Marilin Victoria Martínez-Olivares,1 Blanca Elsi Cegueda-Benítez,2 Guillermina Romero-Quechol,3María Estela Galarza-Palacios,1 María Guadalupe Rosales-Torres1
1Unidad de Cuidados Intensivos, Hospital de Especialidades, Centro Médico Nacional La Raza.
2Unidad Médica de Alta Especialidad, Hospital de Traumatología “Victorio de la Fuente Narváez”.
3Unidad de Investigación Epidemiológica en Servicios de Salud, Coordinación de Investigación en Salud.
Instituto Mexicano del Seguro Social, Distrito Federal, México
Correspondence: Marilin Victoria Martínez-Olivares
Received: April 22nd 2014
Judged: October 27th 2014
Accepted: November 17th 2014
Introduction: To ensure the provision of an effective and safe health services, it is required of a level of expertise that ensures assertive assessment of patients; hence, the importance of determining the level of competence of the nursing staff.
Objective: To evaluate the competences level in the assessment stage using the functional health patterns model.
Methodology: In a high specialty hospital, a cross-sectional and analytical study was conducted. It included 187 nurses from different categories and shifts, assigned to hospitalization services, critical care areas and operation room. By means of an instrument based on clinical simulation, the labor competences were explored in its declarative, attitudinal and procedural dimension. For the conceptual and content validity, experts subjected the instrument to two rounds of evaluation.
Results: The average age of the nursing staff was 39.5 years, 87.7 % were female, 51.3 % had coursed post-technical education, 26.7 % technical education, and only 2.1 % had coursed a master degree; 66 % showed competence in the assessment of patients. The attitudinal core was the best evaluated.
Conclusions: The competences of the nursing staff reflected is not even reached the level of expertise, situation that it may influence the quality care provided to patients.
Keywords: Clinical competence; Nursing assessment; Competency-based education
A professional is competent to the extent that they "use the knowledge, skills, attitudes, and good judgment associated with their profession, to function effectively in situations that correspond to their field of practice".1
The concept "competency" emerged in 1975 with David McClellan, who said that "to predict more efficiently it is necessary to study people at work".2 This refers to a set of attributes that a person possesses and that allow them to develop effective action in a particular field.3
The nursing area requires great capacity to resolve problems, and an environment of organization must be created in order to exercise care practice with fullness that impacts the patient's health. In this context, nursing practice is based on the development of various skills to provide comprehensive care with a holistic approach to the patient.
In 1984, Patricia Benner took up the Skills and Abilities Development Acquisition model, in which five types of professionals are recognized according to their level of experience:4
The nurse-patient dyad allows the social construction of useful lessons for productive activity in a particular work context. According to the quality requirements expected by the productive sector, it is intended to be a comprehensive approach to training that connects the workplace with society through education.
Currently there are various ways to assess competencies: oral exams, portfolios, or clinical cases. For example here we cover two:
This lets one know the problem-solving ability of an individual, seeing as the three domains interact (knowledge, skills, and attitudes).
Nursing care is a complex concept that includes care in line with scientific advancement, in order to provide care that meets the needs of each patient and to ensure its continuity.
In this sense, occupational competencies can be explored in three dimensions: conceptual (knowledge), interpersonal (abilities), technical (skills)5 or by cores: declarative, procedural, and attitudinal, as Patricia Benner called them.
Nursing staff is one of the major players in the health care process, so they must analyze, plan, and apply knowledge that responds to the needs of patients.
The nursing process is considered an effective tool in care provided to the patient; it is systematic and can generate rational care to sustain the actions of nurses. Assessment is the first stage and it involves collecting, organizing, and validating data related to the health of patients.6 It is done through interviews, observation, and physical examination, so it must be approached in a structured manner, to then make the formulation of nursing diagnoses, which can facilitate the implementation of a plan of care.
The model of functional patterns structures and orders this assessment, both individually and as a family member or community, throughout the life cycle of a person in health or disease situations, and it clearly facilitates nursing diagnosis.
In this sense, Marjory Gordon said that nursing staff must focus on assessment, since it is the foundation of the success or failure of nursing care.
The COM-VA project - which identifies and assesses the skills of the nurse in the hospital environment - was developed under the Plan Estratégico de Enfermería de la División de Hospitales of the Institut Catala de la Salut. Its aim was to evaluate the care responsibility of nurses in six domains of core competency and to analyze the relationship between the elements of competency of the instrument and levels of expertise (from apprentice to expert) by setting a threshold. It was found that the level of nursing competency for assessment was lower than expert level.4
In recent years, the Instituto Mexicano del Seguro Social has been concerned with continuous training in the nursing process, since this institution is responsible for a third of nurses in the country, which presents a challenge for training. In 2009, the clinical records sheet (Evaluation of Clinical Records, Treatment Scheme, and Nursing Interventions, code 2660-009-054) included assessment by functional patterns per Gordon, who conceived of the functional pattern as a construct that describes the patient’s health status and encompasses health patterns into 11 groups.7
The purpose of this study was to evaluate the occupational skills of nursing at the assessment stage, since an accurate assessment allows nurses to develop a plan to improve and maintain the health of the user and to ensure the success of the nursing care process given.
The assessment of competencies reveals the actions of improvement at the assessment stage, with efficiency, efficacy, and effectiveness, and encourages individual improvement as a means to achieve professional development that enables the transformation of health care for the patient.
Cross-sectional study approved by the local research committee with registration R-2013-3501-66, conducted between February and June 2013 at the Hospital de Especialidades del Centro Médico Nacional La Raza. The study included general nurses, specialists, and floor managers in inpatient services, surgery, and critical areas (intensive care unit, coronary care unit, and renal transplant unit) of the different shifts. The sampling was non-probabilistic for convenience. The finite population formula was used to determine the size. An instrument based on a clinical case contextualized in real scenarios was applied through self-administration.
Construction of the instrument
The instrument was constructed with 62 items, whose conceptual and content validity was calculated with the evaluation of two rounds of experts with more than five years of institutional experience (care experience) and teaching experience of more than three consecutive years at the time of study, using a consensus of four out of four and a majority decision of three out of four. Based on observations of the first round changes were made to 5% of the instrument items. With the evaluation of the second round it was determined to retain the 62 items (22 related to declarative indicators, 15 to attitudinal, and 25 to procedural). Response options were false, true, and I do not know. The internal reliability was assessed using Cronbach's alpha (0.71).
Taking as reference the number of items in the instrument, nursing staff were classified by competency in accordance with the criteria established by Patricia Benner: less than 12 points, novice; 13-25, advanced beginner; 26-38, competent; 39-51, efficient; 52-62, expert.
To estimate the consistency of the instrument, a pilot test was performed in 20 nurses.
The data collection took place from Monday to Friday in the three shifts, for which the nurses were asked for their collaboration, emphasizing that the information would be used for statistical purposes and guaranteeing confidentiality. The average time for implementation of the instrument was 40 minutes.
Since the research was low-risk, according to the Declaration of Helsinki8 and Reglamento de la Ley General de Salud en Materia de Investigación, it was not necessary to obtain written informed consent from the nurses.
The measurement of the study variables was done with descriptive statistics, after development of a database in SPSS version 20. For comparison of nominal or ordinal variables non-parametric statistics were used (Kruskal-Wallis).
The average age of the 187 subjects in the sample was 39.5 ± 7.7 years, and it ranged between 24 and 54 years; as for sex, women prevailed (87.7%). The prevailing academic level was post-technical with 51.3%; only 2.1% reported master’s degree. The average time of service was 5.2 ± 3.2 years, with a minimum of 5 and a maximum of 26 years. Only 45.4% of respondents mentioned being trained on nursing process; of these, 76.4% had received such training at Instituto Mexicano del Seguro Social; 70% of general nurses and nurse specialists proved to be competent at patient assessment; 52% of floor nursing managers had the same level of competency.
The competent performance of patient assessment was more common in staff with academic level of bachelor's degree (77%) and post-technical training (65%); 50% of staff with master's degrees stood at levels of competent and efficient (Figure 1); 85% of nurses who worked the night shift, 59% of those who worked in the morning, and 59% of those who worked evenings had performance levels of competency (Figure 2).
Figure 1. Competency of nurses by academic level for patient assessment by functional health patterns
Figure 2. Competency of nurses by shift for patient assessment by functional health patterns
Overall, 66% of nurses were found competent at assessing patients, and 20% attained efficiency; the rest were beginner or novice (Figure 3).
Figure 3. Competency of nurses for patient assessment by functional health patterns
The assessment of patient health in all dimensions of the human being is a planned, systematic, continuous, and deliberate process of collection, selection, and interpretation of data. As the first stage of the nursing process, it is depended on for the diagnostic accuracy in clinical trials, the decision in choosing the best interventions, and expected results, which are interrelated and are made explicit through the care plan. Therefore, to perform this process, it is necessary for the nurse to develop a set of technical, intellectual, and relational competencies that enable them in everyday practice to implement and evaluate the care provided to the patient.
Evidence indicates that there were no differences in the competency level for patient assessment between trained and untrained nurses. The results agree with the study of Juvé Udina, in which the competency level of nurses for assessment was lower than expert.1
With these results, it is possible that health organizations may adopt proactive approaches to improve the skills of nurses by identifying when and how to help them. As Diaz-Garcia said, "when the nurse performs their duties at an occupational level, the competency reflects understanding, knowledge, and judgment, along with a range of cognitive, technical, and interpersonal skills, and personal attributes and attitudes".9
As such, the nurse is considered an agent of change and the reason for their existence is to promote the welfare and health of patients; in the care area, they have an established role, which is to provide care according to the physical, physiological, emotional, psychological, and spiritual needs identified in the assessment of each patient, family, or group. Making change involves a long and complex process that will progressively integrate the attitudinal, procedural, and declarative cores in acquiring the desired levels of competency.
According to Patricia Benner, the strategy is to train nursing monitors who make inroads into the operation model of Marjory Gordon, through the systematic and methodical application of the 11 functional health patterns in patient assessment.
The results showed that 66% of the study population showed a competent level and 20% efficient; however, no professional reached expert level. Knowing competency level is an area of opportunity to reflect and redirect the educational processes aimed at nurses, with the intention of improving them.
Given that the nursing process is the methodological tool of the professional work of this discipline and that the key to its success is continuous assessment - which allows decisions on performance and ensures the quality of care - the implementation, monitoring, and progressive analysis of the evaluation of nursing competencies is suggested, inserting strategies to improve conventional training techniques.
The authors declare that there is no personal or institutional conflict of interest of a professional, financial, or commercial nature, during the planning, execution, writing of this article.