INTRODUCTION:

Nursing professionals constitute about 75% of the hospital workforce¹. Globally there is a shortage of nurses which has always remained a challenging problem.^2,3 Nursing education refers to formal learning and training in the science of nursing.⁴ New nursing graduates are increasingly being employed to address nursing shortage.⁵

Entering world of nursing presents students with an array of changes. Still in their teens, they are asked to change both from adolescent to adult and from lay person to a professional.⁶However their nursing curriculum gives only brief exposure of complex hospital environment.

When approaching graduation; nursing students are expected to have adequate clinical competence to fulfill their duties safely and effectively.⁷In a study done by Devakirubai E. it is suggested that nurse educators to re-examine and to use innovative clinical teaching strategies to promote an effective learning environment ⁸. When after several years of educational preparation they go to clinical they experience reality shock⁹. Thus Clinical competence evaluation is very significant as mentioned in a study done by Aniruddh kubavat integrated form of evaluation seeking to combine knowledge, understanding, problem solving, technical skills, attitudes, and ethics in evaluation. Evaluation, as a way of determining the clinical competence, is one of the fundamental principles of development and student achievement measurement in nursing education¹⁰. Clinical evaluation has always been a challenge for all, especially students as they are being evaluated¹¹

Nursing graduates are expected to be competent in a range of skills for patient management. Patients have the right to expect quality of nursing care be it from a new nursing graduate or an experienced one¹². These skills includes, “physical examination, wound care, management of tubing’s and drainages, positioning, medication administration, intravenous therapy, chest physiotherapy, suctioning, airway management, patient education, infection control, and patient safety”.^7,8

However, it has been documented in many nursing studies that newly graduated nurses feel their inability in many areas as to take decisions independently without any help from senior nurse practitioners in complex clinical situations. It is thus suggested based on the findings of these studies that clinical competence of new nurse’s needs ongoing improvement and development.^8,15For this the gap in the competencies of a nursing student needs to be identified first.

In a review of 10 years of data for new nurses on performance based development system, 65% to 76% did not meet expectations for entry level clinical judgment and majority had difficulty in translating knowledge and theory into practice.⁵ Results from a national survey of new graduate nurses conducted in 2004–2005 further supports the existence of a gap in competence levels of new nurses .^16,18If the assessment of clinical competence is done at the point of graduation it enables the graduate to prepare for specific shortcomings as well and an individual tailored induction program can be planned.

Competence in nursing mainly refers to “knowledge and or skills and professional standards”.^19,20 Nurses to care with their hearts and minds to provide comfort to the patient and they need to be critical thinkers, good communicators and abreast of all the important aspects of patient care¹¹.There had been few researches conducted to develop tools to measure competence of nursing graduates. Lack of valid and reliable tools to assess competence is suggested in literature review.^{7, 16, 18}

The studies identifying essential nurse competencies as available in the literature were mostly descriptive, had small convenience samples, based mainly on nursing skills and were not developed based on theoretical models. Strong reliability and validity was also lacking.^22-24

Most of the instruments used to measure nurses competence were for those practicing in clinical sites than student nurses and nursing teachers .^25,7Thus very few available studies are documented which measured clinical competence in new nursing graduates. However “the competence of graduating nursing students is an important issue in health care as it is related to professional standards, patient safety and the quality of nursing care”.²

AIM:

To establish reliability and validity of CCSAT.

MATERIALS AND METHODS:

A Cross sectional descriptive study design was used to collect the data. Study period was from December 2017 to February 2018. Research setting was 09 randomly selected (using lottery method) nursing colleges of Western Uttar Pradesh.

A sample of 410 upcoming nursing graduates were self-administered CCSAT. The sample size was determined on the basis of the number of items of the tool.

Data collection tools:

Clinical Competence Self Assessment Tool (CCSAT):

this tool was developed using literature review, Delphi consensus and try out of the tool on a sample of 210 upcoming nursing graduates.¹ The developed tool had a total of 92 items post pilot study and had “three subscales with 19 items in the professional behavior, 20 items in knowledge and 53 items in skills subscale”.

The Professional behavior subscale had 19 items with 10 items on professional conduct, ethics and professional development; 03 items in awareness of maintaining therapeutic environment for the client; 04 items on communication with client and health care team; and 02 items on implementing critical thinking in patient care.

The Knowledge subscale had 20 items with 01 item on basic health sciences; 04 items on nursing science and 15 items on theory of common nursing procedures.

The skills subscale had 53 items with 03 items on health assessment; 42 items on nursing care skills; and 08 items on observation and communication skills.

Procedure for data collection:

Obtained written consent from study subjects. CCSAT was self-administered and took 30-45 minutes for tool completion.

Data analysis was done using descriptive analysis, exploratory factor analysis for construct validity and Cronbach’s alpha for measuring internal consistency. Principal component factor analysis was used. For deciding the number of factors to extract scree plot and Kaiser’s criterion was used. KMO test and Bartlett’s test of sphericity were used to determine sample adequacy and appropriateness of data for factor analysis.

RESULTS:

Majority of study participants 332 (81%) were females with a mean age, of 21 years. Majority 384(93.7%) were 12th pass at the time of joining nursing course. For reason for choosing nursing as a career about half 201(49.0%) joined as a forced decision from their parents. Majority of the subjects preferred working in hospital, more than half 233(56.8%) preferred to work in government hospital however 74(18.0%) in private hospital. Majority 342(83.4%) of the participants expressed that they will not consider leaving nursing profession in future however 58(14.1%) were of the view to leave. A large number of subjects 297(72.4%) were satisfied with the nursing education imparted at their nursing institute however 78(19.0%) were somewhat satisfied and 35(8.5%) were not at satisfied. Majority 262(63.9%) of the subjects opined that preparedness for clinical practice based on the nursing education was totally sufficient in their nursing institute, however 118(28.8%) felt that it was somewhat sufficient. A large number of the subjects 313(76.3%) were of opinion that supervision in clinical area helps in developing competence. Majority 313(76.3%) felt that the clinical experience provided at their institute was adequate. A large number of subjects 306(74.6%) felt that they are ready to work in hospital at the point of their graduation.

Table 1: Results of KMO & bartlett’s test of sphericity

Scale name	KMO	Bartlett’s test of sphericity
CCSAT-Professional Behavior Subscale	0. 760	Df 171, p<.000
CCSAT - Knowledge Subscale	0. 776	Df 190, p<.000
CCSAT - Skills Subscale	0. 883	Df 1378, p<.000

The data is considered suitable for factor analysis if KMO value is > 0.8 and p values <0.00. As for all the subscales the KMO value is >0.76 and the p values was also < 0.00 the Factor analysis was considered.

Table 2: Results of FA for Professional Behavior subscale

Factors	Item	Eigen values	Variance %	Cumulative %
I	8,9,10,17,19	4.843	25.489	25.489
II	1,2,3,4	1.863	9.805	35.294
III	13,14,15,16	1.687	8.880	44.175
IV	5,6,7	1.546	8.138	52.313
V	10,11,12	1.106	5.823	58.136

Five factors were extracted using Kaiser’s criterion (factors with Eigen values of >1 were retained) for professional behavior subscale. No items were reduced prior and post factor analysis. Thus all the 19 items were retained in professional behavior subscale post main testing.

Table 3: Results of FA for knowledge subscale

Factor	Item no.	Eigen values	Variance %	Cumulative %
I	1,2,3,4,5	5.456	27.279	27.279
II	7,8,9,10	1.791	8.957	36.236
III	16,18	1.714	8.570	44.806
IV	11,12,13,14,15	1.327	6.635	51.442
V	19,20	1.180	5.899	57.340
VI	17	1.108	5.542	62.882

Six factors were extracted for knowledge subscale. Item 11 had secondary loadings. It loaded on factor II at 0.456 and on factor IV at 0.494 however was retained in factor IV. Item 6 (principles of medication administration had no loading >0.40 on any factor thus with the experts consultation it was deleted. One item was deleted post main testing in knowledge subscale thus retaining a total of 19 items.

Table 4: Results of F results for skills subscale

Factor	Item no.	Eigen values	Variance %	Cumulative %
I	1-7	17.104	32.273	32.273
II	8-14	3.699	6.980	39.252
III	19-25	3.131	5.907	45.159
IV	30-35	2.137	4.032	49.190
V	50,51	2.018	3.808	52.999
VI	46-49	1.891	3.569	56.567
VII	36-39	1.657	3.127	59.694
VIII	15-18	1.430	2.699	62.393
IX	26-28	1.293	2.439	64.832
X	15-18	1.204	2.271	67.104
XI	44-45	1.100	2.076	69.180
XII		1.038	1.959	71.139

Twelve factors extracted using Kaiser’s criterion for skills subscale. Item 29, providing care to a patient with splint was deleted with experts consultation as had no loading >0.40 on any factor.

Many items had secondary loadings and as per experts suggestions were retained in the most relevant factor. One item was deleted post main testing in skills subscale thus retaining a total of 52 items.

Reliability of CCSAT:

Cronbach’s alpha was calculated to assess internal consistency of CCSAT. The overall Cronbach’s alpha value of CCSAT developed in current study was calculated as shown below in table 5. For all the subscale it was between0.83 to 0.95 and for overall CCSAT it was 0.96 (Ideally Cronbach’s alpha coefficient should be > 0.70) and item score to total score correlation was between 0.2-0.91. Though for few items the item score to total score correlation was < 0.2 and when the individual item was deleted the Cronbach’s alpha value of the item did not increase that meant all items were internally consistent and contributing to the total reliability of the checklists but for few items Cronbach’s alpha value increased when that individual item was deleted. It indicated that these items were not contributing to the total reliability of tool and could be discarded.

No change in Cronbach’s alpha was noted with the deletion of any item. For a scale to be reliable the Cronbach’s alpha value should be more than 0.70. In this CCSAT all the subscales achieved value more than 0.83 thus all subscales were found reliable and none of the items were deleted. As a whole the tool achieved Cronbach’s alpha value of 0.954.

DISCUSSION:

The nursing graduates constitute around 10% of the hospital nursing staff. As maintaining patient safety and reducing cost burden of health care it is crucial to determine the competence area gaps so as to assist in their adjustment to the demanding and dynamic clinical setting. The baccalaureate study equips a nursing student with theoretical knowledge and fundamental skills but they may still lack confidence and adequate clinical exposure. Challenge remains for the promotion of nursing student’s competence before graduation. In the past very few studies have been done to assess competence of the upcoming nursing graduates. Thus it becomes pertinent to develop tool to assess their competence so that the weakness areas can be identified and focus can be given to improve them.^3,4,5

“Clinical Competence Self Assessment Tool” assesses perceived clinical competence of upcoming nursing graduates. Cronbach’s alpha and Principal Component Analysis was applied to check the content and construct validity of the tool. Cronbach’s alpha of newly developed tool should be 0.60 as per literature¹⁹, for CCSAT it was 0.953 suggesting its reliability.

When compared with similar studies, as in a tool developmental study by Shwu-ruliou and Ching yu cheng in Taiwan who developed Clinical Competence Questionnaire” the Cronbach’s alpha was found to be 0.98.¹⁸In another study by Jan Nilsson et al who developed a tool for self reported professional competence, had 88 items and eight factors. All the factors achieved Cronbach's alpha values > 0.70.²⁰

Two tests Bartlett’s test of sphericity and Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy assess suitability of data for EFA. Bartlett’s test of sphericity should reach a significance of p < 0.05 and the KMO index should be > 0.6.^21,22 The KMO value for all the three subscales for CCSAT was > 0.76. Bartletts test of sphericity values for all the three subscales was <0.00. In a similar study on Validation of a Sonographer Skill-Teaching Questionnaire KMO and Bartlett’s value was >0.5.

Exploratory Factor Analysis identified five, six and twelve factors in professional behaviors, knowledge and skills subscales each with 58%, 63% and 71% variance.²³ As per literature, item extraction to continue until researcher reaches at least 60% variance.^19,21,22 Thus variance explained by the factors in present study was found to be appropriate.

CONCLUSION:

The newly developed Clinical competence self assessment tool is found valid and reliable in its pilot testing. The tool can be tried on a larger sample to further establish its reliability and validity.

CONFLICT OF INTEREST:

Nil.

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Received on 24.09.2021 Modified on 15.01.2022

Int. J. Nur. Edu. and Research. 2022; 10(2):104-108.

DOI: 10.52711/2454-2660.2022.00024

Subscale name	No of items	Scoring range	Cronbach’s alpha		Mean inter item correlation (min/max)	Mean score, SD before and after deletion
Subscale name	No of items	Scoring range	Before deletion	After deletion	Mean inter item correlation (min/max)	Mean score, SD before and after deletion
Professional behavior subscale (n=410)	19	0-3	0.831	Nil deleted	0.208(-0.087/.584)	44.44±7.322
Knowledge subscale (n=410)	20	0-2	0.855	0.850	0.229 (-.041/ 0.636),	31.73± 5.865/30.01, 5.634/30.01
Skills subscale (n=410)	53	0-4	0.958	0.957		±/154.52, 30.959±5.634
CCSAT (n=410)	92		0.954	0.953	2.539(1.273/3.693) / 2.544(1.273/3.693)	233.60±37.152 / 228.98±36.283