Competence and competency are two terms that are often confused, and the usage of these two terms are inconsistent in many publications. McMullan et al. (2003) suggested that competence is a description of action, behavior, and outcome of job-related performance, whereas competency refers to a person's characteristics and qualities that led to such performance. On the contrary, McConnell (2001) and Nolan (1998) stated that competence focuses on the capacity and ability of an individual to perform the job responsibilities, whereas competency focuses on the actual performance of an individual in performing a specific task. In this study, the latter definition is used, where competence refers to the capacity and ability and competency refers to the actual performance.
Regarding the definitions and attributes of nurse competence, to date there hasn't been a unified concept. Short (1984) raised that knowledge and skill are two main components defining competence. Milligan (1998) suggested that nurse education and training are two key fields in competence development. Bechtel, Davidhizar, and Bradshaw (1999) argued that critical thinking skills and mechanical skills are indispensable parts of competence. O'Shea (2002) defined nursing competence as the knowledge, skills, ability, and behaviors required in correctly performing nursing tasks. Fukada (2018) further extended nurse competence into three theories including behaviorism, trait theory, and holism: behaviorism treats competence as the ability to perform core skills and is evaluated by skill performance; trait theory treats competence as the individual traits such as knowledge and critical thinking skills required for performing nursing duties; holism treats competence as a cluster of elements including knowledge, skills, critical thinking ability, and values.
It has long been noted that the safety of the patients receiving medical treatments is directly related to the competence levels of health care providers, including nurses who are on the forefront of patient care in hospitals (Smith, 2012). The usage of competence as a strategy to evaluate nursing competence has been introduced and implemented since the mid-1990s (Axley, 2008), and until today, many evaluation instruments have been developed to measure the competence levels of nursing students, clinical-based nurses, and health care providers (Flinkman et al., 2017; McMullan et al., 2003; Watson, Stimpson, Topping, & Porock, 2002; Yanhua & Watson, 2011). However, few studies exist about the comprehensive analysis of the competence-influencing factors such as age, nursing title, staffing levels, education background, and work experience. In this study, we attempted to address this issue by analyzing the relationship between nurse competence levels of 160 nurses in a Chinese hospital and their nurse characteristic profiles.
Materials and Method
One hundred sixty nurses were recruited from a hospital located in the central east region of China. The participants were all RNs and involved in patient care.
A questionnaire method was used to collect the required information in this study. Prior to this study, a written application containing the purpose and method of this study was provided to the hospital ethical committee board, and written approval was obtained. A survey package containing a cover letter, an information form, and a questionnaire was delivered to each of the 160 nurses on April 11, 2017. The cover letter explained the purpose and method of this study. The information form collected the nurses' characteristic information. The questionnaire contained a scale to measure the nurses' competence. The finished survey package was collected after 1 week.
Nurses' Characteristic Information
The following information was collected through the information form: basic information including name, employee identification, gender, and age; work information including title (i.e., nurse, nurse practitioner, nurse in charge, co-chief nurse, chief nurse), staffing levels (N0/N1/N2/N3/N4), work years, work history (i.e., experience working in different departments or hospitals); education information (i.e., technical secondary school degree, junior college degree, university degree); and research information including patents, publications, or research projects. All categories were weighted equally in the later relationship analysis.
The staffing levels of nurses were determined using the standards (Jiang, Wen, & Xie, 2013) listed in Table 1. Corresponding training and assessments are required in the promotion of staffing levels.
Nurse Staffing Level Standards
Nurse Competence Scores
To evaluate competence levels of participating nurses, the Competence Inventory for Registered Nurses, revised from Liu, Kunaiktikul, Senaratana, Tonmukayakul, and Eriksen (2007), was used. This scale (Table 2) contained seven categories and 55 items. A 5-point Likert scale was used to rate all seven factors, ranging from 1 point (not competent at all), 2 points (rarely competent), 3 points (sometimes competent), 4 points (most of the time competent), to 5 points (always competent). Each item in all seven categories was weighted equally in the generation of final competence score. The total scores were ranged from 0 to 275 points, with higher scores indicating a stronger competence ability: 192 to 275 points (> 75%) represented a high level, 110 to 192 points (50% to 75%) represented a medium level, and <110 points (< 50%) represented a low level.
Competence Inventory Scale for RNS
SPSS 17.0 and R (version 3.5.2) software were used in collecting characteristic information and statistical analysis. Welch's t test and one-way ANOVA were used to compare the means of two or more samples. Multiple linear regression analysis was used to explore the factors effecting nursing core competency scores. A p value of .05 was used in this study.
This study was conducted after receiving the approval from ethical committee board of the hospital, and participants were provided with information regarding the research purpose and methods in the cover letter.
Summary of the Participating Nurses' Characteristics
The characteristics of 160 participating nurses are summarized in Figure 1. Among these 160 nurses, seven (4.4%) were men and 153 (95.6%) were women. Regarding to age, 119 (74.4%) were ages 20 to 30 years; 37 (23.1%) were ages 31 to 40 years; four (2.5%) were older than 40 years; the average age was 28.3 years, with a range of 20 to 47 years. Regarding titles, 90 (56.3%) were nurses; 61 (38.1%) were nurse practitioners; nine (5.6%) were nurses in charge. Regarding working years, 69 (43.1%) had 1 to 5 years of work experience; 63 (39.4%) had 6 to 10 years; and 28 (17.5%) had more than 10 years. Regarding education levels, 32 (20%) had technical secondary school degrees; 85 (53.1%) had junior college degrees; and 43 (26.9%) had university degrees. Regarding staffing levels, 13 (8.1%) were at the N0 level; 65 (40.6%) were at the N1 level; 67 (41.9%) were at the N2 level; and 15 (9.4%) were at the N4 level. Regarding work experience, 56 (35%) had only one department and one hospital experience; 47 (29.4%) had one hospital but more than one department experience; 42 (26.2%) had one department but more than one hospital experience; and 15 (9.4%) had more than one department and more than one hospital experience. Regarding research experience, two (1.3%) had research publications; 158 (98.7%) had no publications.
Summary of the characteristics of participating nurses. Seven categories, including gender, age, title, work years, education, staffing level, and work experience are listed here. Note. N0, N1, N2, N3 = staffing levels; C1, C2, C3, C4 = the experience categories of one department/one hospital, one department/more than one hospital, more than one department/one hospital, and more than one department/more than one hospital, respectively.
Summary of the Competence Results of Participating Nurses
The competence scaling results of 160 participating nurses are illustrated in Figure 2. The average competence score was 158.28 points, which was at the medium level (110 to 192 points). The histograms representing score distribution are shown in Figure 2. Thirteen participants had scores lower than 110 (8.1%, low level), 113 participants had scores between 110 and 192 points (70.6%, medium level), and 34 had scores higher than 192 points (21.3%, high level). The radar map representing the average scores of participating nurses in seven subcategories are shown in Figure 2B. Among the 7 factors, participating nurses performed best in the subcategory of clinical care ability (3.96 of 5), followed by the subcategories of legal/ethical practice ability (3.68 of 5), interpersonal relationship ability (3.23 of 5), leadership ability (2.75 of 5), teaching/coaching ability (2.05 of 5), and critical thinking and research ability (1.78 of 5).
Summary of the nurse competence scaling results. (A) The bar plot showing the score distribution of participating nurses. (B) Radar plot illustrating the competence performance on seven different factors (maximum score = 5).
Relationship Between Competence and Characteristics
To explore the relationship between nurses' competence and their characteristics, the mean competence score from each subcharacteristic category was compared with each other, as listed in Table 3. Welch's t test (on characteristics with two subcharacteristic categories: gender, research) and one-way ANOVA (on characteristics with more than two subcharacteristic categories: age, title, staffing levels, work years, education, experience) were performed to test the statistical significance of each comparison. The competence score distribution in correspondence with different characteristics are illustrated in Figure 3.
Participating Nurse Characteristics and Differences in Nurse Competence (N = 160)
The competence score distribution in relation to different characteristics: (A) Age. (B) Nursing titles. (C) Work years. (D) Education level. (E) Staffing level. (F) Work experience. Note. UD = university degree; JCD = junior college degree; TSSD = technical secondary school degree.
Among all characteristic categories, the competence scores differed dramatically in characteristics of staffing levels and education (p < .001). In staffing level category, the mean competence score increased with the increasing of staffing levels (N3 > N2 > N1 > N0). In education level category, the mean competence score increased with the increasing of education levels (university degree > junior college degree > technical secondary school degree). The mean competence scores also differed in characteristic categories of title (p = .011), where only the mean competence score of nurses with the title of nurse in charge was higher than the mean score of nurses with the title of nurse.
The competence score distribution in correspondence to staffing levels and education levels are also illustrated in Figure 3. In the education level category, all nurses with university degrees had scores located in medium and high regions, and nurses with technical secondary school degrees (TSSD) had scores locating more to the left. In the staffing level category, all nurses at level N0 had scores located in the low and medium regions, and all nurses at level N3 had scores in the medium and high regions. Nurses at levels N1 and N2 had scores located across all three regions, with level N1 located more toward the left and level N2 located more toward the right. All these were consistent with previous one-way ANOVA analysis.
The variables that were significant in t test and oneway ANOVA analysis were further used in the following formula: Lm (Score = Age + Title + Staffing level + Education) to perform multiple linear regression analysis, and the results are provided in Table 4. Among them, subcharacteristics title (nurse in charge), staffing levels (N1/N2), and education (TSSD/JCD) had p values < .05, and these variables together explained 33% of the variance in nursing core competencies.
Factors Influencing Nursing Competence, Analyzed by Multiple Regression
As of 2018, approximately 3.8 million RNs serve 1.4 billion people in China (data retrieved from Chinese nursing website: http://www.chinanurse.cn). The nursing system in China is different from that in in other countries in many ways:
- Five levels of nurse titles exist from low to high, including nurse, nurse practitioner, nurse in charge, co-chief nurse, and chief nurse, which is different from the four-level nurse title system in the United States, which includes certified nursing assistant, RN, licensed practical nurse, and advanced practice registered nurses.
- Five levels of nurse staffing levels (N0, N1, N2, N3, N4) exist, as described in the Materials and Methods section. This system is similar to the classification of five stages in clinical competence described by Benner (2001). There are specific trainings and assessments in each level.
- Three main levels of nursing education programs exist, including technical secondary school program (4 years), junior college program (3 years), and university program (4 years). Nurses with master's or PhD degrees are rare.
- There are 3 levels of hospital systems, including level 1 hospitals (community hospital), level 2 hospitals (county hospital), and level 3 hospital (city, provincial, national hospital). The hospital involved in this study is a level 3 hospital. As of 2017, the physician/nurse ratio is 1:1.46 in level 2 hospitals and 1:1.54 in level 3 hospitals, whereas this number was 3.33 in the United States (data retrieved from American Medical Association website: http://www.ama-assn.org). Hence, there is still a large demand for RNs in China (Xu, Wu, Zhang, Ma, & Li, 2016). Aside from that, more complex and sophisticated nursing requirements have been raised by patients. In short, quantity and quality are two urgent issues need to be addressed in the modern Chinese nursing system.
Over the past several decades, many instruments have been designed to scale nurse competence, with subcategories ranging from four to 10 dimensions and items ranging from 18 to 108 items (Cowan, Jenifer Wilson-Barnett, Norman, & Murrells, 2008; Liu et al., 2007; Meretoja, Isoaho, & Leino-Kilpi, 2004). In this study, the Competence Inventory for Registered Nurses, with seven dimensions and 55 items, was used in this study because this scaling tool was specially designed for the Chinese nursing system (Liu et al., 2007). The competence results indicate that the competence levels of participating nurses were at a medium level (158.28/275), and among seven different subcategories, the participating nurses had the best performance in clinical care ability category (3.96 of 5) and the worst performance in critical thinking/research ability (1.78 of 5). The lack of critical thinking and research ability in nurse competence evaluation has been reported in many countries and districts, such as in Taiwan (Chang, Chang, Kuo, Yang, & Chou, 2011), Japan (Takase & Teraoka, 2011), and Europe (Cowan et al., 2008), and our results are consistent with these previous reports. Critical thinking skill is an important part of nurse competence, in addition to mechanical skill (Bechtel et al., 1999), and the lack of such ability has become the bottleneck restricting nurse competence. The incorporation of critical thinking training into nursing education programs such as simulation exercises might help solving this issue, as suggested by Von Colln-Appling and Giuliano (2017).
The relationship between nursing characteristics and competence was also explored in this study, and among all the characteristic categories, education and staffing levels were two main influencing factors, as shown in Tables 3–4 and Figure 3. Nurses with higher education degrees performed better than nurses with lower education degrees, and nurses from higher staffing levels performed better than these from lower staffing levels. It has long been reported that education and staffing levels greatly influence nursing quality. Milligan (1998) suggested that nurse training, an important factor judging staffing levels, together with nurse education, were two key factors in the implementation of competence. Aiken et al. (2011) found that nurse staffing and education levels were directly related to better patient outcomes. Regarding other characteristics, although they did not show strong relationships with the results of nurse competence in this study, other reports showed they could affect nurse competence. For example, Bahreini et al. (2011) found that nursing titles had an influence on competence scaling results. Takase (2013) found that the length of nurses' clinical experience or working years also affected nurse competence.
Given that education and staffing levels are two main constraints, these two factors deserve more attention in the improvement of nurse competence levels. From nurse employers' perspectives, education background should have more weight during the recruitment of new nurses. Currently, no significant difference exists in the compensation for nurses with different education backgrounds, and a more educated nurse workforce is not necessarily more costly for hospitals. Moreover, employers should provide more options for existing nurses to improve their education levels, such as encouraging nurses to pursue a part-time nursing degree and using work-based learning strategies (Flanagan, Baldwin, & Clarke, 2000). From a nursing management perspective, more training programs should be offered to nurses from different staffing levels, and nurses from different levels can be mixed to perform certain tasks where higher level nurses can lead the team to provide higher quality nursing service. From nursing educators' perspectives, competence-based education should be provided to nursing students to ensure that graduates have the essential knowledge, skills, and attitudes to enter the nursing workforce (Pijl-Zieber, Barton, Konkin, Awosoga, & Caine, 2014). From nurses' perspectives, although going back to school can sometimes be an intimating idea, a higher education degree is not only a trend but also a necessity. Nurses can also take advantage of modern technologies such as online courses (Wu, Chan, Tan, & Wang, 2018) to gain more knowledge and improve their education levels.
China is a fast-developing country, with 1.4 billion people accounting for 18% of world's population. The exploration of Chinese nurse's competence status has important implications and can greatly promote the nursing studies worldwide. In this study, the nursing competence status in a Chinese hospital was explored, as well as the relationship between competence and nurse characteristics. Education and staffing levels are found to be two influencing factors of nurse competence. This study also addressed how to improve nurse competence from different perspectives, such as those of nurses, nursing employers, managers, educators, and students.
- Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L. & Neff, D.F. (2011). The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49, 1047–1053. doi:10.1097/MLR.0b013e3182330b6e [CrossRef]
- Axley, L. (2008). Competency: A concept analysis. Nursing Forum, 43, 214–222. doi:10.1111/j.1744-6198.2008.00115.x [CrossRef]19076465
- Bahreini, M., Moattari, M., Ahmadi, F., Mirzaei, M., Kaveh, M.H., Hayatdavoudy, P. & Mirzaei, M. (2011). Comparison of head nurses and practicing nurses in nurse competence assessment. Iranian Journal of Nursing and Midwifery Research, 16, 227–234.
- Bechtel, G.A., Davidhizar, R. & Bradshaw, M.J. (1999). Problem-based learning in a competency-based world. Nurse Education Today, 19, 182–187. doi:10.1016/S0260-6917(99)80003-3 [CrossRef]10578827
- Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice-Hall.
- Chang, M.J., Chang, Y.J., Kuo, S.H., Yang, Y.H. & Chou, F.H. (2011). Relationships between critical thinking ability and nursing competence in clinical nurses. Journal of Clinical Nursing, 20, 3224–3232. doi:10.1111/j.1365-2702.2010.03593.x [CrossRef]21414054
- Cowan, D.T., Jenifer Wilson-Barnett, D., Norman, I.J. & Murrells, T. (2008). Measuring nursing competence: Development of a self-assessment tool for general nurses across Europe. International Journal of Nursing Studies, 45, 902–913. doi:10.1016/j.ijnurstu.2007.03.004 [CrossRef]
- Flanagan, J., Baldwin, S. & Clarke, D. (2000). Work based learning as a means of developing and accessing nursing competence. Journal of Clinical Nursing, 9, 360–368. doi:10.1046/j.1365-2702.2000.00388.x [CrossRef]
- Flinkman, M., Leino-Kilpi, H., Numminen, O., Jeon, Y., Kuokkanen, L. & Meretoja, R. (2017). Nurse competence scale: A systematic and psychometric review. Journal of Advanced Nursing, 73, 1035–1050. doi:10.1111/jan.13183 [CrossRef]
- Fukada, M. (2018). Nursing competency: Definition, structure and development. Yonago Acta Medica, 61(1), 1–7. doi:10.33160/yam.2018.03.001 [CrossRef]29599616
- Jiang, R., Wen, X.X. & Xie, C.X. (2013). The practice of nursing post management. Chinese Journal of Nursing, 48, 419–422.
- Liu, M., Kunaiktikul, W., Senaratana, W., Tonmukayakul, O. & Eriksen, L. (2007). Development of competency inventory for registered nurses in the people's Republic of China: Scale development. International Journal of Nursing Studies, 44, 805–813. doi:10.1016/j.ijnurstu.2006.01.010 [CrossRef]
- McConnell, E.A. (2001). Competence vs. competency. Nursing Management, 32(5), 14. doi:10.1097/00006247-200105000-00007 [CrossRef]
- McMullan, M., Endacott, R., Gray, M.A., Jasper, M., Miller, C.M., Scholes, J. & Webb, C. (2003). Portfolios and assessment of competence: A review of the literature. Journal of Advanced Nursing, 41, 283–294. doi:10.1046/j.1365-2648.2003.02528.x [CrossRef]12581116
- Meretoja, R., Isoaho, H. & Leino-Kilpi, H. (2004). Nurse competence scale: Development and psychometric testing. Journal of Advanced Nursing, 47, 124–133. doi:10.1111/j.1365-2648.2004.03071.x [CrossRef]15196186
- Milligan, F. (1998). Defining and assessing competence: The distraction of outcomes and the importance of educational process. Nurse Education Today, 18, 273–280. doi:10.1016/S0260-6917(98)80044-0 [CrossRef]9847712
- Nolan, P. (1998). Competencies drive decision making. Nursing Management, 29(3), 27–29.9544028
- O'Shea, K.L. (2002). Staff development nursing secrets. Philadelphia, PA: Hanley & Belfus.
- Pijl-Zieber, E.M., Barton, S., Konkin, J., Awosoga, O. & Caine, V. (2014). Competence and competency-based nursing education: Finding our way through the issues. Nurse Education Today, 34, 676–678. doi:10.1016/j.nedt.2013.09.007 [CrossRef]
- Short, E.C. (1984). Competence reexamined. Educational Theory, 34, 201–207. doi:10.1111/j.1741-5446.1984.50001.x [CrossRef]
- Smith, S.A. (2012). Nurse competence: A concept analysis. International Journal of Nursing Knowledge, 23, 172–182. doi:10.1111/j.2047-3095.2012.01225.x [CrossRef]23043658
- Takase, M. (2013). The relationship between the levels of nurses' competence and the length of their clinical experience: A tentative model for nursing competence development. Journal of Clinical Nursing, 22, 1400–1410. doi:10.1111/j.1365-2702.2012.04239.x [CrossRef]
- Takase, M. & Teraoka, S. (2011). Development of the holistic nursing competence scale. Nursing & Health Sciences, 13, 396–403. doi:10.1111/j.1442-2018.2011.00631.x [CrossRef]21883769
- Von Colln-Appling, C. & Giuliano, D. (2017). A concept analysis of critical thinking: A guide for nurse educators. Nurse Education Today, 49, 106–109. doi:10.1016/j.nedt.2016.11.007 [CrossRef]
- Watson, R., Stimpson, A., Topping, A. & Porock, D. (2002). Clinical competence assessment in nursing: A systematic review of the literature. Journal of Advanced Nursing, 39, 421–431. doi:10.1046/j.1365-2648.2002.02307.x [CrossRef]12175351
- Wu, X.V., Chan, Y.S., Tan, K.H.S. & Wang, W. (2018). A systematic review of online learning programs for nurse preceptors. Nurse Education Today, 60, 11–22. doi:10.1016/j.nedt.2017.09.010 [CrossRef]
- Xu, Y.M., Wu, Y., Zhang, Y., Ma, R.Y. & Li, X.H. (2016). Investigation of nursing human resources in Chinese hospitals. Chinese Journal of Nursing, 51, 819–822.
- Yanhua, C. & Watson, R. (2011). A review of clinical competence assessment in nursing. Nurse Education Today, 31, 832–836. doi:10.1016/j.nedt.2011.05.003 [CrossRef]21636181
Nurse Staffing Level Standards
Completing nursing task under supervision
Certain written and communication skills
Better skills in general and specialized nursing
Ability to find nursing-related problems
Ability to provide nursing care to critically ill patients under supervision
Better written and communication skills
Certain teaching ability
|Nurse practitioners||1–3 years|
|N2||Nurse||> 5 years|
Excellent skills in general and specialized nursing
Ability to solve problems using nursing procedures
Ability to provide nursing care to critically ill patients independently
Excellent written and communication skills
Active involvement in nursing research and teaching
|Nurse practitioners||> 3 years|
|N3||Nurse practitioner||> 5 years|
Ability to solve nursing related problems using evidence-based methods
Ability to provide nursing care to patients with difficult diseases independently
Supervising ability in specialized nursing care
Excellent written and communication skills
Certain research and creativity ability
Certain management ability
|N4||Co-chief nurse and above||Not applicable|
Proficient in general and specialized nursing care
Ability to complete high-demanding and difficult nursing tasks independently
Strong teaching ability
Ability to solve problems using comprehensive methods
Strong research ability
Strong management ability
Competence Inventory Scale for RNS
|Category||No. of Items||Ability Assessed|
|1||8||Critical thinking and research ability|
|2||10||Clinical care ability|
|4||8||Interpersonal relationship ability|
|5||8||Legal/ethical practice ability|
|6||6||Professional development ability|
Participating Nurse Characteristics and Differences in Nurse Competence (N = 160)
|Variable and Subcharacteristic||N||Mean||SD||p|
|Age (years)||.21; eta-squared = 0.019|
|Title||.011; eta-squared = 0.056; nurse in charge > nurse*|
| Nurse practitioner||61||165.05||40.58|
| Nurse in charge||9||182.78||39.83|
|Staffing level||< .001; eta-squared = 0.21; N3 > N2*; N3 > N1**; N3 > N0**; N2 > N1*; N2 > N0**; N1 > N0*|
|Work history (years)||.12; eta-squared = 0.026|
|Education level||< .001; eta-squared = 0.22; UD > JCD**; UD > TSSD**; JCD > TSSD**|
| Technical secondary school||32||132.76||30.89|
| Junior college||85||155.02||36.38|
|Work experiencea||.25; eta-squared = 0.026|
| Category 1||56||151.92||35.58|
| Category 2||47||167.25||37.39|
| Category 3||42||156.31||43.15|
| Category 4||15||159.79||33.48|
Factors Influencing Nursing Competence, Analyzed by Multiple Regressiona
|Variable and Subcharacteristic||Estimate||SE||t Value||p Value|
| Nurse in charge||−34.29||17.46||−1.96||< .001**|
| Nurse practitioner||1.86||6.17||0.31||.051|
| N2||41.79||10.31||4.06||< .001**|
| N3||85.47||16.15||5.29||< .001**|
| Technical secondary school degree||−26.63||6.59||−4.04||< .001**|
| University degree||18.43||6.61||2.79||.0059*|