. Simpson, J.G., Furnace, J., Crosby, J., Cumming, A.D., Evans, P.A., Friedman, M., et al., 2002. The Scottish doctor-learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners. Medical Teacher 24 (2), 136–143. Sporrong, S.K., Arnetz, B., Hansson, M.G., Westerholm, P., Höglund, A.T., 2007. Developing ethical competence in health care organizations. Nursing Ethics 14 (6), 825–837. Sultana, R.G., 2009. Competence and competence frameworks in career guidance: complex and contested concepts. International Journal for Educational and Vocational Guidance 9, 15–30. Taiwan Nursing Accreditation Council, 2009. The criteria of accreditation[www] http:// www.heeact.edu.tw/lp.asp? ctNode=352&CtUnit=118&BaseDSD=7&mp=52009accessed 12, 10, 11. Takase, M., 2011. Development of the holistic nursing competence scales. Nursing and Health Sciences 13, 396–403. Tekian, A., 2002. Have newly graduated physicians mastered essential clinical skills? Medical Education 36, 406–407. Tigges, B.B., 2009. Psychometric properties of the social comparison motives scale. Journal of Nursing Measurement 17 (1), 29–44. Toofany, S., 2008. Critical thinking among nurses. Nursing Management 14 (9), 28–31. Whelan, L., 2006. Competency assessment of nursing staff. Orthopaedic Nursing 25 (3), 198–202. Wilkinson, T.J., Frampton, C.M., 2003. Assessing performance in final year medical students. Can a postgraduate measure be used in an undergraduate setting? Medical Education 37, 233–240. Wood, G.L., Haber, J., 2002. Reliability and Validity. In: Wood, G.B., Haber, J. (Eds.), Nursing Research: Methods, Appraisal and Utilization. Mosby, St Louis, pp. 311–330.