Self-assessed competence and need for further training among registered nurses in somatic hospital wards: a cross-sectional survey

Background: Professional competence and continuous professional development is essential for ensuring high quality and safe nursing care, and it might be important for motivating nurses to stay in the profession. Thus, there is a need to identify the developmental process of nursing competency. Assessment of competence and need for further training helps to identify areas for quality improvement, and to design interventions in order to facilitate continuous competence development in different work contexts. The current study aimed to 1) describe registered nurses’ self-assessment of clinical competence as well as the need for further training, and 2) explore possible differences between registered nurses with varying lengths of professional experience as a nurse (≤ 0,5 year, >0,5-5 year, and ≥ 6 year). Methods: A cross-sectional survey design was applied, using the Professional Nurse Self-Assessment Scale of clinical core competencies II. Registered nurses (n=267) working in medical and surgical contexts in hospitals in Sweden responded (response rate 51 %). Independent student t-test and analysis of variance were carried out. Results: Registered nurses assessed their competence highest in statements related to cooperation with other health professionals; taking full responsibility; and acting ethically. They assessed their need for further training most for statements related to assessing patients’ health needs by telephone; giving health promotion advice and recommendations to patients by telephone; as well as improving a creative learning environment for staff at the workplace. For self-assessed competence and need for further training, differences between the groups for 35 and 46 items respectively, out of 50 were statistically significant. Conclusions: Although the registered nurses assessed their competence high for important competence components expected of professionals such as cooperation with other

healthcare professionals, it is problematic that knowledge of interactions and side-effects of different types of medication were reported as having the highest need of training.
Longitudinal follow up of newly graduated nurses regarding their continuous development of competence as well as further training is needed.

Background
Registered nurses (RNs) have a crucial impact on clinical practice. Professional competence and a continuous competence development are essential for ensuring high quality and safe nursing care [1][2][3][4]. Educational qualifications of nurses, and patient to nurse staffing ratios have been directly linked to variations in hospital mortality [5]. The increasing number of reported cases of such things as health-related infections, pressure ulcers and fall injuries of a milder character during recent years [6] indicate a care that is not optimal.
Nursing competence is a core ability that is required for fulfilling nursing responsibilities.
Although employers have to promote and motivate a continuous professional development [7], RNs have their own responsibility for maintaining their competence through continuous learning and use of judgement regarding their competence [8][9][10]. Education has to prepare students for a variety of healthcare settings, but job specific competencies should be obtained through the workplace and supported by employers [11].
According to  competence is the 'functional adequacy and capacity to integrate knowledge and skills to attitudes and values into specific contextual situations of practice' (pp. 330-331) [12]. There is, however, inconsistency surrounding the definition of nurse competence, and the definitions have changed over time [13][14][15][16]. In order to find consensus, concept analyses identified clusters from the competence literature focusing on: discipline knowledge, discipline-specific skills, judgement, professional standards, interpersonal relationships, situational application of skills and knowledge, and outcome evaluation [2]. Differences in defining nurse competence may be a result of the various nurse roles, specialties and work contexts.
Nursing has changed considerably and become a technology-enriched profession requiring such things as a willingness and motivation to incorporate digitalization into clinical practice [4]. Along with an increasing advanced and technical care, a requirement to perform more compassionate and fundamental care based on a person-centred approach has been emphasized [17]. RNs in a Swedish study described that a combination of different kinds of knowledge is important to provide good secure nursing care [18]. In parallel with increasing requests on the nursing profession, nursing turnover continues to be a concern. The intention to leave the profession is most common among newly graduated nurses, and previous research has paid attention to nurses in the early stages of their career. Goh et al (2015) showed that 22 % of nurses under 30 years of age, with less than five years of nursing, had the intention to leave [19]. In the US, Kovner et al (2014) found that about 17 % of new nurses intended to leave their job within the first year [20]. In a Swedish longitudinal study every fifth nurse strongly intended to leave the profession after five years of employment [21]. During the same period, the proportion who were actively applying for jobs outside the profession more than doubled [21]. Lack of job readiness, heavy workload and stress are factors leading to nurses' turnover intent [22][23][24]. In a diary study, newly graduated nurses described their work as both cognitive, emotional and physically challenging, resulting in stress and exhaustion [25]. High levels of stress remain during the first year of a newly graduated nurse's career [26]. Having sufficient knowledge and skills needed for the profession reduces stress and the intention to leave [24]. Although turnover is most common among newly graduated nurses, it is not an isolated phenomenon within this group. In a systematic review, a multifaceted range of determinants for turnover among experienced nurses was described at individual (e.g. stress and burnout), job-related, interpersonal (e.g. managerial style) and organizational (e.g. work environment and organizational structure) levels [27]. Leaving the profession generates a permanent loss of resources and an unstable nurse staffing that may compromise patient care [22]. The fact that nurses leave the organization has negative consequences for both the individual and society. Due to nursing turnovers, there is a growing need to identify the developmental process of nursing competency [ [33]. To our knowledge, the PROFFNurse SAS II is the only questionnaire measuring both self-assessment of competence and the need for further training.
To summarize, nurse turnover is an issue of concern in Sweden, as in other countries [21].
This, together with a working environment where RNs experience higher stress, burnout and decreasing job satisfaction, makes it vital to further explore RNs' role and competence. Assessment of competence and the need for further training helps determine professional development needs and areas for quality improvement [33]. Knowledge of RNs' competence and needs for further training are fundamental to design interventions in order to facilitate continuous competence development in different work contexts.
Therefore, the aim of the current study was to 1) describe registered nurses' selfassessment of clinical competence and need for further training, and 2) explore possible differences between registered nurses with varying lengths of professional experience as a nurse.
Three research questions were identified: How do RNs assess their competence?
How do RNs assess their need for further training?
Are there any differences between RNs with varying lengths of professional experience with respect to their Self-assessment of competence?
Self-assessment of the need for further training? Methods A cross-sectional survey design was used.

Sample and setting
A convenience sample of RNs working in medical and surgical contexts in four hospitals in Sweden (two district hospitals, one county hospital, and one university hospital) was invited to participate. The RNs at the different departments had varying lengths of work experience as an RN, and different educational levels. All the RNs at the departments were given information about the study and were asked to participate. A total number of 528 RNs were invited to participate and 267 responded (response rate 51 %).

Data collection
The head nurses of the included departments, a director of studies, and a coordinator at the Clinical Skill Centre (CSL) at one of the hospitals, handed out a questionnaire to all the RNs. The RNs could return the questionnaires in boxes at the department or give it to the head nurse or the CSL coordinator. The survey was anonymous, no coding system to identify respondents was used. No reminder was given. Data were collected during September 2016 to February 2019.

Questionnaire
The Professional Nurse Self-Assessment Scale of clinical core competence II (PROFFNurse SAS II) [33] was used for data collection in the present study. The theoretical foundation of PROFFNurse SAS I and the PROFFNurse SAS II is Aristoteles' three dimensions of knowledge (episteme, techê and phronesis) [32].The questionnaire consists of 50 items and asks for responses on self-assessment of: a) competence (A-scale) and b) need for further training (B-scale). Both scales range from 1 to 10 where 1 indicates a very low level and 10 a very high level. Cronbach's alpha values for the questionnaire for total score is reported to be 0.963 [33] and 0.936 [34].

Data analysis
All data were entered and analysed in IBM SPSS Statistics 25. Frequency, mean, median, range and standard deviation were used to summarize the data. To analyse differences between RNs with varying lengths of professional experience, the sample was divided into three groups based on years as a nurse (≤ 0,5 year, >0,5-5 year, and ≥ 6 year). The demarcation between groups was based upon reports on RNs intent on leaving the profession within the first year, due to strong emotional reactions to the demands placed on them by the profession of other staff members, and sick leave reports [11]. Differences between the groups were tested by analysis of variance (ANOVA). Significant differences were further analysed with post hoc Tukey test. The significant level was set to < 0.05.

Ethical approval
The study was carried out in accordance with the Declaration of Helsinki [35]. The participants received both verbal and written information about the aim, the procedure, and that participation was voluntary. Informed consent was sought by a covering letter explaining the purpose of the study. Returning the questionnaires was regarded as consent to participate. The study was approved by the Research Ethics Review Board of Uppsala University, Sweden (reg. no. 2011/071).
All respondents worked in hospital somatic medical and surgical contexts.    (Table 3). Looking further into differences between the groups the post hoc test of these 35 items demonstrated statistically significant differences between all three groups for four items (statements related to medication and treatment, quality development and routine improvement), between group A/C and B/C, for 14 items, between group A/B and A/C for one item, and between group A/C for 16 items (   items. The two items where no significant differences were found either for the A-scale or B-scale contains statements related to having an ethical approach. Looking further into the differences between the groups the post hoc test of the 46 items demonstrated statistically significant differences between all three groups for six items (statements related to health assessment, medical treatment, examinations, differential diagnoses, and incident reports), between group A/C and B/C for nine items, between group A/B and A/C for 19 items; and between group A/C for 12 items ( Concurrence between self-assessed competence and need for further training Seven of the top 10 items regarding highest need for further training (Table 4) were found among the ten items with lowest self-assessed competence. In the same way, seven of the top 10 items assessed with lowest need for further training were found among the ten items with highest self-assessed competence ( Table 2) (Table 3 and 5). For most items there was no concurrence between self-assessed competence and the need for further training regarding statistically significant differences between the groups.

Discussion
The aim of this study was to describe nurses' self-assessment of clinical competence and need for further training. The items where the respondents assessed their competence highest related to statements of cooperating with other healthcare professionals and experts; taking full responsibility; and acting ethically. These are all components of phronesis, understood as practical wisdom [36], and are fundamental competence components expected of nurses in their role as professionals [8]. This is consistent with a previous study exploring clinical competence and need for further training among RNs in postgraduate programmes [33]. Personal responsibility implies a moral requirement to choose actions to take ethical responsibility for the patient [37].
The lowest self-assessments for competence were seen for statements related to managing healthcare without seeing the patient (i.e. using the telephone, e-mail or other electronic devices), and giving health promotion advice. It might be argued that the RNs in this study worked with hospitalized patients, and therefore did not have the same experience of assessing health needs by telephone, as if they had been working in primary care. However, nursing is becoming a technology-enriched profession [4], with an increasing use of information-and communication technologies in healthcare, i.e. e-Health [38], irrespective of healthcare contexts. Both managing healthcare without seeing the patient and giving illness and preventive recommendationswere among the items the respondents assessed highest regarding the need for further training, which indicate that they are conscious about their weakness. The respondents also assessed their competence low regarding improving a creative learning environment for staff at the workplace, improving routines, and knowledge of interactions and side effects of various types of medication. This can imply a challenge because establishing key abilities, such as identifying a learning need contributes to improving nursing practice [39]. Positive work experiences in the first year of practice, in terms of sharing experiences and getting encouraging support from colleagues, has been pointed out as important for remaining motivated at work [25], and for sustaining the future of the profession [40]. These findings are of importance to highlight in connection with the development of both nursing programmes and of introduction programmes for newly graduated RNs.
The second aim of the study was to explore if there were differences with respect to selfassessment of clinical competence and the need for further training between RNs with varying lengths of professional experience as a nurse. Statistically significant differences between the RN groups were seen for several items regarding both self-assessed competence and self-assessed need for further training. Previous research has demonstrated that nurse competence differs depending on length of work experience [28,41], and frequency of using these experiences [42], which has been found to explain up to 40% of variance in self-assessed competence among newly graduated nurses [43].
Furthermore, higher academic degree has been connected to higher self-assessed competence among RNs in postgraduate programmes [33], and among operating theatre nurses [44]. According to Aiken et al. (2014), RNs with an academic degree are associated with improved patient outcomes [5]. Although the educational environments are academic, there is a risk that newly graduated nurses will be introduced into a vocational and taskoriented view of the profession if employers do not take responsibility for the academic culture within the healthcare sector, which could jeopardize safe nursing care [11,45].
In the present study only four of the top 10-items for self-assessed competence showed statistically significant differences between the groups. For example, no statistically significant differences were found between the groups regarding two of the items with highest competence assessment: cooperating with other healthcare professionals and experts (item 37) and acting ethically (item 24). This finding could be seen in relation to interprofessional collaboration, which has become an important component of a well-functioning healthcare system [46]. A previous study exploring interprofessional collaboration between nurses and junior doctors showed that nurses needed to be more active by taking more responsibility in improving their ability to collaborate with other professionals [47]. However, according to Regan et al. (2015) nurses are more confident in interprofessional collaboration when they control their work situation and have the independence to make patient care decisions on their own [48]. This might explain why the RNs in the present study, regardless of experience, assessed their competence as high.

Methodological considerations
The response rate was 51 %, which could be considered less than ideal. However, no reminder was given, and the questionnaire was distributed to the RNs to be completed, without setting a strict timeframe. The response rate might have been higher if a followup reminder had been used. However, it should be noted that low response rates do not mean that the results are biased [49]. High workload and a comprehensive questionnaire were stated as reasons for not answering the questionnaire. Even if the value of selfassessment has been questioned, it has been reported as the most common form of competence assessment [50]. In the present study, the correspondence between the respondents' self-assessment of competence and the perceived need for further training indicates that their self-assessment of competence might be reliable. The timeframe for how long an RN is considered to be newly graduated is undetermined as the transition and experience are individual [25]. The decision to limit one of the groups to six months of experience as an RN, instead of one year that is commonly done, was based on the reports of turnover early in the nursing career [11,45].
Data were collected over a longer period, to some extent depending on inclusion of participants in different hospitals. However, a longer collection period might reduce the risk of being affected by special conditions and therefore provide an opportunity for improved relevance for the population.

Conclusions
Although

Consent for publication
Not applicable.

Availability of data and materials
The dataset analysed during the current study are available from the corresponding author on reasonable request.

Competing interest
The authors declare that they have no competing interests.

Funding
This study did not receive any funding.