The Comparative Study of Clinical Competence of Emergency Nurses Using Self-Assessment and Evaluation Methods by Head Nurses

Background: Clinical competency is the ability of nurses in playing a professional role in a clinical environment specially emergency department as the quality of the services provided. The present study aimed to compare the clinical competence of the emergency nurses using self-assessment and evaluation methods by head nurses. Method: The study was designed in a descriptive-analytical way, collecting self-assessment questionnaire and evaluation methods by head nurse’s data. 70 nurses working in Emergency Departments of 3 Hospitals were selected and studied for 3 months based on entry requirements to the census. The instrument was a clinical competency questionnaire with questions in 7 functional fields and 63 skills. The data obtained from descriptive and inferential statistics were analyzed by SPSS-16. Result: The viewpoints of nurses and head nurses on the clinical competencies of nurses were assessed at a moderate level in the majority of domains. Nurses defined their clinical competencies at a significantly higher level compared to the head nurses (P<0.05). conclusion : The periodic assessment of emergency nurses as a critical part and the turning point of the hospital can guide the managers and nursing managers to pay attention to professional competence and promote continuing education programs for improving their competencies in this section.


Introduction
The health and treatment section, as the most important area of human health, is directly related to human health and is responsible for the maintenance and the promotion of health in the human society [1]. The nurse as the largest provider of health services includes 70% of the health and treatment team [2]. Nursing is a professional activity due to the multiplicity and complexity of the role, which requires a sense of responsibility, tact, accuracy, and much consciousness. Any lack or inadequacy of training in this group will certainly have a significant impact on the quality and quantity of health services, and ultimately on the health of individuals and the community. Therefore, the ultimate goal of nursing education is to educate competent and qualified nurses having the necessary knowledge and skills to provide nursing care with quality, preservation, and promotion of community health [3].
Nursing competency is a complex integration of knowledge including professional judgment, skills, values and attitude. It is an intelligent practical skill set that integrates or combines different factors and issues in complex ways, specific to each circumstance [3]. Various factors such as rapid change in health monitoring systems, the need for providing safe and affordable services, enhancing the awareness of the community about health issues and consequently increasing the level of expectations in the society for receiving high-quality services, along with the desire of organizations of health service provider based on the use of efficient and skilled personnel resulted in paying special attention to the adaptability and clinical competence of people working in health-related professions [4]. professional qualifications should include five characteristics: 1) nursing knowledge 2) nursing specialty 3) motivation 4) personality traits 5) self-concept [5]. Based on Heshmati Nabavi and Vanaki's (2012) and Memarian's (2006) studies, the role of nursing professors and educators in theoretical teaching, the way of using these materials in the clinical environment, clinical experience, professional growth, and the quality assurance of nursing care are among the factors which play an influential role in nursing professionalism [6]. Therefore, it is important to ensure the clinical competence of nurses. From the management point of view, development of competencies enables management to be demystified as an ability and a natural talent, also it helps nurses to understand and master new situations at work, take responsibility and be recognized for their actions [7]. Self-assessment used extensively in educational program that have adopted a problem-based, selfdirected approach. Professionals such as nurses require self-regulation to maintain their professional competence. Nurses need to develop self-assessment skills to determine their level of knowledge and identify knowledge gaps, to remain current and safe in practice [8]. On one hand, Head nurses are competent people and technically competent who need management skills because they are working in close contact with patients and health care groups. So they are responsible for assessing and supervising the providers of direct patient care and they are the closest manager to the organization's goals and objectives [9]. In a study on 7,500 nursing graduates, among whom 75.5% were RN nurses, Hickey (2010) suggested that one-fifth of them had problems in performing their clinical tasks, and 52% of RN nurses reported that they failed to do their work in the real-world clinical environment [9]. in Iran, Vosoughi et al. (2014) compared the results of selfassessment of the professional competence for beginner nurses with the assessment by head nurses and indicated that the average of all professional qualification scores in the self-assessment was higher than that of the head nurses except for care measures and professional development and progress [10]. Bahraini (2010) considered the role of the environment as one of the indicators affecting clinical competence, emphasized the difference between the degree of clinical competence and the frequency of using skills in different departments and hospitals [11]. The study of Hassankhani et al. (2018) indicated that nurses in the emergency department have a lower perceived level of competence for performed skills within the domains of effective management of rapidly changing situations and administering and monitoring therapeutic interventions [12]. The quality of the services provided in the emergency department is important in the official evaluation of the hospital, and the evaluation of other parts of the hospital depends on the acquisition of the necessary point in the emergency unit [13]. Sample size and sampling procedure: The statistical population included all nurses working in Emergency departments of hospitals affiliated to Dezful University of Medical Sciences, which were studied for 3 months from July to September 2017. Generally, 70 nurses were selected by census method based on entrance conditions after explaining the goals of the study, obtaining informed consent, and ensuring the confidentiality of personal information, from 90 nurses working in each of the three emergency departments of affiliated hospitals. The entry requirements for the study were as follows: 1) having the written consent to participate in the study, 2) employment in the emergency department as formally, contractual, conventional, project, corporative, and 3) having bachelor and master in nursing.

Study Instrument
The data collection tool was a two-part questionnaire. The first part was related to demographic information such as age, gender, degree, marital status, field of study, type of employment, work experience in general, work experience in emergency department, general average, type of university, passing education courses). The  [14,15]. The reliability of the translated questionnaire, which was used in the study of Bahraini et al. (2011), was reported between 0.70 to 0.85 with a pilot study in seven areas, which was in a good level [11]. We used a reduced form of the questionnaire that was valid and reliable in study of Roohani et al (2016). In mentioned study, The questionnaire was distributed to 11 members of the Nursing Faculty and reduced to 63 items, which confirmed its content validity. The tool reliability was calculated by using Cronbach's alpha [16]. Likewise, the questionnaires were distributed among 30 nurses, which the reliability was Data collection First, we made contact with each hospital medical and nursing directors to grant a permission with a copy of approved ethical clearance letter obtained from Dezful of Medical Sciences University Ethics Committee. After accepting our request, we coordinated with head nurses to prepare a list of permanent nurses staff in their department. Nurses from all emergency departments in each hospital who fulfill the inclusion criteria were included in the study. In the next step, two supervisors from nursing faculty with degree of MS.c in nursing, held an introduction meeting for participants to discuss with them, explain the study objectives, assure the confidentiality of information, obtain personal satisfaction, and describe how to complete the questionnaires in each of three work shifts in the morning, evening, and night. As the questionnaires were distributed among the nurses with the help of an assistance, the questionnaires with names were sent to head nurses. The participants were given one week's opportunity to return the questionnaires.
Further, two weeks were considered to return the questionnaire in case of leave, sick leave, problem, and busy. If the questionnaire was not returned after a specified period, the sample was removed from the study by mentioning the cause.

Data analysis
The data were collected using SPSS software version 16. Additionally, the descriptive statistics including frequency, mean, and standard deviation were used to describe the demographic characteristics of the people and evaluate the clinical competencies. Furthermore, the inferential test including independent t-test was used to compare clinical competency by self-assessment and assessment by the head nurse.

Sociodemographic characteristics of nurses
The statistical population of the study was as follows: 78.6% (n=55) were female nurses, 67.1% (n=47) were nurses under 30 years old, 51.4% (n=36) were single, 88.6% (n=62) had Bachelor's degree, 71.4% (n=50) has an average of 16-18, 58.6% (n=41) had a work experience of less than 5 years, 74.3% (n=52) had a work experience of more than 5 years in an emergency department, 50% (n=35) worked partly, and the total nurses population of the emergency department of Ganjouyan hospital was 33 nurses (47.1%). These factors are the most frequent in the statistical population of the study.  from the nurses and head nurses' point of view, respectively. This difference was statistically significant (p<0.03) based on the independent t-test (Table 2). In order to compare nurses' clinical competency by using two methods of self-assessment and assessment by head nurses, there was a statistically insignificant difference between the scores average of education and guidance, therapeutic measures, and quality assurance fields, which is not statistically significant (P<0.05). However, this difference was statistically significant in the fields of patient support and assistance, diagnostic measures, managerial abilities, and occupational tasks.
Consequently, nurses working in Emergency departments of Dezful, Shoosh, and Gatond hospitals assessed their clinical competencies in a significant higher level, compared to the assessment of head nurses, in the self-assessment method in all fields of patient support and assistance, diagnostic measures, managerial abilities, and occupational tasks ( Table 2).  (Table 3).

Discussion
The present study aimed to compare the nurses' clinical competency with self-  [19]. The lowest obtained score was related to the assessment of the quality assurance field in both methods.
These findings were similar to the results of studies conducted by Meretoja et al. (2003) [20]. Thus, it is necessary to train how to use new research findings in the clinical setting and its improvement among the nurses working in the emergency department since this area is related to the four expertise related to the use of clinical research, the assessment of patient care, the use of research findings in nursing care, and the ability to identify the areas related to care which need to be upgraded and evaluated. In addition, there is a downward trend in the use of this skill in emergency nurses, due to the lack of nurses' knowledge about the meaning of quality assurance and its related nursing skills, as well as the lack of competent and skilled people in this field [21]. From the head nurses perspective, the highest clinical competence is related to the managerial ability, while the lowest competency is related to support and assistance and quality assurance [18]. These  [11,16]. By describing patient assistance for adaptation, Meretojah (2004) considered the area of assistance tasks as one of the nursing skills, which is very important in assessing the competence of nurses and is partly overlapped with helping the patient and companions to make appropriate decisions [15]. Little experience in the emergency department, the younger age of the majority of nurses, and insufficient experience in dealing with the patient are among the reasons for lower competency from the head nurses perspective. Limitation some limitation of the study can be related to low reliability in self -evaluation methods, particularly in the case of respondents whose level of competence is low.
There is also a greater likelihood that those who feel the least competent, refrain from taking part, or that they award themselves a higher score because the results may affect their opportunity of future employment as well as their level of commitment and accountability in the workplace, the level of perceived support, addressing their desires and needs by head nurses and nurse managers are other limitations and factors affecting the results of this study.

Conclusion
In the present study, the clinical competencies of nurses were evaluated at a moderate level in most areas based on nurses' and head nurses' viewpoints and nurses rated higher their clinical competencies compared to head nurses. Based on the results, using more than one method and simultaneously applying multiple methods in an assessment will present more accurate results about the nurses' clinical competencies. However, the self-assessment leads to more awareness and attention by the nurses about their own clinical competencies. In addition, the assessment by head nurses makes nurses more aware of the weakness and strength of their performance in different areas of clinical competence from the head-nurses' viewpoints. Hence, they will try to improve their weaknesses in their professional competencies.

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