Development and validation of a new tool measuring ...

YNEDT-02574; No of Pages 7 Nurse Education Today xxx (2013) xxx–xxx

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Development and validation of a new tool measuring nurses self-reported professional competence—The nurse professional competence (NPC) Scale Jan Nilsson a,⁎,1, Eva Johansson b,1,2, Ann-Charlotte Egmar c,3, Jan Florin d,4, Janeth Leksell d,5, Margret Lepp e,f,6, Christina Lindholm g,7, Gun Nordström a,h,8, Kersti Theander a,9, Bodil Wilde-Larsson a,h,10, Marianne Carlsson i,j,11,13, Ann Gardulf k,12,13 a

Department of Health Sciences, Faculty of Health, Science, and Technology, Karlstad University, SE-651 88 Karlstad, Sweden Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, SE-141 83 Huddinge, Sweden c The Red Cross University College, SE-102 15 Stockholm, Sweden d School of Health and Social Studies, Dalarna University, SE-791 31 Falun, Sweden e Institute of Health and Care Science, University of Gothenburg, SE-405 30 Gothenburg, Sweden f Østfold University College, Halden, Norway g Sophiahemmet University College, SE-114 86 Stockholm, Sweden h Department of Nursing, Hedmark University College, Hedmark, Norway i Department of Public Health and Caring Sciences, Uppsala University, SE-751 05 Uppsala, Sweden j Gävle University, SE-801 76 Gävle, Sweden k Unit of Clinical Nursing Research, Immunotherapy and Immunology, Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, SE-171 77 Stockholm, Sweden b

a r t i c l e

i n f o

Article history: Accepted 17 July 2013 Available online xxxx Keywords: Nurses' competence Professional nursing Nursing education Nursing students Graduate nurses Quality of care Safety in healthcare Scale development Validation Psychometric properties

s u m m a r y Objectives: To develop and validate a new tool intended for measuring self-reported professional competence among both nurse students prior to graduation and among practicing nurses. The new tool is based on formal competence requirements from the Swedish Board of Health and Welfare, which in turn are based on WHO guidelines. Design: A methodological study including construction of a new scale and evaluation of its psychometric properties. Participants and settings: 1086 newly graduated nurse students from 11 universities/university colleges. Results: The analyses resulted in a scale named the NPC (Nurse Professional Competence) Scale, consisting of 88 items and covering eight factors: “Nursing care”, “Value-based nursing care”, “Medical/technical care”, “Teaching/ learning and support”, “Documentation and information technology”, “Legislation in nursing and safety planning”, “Leadership in and development of nursing care” and “Education and supervision of staff/students”. All factors achieved Cronbach's alpha values greater than 0.70. A second-order exploratory analysis resulted in two main themes: “Patient-related nursing” and “Nursing care organisation and development”. In addition, evidence of known-group validity for the NPC Scale was obtained.

⁎ Corresponding author. Tel.: +46 73 9873870; fax: +46 547001460, +46 54 700 14 16. E-mail addresses: [email protected] (J. Nilsson), [email protected] (E. Johansson), [email protected] (A.-C. Egmar), jfl@du.se (J. Florin), [email protected] (J. Leksell), [email protected] (M. Lepp), [email protected] (C. Lindholm), [email protected] (G. Nordström), [email protected] (K. Theander), [email protected] (B. Wilde-Larsson), [email protected] (M. Carlsson), [email protected] (A. Gardulf). 1 The two first authors: Jan Nilsson and Eva Johansson have contributed equally. 2 Tel.: +46 8 52480000; fax: +46 8 311101. 3 Tel.: +46 8 58751600; fax: +46 8 58751690. 4 Tel.: +46 23 778446; fax: +46 23 778080. 5 Tel.: +46 23 778481; fax: +46 23 778080. 6 Tel.: +46 31 7866016; fax: +46 31 7861064. 7 Tel.: +46 4062000; fax: +46 102909. 8 Tel.: +46 73 9872067; fax: +46 54 700 1460. 9 Tel.: +46 73 9871930; fax: +46 54 7001460. 10 Tel.: +46 73 9872486; fax: +46 54 7001460. 11 Tel.: +46 18 4716482; fax: +46 18 4711500. 12 Tel.: +46 8 52483596; fax: +46 8 58751690. 13 The two last authors Marianne Carlsson and Ann Gardulf have contributed equally. 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.07.016

Please cite this article as: Nilsson, J., et al., Development and validation of a new tool measuring nurses self-reported professional competence— The nurse professional competence (NPC) Scale, Nurse Education Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.07.016

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J. Nilsson et al. / Nurse Education Today xxx (2013) xxx–xxx

Conclusions: The NPC Scale, which is based on national and international professional competence requirements for nurses, was comprehensively tested and showed satisfactory psychometrical properties. It can e.g. be used to evaluate the outcomes of nursing education programmes, to assess nurses' professional competences in relation to the needs in healthcare organisations, and to tailor introduction programmes for newly employed nurses. © 2013 Elsevier Ltd. All rights reserved.

Introduction The World Health Organisation (WHO) considers nurses constitute the backbone of healthcare systems in all societies; a lack of competence among nurses will therefore have substantial negative effects on patient outcomes (WHO, 2006). Nurses' competence in relation to safety and quality of care has been extensively discussed (Aiken et al., 2001, 2003; Stanton, 2004; Clarke and Aiken, 2006; Kane et al., 2007; Kendall-Gallagher and Blegen, 2009). Indeed, Aiken and colleagues have shown that the educational level of nurses is crucial, i.e. higher competence among nurses in hospital wards results in a reduced incidence of mortality, morbidity and adverse events (Aiken et al., 2003). In 2001 the WHO presented the European Strategy for Nursing and Midwifery to improve and unify education programmes for nurses and midwives (WHO, 2001). This is in line with the International Council of Nurses, which recommends that the nursing education community should strive to maintain a high level of competence among registered nurses (ICN, 2006). The WHO, 2001 strategy was strengthened in 2009 to establish global standards for education of nurses, and to emphasise the importance of basing nurses' and midwives' study programmes on evidence and competency (WHO, 2009). Derived from nursing and midwifery practice, the WHO describes nurses' professional competence as a framework of skills reflecting knowledge, attitudes and psycho-social and psycho-motor elements (WHO, 2009). However, there is little consensus in defining the concept of professional competence in relation to nursing practice. Nurses' professional competence and the gaining of competencies are considered basic for the exercise of the profession, but the concept is not uniformly defined. The often-presented dichotomy between nursing competence perceived either as a behavioural objective or as a psychological construct is redundant (Bradshaw, 1998; Mc Mullan et al., 2003; Cowan et al., 2005). As nursing requires complex combinations of knowledge, performance, skills and attitude, a definition drawing on the holistic conception of competence should be agreed upon and utilised according to Cowan et al. (2005). Despite the lack of consensus, some basic elements of professional competence gain an interest and are revived; the nurses' implementation of nursing and the nurses' attitudes (O'Connor et al., 2009). In addition, the concept of competence usually includes generic components such as problem solving skills and critical thinking, which seem appropriate to use also for nurse professional competence. What skills that are being utilised of the single nurse depend on the current nursing situation (O'Connor et al., 2009). Recently, in a review of the literature, eight main categories – based upon 67-competence areas within professional nursing competence – were identified by Kajander-Unkuri et al. (2013). The main categories were: i) professional and ethical values and practice, ii) nursing skills and intervention, iii) communication and interpersonal skills, iv) knowledge and cognitive ability, v) assessment and improving quality in nursing, vi) professional development, vii) leadership management and teamwork, and viii) research utilisation. In response to the WHO strategy, the Swedish National Board for Health and Welfare developed competence requirements for registered nurses (henceforth referred to as nurses), thereby describing the views and recommendations of the Swedish government and society with respect to nurses' expected knowledge and skills. The goal of the competence requirements is to contribute to safe and high-quality patient care (The National Board of Health and Welfare, 2005). The competence requirements, which comprise 72 statements, are presented in the

document from the Swedish National Board for Health and Welfare as three main areas of professional competence: – Nursing theory and practice – Research, development and education/supervision – Leadership. These three areas of competence are similar to the eight categories mentioned above and described by Kajander-Unkuri et al. (2013). The competence requirements strongly emphasise a holistic view and ethical conduct in nursing (The National Board of Health and Welfare, 2005). They were established by experts in nursing through a comprehensive process and are utilised by Swedish healthcare organisations, as well as Universities/University colleges offering nursing programmes. The nursing education programme in Sweden covers three years post-secondary education. When graduated, nurses achieve a Degree of Bachelor of Science in Nursing and are licenced to practise by the Swedish National Board of Health and Welfare. “Nurse” is a protected professional title that may be used only by those who hold a nurse licence. After graduation, no further specific post-basic courses or re-validation of competences are required by the Swedish regulations. It is only if a nurse wants to become a specialised nurse, e.g. in intensive care, anaesthetics or paediatric care, that further education is required. Although the competence requirements have been in force for eight years, they have not been formally evaluated to investigate whether nurses hold the competence required, and no tool exists to assess whether Swedish nurses fulfil the competence requirements. A reason for the slow progress in this area might be the absence of Swedish requirements of formal re-validation of professional nurse competence throughout nurses' occupation. Not having knowledge of nurses' competence poses risks to the quality of care and patient safety. Tools for assessment of nursing students' and nurses' competences have been developed in other countries than Sweden (Clark et al., 2004; Hanley and Higgins, 2005; Poulton and McCammon, 2007; Greenberger et al., 2005; Meretoja et al., 2004a, 2004b; Cowan et al., 2008; Schwirian, 1978); however, very few of these have been tested for psychometric properties (Meretoja et al., 2004a, 2004b; Cowan et al., 2008; Schwirian, 1978) and to our knowledge none is based on national competence requirements. Thus, a research group was formed in 2009 with the goal to develop and implement a new tool based on the formal competence requirements determined by the Swedish Board of Health and Welfare for measuring self-reported professional competence prior to graduation and over time when working as a nurse. In this paper we describe the development and validation of the Nurse Professional Competence (NPC) Scale. Development and Validation Process Study Subjects Nursing students in the final phase of a three-year full-time Bachelor's programme at 11 higher educational institutions (HEIs), i.e. universities/ university colleges, in Sweden took part in the study. The students had passed all courses and theoretical and clinical tests, and were just about to start working as nurses a few days later, and they were therefore regarded as newly graduated nurses. In total, 1086 nurse students prior to graduation (response rate 77%) answered the questionnaire during



2011–2012. The respondents had a median age of 26 (range 20–56, mean 28) years and 87% were women. Ethical Considerations The principals of the included HEIs gave permission to perform the study. Informed consent was obtained from all participants prior to filling in the questionnaire, which was done anonymously. The formal approval of an ethics committee was not required, according to the Swedish Act on the Ethical Review of Research Involving Humans (Ministry of Education and Research, 2003), as no physical or psychological intervention was performed and no handling of sensitive personal data occurred. The use of a nurse professional competence scale will most probably result in the identification of competence gaps among nurses. This may constitute an ethical dilemma and constitute a significant challenge to handle by the individual nurse and by the leaders of healthcare organisations. However, when discussing the ethical benefits from a patient perspective when using a measurement tool such as the one developed here, the research group considered that the advantages outweigh the disadvantages, as not measuring nurse professional competence constitute an even greater ethical dilemma in relation to patient safety. Overview of the Development Process A questionnaire based on the formal competence requirements determined by the Swedish Board of Health and Welfare was developed using two steps: construction of the questionnaire and evaluation of psychometric properties. Construction of the Questionnaire Based on the national competence requirements for nurses the questionnaire was constructed by six professors or senior lecturers in nursing: authors JN, AG, ACE, EJ, GN and BWL—all with extensive knowledge in the field of clinical nursing, nursing education and nursing competence requirements. In the original document from the Swedish Board of Health and Welfare, the competence requirements are given as statements, but they were reformulated as questions, e.g.: • Statement: “A nurse should be able to follow up on patients' status after investigations and treatments”. • Question: “Do you perceive you have the ability to follow up on patients' status after investigations and treatments?” The following response alternatives were developed and are used in the questionnaire (boxes to be ticked): To a very low degree = 1; To a relatively low degree = 2; To a relatively high degree = 3; and To a very high degree = 4. The response alternative “Cannot take a standpoint” is also provided. Furthermore, questions regarding demographic data and other background data were added. After all statements had been reformulated to questions, a group of 12 professors or senior lectures discussed and assessed the wording and relevance of each questions and resulting in the following minor adjustments; some statements were considered to include more than one question and were therefore divided into two or more questions; four statements differed from the others, in that they had a global character regarding nursing, and it was decided not to transform these four statements into questions. This part of process resulted in a questionnaire consisting of 130 items. Evaluation of Psychometric Properties The 130-item questionnaire was evaluated for the following psychometric properties; face validity, data quality, construct validity, reliability and known-group validity.

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Face Validity The questionnaire was evaluated for face validity by asking 27 nurse students prior to graduation from one of the HEIs to respond to the items and to critically review them in terms of understanding. All comments from the respondents were analysed and resulted in minor linguistic adjustments to clarify a few items. Data Quality The mean item score ranged from 2.40 to 3.88 and the corresponding standard deviation ranged from 0.34 to 0.80. It was found that the response alternative “To a very high degree” was selected for 107 (86%) of the items by ≥15% of the respondents, and for 69 (55%) of the items by ≥25%. The proportion on an item level for the response alternative “To a very low degree” ranged between 0 and 9.3%. Internal attrition ranged between 0 and 1.2% across all items. Construct Validity and Reliability To identify the underlying constructs of the questionnaire, principal component analyses were applied with orthogonal rotation (varimax). The Kaiser–Meier–Olkin measure was applied to verify the sampling adequacy. Appropriateness of the data set was evaluated by Barlett's sphericity test. A factor loading of ≥0.35 was considered acceptable (Tabachnick and Fidell, 1996). Reliability for each factor in terms of internal consistency was evaluated by calculating Cronbach's alpha values and a value of ≥0.70 was considered sufficient (Fayers and Machin, 2000). Psychometric properties were analysed using the SPSS Statstics 19.0 for Windows (SPSS Inc., an IBM Company, Chicago, IL, USA). The exploratory factor analyses resulted in a total of 23 factors explaining 68% of the total variance. Cronbach's alpha values were found to be high (0.75–0.96) for all factors except one with α 0.64. Based on the result with the high alpha values, many higher than 0.90, together with the fact that the 23-factor version of the questionnaire consisted of 130 items, it was decided to further develop the questionnaire by reducing the number of items. The following process was therefore initiated: 42 items with high inter-correlation (N0.60) were scrutinised and became objectives of a logical semantic analysis (Gorsuch, 1983). The content of the 42 items was verbally integrated into the other items. This intellectual work resulted in a tool consisting of 88 items, which was named the Nurse Professional Competence (NPC) Scale. The 88-item version of the scale constituted the basis of a new exploratory factor analysis resulting in factors that explained 48% of the total variance. The factor loadings are presented in Table 1. The eight factors had Cronbach's alpha values ranging from 0.75 to 0.94 for the single factors, and 0.97 for the entire NPC Scale (Table 1). A second-order principal component analysis was performed to explore whether there was a higher order underlying construct for the eight factors. The exploratory factor analysis resulted in two secondorder factors (called themes) explaining 65% of the variance. Theme I was named “Patient-related nursing” (factor loadings 0.51–0.81), and Theme II was called “Nursing care organisation and development” (factor loadings 0.57–0.86) (Fig. 1). One of the eight factors – “Legislation in nursing and safety planning” – loaded in both themes. “Legislation in nursing and safety planning” was considered to be so important for both patient-related nursing (Theme I) and for nursing care organisation and development (Theme II), that it was included in both themes. Theme scores were calculated by summing up the factor scores within each theme divided by the number of factors. Known-group Validity Evidence of known-group validity was evaluated by comparing the mean scores for respondents from one of the included HEIs (named HEI 6) with the other respondents on questions regarding disaster preparedness and response included in the NPC Scale. At the time of data collection, HEI 6 was unique in integrating knowledge in disaster preparedness and response – both from a national and international


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Table 1 Factor loadings of principal component analysis after varimax rotation. Items (n = 88) Ability to … Nursing care, 15 items –Enhance patient health –Independently apply the nursing process (assessment) –Independently apply the nursing process (nursing diagnosis) –Independently apply the nursing process (nursing intervention) –Independently apply the nursing process (planning, implementation and evaluation) –Meet patient's basic physical needs –Meet patient's specific physical needs –Meet patient's psychological and social needs –Meet patient's cultural and spiritual needs –Manage changes in patient's physical status –Document patient's physical status –Manage changes in patient's psychological status –Document patient's psychological status –Recognise patient's experiences and suffering –Alleviate patient's experiences and suffering Value-based nursing care, 8 items –Respectfully communicate with patients, relatives and staff –Perform nursing care based on humanistic values –Show respect for patient autonomy, integrity and dignity –Enhance patients' and relatives' knowledge and experiences –Show respect for different values and beliefs –Act upon patients' and relatives' wishes and needs –Use principles of research ethics –Contribute to a holistic view of the patient Medical technical care, 10 items –Manage drugs and clinical application of knowledge in pharmacology –Independently perform or participate in examinations and treatments –Independently administer prescriptions –Pose questions about unclear instructions –Support patients during examinations and treatments –Follow up on patient's conditions after examinations and treatments –Handle medical/technical equipment according to legislation and safety routines –Apply hygienic principles and routines –Prevent complications in relation to care –Prevent transmission of pathogenic microorganisms Teaching/learning and support, 11 items –Provide patients and relatives with support to enhance participation in patient care –Inform and educate individual patients and relatives –Inform and educate groups of patients and relatives –Make sure that information given to the patient is understood –Pay attention to patients who do not themselves express information needs –Motivate the patient to adhere to treatments –Identify and prevent risk factors for ill health –Motivate changes in lifestyle –Identify and assess patient's ability to self-care –Educate and support patients and relatives individually to enhance health –Educate and support patients and relatives in groups to enhance health Documentation and information technology, 4 items –Make use of relevant data in patient records –Scrutinise the quality of own documentation –Use information technology as a support in nursing care –Document according to current legislation Legislation in nursing and safety planning, 9 items –Comply with current legislation and routines –Handle sensitive personal data in a safe way –Advocate patients' rights –Provide contact with the right authority regarding patients' rights –Comply with safety routines and notify according to current legislation –Act adequately in the event of unprofessional conduct among employees –Manage violent and/or threatening situations –Act according to regulations in case of a fire or other devastating events –Apply principles of disaster medicine Leadership in and development of nursing, 26 items –Participate in continuous quality assurance and patient safety work –Act based on an environmentally friendly perspective –Motivate and contribute to a good care environment –Care for an esthetical care environment –Participate in improvement of work environments –Observe work-related risks and prevent them –Critically reflect upon current routines and methods –Inspire dialogue for implementation of new knowledge –Search and review relevant literature for evidence-based nursing

Factors 1

2

3

4

5

6

7

8

.41 .69 .66 .63 .66 .57 .55 .60 .41 .56 .50 .61 .56 .43 .43

.15 .14 .08 .06 .12 .19 .12 .11 .07 .02 .10 .07 .13 .26 .11

.11 .28 .24 .26 .27 .28 .31 .10 .19 .43 .39 .03 .04 .08 .20

.32 .08 .08 .13 .08 .13 .15 .35 .34 .13 .04 .24 .15 .34 .40

.01 .08 .04 .04 .06 .13 .02 .04 .01 .10 .32 .03 .12 .15 .11

.03 .06 .08 .03 .04 .02 .09 .21 .31 .15 .04 .25 .24 .09 .14

.16 .14 .16 .14 .12 .13 .14 .16 .22 .13 .07 .18 .09 .09 .13

.03 .11 .15 .08 .13 .02 .11 .03 .07 .15 .02 .11 .01 .01 .03

.25 .10 .13 .12 .09 .14 .06 .17

.42 .68 .78 .64 .76 .66 .40 .52

.08 .09 .11 .10 .05 .07 .11 .14

.28 .05 .02 .26 .09 .24 .03 .12

.26 .13 .08 .04 .03 .03 .01 .08

.01 .03 .00 .13 .12 .11 .19 .09

.01 .23 .06 .14 .10 .17 .41 .34

.01 .04 .04 .07 .05 .09 .10 .10

.29 .19 .23 .09 .18 .20 .16 .10 .29 .21

.03 .05 .04 .06 .23 .15 .14 .39 .04 .24

.57 .56 .56 .42 .41 .53 .61 .40 .38 .40

.07 .14 .11 .25 .34 .23 .08 .10 .18 .10

.12 .11 .00 .19 .17 .12 .13 .11 .04 .12

.09 .12 .11 .10 .10 .14 .20 .14 .20 .22

.03 .15 .09 .19 .22 .18 .14 .15 .33 .22

.08 .20 .16 .12 .04 .01 .07 .07 .01 .10

.26 .20 .10 .19 .29 .11 .18 .17 .21 .23 .14

.27 .19 .08 .23 .18 .12 .04 .06 .09 .14 .04

.05 .24 .07 .17 .17 .35 .20 .14 .14 .16 .04

.55 .56 .66 .49 .38 .49 .42 .57 .49 .58 .65

.21 .22 .08 .18 .10 .07 .00 .04 .08 .03 .06

.05 .03 .17 .07 .07 .12 .14 .16 .18 .19 .22

.12 .17 .07 .11 .24 .23 .34 .27 .33 .32 .19

.10 .23 .35 .04 .09 .05 .04 .03 .11 .12 .28

.29 .25 .07 .33

.09 .12 .19 .05

.43 .31 .31 .39

.10 .21 .00 .05

.53 .56 .41 .39

.07 .04 .19 .15

.06 .14 .18 .08

.04 .01 .08 .09

.14 .10 .17 .21 .12 .10 .15 .07 .14

.27 .35 .25 .06 .10 .05 .05 .07 .06

.39 .28 .21 .17 .17 .13 .06 .25 .17

.09 .09 .19 .24 .12 .28 .16 .06 .08

.20 .28 .13 .05 .07 .04 .03 .02 .04

.41 .34 .45 .55 .60 .56 .51 .52 .43

.22 .06 .14 .16 .18 .20 .15 .24 .28

.11 .01 .01 .12 .09 .15 .31 .31 .38

.09 .08 .19 .21 .09 .07 .12 .11 .11

.04 .15 .16 .17 .06 .07 .11 .02 .20

.17 .16 .01 .06 .01 .10 .11 .02 .19

.09 .03 .11 .18 .09 .14 .05 .19 .02

.21 .05 .15 .04 .13 .04 .37 .32 .41

.40 .35 .26 .25 .29 .33 .10 .15 .01

.41 .42 .56 .47 .61 .61 .53 .56 .52

.14 .09 .04 .09 .05 .12 .12 .22 .05

Communalities

Cronbach's alpha

0.72

0.90

0.46

0.85

0.69

0.85

0.61

0.89

0.71

0.75

0.59

0.84

0.75

0.94



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Table 1 (continued) Items (n = 88) Ability to … –Implement new knowledge for evidence-based nursing –Initiate, participate in and/or carry out development activities for improved care –Initiate and participate in research –Independently analyse own professional strength and weaknesses –Continuously engage in professional development –Lead and develop health staff teams –Evaluate actions taken by the health staff teams –Develop groups and manage conflicts –Motivate the team and give feed-back –Involve staff in how to develop patient care –Provide person-centred care with focus on quality –Provide person-centred care with focus on economy –Enhance research and development –Lead and provide nursing care based on best knowledge –Participate in strategic planning and evaluation –Interact with other professionals in care pathways –Enhance information and communication to obtain continuity, effectiveness and quality Education and supervision of staff/students, 5 items –Participate in supervision of staff/students in development activities for improved care –Teach, supervise and assess students –Supervise and educate staff –Development of health-care teams –Enable multi-professional education activities to optimise patient care?

Factors 1

2

3

4

5

6

7

8

.13 .11 .07 .08 .09 .28 .18 .13 .08 .08 .12 .06 .07 .13 .11 .21 .16

.07 .04 .10 .31 .34 .08 .05 .06 .16 .16 .16 .03 .08 .15 .07 .26 .18

.11 .04 .04 .16 .12 .36 .22 .06 .13 .11 .27 .18 .08 .31 .16 .39 .37

.14 .13 .02 .12 .09 .19 .20 .29 .25 .21 .17 .22 .07 .17 .13 .04 .09

.26 .21 .22 .22 .23 .06 .01 .13 .01 .01 .05 .16 .07 .11 .09 .03 .06

.13 .14 .10 .02 .01 .06 .06 .25 .12 .01 .01 .14 .02 .03 .11 .00 .07

.56 .61 .56 .39 .42 .46 .53 .47 .53 .55 .61 .55 .65 .55 .55 .45 .46

.21 .30 .23 .10 .08 .22 .16 .25 .22 .16 .03 .05 .17 .16 .26 .20 .12

.12 .09 .10 .14 .18

.06 .07 .05 .07 .01

.10 .12 .16 .11 .01

.09 .13 .13 .12 .14

.18 .07 .04 .01 .03

.10 .15 .12 .12 .19

.37 .27 .33 .38 .42

.56 .70 .71 .60 .49

Communalities

Cronbach's alpha

0.78

0.88

Bold text in the table indicates the highest loadings within each factor.

perspective – into each semester of the three-year education programme. Moreover, the students were required to take a two-week, full-time course in the subject during their last semester. Therefore we made the assumption that the sample of nurse students prior to graduation from HEI 6 would score higher than those graduating from the ten other HEIs on these disaster-related items. Student's t-test was used for these comparisons. The analyses showed that the students from HEI 6 scored significantly higher on the items “Ability to act according to regulations in case of a fire or other devastating events” (mean score 2.92 vs 2.68, p b 0.000) and “Ability to apply principles of disaster medicine in case of a devastating event occurring in a healthcare unit or in the community” (mean score 2.94 vs 2.55, p b 0.000). Discussion This study provides a new tool, the NPC Scale, intended for measuring self-reported professional competence among nurse students prior to graduation and among practicing nurses over time. As a base for the development and validation of the questionnaire, nurse students in the final days of their education were asked to answer a 88-items questionnaire. These respondents could also be regarded as newly graduated nurses as they only a few days later where scheduled for independently starting their work as employed nurses. The reason for asking the students in the final phase of the education to participate was that it was a practical way to achieve the sample size needed for conducting the exploratory factor analyses (Tabachnick and Fidell, 1996). This group also constitutes a base for follow-up studies on the development of the different aspects of nurse professional competences that, as shown in the present study, can be captured by the NPC Scale. The 88-item self-reported scale includes eight factors, which refer to two overarching themes: “Patient-related nursing” and “Nursing care organisation and development”. The psychometric properties of the NPC Scale were comprehensively tested and found satisfactory. The results indicate that the NPC Scale can make a valuable contribution to safe and high-quality patient care, by assessing nurses' competences from various perspectives, e.g. in accordance with national competence requirements and healthcare organisations' needs, and it can also be used to evaluate nursing education programmes. Furthermore, as also suggested by others (Danielsson and Berntsson, 2007), results from using the NPC Scale to evaluate competences may assist nurses in their

own professional development by identifying strengths as well as areas that need to be improved. The NPC Scale could also be an asset (time- and cost-effective) when designing introductory programmes for newly employed nurses. As it has been shown that nurses' competence is crucial for safe and qualitative care (e.g. Aiken et al., 2001, 2003; Stanton, 2004; Clarke and Aiken, 2006; Kane et al., 2007; Kendall-Gallagher and Blegen, 2009), it is considered important to measure nurses' competence. Therefore, several questionnaires have been developed during the last ten years to assess students' and graduated nurses' competence: a) students' self-assessed clinical competence (Clark et al., 2004), students' assessment of clinical competence in intensive care units (Hanley and Higgins, 2005) and specialist students' perceived public health competence (Poulton and McCammon, 2007); and b) newly graduated nurses' self-assessed competence (Löfmark et al., 2004), newly graduated nurses' self-assessed technical skills (Greenberger et al., 2005) and nurses' perception of educational preparation three years after education (Danielsson and Berntsson, 2007). Of the existing questionnaires designed to measure nursing competence, only a few have been psychometrically tested and have adequate levels of reliability and validity. One of these focuses on nursing practice in the early phase of the carrier as a nurse (Schwirian, 1978) and may therefore not be suitable for follow-up of nursing competence over time. Another questionnaire, the Nurse Competence Scale (NCS), developed by Meretoja et al. (2004a, 2004b), is derived from the nursing framework of Benner et al. “From Novice to Expert” (Benner and Hall, 2001). Although the questionnaire by Meretoja et al. (2004a, 2004b) and Meretoja and Koponen (2012) is well used and can discriminate between nurses with more or less experience in nursing, it is not based on formal guidelines as compared to the NPC Scale. Another questionnaire recently developed through the European Healthcare Training and Accreditation Network project (the EQT instrument), measures how frequently a nurse performs a number of competences in her current job (Cowan et al., 2008). Results from using such a questionnaire cannot detect the level of performance and need for continuing training in nursing. The NPC Scale has the capacity to evaluate the quality of nursing education programmes and also to identify skill gaps in clinical care because it assesses the level of ability to perform different nursing tasks. The development of the NPC Scale involved several steps. It is believed that the process used here provides a high degree of confidence


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Factor 1 Nursing care 15 items (α 0.90)

Factor 2 Value-based nursing care 8 items (α 0.85)

Factor 3 Medical technical care 10 items (α 0.85)

Theme I Patient-related nursing (0.51-0.81)

Factor 4 Teaching/learning & support 11 items (α 0.89) Nurse Competence Scale 88 items

Factor 5 Documentation and information technology 4 items (α 0.75) Factor 6 Legislation in nursing & safety planning

Theme II Nursing care organisation and development

9 items (α 0.84)

(0.57-0.86)

Factor 7 Leadership in and development of nursing 26 items (α 0.94)

Factor 8 Education & supervision of staff/students 5 items (α 0.88)

Fig. 1. Flow chart presenting the underlying construct of the NPC Scale. *Factor 6 “Legislation in nursing and safety planning” loaded in both themes.

in the scale's content, construct and known-group validity. Students from about half of all HEIs in Sweden offering nursing education participated and the response rate was high (77%), indicating that it was feasible to answer the questions, and also that the results are representative of the target population. Regarding the data quality of the NPC Scale, the internal attrition rate was very low. However, a number of the respondents used the highest response alternative on several items. One plausible explanation for this might be that a substantial number of the respondents answering the NPC Scale engaged in socially desirable responding (Polit and Beck, 2008), i.e. they responded in a manner that was viewed favourably (high levels of competence). Another reason for scoring the highest response alternative might be that many of the respondents considered that their competence had increased considerably during their nursing studies when comparing with before they entered the nurse education programme, and that they had not yet have been confronted with the responsibilities of independently practising as a nurse. Taken together, this indicates the importance of additional validation of the scale, and measuring self-reported competence over time, using one and the same scale. The exploratory factor analyses of the NPC Scale showed an eightdimensional underlying structure responsible for 48% of the total

variance. In the second-order exploratory analysis, two higher-order themes were identified: “Patient-related nursing” and “Nursing care organisation and development”. One factor (“Legislation in nursing and safety planning”) was included in both themes, which is logical, as legislation and safety planning are needed for both patient-related care and nursing care organisation and development. The two themes and the eight factors are well in accordance with the competence areas in the competence requirements stipulated by the Swedish Board of Health and Welfare (The National Board of Health and Welfare, 2005) and the competence areas identified by KajanderUnkuri et al. (2013). This observation further strengthens the validity of the scale. Exploratory factor analysis is typically used in the early stages of a scale development for understanding the underlying constructs (Tabachnick and Fidell, 1996). The underlying structure of the NPC Scale identified in this study will be the target for hypothesis testing through a confirmatory factor analysis, preferably in another large group of nurses. The NPC Scale is a new tool to measure nurses' professional competences. The development of the NPC Scale has been influenced by international guidelines (WHO, 2001; ICN, 2006; WHO, 2009) and based on national competence requirements (The National Board of Health and



Welfare, 2005). In this report we present that the NPC Scale shows satisfactory psychometrical properties in a sample of newly graduated nurses. It can be used to evaluate the outcomes of nursing education programmes, to assess nurses' competences in relation to the needs in healthcare organisations, to identify self-reported competences and might be used in tailoring introduction programmes for newly employed nurses. We also see a potential future use of the NPC Scale in international contexts. Author Contribution Study conception/design: Jan Nilsson, Ann Gardulf and Ann-Charlotte Egmar. Data collection: Jan Nilsson, Ann-Charlotte Egmar, Ann Gardulf, Jan Florin, Janeth Leksell, Margret Lepp, Kersti Theander, and Marianne Carlsson. Drafting of manuscript and data analyses: Ann Gardulf, Jan Nilsson, Marianne Carlsson, and Eva Johansson. Critical revisions for important intellectual content: Ann Gardulf, Jan Nilsson, Marianne Carlsson, Eva Johansson, Gun Nordström, Kersti Theander, Margret Lepp, Bodil Wilde-Larsson, Jan Florin, Janeth Leksell, Christina Lindholm, and Ann-Charlotte Egmar. Statistical advisor: Marianne Carlsson. Funding This study was mainly supported by research funds from Karolinska Institutet, Sweden, but also by research allocations within the other universities/university colleges to support all the authors. Acknowledgements We are grateful to all the individuals who participated in the study, and to Hilary Hocking, Östersund, Sweden, for language revision. References Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A.M., Shamian, J., 2001. Nurses' reports on hospital care in five countries. Health Affairs 20 (3), 43–53. Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., Silber, J.H., 2003. Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association 209, 1617–1623. Benner, P.E., Hall, P., 2001. From Novice to Expert: Excellence and Power in Clinical Nursing. Prentice Hall Inc., New Jersey. Bradshaw, A., 1998. Defining ‘competency’ in nursing (part II): an analytical review. Journal of Clinical Nursing 7, 103–111. Clark, M.C., Owen, S.V., Tholcken, M.A., 2004. Measuring student perceptions of clinical competence. Journal of Nursing Education 43, 548–554. Clarke, S.P., Aiken, L.H., 2006. More nursing, fewer deaths. The need to connect organizational components and outcomes for improve patient safety. Quality & Safety in Health Care 15, 2–3. Cowan, D.T., Norman, I., Coopamah, V.P., 2005. Competence in nursing practice: a controversial concept—a focused review of literature. Nurse Education Today 25, 355–362. Cowan, D.T., Wilson-Barnett, D.J., 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.

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