Competence of Nurses and Factors Associated With It

to upgrade nursing education programs at all levels of nursing education in Lithuania: university, non-university, and professional development courses. The qualities of preconditions for nursing care, cooperation with relatives, caring and supporting initiative are related to nurse competence.


Introduction
The abdominal perioperative/surgical nursing care requires a unique, highly developed set of knowledge, skills, and attitudes. Offi cial documents of different countries show what kind of competence is expected from a nurse. In Lithuania, the competence of general practice nurse was defi ned in the Lithuanian Norm of Medicine MN: 28,2004, "General Practice Nurse. Rights, Duties, Competence, and Responsibility" (1). According to this Norm of Medicine (1), professional competence of general practice nurse is a set of knowledge, abilities, and skills, which a nurse is achieving after graduating studies of general practice nursing with professional qualifi cation and during permanent development according to evidence-based nursing. There is a lot of discussion in public that the competence of a nurse needs to be expanded and responsibilities should increase.
Lithuanian nurses, trained in the Soviet style, are technically competent but lack information and a grounding framework (2). However, considerable changes in nursing education have occurred after the declaration of Lithuanian Independency from the Soviet Union (2)(3). Higher education is the requirement for nurses from 2010 (4). There are two types of higher nursing education institutions in Lithuania: universities (university level) and colleges (nonuniversity level). In April 2009, the Seimas (Lithuanian Parliament) passed a new Law on Science and Studies, which provides for a major reform of higher education (5). There are still a lot of discussions in media and society about the nursing education, the competence of nurse, and the quality of nursing care.
The competence of perioperative nurse is defi ned by the US Association of periOperative Registered Nurses (AORN) as knowledge, skills, and abilities to fulfi ll patient care activities before, during, and after operation (6). The concept of nurse competence has been also widely analyzed by many authors (7)(8)(9)(10)(11)(12)(13). Meretoja et al. (8)(9)(10)(11) defi ne nurse competence from three aspects: the ability of a nurse to practice in a specifi c role; the capacity to incorporate knowledge and skills into actual practice by integrating the cognitive, affective, and psychomotor domains of practice; and the professional development toward expertise. In some studies (11)(12)(13), nurse competence has been divided into clinical competence and professional competence. Furthermore, Cowan et al. (12) and Aari et al. (13) explored nurse competence in the review articles and concluded that nurse competence is a complex combination of knowledge, performance, skills, attitudes, and values; however, a holistic defi nition of competence needs to be agreed upon and operationalized (12)(13). However, the clear defi nition what is the competence of perioperative/surgical nurse is need to be developed.
There are many factors associated with the evaluation of competence by nurses. Based on previous studies, nurses with higher education level (14) and working in the operating room (11) were more critical in the evaluation of their competence, but fi ndings of other studies showed no associations between nurse educational level and evaluation of competence (15) or associations were positive (7). Furthermore, older nurses and nurses with longer work experience (11,(15)(16)(17) as well as nurse managers (10) evaluated their competence better. Previous studies indicated that most often clinical nurses and nurse managers (7-11, 13, 15, 16, 18) self-assessed their competence and usually nurse managers assessed higher than clinical nurses (10). It is important to explore all factors related to the competence of a nurse for getting comprehensive understanding how the background factors infl uence the competence of a nurse and how the competence may be developed by controlling these factors.
Nurse competence can be seen in association also with other factors. The association between the nurse competence and the quality of nursing care was found to be positive in previous studies (11)(12)(13)(14)(15)(16)(17). The quality of abdominal surgical/perioperative nursing care has been defi ned in previous studies from nurses' (19)(20)(21)(22)(23)(24)(25)(26)(27) and patients' perceptions (22,(27)(28)(29). It would be relevant to assume that those evaluating their competence higher would evaluate the quality of care in their ward higher. Competence standards are related with the quality of nursing care, and maintaining minimum standards may level down the quality of nursing care (12,30). However, Salonen et al. (15) showed that competence in the ensuring quality was assessed the lowest by nurses. We need the competence assessment because it signifi cantly improves the quality of patient care and increases nurse opportunities for professional growth and career development (10). There is a lack of literature about the relationship between the surgical nurse competence and the quality of nursing care. This relationship needs to be explored in more details for gaining the knowledge how to improve the nursing education and practice.
The aim of this study was to evaluate the competence of nurse and factors associated with it from the perspective of nurses working in abdominal surgical units for predicting the possible ways to upgrade the nursing practice.
The research questions for this study were as follows: 1. What is the level of the competence of nurses? 2. How are frequently nurses using the competencies in practice? 3. What background factors are associated with nurses' perceptions of their competence? 4. What is the relationship between the competence of nurse and the quality of nursing care?

Material and Methods
A multicenter, descriptive study was performed in 11 abdominal surgical wards of 7 Lithuanian hospitals. The data were collected between November 2007 and January 2008. One of researchers (N.I.) personally came to all hospitals and left the questionnaires in wards. One person was responsible for collection of the data in one unit. All Lithuanian registered nurses (N=270) who were working with patients after abdominal surgery in these units were invited to participate in the study. A total of 247 questionnaires were returned. The response rate was 91%. A total of 218 responses were analyzed (n=218).
Instruments. The competence of nurses was evaluated by using an instrument -Nurse Competence Scale (NCS) -originally developed in Finland, (8). The NCS consists of 7 categories (73 items): 1) helping role; 2) teaching-coaching; 3) diagnostic functions; 4) managing situations; 5) therapeutic interventions; 6) ensuring quality; and 7) work role. The competence categories were derived from Benner's (31) competency framework. The level of competence is measured with a visual analogue scale (VAS), where 0 means a very low level of competence and 100 means a very high level of competence. The frequency with which the competencies are actually used in clinical practice is indicated on a 4-point scale (0=not applicable, 1=very seldom, 2=occasionally, 3=very often). For descriptive purposes, the VAS 0-100 is divided into four parts to represent the level of nurses' competence as low (0-25), rather good (>25-50), good (>50-75), and very good (>75-100).
In connection of the NCS, there were also background factors included into the instrument. As sociodemographic factors, respondents' age and family status were recorded. There were also factors related to education, license, and professional development as well as those related to workload in the hospital, level of independence, and level of work satisfaction. We were also interested to see the association between the evaluation of competence and evaluation of the quality of nursing care in the words.
For evaluating the quality of nursing care, the Good Nursing Care Scale for Nurses (GNCS-N) (28) was used. This instrument was developed by Finnish researchers. The GNCS-N consists of 7 categories and 13 subcategories (64 items): 1) staff characteristics; 2) task-oriented activities; 3) human-oriented activities; 4) preconditions; 5) progress of nursing process; 6) environment; and 7) cooperation with relatives. The responses were obtained on a 6-point Likert-type scale from "always" (=6) to "never" (=1). Number 0 represented the choice "I cannot evaluate this aspect." Both the NCS and the GNCS-N were adapted to the Lithuanian context according to all requirements (32): fi rst, they translated by one of researchers from English to Lithuanian; second, back-translation procedure was performed; and third, monolingual test was conducted (33). Face validity of the instruments was performed by two groups: nursing master students (n=10) and nursing teachers (n=23) at the university level. The principal component analysis (PCA) and factor analysis were carried out to examine construct validity of the instruments. For testing the instruments and design, a pilot study including 114 nurses was done in 3 abdominal surgical departments of one large Lithuanian University Hospital in 2006 (response rate, 95%). Based on that, some corrections were made because Cronbach alpha values for the GNCS-N ranged from 0.352 to 0.928. The value for the NCS was 0.930. Power analysis (PASS, 2005) was used to compute the sample size of nurses to explore the quality of abdominal perioperative nursing care and nurse competence. A power analysis was conducted to determine the number of participants needed for this study. To achieve power of 0.80 and a medium effect size (f=0.35), a total sample size of 159 is required to detect a signifi cant model (F (2, 156)=3.05).
Ethical Considerations. All ethical standards of research were followed according to the Word Medical Association Declaration of Helsinki (2008) and the Lithuanian Bioethics Committee (LBEC) requirements (34,35). The permission to carry out the research was obtained from heads of Hospitals and the approval to perform the study was received from the LBEC ( March 24, 2006;No. 13). Permissions to use the NCS and the GNCS-N were re-ceived from the copyholders.
Statistical analysis. Statistical data analysis was performed with the Statistical Package for Social Sciences for Windows (SPSS, version 12.0; SPSS Inc., Chicago, IL, USA) software package. Descriptive analyses (mean, standard deviation, range, and frequency tables) were carried out to understand the background variables of nurses. Sum variables were formed according to 7 quality categories and 7 competence categories. Afterward, they were calculated by summing up the values obtained for the items and then dividing the sum by the number of variables. An overall VAS score was calculated as the mean value of the average competencies assessed for seven categories. Cronbach alpha coeffi cients were used to check the reliability of the whole instrument and sum variables. Associations between variables were determined by means of Spearman correlation. A signifi cance level of P<0.05 was set during the analysis of statistical hypotheses. Factor analysis was performed for the evaluation of structural validity. Construct validity was tested with principal component analysis (PCA).

Results
Background Characteristics. The typical nurse respondent was 39 years old (range, 22-62 years) and had been employed in abdominal perioperative nursing for 17 years (range, 0-40 years) ( Table 1). The majority of nurses (77%) lived with a partner or family. Only 8% of respondents graduated university (bachelor degree); only 1% had master degree of nursing science. Almost all respondents had general practice nurse license. All nurses fi nished courses during the last 5 years with the goal to develop their professional competence. "Clinical Skills Improvement" (90%) and "Upgrading the Quality of Perioperative Care" (63%) were the most popular courses. More than half of the respondents were working more than full time. The majority of nurses (60%) indicated that the level of their satisfaction with work was high.
The Level of Nurse Competence as Perceived by Nurses. The overall level of nurse competence was high (mean VAS, 72.2; range, 68.0 to 79.7) (Table 2). Next, the results are presented according to competence categories, and the highest and lowest items in these categories are presented. Nurses indicated that their competence was highest in the managing situations and work role. The competencies of ensuring quality and teaching-coaching were assessed somewhat lower, but still on a high level.
Managing situations was ranked as the highest in perioperative settings. The ability to recognize situations posing a threat to life (mean, 82.8) as well as the keeping nursing care equipment in good condition were rated the highest. Nurses practicing in perio- *This is education for nurses who had graduated before 2001. All medical schools became colleges after education reform, part of them were liquidated. **This level is non-university degree. Nurses can accomplish education at the colleges or at the universities. Ensuring quality and teaching-coaching competencies were assessed somewhat lower but still on a high level in perioperative settings. Nurses reported that they were not able to critically evaluate care philosophy in their unit (mean, 64.7) and they rarely use this competence in practice. Nurses rated their competence as the lowest in the evaluation of patient education outcomes with the family (mean, 63.1) and the developing orientation programs for new nurses (mean, 63.1) and did not use these competencies in practice frequently. However, taking active steps to maintain and improve nurses' professional skills was assessed on a very high level (mean, 81.1) and was often used in practice.
The Frequency of Using Competencies in Practice as Perceived by Nurses. The majority of nurses (86%) frequently used the competencies in their clinical practice ( Table 2). The frequency of using the competences of managing situations and work role was the highest, and the frequency of using the competencies of ensuring quality and teaching-coaching was the lowest.
The majority of surgical nurses were often using their competencies of managing situations and work role in their clinical practice (92% and 87%, respectively). The frequency of using the competencies of ensuring quality and teaching-coaching was the lowest.
Factors Associated With Nurses' Perceptions of Nurse Competence. Several factors such as sociodemographic factors and nurse perceptions of the quality of nursing care were explored as related to nurse competence.
Several sociodemographic background variables perative settings were able to orchestrate the whole situation when needed (mean, 80.3), but only occasionally they were able to coordinate nursing students (mean, 65.0). In diagnostic functions, coaching other staff members in use of diagnostic equipment were associated with nurse competence (P<0.05). Nurses with higher education as well as those who completed additional educational courses based on professional development better assessed the competence in general and some competencies separately. For example, nurses who graduated the college or university used the competencies of quality ensuring in practice more frequently than nurses who graduated the medical school (P<0.05). Nurses who completed the communication course rated better their competence in teaching-coaching and using of diagnostic functions and managing situations, and nurses who completed ethics course generally assessed their overall competence higher than other nurses (P<0.05). In addition, nurses with high level of independence at work better assessed their overall level of competence (P<0.05), and nurses with higher satisfaction with work used the competencies of teaching-coaching and work role in practice more frequently. However, some background variables showed a negative relationship with nurses' viewpoint of nurse competence. For example, nurses who had the operating theatre license assessed their competencies of helping role and diagnostic functions lower than nurses with other licenses. Nurses who completed course of "Improving the Clinical Skills" evaluated used the competencies of managing situations and quality ensuring rarely than other nurses (P<0.05).
Evaluations of the competence were associated with the evaluations of the quality of nursing care. The quality of nursing care was divided into subcategories, and signifi cant correlations were determined. The overall quality of abdominal perioperative/surgical nursing care (Table 3) was highly assessed by nurses (mean, 4.71; range, 1-6). The quality in environment and preconditions for nursing care was evaluated the highest, and the cooperation with relatives/significant others and the progress of the nursing process were rated the lowest. The correlations between nurse competence and the quality of nursing care was identifi ed in all categories of competence, but there was no consistent (systematic) pattern related to the categories of quality ( Table 4).
The correlation between nurse competence and the following categories/subcategories was found: a) the task-oriented activities/supporting initia-   A positive correlation between the quality in supportive initiative and competence in diagnostic functions (P<0.01) as well as between the quality in co-operation with relatives and competence in managing situations (P<0.01) was identifi ed.

Discussion
The aim of this study was to explore nurse competence and factors associated with it from the perspective of nurses for predicting the possible ways for upgrading the nursing practice. The overall level of nurse competence, the frequency of using the competence in practice, and the quality of abdominal perioperative care were assessed on a good level by nurses as in previous studies (7-10, 15, 16, 18, 19, 23-25, 29).
Limitations of Study. This study has some limitations related to validity and reliability. The evaluation of nurse competence was made only by clinical nurses who have a subjective view to themselves. Managers, other health care providers, and patients should be involved in future studies aimed to assess nurse competences. However, the data were collected from 11 different surgical units, and almost all nurses working in the fi eld of abdominal surgery were involved in the study. It was the fi rst validation of the NCS and GNCS-N in Lithuania, and cultural and environmental factors could limit the generalizations that can be made from empirical fi ndings. The principal component analysis of the NCS supported the structure of validity only partly: the part of questionnaire with VAS supported the structure of the instrument; however, the factors in the Likert scale (from 0 to 3) were not identical to the theoretical categories. The factor analysis of the GNCS-N supported the structure of instrument with minor nonconformity: fi ve conformable factors were identifi ed for items of seven original categories; 11 items were attributed to other categories.
Nurse Competence as Self-Assessed by Nurses. The overall nurse competence and frequency of using the competences in practice were assessed higher by Lithuanian than Finnish nurses, as indicated in the studies by Meretoja et al. (8)(9)(10)(11) and Salonen et al. (15), and Italian nurses, as indicated in a study by Dellai et al. (16), but lower than by Australian nurses as it is reported in a study by Cowin et al. (18). Nurse competencies in managing situations were assessed the highest by nurses, the same as in the study by Meretoja et al. (8); competencies in teaching-coaching were assessed the lowest. However, these fi ndings are not confi rmed by other studies (15,16,18), where nurses assessed the competen-cies in helping role the highest and competencies in ensuring quality and work role the lowest. The educational competence (teaching-coaching) of Lithuanian nurses need to be improved. This competence is essential for competence development (12,14,15).
The Frequency of Using Competencies in Practice as Perceived by Nurses. Most often in their clinical practice, the nurses reported that they used managing situations (8,15) and work role, contrary earlier studies (11,16). It was an interesting fi nding that the level of nurse competence and the frequency of using the competencies in practice almost in all categories were assessed the same by nurses as in previous studies (8,11). However, the level of competence in diagnostic functions was evaluated higher than that of helping role, but the frequency of using these competencies was not so high (15). These differences between nurse perceptions of their competence and the frequency of using competencies in practice may show that not all competencies are relevant in the practical work of surgical nurses, but they are important for general nurse competence.
Factors Associated With Nurses' Perceptions of Their Competence. The associations between background factors and nurse competence were identifi ed in previous studies (7-11, 15, 16, 18). Contrary to our fi ndings, Salonen et al. reported that nurses with different education had similar assessments of their competence (15), but a study by Švedienė et al. (7) confi rmed our results. Nurses who completed some professional development courses to improve their skills were more critical in their evaluation of competence (14). Operating theatre nurses ranked the competencies in helping role and diagnostic functions worse, similarly to a study of Meretoja et al. (11), which revealed that operation room nurses assessed the use of competencies in diagnostic functions and teaching-coaching lower. The evaluation of nurse competence was related to the type of educational course, but not generally to nurse professional development. For example, after graduating the courses of "Improving the Clinical Skills," nurses were more critical in their evaluation, but after graduating the course of "Nursing Ethics," they evaluated their competence better. The nurse educational level, professional development, and working experience may have a positive as well as negative infl uence on nurse perceptions of their competence.
A statistically signifi cant, but weak, correlation between the nurse competence and the quality of abdominal perioperative nursing care was determined. When surgical nurses' perceptions of their competence were positive and high, the quality of nursing care was also evaluated higher as perceived by nurses (e.g., 11,16). The improvement of qualities in the task-oriented nursing activities, preconditions, and cooperation with relatives may lead to better competence of a surgical nurse.

Conclusions
Generally, the level of nurse competence and the frequency of using the competencies in practice were high as perceived by nurses. Comparison with other studies showed that nurses' self-assessment of their competence has national characteristic features, probably because of differences in nursing culture traditions, nursing care process, nurses' education traditions and levels. Furthermore, it is necessary to upgrade the nurse competencies of teaching-coaching and ensuring quality, and in future studies, it is important to involve not only nurses, but also patients, managers, and other health care providers.
The fi ndings of study allow us to make the as-sumption that nurse education, nurse experience, and nurse professional development play a significant role in the evaluation of nurse competence. It is necessary to improve nursing education programs at all levels of nursing education in Lithuania: university, non-university, and professional development courses. The study highlights the importance of assessment of association between the competence of nurse and quality of nursing care. Qualities in preconditions for nursing care, co-operation with relatives, caring and supporting initiative are the key qualities for increasing and developing nurse competencies.