- Email: [email protected]
Measuring self-perceived public health nursing competencies using a quantitative approach
Nurse Education Today (2007) 27, 238–246
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Measuring self-perceived public health nursing competencies using a quantitative approach Brenda Poulton
a,*
, Valerie McCammon
b
a
Institute of Nursing Research, University of Ulster at Jordanstown, Newtownabbey BT37 OQB, United Kingdom b School of Nursing, University of Ulster at Jordanstown, Newtownabbey BT37 OQB, United Kingdom Accepted 10 May 2006
KEYWORDS
Summary Background: The contribution of nurses to the public health agenda is acknowledged in all health care systems. To integrate public health into nursing curricula competency based models are being proposed. Despite general agreement on public health competencies, there has been limited research on how community nursing students self-assess their public health competencies and the impact of public health programmes on qualifying students’ self-assessed competence. Aim: The aim of this paper is to report on the development of a research tool to assess self-perceived public health competencies of community nursing students, pre and post studying on a community and public health nursing programme. Methods: A pre and post intervention quantitative survey was conducted with a nonprobability sample of community nursing students (n = 108) studying on a public health programme. The questionnaire was developed using public health competencies derived from a United Kingdom (UK) national consensus exercise and informed by international literature. Analysis used SPSS, generating descriptive and inferential statistics. Results: There were statistically significant improvements in students’ self-perceived public health competencies following participation in the public health programme. Conclusion: It is possible to assess self-perceived competency in public health skills using a validated measurement tool. c 2006 Elsevier Ltd. All rights reserved.
Public health nursing; Nurse education; Quantitative approaches
Background * Corresponding author. Tel.: +44 28 90366128; fax: +44 28 90368202. E-mail address: [email protected] (B. Poulton).
The contribution of nurses to the public health agenda is well documented (Poulton et al., 2000;
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.05.006
Measuring self-perceived public health nursing competencies using a quantitative approach Elliot et al., 2001; Clarke, 2004; Smith and Bazinini-Barakat, 2003; Turner et al., 2003). However, describing the content of public health nursing and translating this into education for practice has proved a challenge (Abrams, 2004). Responding to this challenge, professional nursing organisations have developed competencies for public health practice. For example, in the United States of America (USA), the Quad Council of Public Health Nursing Organization (2004) recently published public health nursing competencies based on 10 years of work and involving consultation with over 1000 public health professionals. These competencies are structured within eight domains, ranging from assessment skills at individual and family level, to community dimensions of practice and public health science skills. Within the European Union (EU) a new education programme in public health for nurses is being developed (Danielson et al., 2005). The programme aims to develop professional continuous education for nurses, within the EU, who have a responsibility for health promotion and education within every healthcare system. Whilst it is acknowledged that there is, as yet, no uniformity among member states, with regard to nursing competencies, a theoretical framework was constructed. This framework was founded on national legislation and regulation of the profession plus EU and WHO strategies and guided development of six common compulsory modules. In the UK the Nursing and Midwifery Council (NMC, 2003) has recognised the need for a separate part of the register to regulate specialist public health practice. In August 2004, the NMC opened a new register designating three parts: nursing, midwifery and specialist community public health nursing. The third part of the register, specialist community public health nursing (SCPHN) is for those practitioners who are already registered on the nursing or midwifery register and whose work is substantially within the area of public health. Health visitors on the former UKCC register were automatically placed on the third part and occupational health nurses and school nurses subsequently migrated to the third part of the register. In exercising its function of protecting the public the NMC developed standards for proficiency for this third part of the register. These standards (NMC, 2004) underpin 10 key principles of public health grouped in four domains based on the principles of health visiting (Council for the Education and Training of Health Visitors, 1977): search for health needs, stimulation of awareness of health needs,
239
influencing policies affecting health, facilitation of health enhancing activities. In parallel with the work of the NMC the UK Government commissioned the development of a competency framework that could be used to inform all public health programmes. The results of this work were firstly the development of an audit tool for public health skills (Burke et al., 2001) and finally the publication of National Occupational Standards for Public Health (Skills for Health, 2004). The 10 broad areas depicted in this latter publication (Table 1) mirror those of the NMC competencies for the third part of the professional nursing register. The use of competency based approaches to education and practice is not without its critics. Chapman (1999) suggests that such approaches have come to the fore, over the last decade, in an attempt to counteract the tension of interest between nurse employers (requiring skilled practitioners) and nurse educationalists (requiring academic achievement). Cowan et al. (2005) reviewing the literature relating to competence in nursing practice, concluded that a holistic definition of competence, incorporating knowledge, performance and attitude is required. Moreover the self-assessment of competence, whilst fundamental within the Code of Professional Conduct (NMC, 2005), is a skill that must be learned (Redfern et al., 2002). There is limited international literature on the use of competencies in public health nursing. However, in the USA, Lundy et al. (1993) used a quasi-experimental design to
Table 1 National Occupational standards for the practice of public health 1. Surveillance and assessment of the population’s health and wellbeing 2. Promoting and protecting the population’s health and wellbeing 3. Developing quality and risk management within an evaluative culture 4. Collaborative working for health and wellbeing 5. Developing health programmes and services and reducing health inequalities 6. Policy and strategy development and implementation to improve health and wellbeing. 7. Working with and for communities to improve health and wellbeing 8. Strategic leadership for health and wellbeing 9. Research and development to improve health and well being 10. Ethically manage self, people and resources to improve health and wellbeing (Skills for Health, 2004)
240 compare students, self-perceived competencies prior to and following a public health nursing programme and found significant improvements. In summary the contribution of nurses to the public health agenda is well accepted globally and the need to develop nurses with the necessary knowledge and skills to deliver this agenda is acknowledged. Despite reservations as to the value of the competency based approach to developing public health nurses, fit for practice and purpose (UKCC, 1999) this is currently the acceptable route adopted by nursing regulatory bodies. However, while much attention has been given to the development of competencies and theory relevant to public health nursing, much less attention has been given to the impact of public health programmes on students’ self-perceived achievement of public health competencies. Consequently, the challenge was to develop a suitable measurement tool against which students could self-assess their public health competencies. prior to and following completion of a degree level community and public health nursing programme.
Research design and methods A quantitative pre and post intervention study design was used. The aim of the study was to develop and pilot a research tool to investigate community nursing students’ self-assessed knowledge and skills in the ten key areas of public health practice.
Developing the research tool A questionnaire design was considered appropriate due to the specific nature of nursing competencies, which require students to assess knowledge and skills against a required standard of practice. Furthermore, a questionnaire study affords anonymity to respondents (Parahoo, 1997), is less time consuming and provides the opportunity to develop a research instrument, which, with refinements, can be used in a proposed national study. The National Occupational Standards for Public Health (Skills for Health, 2004), the NMC standards for SCPHNs (NMC, 2004) and the public health skills audit tool developed by the Health Development Agency (HDA) (Burke et al., 2001) were used to inform the design of the questionnaire.
Validity and reliability The content validity of the questionnaire was based on the outcomes of the Skills for Health (2004) project to develop national UK standards
B. Poulton, V. McCammon for public health practice. Development of these standards involved a UK wide consultation with the whole range of stakeholders in the public health process, including not only practitioners but also governmental agencies and professional regulatory bodies, including the NMC. The competency statements were not changed substantially but some that did not pertain to nursing were removed. Likert scales were included to give some level of magnitude to competency assessment (Polit and Beck, 2004). Following these changes a panel of expert educators (n = 3) reviewed the questionnaire and suggested adjustments were made. Scale reliabilities were assessed statistically and are reported later in this paper. Initially the questionnaire asked for background details of respondents, including the pathway of the programme on which they were currently enrolled. Competency statements were divided into six categories: personal skills, professional skills, underpinning public health principles, policy and strategy, leadership and management. Statements presented within each of the six categories are listed in Table 3. Respondents were asked to rate their level of competency on a 5 point Likert scale in which 5 signified highly competent; 4 – competent; 3 – average; 2 – barely competent and 1 – not at all competent.
Participants The sample included all students registered on the 2004 BSc(hons)/PG diploma in Community and Public Health Nursing at one UK university (n = 108). These students were all enrolled on the specialist public health core module but then followed one of two routes: specialist community nursing (district nursing, community mental health nursing, community children’s nursing or community learning disability nursing) or SCPHN (health visiting, occupational health nursing or school nursing). The questionnaire was distributed and completed by students (n = 108) at the beginning of the first session of the public health module and repeated at the end of the taught programme eight months later.
Ethical considerations This study forms part of a larger study for which ethical approval was granted by the University ethics committee, pre dating implementation of the new Research Governance arrangements (DoH, 2001). Participants were assured that completion of the questionnaire was a matter of personal
Measuring self-perceived public health nursing competencies using a quantitative approach choice: that anonymity and confidentiality would be maintained throughout the study and results would only be published in aggregated form so that no individuals could be identified.
Data analysis Data was analysed using SPSS Version 11. Initially descriptive statistics were generated to check data for errors and to describe the characteristics of the sample. The distribution of the scores for the questionnaire scales were assessed and found to be normally distributed so parametric analyses were completed throughout (Pallant, 2005). To explore the relationship between the questionnaire variables a Pearson product-moment correlation analysis was undertaken. Furthermore the suitability of the data for factor analysis was explored using the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy and the Bartlet test of sphericity (Tabachnick and Fidell, 2001). Following principal components analysis the identified dimensions were tested for internal reliability using the Cronbach alpha coefficient. t-Tests were used to compare scores before and after the educational intervention.
Results Of the 108 questionnaires distributed at the commencement of the course 95 were returned completed, a response rate of 88%. A breakdown by pathway showed that students enrolled on district nursing (n = 31) and health visiting programmes (n = 30) accounted for almost two thirds of the response rate (65%). The remaining third (35%) was made up of students enrolled on programmes relating to: school nursing (n = 7), community mental health nursing (n = 7), community learning disability nursing (n = 4), community children’s nursing (n = 9) and occupational health nursing (n = 6). At the end of the course 98 questionnaires were distributed and 61 were returned completed, a response rate of 62%. While health visiting (n = 23) and district nursing (n = 13) students again accounted for the majority of respondents (61%) these numbers were reduced from time one. The smaller options accounted for 39% of responses: (school nursing (n = 8), community mental health nursing (n = 4), community learning disability nursing (n = 4), community children’s nursing (n = 5) and occupational health nursing (n = 4)).
241
Competencies for public health To tap all the multiple dimensions of public health a large number of variables were included in the questionnaire (n = 54). To reduce these variables down to a more manageable size factor analysis was used. The first step was to assess the suitability of the data for factor analysis. The pre course student data set was explored for intercorrelation of variables by calculating a Pearson product moment correlation matrix. Inspection of the correlation matrix demonstrated a substantial number of coefficients greater than 0.3 justifying the suitability of the data for factor analysis. The KMO measure of sampling adequacy was 0.8 exceeding the minimum value suggested by Tabachnick and Fidell (2001). Furthermore, the Bartlet test of sphericity reached statistical significance (p = <.001), supporting the factorability of this set of variables. Principal components analysis revealed the presence of 12 components (factors) with eigen values in excess of one, explaining 75% of the variance. However, inspection of the Scree plot revealed a definite break after the third component and therefore it was decided to retain these three components for further analysis. This was supported by the results of the parallel analysis which showed only three components with eigen values exceeding the corresponding criterion values for a randomly generated matrix of the same size (54 variables · 153 respondents). These results are presented in Table 2. The principal components analysis was repeated, limiting the analysis to three components. To aid in the interpretation of these three components, Varimax rotation was performed. The rotated solution revealed the presence of a clear structure with
Table 2 Comparison of eigen values from principal components analysis (PCA) and the corresponding criterion values obtained from parallel analysis Component no.
Actual eigenvalue from PCA
Critical value from parallel analysis
Decision
1 2 3 4 5 6 7 8 9 10
25.057 3.345 2.478 1.982 1.676 1.428 1.314 1.214 1.108 1.022
2.3868 2.2425 2.1359 2.0430 1.9601 1.8849 1.8164 1.7508 1.6918 1.6338
Accept Accept Accept Reject Reject Reject Reject Reject Reject Reject
242 Table 3
B. Poulton, V. McCammon Principal components analyses (with varimax rotation) of Public Health Competencies
Item
Component 1
Building commitment Empowering others Building a shared vision Clarifying a direction and purpose Influencing others Creating a learning culture Political sensitivity and awareness Exercising advocacy for community issues Influencing policy and strategy Motivating and building teams Enabling others Policy development Understanding local policy context Understanding national policy context Encouraging community participation Exercising advocacy for individuals Sharing skills with other organizations Project management Understanding relevant legislation Managing change Project development Sharing skills in your organization Managing quality Understanding cultural diversity Statistical analysis Commissioning research Critical appraisal of research Evaluation methodology Undertaking research Population health needs assessment Preparation of reports Risk analysis Evidence based decision making Partnership working Health impact assessment Understanding inequality issues Epidemiology Building partnerships Understanding influences on behaviour Understanding own contribution to health and well being
2 .786 .783 .776 .754 .744 .725 .705 .696 .675 .674 .671. .666 .666 .661 .637 .627 .614 .605 .601 .593 .591 .573 .545 .530
.432 .458
.428 .506 .528 .419 .449 .507 .432
Information Technology (IT) skills Managing self Written and verbal communication Prioritising needs Interpersonal skills Planning interventions Working in multidisciplinary teams Delegating Negotiation skills Health and Safety issues Presentation skills Group facilitation skills Conflict management Working with communities Eigen value of factor Percentage of variance explained (%)
.429
.460 .509 .519
.447 .536 .550 .516 .487 .503 .461 .507 .727 .721 .721 .676 .675 .644 .624 .584 .580 .555 .553 .545 .537 .535 .526 .507
.481 .409 .429
25.4 47
3
3.28 6.1
.655 .654 .620 .592 .574 .566 .562 .543 .508 .484 .465 .442 2.43 4.5
Measuring self-perceived public health nursing competencies using a quantitative approach the three components showing a number of strong loadings as shown in Table 3. Only items with absolute values above 0.4 were retained (Hinton et al., 2004). The three components explain a total of 57.6% of the variance. The first component comprises 24 items. These items reflect those included in the leadership category of the questionnaire (e.g. clarifying direction and purpose; empowering others). Closely linked to these are aspects of the understanding and influencing of policy and practical skills of management (e.g. project development and management). It was therefore decided to label this dimension ‘leadership and management for public health’. The second component comprises 16 items. These consist of all the professional skills included in the questionnaire (e.g. population health needs analysis; partnership working) together with some of the underpinning principles (e.g. understanding inequality issues). This dimension was labelled ‘principles and practice of public health’. The third component comprises 12 items, the majority of which relate to communication (e.g. written and verbal communication; group facilitation). It therefore seemed appropriate to label this dimension ‘communication’. Although three clear components with high loadings emerged, several items loaded on more then one component. Further analysis using different forms of rotation did not yield a better result so it was decided to retain the current structure.
Table 4 Mean item scores and Cronbach alpha coefficient (a) for the three dimensions of public health competencies Item
Mean alpha item coefficient score
Leadership and management for 2.91 PH (24 items) Principles and practice of PH 2.72 (16 items) Communication (12 items) 3.49
.96 .91
243
Two items did not load at sufficient magnitude on any of the components. The first one IT skills was excluded from the analysis and the second one working with communities was treated as an independent variable for the purpose of analysis. Whilst it was considered that IT skills were important such skills are fast becoming important in all healthcare practice and are not specific to public health. Cronbach’s alpha measures of internal consistency were computed for each of the three component scales. The results, presented in Table 4, suggest a high level of internal reliability for each of these scales, with all samples exceeding 0.7, the accepted level for scale reliability (Pallant, 2005).
Pre course assessment of students’ public health competence Although students followed either a public health route (health visiting, occupational health nursing or school nursing) or a specialist community-nursing route (district nursing, community mental health nursing, community children’s nursing or community learning disability) all undertook the core public health module, which included the theoretical content to achieve public health competencies (NMC, 2004). For this reason and to boost sample size for testing the validity and reliability of the measurement tool, analysis included the whole sample. Table 5 demonstrates that students rated themselves as below average competence in leadership and management for public health and principles and practice of public health but above average for communication skills. This is as would be expected as all were qualified nurses and had worked in a range of health care settings before embarking on the course.
Impact of public health nursing programme on students’ self-perceived competency Paired sample t-tests are advocated when the study includes only one group of people and data is collected on two occasions (Pallant, 2005).
.85
Table 5 Scale means, standard deviations, t-values and level of significance for three dimensions of public health competency plus working with communities: comparing students pre and post education programme Dimension Leadership and management for PH Principles and practice of PH Communication Working with communities
Pre course
Post course
mean
SD
mean
SD
69.96 43.58 41.85 3.31
12.89 7.94 4.91 .85
85.08 57.68 44.85 3.63
9.88 11.14 6.00 .58
t-value
df
sign
g2
8.20 9.16 3.37 1.09
145.28 152 152 152
.000 .000 .001 .276
0.31 0.36 0.06 0.007
244 However, such an analysis demands that scores for each respondent are available at time one and time two. Due to the anonymity of this study it was not possible to identify scores in this way. Furthermore, as the response rate at time one and time two were different it was decided to treat time one and time two respondents as independent samples. For this reason an independent sample ttest was conducted to compare students pre and post exposure to the public health nursing programme. Results of this analysis are presented in Table 5. Students completing the public health programme rated themselves higher on all three dimensions of public health plus ‘working with communities’. There were highly significant improvements for the first two dimensions (Leadership and Management for Public Health and Principles and Practice of Public Health) (p = <0.001) and a moderately significant improvement in Communication skills (p = <.01) The perceived improvement in working with communities did not achieve significance. To assess the relative magnitude of the differences between the mean scores effect sizes were calculated using the eta squared statistic. Using Cohen’s (1988) guidelines for interpreting this value (i.e. .01 = small; .06 = moderate; 14 = large) the magnitude of the difference between pre and post scores was large for the first two dimensions and moderate for communication skills.
Comparison between qualifying students recording as specialist community nurses and those registering as SCPHNs Although all the students in this study were exposed to a dedicated public health module with learning outcomes based on the 10 areas of public health (NMC, 2004), they then followed differing routes of study and practice to qualify as specialist community nurses or SCPHNs. Although there remains debate about this division (Poulton, 2003) only the latter group are considered by the NMC as having a substantial input into public health. Consequently it should follow that given their increased exposure to public health education and practice their self-perceived competency in public health should differ from that of their community nursing colleagues, at the end of the course. For this reason an independent sample t-test was conducted to compare self-perceived public health competencies for qualifying specialist community nursing students (district nursing, community children’s nursing, community mental health nursing and community
B. Poulton, V. McCammon learning disability nursing) and specialist community public health nursing students (health visiting, occupational health nursing and school nursing). There was no significant difference, between the groups, on any of the dimensions of public health.
Discussion The data in this study was derived from a nonprobability sample of students in one area of the UK therefore results cannot be generalised to other cohorts of students. However, by generating a reasonable sample size it has been possible to establish an acceptable level (Nunnally, 1978) of scale reliability for the dimensions of public health measured. Furthermore, the strength of the content validity of the measurement tool is based on the fact that it includes dimensions of public health competencies identified in the international literature (Quad Council of Public Health Nursing Organization, 2004; Danielson et al., 2005) and items derived from a wide consultations process within the UK (Skills for Health, 2004). The tool was shown to be sufficiently sensitive to discriminate between independent groups of students supporting the feasibility of such pre and post test studies (Lundy et al., 1993). It is acknowledged, however, that the study would have been strengthened by the use of a paired sample t -test and in future studies it would be more prudent to match respondents in the pre and post intervention design. The use of self-rating questionnaires to assess competencies in nursing is relatively rare in the UK. Redfern et al. (2002) in a review of the literature found only three examples of such questionnaires, all focusing on general nursing competencies. These authors concluded that most available self-rating scales lacked adequate testing of reliability and validity. However, in partial validation of one tool they concluded that such measures could be valuable in self-assessment of competence. Whilst acknowledging the limitations of student self-assessment of competence it is proposed that the questionnaire developed in this study could, with further testing, be used as one element within, a multi method approach in the assessment of public health nursing competency, combined with teacher assessment of the same criteria. More importantly, having ascertained that qualifying students do rate their public health competencies higher, on completion of a dedicated public health programme, there is little evidence as to whether
Measuring self-perceived public health nursing competencies using a quantitative approach such competencies continue to be applied in practice. To address such deficiencies a larger study is planned, across two sites. Not only will students self-assess their competency pre and post the education programme but they will be followed up at six months and eighteen months. Data will be collected on the extent to which competencies are applied in practice and case studies will be used to investigate community focused public health practice.
Conclusions As registered nurses the participants in this study should be well able to reflect on their knowledge and skills and self-assess their own level of competence following exposure to a post registration public health nursing programme. The literature suggests that there are few psychometrically tested competency measures in nursing and even less addressing public health competencies. This study established the validity and scale reliability of a measurement tool, which was developed from a range of competencies developed within the UK but concurring with those developed in the EU and USA. Moreover, the study is the first of its kind to measure the self-perceived competencies of community and public health nursing students pre and post being exposed to a dedicated public health programme. Development of this questionnaire is the first stage in a research programme, which will follow through acquisition of public health competencies, and application in practice.
Recommendations Replicate the research with randomised samples from more diverse and international populations of public health nursing students. Follow through groups of such students using a range of qualitative and quantitative techniques to assess application of public health skills in practice.
References Abrams, S.E., 2004. From function to competency in public health nursing. Public Health Nursing 21 (5), 507– 510. Burke, S., Meyrick, J., Speller, V., 2001. Public Health Skills Audit 2001 – Research Report London: Health Development Agency (HAD).
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Chapman, H., 1999. Some important limitations of competency-based education with respect to nurse education: an Australian perspective. Nurse Education Today 19 (2), 129– 135. Clarke, J., 2004. Public health nursing in Ireland: a critical overview. Developed from a Presentation made at the Annual Conference of the Institute of Community Health Nursing, Ireland. September 29, 2001. Public Health Nursing 21 (2), 191–198. Cohen, J., 1988. Statistical Power analysis for the Behavioral Sciences Hillsdale. Erlbaum, NJ. Council for the Education and Training of Health Visitors (CETHV), 1977. An Investigation into the Principles of Health Visiting. CETHV, London. Cowan, D., Norman, I., Coopamah, V., 2005. Competence in nursing practice: a controversial concept – a focused review of literature. Nurse Education Today 25 (5), 355–362. Danielson, E., KrogerusTherman, I., Sivertsen, B., Sourtzi, P., 2005. Nursing and Public Health in Europe – a New Continuous Education Programme. International Nursing Review 52 (1), 32–38. Department of Health (DoH), 2001. Research Governance Framework for Health and Social Care. DoH, London. Elliot, L., Crombie, I., Irvine, L., Cantrell, J., Taylor, J., 2001. The Effectiveness of Public Health Nursing: a Review of Systematic Reviews. Scottish Executive, Edinburgh. Hinton, P.R., Brownlow, C., McMurray, I., Cozens, B., 2004. SPSS Explained. Routledge, London. Lundy, K.S., Bender, K.W., Powell, C., 1993. Effects of public health nursing participation in selected academic courses on self-reported functions and competencies: a collaborative pilot study. Public Health Nursing 10 (1), 48–54. Nunnally, J.O., 1978. Psychometric Theory. McGraw Hill, New York. Nursing and Midwifery Council (NMC), 2003. Third part of the New Register: Specialist Community Public Health Nursing, Proposed Competency Framework. NMC, London. NMC, 2004. Standards of Proficiency for Specialist Community Public Health Nursing. NMC, London. NMC, 2005. Code of Professional Conduct. NMC, London. Pallant, J., 2005. SPSS Survival Guide, second ed. Open University Press, Maidenhead. Parahoo, K., 1997. Nursing Research – Principles, Process and Issues. MacMillan Press, Basingstoke. Polit, D.F., Beck, C.T., 2004. Nursing research: principles and methods, seventh ed. Lippincott Williams & Wilkins, Philadelphia; London. Poulton, B.C., Mason, C., McKenna, H., Lynch, C., Keeney, S., 2000. The Contribution of Nurse, Midwives and Health Visitors to the Public Health Agenda. DHSSPS, Belfast. Poulton, B., 2003. Which branches of community practice should be included in the third part of the register?. Community Practitioner 76 (11) 414–417. Quad Council of Public Health Nursing Organization, 2004. Public Health Competencies. Public Health Nursing 21 (5), 443–452. Redfern, S., Norman, I., Calman, L., Watson, R., Murrells, T., 2002. Assessing competence to practice in nursing: a review of the literature. Research Papers in Education 17 (1), 51– 77. Skills for Health, 2004. National Occupational Standards for the Practice of Public Health Guide. Skills for Health, Bristol. Smith, K., Bazinini-Barakat, N., 2003. A public health nursing practice model: melding public health principles with the nursing process. Public Health Nursing 20 (1), 42–48. Tabachnick, B.G., Fidell, L.S., 2001. Using Multivariate Statistics, fourth ed. Harper Collins, New York.
246 Turner, J., Poulton, B., Lazenbatt, A., Patton, L., Curran, C., 2003. Community Health Nursing: Current Practice and Possible Futures. DHSSPS, Belfast.
B. Poulton, V. McCammon United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), 1999. Fitness for Practice: the UKCC Commission for Nursing and Midwifery Education. NMC, London.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Measuring self-perceived public health nursing competencies using a quantitative approach Brenda Poulton
a,*
, Valerie McCammon
b
a
Institute of Nursing Research, University of Ulster at Jordanstown, Newtownabbey BT37 OQB, United Kingdom b School of Nursing, University of Ulster at Jordanstown, Newtownabbey BT37 OQB, United Kingdom Accepted 10 May 2006
KEYWORDS
Summary Background: The contribution of nurses to the public health agenda is acknowledged in all health care systems. To integrate public health into nursing curricula competency based models are being proposed. Despite general agreement on public health competencies, there has been limited research on how community nursing students self-assess their public health competencies and the impact of public health programmes on qualifying students’ self-assessed competence. Aim: The aim of this paper is to report on the development of a research tool to assess self-perceived public health competencies of community nursing students, pre and post studying on a community and public health nursing programme. Methods: A pre and post intervention quantitative survey was conducted with a nonprobability sample of community nursing students (n = 108) studying on a public health programme. The questionnaire was developed using public health competencies derived from a United Kingdom (UK) national consensus exercise and informed by international literature. Analysis used SPSS, generating descriptive and inferential statistics. Results: There were statistically significant improvements in students’ self-perceived public health competencies following participation in the public health programme. Conclusion: It is possible to assess self-perceived competency in public health skills using a validated measurement tool. c 2006 Elsevier Ltd. All rights reserved.
Public health nursing; Nurse education; Quantitative approaches
Background * Corresponding author. Tel.: +44 28 90366128; fax: +44 28 90368202. E-mail address: [email protected] (B. Poulton).
The contribution of nurses to the public health agenda is well documented (Poulton et al., 2000;
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.05.006
Measuring self-perceived public health nursing competencies using a quantitative approach Elliot et al., 2001; Clarke, 2004; Smith and Bazinini-Barakat, 2003; Turner et al., 2003). However, describing the content of public health nursing and translating this into education for practice has proved a challenge (Abrams, 2004). Responding to this challenge, professional nursing organisations have developed competencies for public health practice. For example, in the United States of America (USA), the Quad Council of Public Health Nursing Organization (2004) recently published public health nursing competencies based on 10 years of work and involving consultation with over 1000 public health professionals. These competencies are structured within eight domains, ranging from assessment skills at individual and family level, to community dimensions of practice and public health science skills. Within the European Union (EU) a new education programme in public health for nurses is being developed (Danielson et al., 2005). The programme aims to develop professional continuous education for nurses, within the EU, who have a responsibility for health promotion and education within every healthcare system. Whilst it is acknowledged that there is, as yet, no uniformity among member states, with regard to nursing competencies, a theoretical framework was constructed. This framework was founded on national legislation and regulation of the profession plus EU and WHO strategies and guided development of six common compulsory modules. In the UK the Nursing and Midwifery Council (NMC, 2003) has recognised the need for a separate part of the register to regulate specialist public health practice. In August 2004, the NMC opened a new register designating three parts: nursing, midwifery and specialist community public health nursing. The third part of the register, specialist community public health nursing (SCPHN) is for those practitioners who are already registered on the nursing or midwifery register and whose work is substantially within the area of public health. Health visitors on the former UKCC register were automatically placed on the third part and occupational health nurses and school nurses subsequently migrated to the third part of the register. In exercising its function of protecting the public the NMC developed standards for proficiency for this third part of the register. These standards (NMC, 2004) underpin 10 key principles of public health grouped in four domains based on the principles of health visiting (Council for the Education and Training of Health Visitors, 1977): search for health needs, stimulation of awareness of health needs,
239
influencing policies affecting health, facilitation of health enhancing activities. In parallel with the work of the NMC the UK Government commissioned the development of a competency framework that could be used to inform all public health programmes. The results of this work were firstly the development of an audit tool for public health skills (Burke et al., 2001) and finally the publication of National Occupational Standards for Public Health (Skills for Health, 2004). The 10 broad areas depicted in this latter publication (Table 1) mirror those of the NMC competencies for the third part of the professional nursing register. The use of competency based approaches to education and practice is not without its critics. Chapman (1999) suggests that such approaches have come to the fore, over the last decade, in an attempt to counteract the tension of interest between nurse employers (requiring skilled practitioners) and nurse educationalists (requiring academic achievement). Cowan et al. (2005) reviewing the literature relating to competence in nursing practice, concluded that a holistic definition of competence, incorporating knowledge, performance and attitude is required. Moreover the self-assessment of competence, whilst fundamental within the Code of Professional Conduct (NMC, 2005), is a skill that must be learned (Redfern et al., 2002). There is limited international literature on the use of competencies in public health nursing. However, in the USA, Lundy et al. (1993) used a quasi-experimental design to
Table 1 National Occupational standards for the practice of public health 1. Surveillance and assessment of the population’s health and wellbeing 2. Promoting and protecting the population’s health and wellbeing 3. Developing quality and risk management within an evaluative culture 4. Collaborative working for health and wellbeing 5. Developing health programmes and services and reducing health inequalities 6. Policy and strategy development and implementation to improve health and wellbeing. 7. Working with and for communities to improve health and wellbeing 8. Strategic leadership for health and wellbeing 9. Research and development to improve health and well being 10. Ethically manage self, people and resources to improve health and wellbeing (Skills for Health, 2004)
240 compare students, self-perceived competencies prior to and following a public health nursing programme and found significant improvements. In summary the contribution of nurses to the public health agenda is well accepted globally and the need to develop nurses with the necessary knowledge and skills to deliver this agenda is acknowledged. Despite reservations as to the value of the competency based approach to developing public health nurses, fit for practice and purpose (UKCC, 1999) this is currently the acceptable route adopted by nursing regulatory bodies. However, while much attention has been given to the development of competencies and theory relevant to public health nursing, much less attention has been given to the impact of public health programmes on students’ self-perceived achievement of public health competencies. Consequently, the challenge was to develop a suitable measurement tool against which students could self-assess their public health competencies. prior to and following completion of a degree level community and public health nursing programme.
Research design and methods A quantitative pre and post intervention study design was used. The aim of the study was to develop and pilot a research tool to investigate community nursing students’ self-assessed knowledge and skills in the ten key areas of public health practice.
Developing the research tool A questionnaire design was considered appropriate due to the specific nature of nursing competencies, which require students to assess knowledge and skills against a required standard of practice. Furthermore, a questionnaire study affords anonymity to respondents (Parahoo, 1997), is less time consuming and provides the opportunity to develop a research instrument, which, with refinements, can be used in a proposed national study. The National Occupational Standards for Public Health (Skills for Health, 2004), the NMC standards for SCPHNs (NMC, 2004) and the public health skills audit tool developed by the Health Development Agency (HDA) (Burke et al., 2001) were used to inform the design of the questionnaire.
Validity and reliability The content validity of the questionnaire was based on the outcomes of the Skills for Health (2004) project to develop national UK standards
B. Poulton, V. McCammon for public health practice. Development of these standards involved a UK wide consultation with the whole range of stakeholders in the public health process, including not only practitioners but also governmental agencies and professional regulatory bodies, including the NMC. The competency statements were not changed substantially but some that did not pertain to nursing were removed. Likert scales were included to give some level of magnitude to competency assessment (Polit and Beck, 2004). Following these changes a panel of expert educators (n = 3) reviewed the questionnaire and suggested adjustments were made. Scale reliabilities were assessed statistically and are reported later in this paper. Initially the questionnaire asked for background details of respondents, including the pathway of the programme on which they were currently enrolled. Competency statements were divided into six categories: personal skills, professional skills, underpinning public health principles, policy and strategy, leadership and management. Statements presented within each of the six categories are listed in Table 3. Respondents were asked to rate their level of competency on a 5 point Likert scale in which 5 signified highly competent; 4 – competent; 3 – average; 2 – barely competent and 1 – not at all competent.
Participants The sample included all students registered on the 2004 BSc(hons)/PG diploma in Community and Public Health Nursing at one UK university (n = 108). These students were all enrolled on the specialist public health core module but then followed one of two routes: specialist community nursing (district nursing, community mental health nursing, community children’s nursing or community learning disability nursing) or SCPHN (health visiting, occupational health nursing or school nursing). The questionnaire was distributed and completed by students (n = 108) at the beginning of the first session of the public health module and repeated at the end of the taught programme eight months later.
Ethical considerations This study forms part of a larger study for which ethical approval was granted by the University ethics committee, pre dating implementation of the new Research Governance arrangements (DoH, 2001). Participants were assured that completion of the questionnaire was a matter of personal
Measuring self-perceived public health nursing competencies using a quantitative approach choice: that anonymity and confidentiality would be maintained throughout the study and results would only be published in aggregated form so that no individuals could be identified.
Data analysis Data was analysed using SPSS Version 11. Initially descriptive statistics were generated to check data for errors and to describe the characteristics of the sample. The distribution of the scores for the questionnaire scales were assessed and found to be normally distributed so parametric analyses were completed throughout (Pallant, 2005). To explore the relationship between the questionnaire variables a Pearson product-moment correlation analysis was undertaken. Furthermore the suitability of the data for factor analysis was explored using the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy and the Bartlet test of sphericity (Tabachnick and Fidell, 2001). Following principal components analysis the identified dimensions were tested for internal reliability using the Cronbach alpha coefficient. t-Tests were used to compare scores before and after the educational intervention.
Results Of the 108 questionnaires distributed at the commencement of the course 95 were returned completed, a response rate of 88%. A breakdown by pathway showed that students enrolled on district nursing (n = 31) and health visiting programmes (n = 30) accounted for almost two thirds of the response rate (65%). The remaining third (35%) was made up of students enrolled on programmes relating to: school nursing (n = 7), community mental health nursing (n = 7), community learning disability nursing (n = 4), community children’s nursing (n = 9) and occupational health nursing (n = 6). At the end of the course 98 questionnaires were distributed and 61 were returned completed, a response rate of 62%. While health visiting (n = 23) and district nursing (n = 13) students again accounted for the majority of respondents (61%) these numbers were reduced from time one. The smaller options accounted for 39% of responses: (school nursing (n = 8), community mental health nursing (n = 4), community learning disability nursing (n = 4), community children’s nursing (n = 5) and occupational health nursing (n = 4)).
241
Competencies for public health To tap all the multiple dimensions of public health a large number of variables were included in the questionnaire (n = 54). To reduce these variables down to a more manageable size factor analysis was used. The first step was to assess the suitability of the data for factor analysis. The pre course student data set was explored for intercorrelation of variables by calculating a Pearson product moment correlation matrix. Inspection of the correlation matrix demonstrated a substantial number of coefficients greater than 0.3 justifying the suitability of the data for factor analysis. The KMO measure of sampling adequacy was 0.8 exceeding the minimum value suggested by Tabachnick and Fidell (2001). Furthermore, the Bartlet test of sphericity reached statistical significance (p = <.001), supporting the factorability of this set of variables. Principal components analysis revealed the presence of 12 components (factors) with eigen values in excess of one, explaining 75% of the variance. However, inspection of the Scree plot revealed a definite break after the third component and therefore it was decided to retain these three components for further analysis. This was supported by the results of the parallel analysis which showed only three components with eigen values exceeding the corresponding criterion values for a randomly generated matrix of the same size (54 variables · 153 respondents). These results are presented in Table 2. The principal components analysis was repeated, limiting the analysis to three components. To aid in the interpretation of these three components, Varimax rotation was performed. The rotated solution revealed the presence of a clear structure with
Table 2 Comparison of eigen values from principal components analysis (PCA) and the corresponding criterion values obtained from parallel analysis Component no.
Actual eigenvalue from PCA
Critical value from parallel analysis
Decision
1 2 3 4 5 6 7 8 9 10
25.057 3.345 2.478 1.982 1.676 1.428 1.314 1.214 1.108 1.022
2.3868 2.2425 2.1359 2.0430 1.9601 1.8849 1.8164 1.7508 1.6918 1.6338
Accept Accept Accept Reject Reject Reject Reject Reject Reject Reject
242 Table 3
B. Poulton, V. McCammon Principal components analyses (with varimax rotation) of Public Health Competencies
Item
Component 1
Building commitment Empowering others Building a shared vision Clarifying a direction and purpose Influencing others Creating a learning culture Political sensitivity and awareness Exercising advocacy for community issues Influencing policy and strategy Motivating and building teams Enabling others Policy development Understanding local policy context Understanding national policy context Encouraging community participation Exercising advocacy for individuals Sharing skills with other organizations Project management Understanding relevant legislation Managing change Project development Sharing skills in your organization Managing quality Understanding cultural diversity Statistical analysis Commissioning research Critical appraisal of research Evaluation methodology Undertaking research Population health needs assessment Preparation of reports Risk analysis Evidence based decision making Partnership working Health impact assessment Understanding inequality issues Epidemiology Building partnerships Understanding influences on behaviour Understanding own contribution to health and well being
2 .786 .783 .776 .754 .744 .725 .705 .696 .675 .674 .671. .666 .666 .661 .637 .627 .614 .605 .601 .593 .591 .573 .545 .530
.432 .458
.428 .506 .528 .419 .449 .507 .432
Information Technology (IT) skills Managing self Written and verbal communication Prioritising needs Interpersonal skills Planning interventions Working in multidisciplinary teams Delegating Negotiation skills Health and Safety issues Presentation skills Group facilitation skills Conflict management Working with communities Eigen value of factor Percentage of variance explained (%)
.429
.460 .509 .519
.447 .536 .550 .516 .487 .503 .461 .507 .727 .721 .721 .676 .675 .644 .624 .584 .580 .555 .553 .545 .537 .535 .526 .507
.481 .409 .429
25.4 47
3
3.28 6.1
.655 .654 .620 .592 .574 .566 .562 .543 .508 .484 .465 .442 2.43 4.5
Measuring self-perceived public health nursing competencies using a quantitative approach the three components showing a number of strong loadings as shown in Table 3. Only items with absolute values above 0.4 were retained (Hinton et al., 2004). The three components explain a total of 57.6% of the variance. The first component comprises 24 items. These items reflect those included in the leadership category of the questionnaire (e.g. clarifying direction and purpose; empowering others). Closely linked to these are aspects of the understanding and influencing of policy and practical skills of management (e.g. project development and management). It was therefore decided to label this dimension ‘leadership and management for public health’. The second component comprises 16 items. These consist of all the professional skills included in the questionnaire (e.g. population health needs analysis; partnership working) together with some of the underpinning principles (e.g. understanding inequality issues). This dimension was labelled ‘principles and practice of public health’. The third component comprises 12 items, the majority of which relate to communication (e.g. written and verbal communication; group facilitation). It therefore seemed appropriate to label this dimension ‘communication’. Although three clear components with high loadings emerged, several items loaded on more then one component. Further analysis using different forms of rotation did not yield a better result so it was decided to retain the current structure.
Table 4 Mean item scores and Cronbach alpha coefficient (a) for the three dimensions of public health competencies Item
Mean alpha item coefficient score
Leadership and management for 2.91 PH (24 items) Principles and practice of PH 2.72 (16 items) Communication (12 items) 3.49
.96 .91
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Two items did not load at sufficient magnitude on any of the components. The first one IT skills was excluded from the analysis and the second one working with communities was treated as an independent variable for the purpose of analysis. Whilst it was considered that IT skills were important such skills are fast becoming important in all healthcare practice and are not specific to public health. Cronbach’s alpha measures of internal consistency were computed for each of the three component scales. The results, presented in Table 4, suggest a high level of internal reliability for each of these scales, with all samples exceeding 0.7, the accepted level for scale reliability (Pallant, 2005).
Pre course assessment of students’ public health competence Although students followed either a public health route (health visiting, occupational health nursing or school nursing) or a specialist community-nursing route (district nursing, community mental health nursing, community children’s nursing or community learning disability) all undertook the core public health module, which included the theoretical content to achieve public health competencies (NMC, 2004). For this reason and to boost sample size for testing the validity and reliability of the measurement tool, analysis included the whole sample. Table 5 demonstrates that students rated themselves as below average competence in leadership and management for public health and principles and practice of public health but above average for communication skills. This is as would be expected as all were qualified nurses and had worked in a range of health care settings before embarking on the course.
Impact of public health nursing programme on students’ self-perceived competency Paired sample t-tests are advocated when the study includes only one group of people and data is collected on two occasions (Pallant, 2005).
.85
Table 5 Scale means, standard deviations, t-values and level of significance for three dimensions of public health competency plus working with communities: comparing students pre and post education programme Dimension Leadership and management for PH Principles and practice of PH Communication Working with communities
Pre course
Post course
mean
SD
mean
SD
69.96 43.58 41.85 3.31
12.89 7.94 4.91 .85
85.08 57.68 44.85 3.63
9.88 11.14 6.00 .58
t-value
df
sign
g2
8.20 9.16 3.37 1.09
145.28 152 152 152
.000 .000 .001 .276
0.31 0.36 0.06 0.007
244 However, such an analysis demands that scores for each respondent are available at time one and time two. Due to the anonymity of this study it was not possible to identify scores in this way. Furthermore, as the response rate at time one and time two were different it was decided to treat time one and time two respondents as independent samples. For this reason an independent sample ttest was conducted to compare students pre and post exposure to the public health nursing programme. Results of this analysis are presented in Table 5. Students completing the public health programme rated themselves higher on all three dimensions of public health plus ‘working with communities’. There were highly significant improvements for the first two dimensions (Leadership and Management for Public Health and Principles and Practice of Public Health) (p = <0.001) and a moderately significant improvement in Communication skills (p = <.01) The perceived improvement in working with communities did not achieve significance. To assess the relative magnitude of the differences between the mean scores effect sizes were calculated using the eta squared statistic. Using Cohen’s (1988) guidelines for interpreting this value (i.e. .01 = small; .06 = moderate; 14 = large) the magnitude of the difference between pre and post scores was large for the first two dimensions and moderate for communication skills.
Comparison between qualifying students recording as specialist community nurses and those registering as SCPHNs Although all the students in this study were exposed to a dedicated public health module with learning outcomes based on the 10 areas of public health (NMC, 2004), they then followed differing routes of study and practice to qualify as specialist community nurses or SCPHNs. Although there remains debate about this division (Poulton, 2003) only the latter group are considered by the NMC as having a substantial input into public health. Consequently it should follow that given their increased exposure to public health education and practice their self-perceived competency in public health should differ from that of their community nursing colleagues, at the end of the course. For this reason an independent sample t-test was conducted to compare self-perceived public health competencies for qualifying specialist community nursing students (district nursing, community children’s nursing, community mental health nursing and community
B. Poulton, V. McCammon learning disability nursing) and specialist community public health nursing students (health visiting, occupational health nursing and school nursing). There was no significant difference, between the groups, on any of the dimensions of public health.
Discussion The data in this study was derived from a nonprobability sample of students in one area of the UK therefore results cannot be generalised to other cohorts of students. However, by generating a reasonable sample size it has been possible to establish an acceptable level (Nunnally, 1978) of scale reliability for the dimensions of public health measured. Furthermore, the strength of the content validity of the measurement tool is based on the fact that it includes dimensions of public health competencies identified in the international literature (Quad Council of Public Health Nursing Organization, 2004; Danielson et al., 2005) and items derived from a wide consultations process within the UK (Skills for Health, 2004). The tool was shown to be sufficiently sensitive to discriminate between independent groups of students supporting the feasibility of such pre and post test studies (Lundy et al., 1993). It is acknowledged, however, that the study would have been strengthened by the use of a paired sample t -test and in future studies it would be more prudent to match respondents in the pre and post intervention design. The use of self-rating questionnaires to assess competencies in nursing is relatively rare in the UK. Redfern et al. (2002) in a review of the literature found only three examples of such questionnaires, all focusing on general nursing competencies. These authors concluded that most available self-rating scales lacked adequate testing of reliability and validity. However, in partial validation of one tool they concluded that such measures could be valuable in self-assessment of competence. Whilst acknowledging the limitations of student self-assessment of competence it is proposed that the questionnaire developed in this study could, with further testing, be used as one element within, a multi method approach in the assessment of public health nursing competency, combined with teacher assessment of the same criteria. More importantly, having ascertained that qualifying students do rate their public health competencies higher, on completion of a dedicated public health programme, there is little evidence as to whether
Measuring self-perceived public health nursing competencies using a quantitative approach such competencies continue to be applied in practice. To address such deficiencies a larger study is planned, across two sites. Not only will students self-assess their competency pre and post the education programme but they will be followed up at six months and eighteen months. Data will be collected on the extent to which competencies are applied in practice and case studies will be used to investigate community focused public health practice.
Conclusions As registered nurses the participants in this study should be well able to reflect on their knowledge and skills and self-assess their own level of competence following exposure to a post registration public health nursing programme. The literature suggests that there are few psychometrically tested competency measures in nursing and even less addressing public health competencies. This study established the validity and scale reliability of a measurement tool, which was developed from a range of competencies developed within the UK but concurring with those developed in the EU and USA. Moreover, the study is the first of its kind to measure the self-perceived competencies of community and public health nursing students pre and post being exposed to a dedicated public health programme. Development of this questionnaire is the first stage in a research programme, which will follow through acquisition of public health competencies, and application in practice.
Recommendations Replicate the research with randomised samples from more diverse and international populations of public health nursing students. Follow through groups of such students using a range of qualitative and quantitative techniques to assess application of public health skills in practice.
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