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http://journals.bmsu.ac.ir/ijtmghInt J Travel Med Glob Health. 2016;4(1):3-11International Journal of Travel Medicine and Global HealthDOI: 10.20286/ijtmgh-04013Review ArticleOpen AccessCompetency in Nursing Students: A Systematic ReviewBatool Nehrir1, Zohreh Vanaki2, Jamileh Mokhtari Nouri1, Seyyed Mohammad Khademolhosseini1, Abbas Ebadi1,*12Behavioral Sciences Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, IR IranNursing Department, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran*CorrespondingAuthor: Abbas Ebadi, PhD in Nursing Education, Associate Professor, Baqiyatallah University of Medical Sciences, 6thFloor, Nursing Faculty, Tehran, Iran. Mobile: 98-9122149019, Fax: 98-21-82483480, Email: [email protected]: Nursing students require highly specialized competencies to accurately determine patients' states and to predict and cope withproblems that may occur during nursing care. This study explores the definition, domains, and levels of nursing students' competency.Methods: This study was a systematic review of nursing students’ competencies in English (ISI, SCOPUS, Ovid, Proquest, Iranmedex, Googlescholar, PubMed) and Persian (Scientific Information Database) databases (1985–2015), according to the University of York Center for Reviewersand Dissemination Guidance approach, 2008.Results: From a total of 13,115 articles, 20 were retrieved in the final step. The individual experiences, dynamic process, and positive interactivesocial and beneficial changes in the equality of one’s professional life that cause meta-cognitive abilities, touch reality, motivation, decision making,job involvement, professional authority, self-confidence, knowledge and professional skills formulated the definition of nursing students'competency. Educational, cultural, individual, professional and inter-professional, research, clinical and practical domains were defined asbelonging to nursing students' competency. Seven nursing student competency levels were identified.Conclusion: Although the definitions of competency, its domains, and its levels vary by profession and country, this systematic reviewdemonstrated the comprehensive ones in three scopes. However, more research is needed to examine the three scopes in the nursing studentcompetency concept.Keywords: Competency, Nursing Student, Systematic ReviewArticle History: Received: 30 Oct. 2015; Accepted: 10 Jan. 2016; Online Published: 10 Apr. 2016Cite this article as: Nehrir B, Vanaki Z, Mokhtari Nouri J, Khademolhosseini SM, Ebadi A. Competency in nursing students: a systematic review. Int J Travel Med GlobHealth. 2016;4(1):3-11.1. IntroductionHealthcare institutions and organizations face numerouschallenges, such as increasing amounts of information, theintroduction of new technologies, decreased funding, anddemands for accountability [1-3]; the practice of nursingrequires a complex combination of various attributes [4-7],and nursing students require highly specializedcompetencies to accurately determine patients' states andpredict and cope with the problems that may occur duringnursing care [1, 8]. The urgency of adequate nursingcompetencies in changing and improving care is evident.Most employers expect new nursing graduates to be preparedto perform a wide range of functions and have the skills toprovide safe care [1]. Nurses at the undergraduate levelshould play an important role in developing the competencyof new routines in quality improvement programs forpatients [1]. The requirement reflected in one of the firstdefinitions of nursing competency given by Short et al.describes a competency as a quality possessed by someonewithout exact specifications of what one can do in specificcircumstances [5]; however, many employers are concernedthat recent graduates cannot competently perform basicclinical tasks or that their education and work competenciesare disconnected [1].The assessment of clinical competency has always been akey component of clinical education for health professionals[9].Clinical placement experiences are an integral aspect ofpractice development for undergraduate nursing studentsundertaking a Bachelor of Nursing degree to acquirecompetencies and abilities to learn independently, makedecisions, and express ethical commitments [8, 10, 11].Development of nursing practice requires the synchronicityof both knowledge application and clinical skills, andstudents must demonstrate the ability to integrate theseprofessional requirements of the qualified nurse for whichthey are being prepared [4]. Otherwise, the situation resultsin disappointed employers, frustrated new graduates, anddissatisfied patients [12, 13].According to many authors, the most effective way toensure students acquire competencies is to integrate theteaching of those skills into course curricula in a holisticapproach to teach disciplinary knowledge and generic skills[10].A consensus was reached regarding strategies for assessingthe competence of nursing students as they progress throughtheir program of study based on the views of experiencedclinicians and academics [14]. Furthermore, in health caresettings, it is important to assess the competencies that areessential for the professional role of nursing students toprepare them for future professional duties [15].However, extensive review of the literature showed that thedefinition of nursing student's competency, its dimensions,levels, and scopes were obscure. The purpose of thissystematic review was to explore the definition, domains,and levels of nursing student's competency; it sought toanswer the following questions:1. What is a comprehensive definition of nursing students'competency?2. What are the domains of nursing students' competency?3. What are the levels of nursing students' competency?2. MethodsFor this systematic review of the competency of nursingstudents, the University of York Center for Reviewers andDissemination Guidance approach was used as the researchframework [16, 17]. This approach has seven steps asfollows:

2.1. Research Question FormulationThe study questions were three:1. What is the comprehensive definition of nursingstudents' competency?2. What are the domains of nursing students' competency?3. What are the nursing students' competency levels?2.2. Defining Search StrategyAn extensive review was made of the available literature inEnglish and Persian databases (1985–2015), including ISI,SCOPUS, Ovid, Proquest, Iranmedex, Google Scholar, PubMed, and Scientific Information Database (SID). Thekeywords searched included "nursing student competency,""nursing student ability," "undergraduate nursescompetency," “nursing student professional," "nursingstudent skill," "clinical and educational nursingcompetency," “clinical qualification in nursing student,” anddifferent combinations of the aforesaid words. To find morerelated articles, the references of the searched articles eralization of the retrieved final data, information, andknowledge was increased through a general and specificsearch on http://www.searchenginelist.blogfa.com. Thementioned site has several engine and super-engine searchmotors on different topics and scopes. In this section, oceansand oceans of data and information were retrieved. Some ofthe retrieved materials were repetitious and similar topreviously searched documents, but some novel materialswere detected and used in responding to Question 2.Keywords in the selected databases were utilized in the title,abstract, and keyword domains. It should be noted that somedatabases have overlap as some articles were cited in severaldatabases. A reference manager software (Endnote version7) was used to prevent re-entry of any retrieved articles.2.3. Setting the Inclusion and Exclusion CriteriaThe inclusion criteria for articles were publication from1985 to August 2015; written in either the English or thePersian language; electronic publication with a formal peerreview process; congruency between the topic of the articleand the study questions and purpose; application of differentaspects of competency in nursing students; and originality ofthe paper. A total of 13,115 articles were found, including7,730 articles in Pub Med, 3,590 in Google Scholar, 75articles in Ovid, 14 articles in Proquest, 23 articles inIranmedex, and 1,683 articles in SID. Searches wereconducted by three members (AVA, AE, and BN).2.4. Designing Quality Investigation ChecklistA checklist was designed based on the inclusion criteria,and all articles were assessed accordingly.2.5. Usage of the ChecklistThe full text of the articles was investigated according tothe designed checklist described in the previous step. Afterthe quality of the articles was checked, only 20 articles wereretrieved in the review process (Table 1) [1, 4, 15, 18-34].The validation processes were conducted by three members(AVA, AE, and BN).2.6. Deriving the Question's ResponsesBased on the research questions, the responses wereextracted from the retrieved articles in the review process.2.7. Combination of Information Derived from RetrievedArticlesInformation derived from the retrieved articles regardingthe study questions and purpose were combined in this step.Figure 1 demonstrates the flow diagram of the articleselection.3. ResultsFrom 13,115 articles selected in the first step, only20 articles remained in the last step. The coreconcepts in the nursing students' competency scopewere related to the definition, domains, and levels ofnursing student's competency. In the following, theresponses of the questions are explained.3.1. First Question: Comprehensive Definition of NursingStudents' CompetencyThe common usage domain of the word “competency”existed in nursing and midwifery education from 1983 untilthe present; however, authorities have expressed concernover the lack of knowledge and skills of graduating nursingstudents, saying that they are not necessarily equipped towork [24]. Defining and measuring competency in nursingstudents is difficult [35].Potentially relevant papers were identified by the extensive review of the literature search (n 13115)Excluded duplicated articles (n 8427)Papers evaluated by the title and abstract according to the inclusion and exclusion criteria and relevancy to the review questions (n 4688)Excluded irrelevant articles (n 4635)Full text of the retrieved papers were concisely assessed according to the inclusion and exclusion criteria and relevancy to the review questions bythe critical appraisal checklist (n 53)Excluded articles after critical appraisal (n 33)Retrieved papers were included in the final review process according to the inclusion and exclusioncriteria and relevancy to the review questions by the critical appraisal checklist (n 20)Figure 1. Flow diagram of articles selection

Author &DataRunning TitleStudyDesignParticipants (n)Ebadi(2015)(1)ClinicalCompetence ofCritical CareNursing StudentsDescriptivecrosssectional250 MSc studentsof critical carenursingFan, et al(2015)(2)PerformanceEvaluation ofCompetency-basedEducationQuasiexperimentalKim Fan,et al(2015)(3)Professional Qualityof Life and ClinicalCompetenciesKhomeiran,etal(2006)(4)Table 1. Final retrieved articles in the review processInstrument/Main ve domains and higher areas ofclinical competency.312 second-yearundergraduatenursing studentsOSCE ChecklistHigher scores in medical–surgicalnursing courses and practicum,after adjusting for sevencovariates.Crosssectional335 nurse studentsThe Pro QOLQuestionnaireLow Pro QOL experience, can benegatively impacted on theclinical competenceInfluencing Factorsof ProfessionalCompetenceDevelopmentContentanalysis27 iewsWu, et al(2014)(5)Application ofNursing CoreCompetencyStandard EducationQuasiexperimental42 gbaghery, etal(2004)(6)Iranian Nurses'Understanding andExperiences ofProfessional PowerGroundedtheoryapproach44 participantsSemi-structuredinterviews andparticipantobservationmethodsLičen, et al(2015)(7)NursingCompetencyAssessment Toolsand Possibility Usein NursingEducationSystematicliteraturereviewÄäri, et al(2008)(8)Competence inIntensive andCritical CareNursing.SystematicliteraturereviewForsberg, etal (2014)(9)Clinical Reasoningin Nursing is a basefor an ce, opportunities,environment, personalcharacteristics, motivation andtheoretical knowledge wereidentified.Significantly higher performancein the health informationcollection, physical assessment,scenario simulation andcommunication in theexperimental groupTo enhance the efficiency ofthe course a revisedcurriculum is recommended.Competency-based educationis worth implementing andmay close the gap betweeneducation and the everchanging work environment.As professional quality oflife may affect clinicalcompetence, increase nurses'compassion satisfaction andrelieve compassion fatigueare needed.Influencing factors ofprofessional competencedevelopment extend acrosspersonal and extra-personaldomains.ThemeCare management; Practical competency; Scholarship; Patientcentered. and Individualized managementCompetency-based education; meta cognitive, and abilities.Professional quality of lifeTouching the realities, decision making, learning, opportunities,precious experience, job involvement, motivated agent, andtheoretical knowledge.Nursing core competencystandard education is helpfulfor the training of nursingstudents' core competenciesNursing core competency standard education; professionalknowledge; professional skills; medical humanistic knowledge;rich clinical knowledge of interdisciplinary.Application of knowledge andskills gives feeling powerful innursesNurses' power depends ongaining and applyingprofessional knowledge andskillsApplication of knowledge and skillsAuthority; Being self-confident; Unification and solidarity;Being supported, Organizational culture, and organizationalstructure.7 studiesPRISMAflowchartmethodologyAssessment of clinicalcompetences by access to somehighly reliable toolsFor measures actual clinicalnursing competences, it isimportant to compose anassessment tool in eachcountry.Cognitive performance; critical thinking; general clinical skills;basic biomedical science; humanity; responsibility;communication; teamwork ability; patient care; ethics;accountability;Lifelong learning; simulation, and skill verification.45 articlePRISMAflowchartmethodologyIn intensive care nursing clinicalcompetence has three andprofessional competence fourconstituent domains.Competence in intensive carenursing differs from overallcompetence in nursing.Knowledge base; Skill base; Attitude and value base;Experience base; Ethical activity; Decision making;Collaboration; Development work; Nursing intervention;Clinical guidance, andPrinciple of nursing care.For making clinical decisions,high specific competence andexperience was so important.For assessing the clinicalreasoning process andclinical decision making,virtual patient's model issuitable but how to score andgrade such exams is thechallenge.Hypothesis orientation; high specific competence, and highspecific experience.30 RNsShort interviewwith structuredquestions

Author &DataWallace, etal (2014)(10)Wilhelmsson, et al(2012)(11)Kelton(2014)(12)Hagbaghery, et al(2004)(13)Olson(2014)(14)Andreou,et al(2013)(15)Running TitleSkill Developmentand ReflectiveWriting RubricsStudyDesignTwo FocusgroupssessionParticipants (n)Instrument/ToolMain ResultsConclusionThemeRubrics(scoring toolsspecifyingexpectations forsuccessfulperformance)Rubrics scoring tools clarifylevels of competency inpractitioner nurseHaving a completeunderstanding of thetransitional needs of newNPs from students toadvanced practitioners canmarkedly improve futureefforts in role developmentand skill acquisition andthereby ease the shortage ofPCPs.Analytic skills; Communication skills; Policydevelopment/program; Planning skills; Cultural skills; Basicpublic; Health sciences skills; Financial planning, andmanagement skills.78 studentsThe metacognitive modelas a tool fordesigning IPEcurriculaA meta cognitive model for interprofessional education andpractice has been developed as atool for analyzing professionalcompetence on three levels:individual, team and organizationwith seven basic components ofprofessional competence and theway they are related and interact.The IP learning situations forIPE educators anddeveloping professionalpractitioners is more helpfulthan one profession’sperspective.Teamwork and group processes; Reflection and documentation;Communication; Shared knowledge or general commonknowledge, and Ethics.Using Clinical Coaching modelfor nursing students hassuccessful outcomes for them8 NP facultymembers andpreceptorsInter nical CoachingSystematicliteraturereview188 ating andInhibiting Factors inClinical DecisionMakingQualitativemethod38 participantsSemi-structuredinterviews andparticipantobservationTwo groups of internal andexternal variables can facilitate orinhibit the nurses' clinicaldecision making.93 studentsPRISMAflowchartmethodologySome domains have been used todevelop a framework forintegrating one healthcompetencies into programmers'and curricula based on a commonunderstanding of an interprofessional, multi-sectorialapproach to operating effectivehealth systems from the village tothe clinic.6 studiesThe guidance ofthe Centre forReviews andDisseminationLearning styles' diversities, weakcritical thinking and inconsistentevolution through academicprogress were revealed acrossstudies. Critical thinking differedsignificantly between learningstyles.Interactive Processfor Cross SectorialDevelopmentLearning Styles andCritical reviewClinical Coaching beginswith referral of a studentwhose clinical nursingpractice has raised concernsamongst the supervisingclinical staff.Being competent and selfconfident are the mostimportant personal factorsinfluencing nurses clinicaldecision-making.Priorities include theproduction of a working setof competency domains.Sharing of these domains ismore important thanownership or approval andinforming work in globalhealth about commonalitiesbetween and amongdevelopment efforts formsthe basis for accomplishmentof the goal.All learning styles might bepositive determinants towardcritical thinking evolution,suggesting that there is arelationship between learningstyles and critical thinking.Unconsciously incompetent; Consciously incompetent;consciously competent, and Unconsciously competent.Feeling; Competent; being self-confident; Organizationalstructure;Nursing education, and being supported.Communication conflict resolution systems analysis/thinking;values and ethics; Creating an enabling environment, advocatingchange;Teamwork, and leadership management.Predominant learning styles; Critical thinking scoring; Criticalthinking evolution across academic progress; Learning styles–criticalthinking correlations

Author &DataBallangrud,et al(2014)(16)Running TitleIntensive CareNurses’ Perceptionsof Simulation-basedTeam nts (n)Instrument/ToolMain ewsTraining increases awareness ofclinical practice andacknowledges the importance ofstructured work in teamsIntensive care nursesperceive simulation-basedteam training has advantagesfor building patient safety inthe ICU and that realistictraining makes them moreprepared to care for severelyill patients.Realistic training contributes to safe care reflection andopenness motivates learning, and finding a commonunderstanding of team performance.36 NursesSemi structuredinterviewsClinical competency is acquiredwhen the nurse has an awakenedconscience, possesses aphilanthropic personality, has asense of professionalresponsibility in any clinicalsituation, and aims to seek outessential knowledge and expertiseto provide care in a confidentmannerNurse resorts to sense ofresponsibility andaccountability towardprofessionalObligations in the course of apatient-centered approach tofulfilling their diverseprofessional duties.Philanthropy strong conscience; being attentive; acceptingresponsibility; being committed to and respecting self and othersAppropriate; management systems; in-service training;provision employment laws; control mechanisms; suitable andadequate equipment; love of the profession; critical thinking;nursing knowledge; professional expertise; self- assurance; selfrespect; responsibility; accountability; nursing science; interestin profession, and professional proficiency.The implementation of the NPserved to tackle issues such asexpected shortages in workforceand value for money.18 intensive carenursesVanaki, etal (2009)(17)Professional EthicsQualitativemethodNiezen, etal (2014)(18)ReframingProfessionalBoundaries inHealthcareSystematicliteraturereview13 l health andintellectualdisability nursing(n 16).Nursingpreceptors (n 837)Semi-structuredinterviewAttitudes to competencies; beinga preceptor, and competencies inpractice were categorized.DescriptiveCrosssectionalMaster’s degreefemale withteachingresponsibilities inboth theclassroom andclinical settingsQuestionnaireEducation related to the safety,teamwork, and collaborationcompetencies occurs morefrequently in the clinical settingthan in the classroom.Cassidy, etal (2012)(19)Cabaniss(2014)(20)Preceptors’ Viewsof AssessingNursing StudentsCompetencies ofQuality and SafetyEducationIntroducing nursepractitioners in healthcarerequires organizationalredesign and the reframing ofprofessional boundaries.The importance of a regionaland national review ofcompetency assessmentsystems to find a commonlanguage for studentassessment as well aspromoting greater studentskill development withincompetency frameworks isrecommended.The concepts of quality andsafety, although familiar tofaculty, are not identifiablenor taught at the complexitylevel.Knowledge and capabilities; professional boundaries;organizational environment, and institutional environment.Attitudes to competencies; being a preceptor, and competenciesin practice.Safety and teamwork collaboration

In the literature review, competency in general has beendefined as “the ability to perform the task with desirableoutcomes under the varied circumstances of the real world”[24], and as “the overlap of knowledge with the performancecomponents of psychomotor skills and clinical problemsolving within the realm of affective responses” [36].Competency has general attributes that refers to havingability to successfully perform something [37]. Moreover,the concept in nursing practice has multi factorial naturesincluding empirical evidence, behavioristic, generic, holisticrole [38] and responsibility [39]. Competency has also beendefined as the skill and ability to practice safely andeffectively without the need for direct supervision, and as alevel of performance demonstrating an effective applicationof knowledge, skill and judgment [40]. Moreover,competency reflects knowledge, understanding andjudgment, a range of skills, and a range of personal attitudesand attributes [41].Based on the extensive literature review in this study(Table 1), researchers believe that nursing students'competency is the individual experiences, dynamic process,and positive interactive social and beneficial changes in theequality of one’s professional life which causes metacognitive abilities, touch reality, motivation, decisionmaking, job involvement, professional authority, selfconfidence, knowledge and professional skills, in which areincluded the five factors of "nursing process," "caring,""professionalism," "communities," and "diversity." Thebasic factors of nursing students' competency (Figure 12)were provider of care, manager of care, and professionalidentity, all three of which are very important in the progressof nursing students. Basically, they are basically theinfrastructure of nursing students' competency levels.3.2. Second Question: Domains of Nursing Students'CompetencyAccording to the review of the literature (Table1),competency in nursing students has 6 domains and 12 subdomains. Educational-based competency, Cultural-basedcompetency, individualized-based competency, researchbased competency, professional and inter-professionalbased competency, and clinical and practical-basedcompetency were defined as nursing students' competencydomains (Figure 12).3.3. Third Question: Levels of Nursing Students'CompetencyThe literature review (Table 1) indicated that experiences ofresearchers in the nursing students' competency scope [18],the three basic factors of nursing student's competency(provider of care, manager of care, and professionalidentity), and the combination of the matters define sevenlevels as follows:1. Nursing students do not have sufficient acceptablelevels of educational and clinical abilities.2. Nursing students have sufficient and acceptable levelsof educational abilities but his/her abiliities still need tobe checked and supervised; they do nothave sufficientand acceptable levels of clinical abilities.3. Nursing students have competency in educationalabilities, but still need occasional checking andsupervision in his/her abilities; they do not havesufficient and acceptable levels of clinical abilities, butdo have minimal abilities in the clinical settings.4. Nursing students are proficient in educational abilities,but still need periodic checking and supervision ofhis/her abilities; they are competent and have sufficientand acceptable levels of clinical abilities, but may alsoneed occasional checking and supervision in his/herabilities.5. Nursing students are expert in educational abilities, areproficient, and have sufficient and acceptable levels ofclinical abilities; they may need periodic checking andsupervision in his/her abilities.6. Nursing students are expert in educational and clinicalabilities, but may need to be reminded by theirsupervisors of some special points in educational andclinical settings .7. Nursing students are expert in educational and clinicalabilities and are teachers and supervisors of educationaland clinical skills and proficiencies.4. DiscussionIn this study, the researchers sought to define and describethe definition, domains, and levels of nursing students’competency in light of previous studies using the systematicreview approach. Definitions of competence vary byprofession and country [42, 43], and many of the studiesreviewed offered no clear or coherent definition ordescription of the mentioned concepts (Table 1). In theEnglish language, the terms competence and competency areoften used interchangeably. The term ‘competency’ shouldstrictly be used for a “skill” itself, while competence is “theability to perform that skill and the attribute of theperformer” [42, 43]. In this study, nursing students'competency was clearly defined, and 6 domains with 12 subdomains of nursing student's competency were identified(Figure 2). Moreover, seven steps of nursing students'competency were introduced for the first time incompetency-related literature.The main purpose of the different domains of nursingstudents' competency is proper, correct, and exact use ofknowledge and skills and the ability to apply the three basicfactors of care management, care providing, and achievingand demonstrating a professional identity in differentacademic and clinical settings (Figure 12). This is congruentwith the declaration that competency represents theintegration of knowledge, skills, values, and attitudes [42,43].In other words, the definition, domains, and levels ofcompetency should separate the novice student from theexpert student in the progress of different working,academic, and clinical settings. However, there are someproblematic areas in the application of the mentionedconcepts, including assessment and measurement of clinicalcompetency, general versus specific competency, anddivergent values among stakeholders.In the assessment and measurement area, it is necessary tonote that competency is difficult, perhaps impossible, tomeasure [44]. It is also problematic to determine at whatlevel of performance a student should be deemed competent[42, 43]. In this study, however, seven levels were identifiedfor overcoming the problems in different clinical andacademic settings. Moreover, the holistic nature ofcompetency which “identifies broad clusters of generalattributes which are considered essential for effectiveperformance” means that competency is “more than the sumof individual competencies” [45]. This definition resists thebreaking down of competency into more manageable andmeasurable pieces, and objective assessment of competencesuffers as a result.

Educational-basedCompetencyReflection [9], Problem solving [7], Blueprinting [35], Problem-based learningapproach [7], Scientific approach and critical thinking [2]Feedback [2], Lifelong learning [1], Coaching [3], Service learning [5], Criticallyevaluating [3]Racial/ethnic disparities in healthcare [11], Ineffective or lower quality careculturally/linguistically inappropriate [17], Cultural innovations in healthcaresystem and structure design [7], Interactions between patients and healthcare staff[14], Lack of diversity in healthcare leadership and workforce [9], Cross-culturalcommunication between healthcare providers and patients mmunication [5], Values and beliefs [3], Social determinants (cultural prerequirement) [23], Minority recruitment [16], Socio-cultural differences [3]Blueprinting [35], Problem solving [7],

definition of nursing student's competency, its dimensions, levels, and scopes were obscure. The purpose of this systematic review was to explore the definition, domains, and levels of nursing student's competency; it sought to answer the following questions: 1. What is a comprehensive definition of nursing students' competency? 2.