A short version of the nurse professional competence scale for measuring nurses' self-reported competence

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Nilsson, J., Engström, M., Florin, J., Gardulf, A., Carlsson, M. (2018)

A short version of the nurse professional competence scale for measuring nurses'

self-reported competence

Nurse Education Today, 71: 233-239

https://doi.org/10.1016/j.nedt.2018.09.028

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Nurse Education Today

A short version of the nurse professional competence scale for measuring

nurses' self-reported competence

Jan Nilsson

_{, Maria Engström}

_{, Jan Florin}

_{, Ann Gardulf}

_{, Marianne Carlsson}

a_{Department of Health Sciences, Faculty of Health, Science, and Technology, Karlstad University, SE-651 88 Karlstad, Sweden} b_{Department of Health Promotion Sciences, Sophiahemmet University, SE-114 86 Stockholm, Sweden}

c_{Japanese Red Cross Institute for Humanitarian Studies, Tokyo, Japan}

d_{Department of Health and Caring Science, University of Gävle, SE-801 76 Gävle, Sweden} e_{Department of Public Health and Caring Sciences, Uppsala University, SE-751 22 Uppsala, Sweden} f_{School of Education, Health and Social Studies, Dalarna University, SE-791 31 Falun, Sweden}

g_{Unit of Clinical Nursing Research, Immunotherapy and Immunology, Clinical Research Center, Department of Laboratory Medicine, Karolinska Institutet, SE-171 77}

Huddinge, Sweden

A R T I C L E I N F O Keywords:

Nurses' competence Nursing students' competence Professional nursing Nursing education Validation

Psychometric properties

A B S T R A C T

Background: The Nurse Professional Competence (NPC) Scale with 88-items has been used to measure self-reported competence among nursing students and registered nurses in many national and international nursing research projects. However, a shorter version of the scale with maintained quality has been requested to further enhance its usability.

Objectives: To develop and evaluate the construct validity and internal consistency of a shorter version of the NPC Scale.

Design: A developmental and methodological design.

Participants and Settings: The study was based on a sample of 1810 nursing students at the point of graduation from 12 universities in Sweden.

Methods: The number of items in the original NPC Scale was reduced using several established research steps and then evaluated for data quality and construct validity using principal component analysis and confirmatory factor analysis. Reliability was measured as internal consistency using Cronbach's alpha.

Results: The extensive process of reducing the number of items resulted in a version with 35 items. Principal component analysis resulted in six factors explaining 53.6% of the variance: “Nursing Care”, “Value-based Nursing Care”, “Medical and Technical Care”, “Care Pedagogics”, “Documentation and Administration of Nursing Care”, and “Development, Leadership, and Organization of Nursing Care”. All factors showed Cronbach's alpha values of > 0.70. The confirmative factor analysis goodness-of-fit indexes were for root mean square error of approx-imation 0.05 and for comparative fit index 0.89.

Conclusions: The NPC Scale Short Form (NPC Scale-SF) 35-items revealed promising results with a six-factor structure explaining 53.6% of the total variance. This 35-item scale can be an asset when used alone and together with other instruments it can provide the possibility of more complex analyses of self-reported competence among nursing students and registered nurses.

1. Background

In 2014, the Nurse Professional Competence (NPC) Scale for mea-suring self-reported professional competence among nursing students and registered nurses was published (Nilsson et al., 2014a). The NPC Scale consisted of 88-items and was based on competence requirements

for registered nurses (RNs) published by the National Board of Health and Welfare in Sweden (The National Board of Health and Welfare, 2005) andWHO (2001). The 88-item version of the NPC Scale will henceforth be called the original NPC Scale.

The original NPC Scale measures nursing competence in the fol-lowing eight competence areas, with Cronbach's alpha values ranging

https://doi.org/10.1016/j.nedt.2018.09.028

Received 8 March 2018; Received in revised form 5 September 2018; Accepted 25 September 2018

⁎_{Corresponding author at: Department of Health Sciences, Faculty of Health, Science, and Technology, Karlstad University, SE-651 88 Karlstad, Sweden}

1_{The two authors have contributed equally.}

E-mail addresses:jan.i.nilsson@kau.se(J. Nilsson),Maria.Engstrom@hig.se(M. Engström),jfl@du.se(J. Florin),ann.gardulf@ki.se(A. Gardulf), Marianne.C.Carlsson@hig.se(M. Carlsson).

0260-6917/ © 2018 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

from 0.75 to 0.94 for the single competence area: Nursing Care, Value-based Nursing, Medical and Technical Care, Teaching/Learning and Support, Documentation and Information Technology, Legislation in Nursing and Safety Planning, Leadership in and Development of Nursing and Education and Supervision of Staff and Students. The eight competence areas construct two overarching themes: Patient-Related Nursing and Organization and Development of Nursing Care. Satisfactory results regarding data quality, validity and reliability was found when psychometric properties of the original NPC Scale were investigated (Nilsson et al., 2014a).

The original NPC Scale rapidly attracted national and international interest and it has been translated into sex languages, including English (Nilsson et al., 2016a). The original NPC Scale has been used to assess self-reported competence among nursing students on the point of gra-duation (Gardulf et al., 2016), between students with or without in-ternational study experience (Nilsson et al., 2014b), and after curri-culum changes to a three-year university program (Theander et al., 2016). The original NPC Scale has also been used to measure self-re-ported competence among RNs; conflict management (Leksell et al., 2015), competence to manage violence, serious events, and disasters (Nilsson et al., 2016b), and the effects of inter-professional education in prehospital emergency care (Castrèn et al., 2017). Within the European Network Nursing Academies (ENNA) project, the original NPC Scale is currently used in several countries with an intention to contribute to quality assessments and quality improvements in nursing education programs in Europe (European Network Nursing Academies (ENNA), n.d). A recent literature review with the aim to identify a valid and reliable instrument for assessing professional nursing competence in Austria found among eight identified instrument that the original NPC Scale was the only instrument that responded to nationally defined competence categories (Kellerer et al., 2018).

Although the original NPC scale is appreciated and has already been used in several studies, international nursing researchers have also re-quested a shorter version. The response rate has been high in published studies using the original NPC Scale, but fewer items may potentially en-hance high response rates further (Briller et al., 2012;Melnyk et al., 2012). This request for a shorter scale initiated a discussion within the NPC re-search group and a decision was made to commence the process of reducing the original 88-item NPC Scale without compromising quality. Another recognized advantage of a shorter scale is that it will be easier to combine with other instruments with the aim of providing more complex analyses of the self-reported competence of RNs and nursing students. The aim of the study was thus to develop and evaluate the construct validity and internal consistency of a shorter version of the NPC Scale.

2. Methods

2.1. Study Design

A developmental and methodological design including evaluation of the construct validity and internal consistency of a short form of the Nurse Professional Competence Scale.

2.2. Participants

The sampling was based on an invitation in 2012 and 2017, re-spectively, to all Swedish Higher Educational Institutions (HEI) pro-viding nursing programs on Bachelor level. In 2012, 11 out of 25 HEIs and in 2017, 12 out of 25 HEIs participated.

Nursing students at the point of graduation from the three-year university education at the participating HEIs volunteered to answer the original 88-items NPC Scale. The response rates were high; in total 77% in 2012 and 71% in 2017. In total, 1810 nursing students parti-cipated. The respondents had a median age of 26 years (range 20–57, mean 28.2) and the majority were women (87.1%). The sample size of 1810 was large enough to assess construct validity by using principal

component analysis (PCA) on half of the sample (n = 924) and con-firmative factor analysis (CFA) on the other half (n = 886). The sample was split using a random number generator.

2.3. Data collection

A contact person at each HEI handed out the questionnaires to the students. The contact persons were available to answer questions and collected the questionnaires after completion. The questionnaire con-tained the original 88-item NPC Scale with response alternatives on a 4-point scale ranging from 1 ‘to a very low degree’ to 4 ‘to a very high degree’. There were also background questions for additional data. 2.4. Reduction of the number of items and data analysis

The original 88-item NPC Scale was reduced using two major ana-lytic steps. The first step was to use the Pearson's correlation coefficient to explore associations between items. All pairs of items with a high correlation (> 0.70) were discussed at length by the authors until a consensus was reached and the most relevant items kept. The second step was to perform a PCA where items with a factor loading below 0.4 were discarded (Tabachnick and Fidell, 2007).

2.5. Evaluation of psychometric properties

The 35-item NPC Scale was evaluated for data quality and construct validity using PCA and CFA. Initially, PCA was used to identify the underlying constructs of the 35-item NPC Scale, using orthogonal ro-tation (varimax) on half the sample (n = 924). The Kaiser-Meier-Olkin (KMO) measure was used to test for sampling adequacy. A value of > 0.6 for KMO is considered good (Tabachnick and Fidell, 2007). Scree-test and eigenvalues > 1.0 were used to determine the number of factors. Factor loadings of > 0.71 are considered excellent, > 0.63 very good, > 0.55 good, and > 0.45 fair. Only loadings of 0.32 or more should be interpreted (Tabachnick and Fidell, 2007). CFA was there-after applied using IBM SPSS AMOS on the second half of the sample (n = 886). Goodness-of-fit indexes used were the Chi-square test (χ2_), the Root mean square error of approximation (RMSEA), and the Com-parative fit index (CFI) (Kline, 2005), thus using both absolute para-meters (χ2_{test and RMSEA) and relative parameters (CFI). A} non-sig-nificant χ2_{test is desirable. However, when using a large sample, as in} the current evaluation, the χ2_{test is often significant and researchers} therefore recommend using RMSEA (Kline, 2005). Values for RMSEA < 0.08 have been reported as acceptable, and values < 0.06 as good. For CFI, one of the most common relative parameters, a value > 0.90 is desirable (Kääriäinen et al., 2011). Reliability measured as internal consistency was evaluated using Cronbach's alpha. Values of ≥0.70 were judged to be sufficient (Streiner and Norman, 2008).

IBM SPSS Statistics version 22.0 (SPSS Inc., an IBM Company, Chicago, IL, USA) was used to analyze data.

2.6. Ethical considerations

The deans/coordinators of the nursing programs at the included universities granted permission to perform the study. Informed consent was obtained from all students prior to filling in the questionnaire, which was done anonymously. The formal approval of an ethics com-mittee 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 was necessary.

3. Results

The extensive process of reducing the number of items resulted in a total of 35 items which were further used in the analysis.

J. Nilsson et al. Nurse Education Today 71 (2018) 233–239

3.1. Data quality

The mean item score varied from 2.65 to 3.71 (standard deviation from 0.50 to 0.84) and the median item score from 3 to 4 (item range score was from 1 to 4 for all items). The proportion on an item level for the response alternative “To a very high degree” ranged between 12.2% (item 27) and 73.1% (item 9). For the response alternative “To a very low degree” the proportion ranged between 0.1% and 5.2%. Internal missing values ranged between 0.5% and 9.8% across all items. The highest proportion of missing values was seen for item 10 “To what extent are you able to contribute to a holistic view of the patient?” 3.2. Construct validity

3.2.1. Principal component analysis (PCA)

Using PCA resulted in a six-factor solution explaining 53.6% of the total variance. KMO was 0.920, which justified proceeding with the analysis. Factor loadings ranged from 0.428 to 0.795 (Table 1). Each factor was examined for content in the items and thereafter the six factors were named ‘Nursing Care’, ‘Value-based Nursing Care’, ‘Medical and Technical Care’, ‘Care Pedagogics’, ‘Documentation and Administration of Nursing Care’, and ‘Development Leadership and Organization of Nursing

Care’. Three items (6, 20, 21) cross-loaded on two factors. Based on the content in item numbers 20 and 21, these were included in the factor “Care Pedagogics” (Table 1).

3.2.2. Confirmative factor analyses (CFA)

The six-factor solution for the NPC Scale was then tested using CFA on the second half of the sample (Fig. 1). Firstly, we ran the CFA with participants who had no missing data (n = 515) to examine modifica-tion indexes. The estimamodifica-tion method used was maximum likelihood (ML). Using the results from the modification indexes, we then re-ran the CFA (ML) on all 886 participants and allowed correlations between the six factors and between the error terms for items 2 and 3, items 4 and 5 and items 12 and 13 (Fig. 1). The items we allowed to correlate were excised in the same factors and based on content that was judged as reasonable. The χ2_{test was significant (Chi-square test 1871.33; d.f.} 542; p < 0.001) which is common in a large sample. However, the RMSEA was 0.053, 90% confidence interval 0.050 to 0.055, which in-dicated a good fit, while CFI was 0.89 and did not reach the re-commended value of > 0.90. Estimates of factor loadings are presented inTable 2for the CFA using the ML method of estimation and for a CFA using the Bayesian method of estimation. The results mostly indicate stability when comparing the loadings.

Table 1

Factor loadings of principal component analysis after varimax rotation. Items (n = 35)⁎

Ability to… Factors α

1 2 3 4 5 6

Nursing care, 5 items 0.76

Independently apply the nursing process 0.743

Meet patient's basic physical needs 0.686

Meet patient's specific physical needs 0.707

Document patient's physical status 0.696

Document patient's psychological status 0.583

Value-based nursing care, 5 items 0.71

Respectfully communicate with patients, relatives and staff 0.434 0.447

Show respect for patient autonomy, integrity and dignity 0.322 0.682

Enhance patients' and relatives' knowledge and experiences 0.660

Show respect for different values and beliefs 0.716

Contribute to a holistic view of the patient 0.333 0.471

Medical and technical care, 6 items 0.79

Manage drugs and clinical application of knowledge in pharmacology 0.571

Independently administer prescriptions 0.716

Pose questions about unclear instructions 0.684

Support patients during examinations and treatments 0.347 0.480

Follow up on patient's conditions after examinations and treatments 0.597

Handle medical/technical equipment according to legislation and safety routines 0.616

Care pedagogics, 5 items 0.82

Provide patients and relatives with support to enhance participation in patient care 0.668

Inform and educate individual patients and relatives 0.362 0.727

Inform and educate groups of patients and relatives 0.698

Make sure that information given to the patient is understood 0.524 0.491

Motivate the patient to adhere to treatments 0.435 0.428

Documentation and administration of nursing care, 8 items 0.86

Make use of relevant data in patient records 0.671

Use information technology as a support in nursing care 0.641

Document according to current legislation 0.655

Comply with current legislation and routines 0.682

Handle sensitive personal data in a safe way 0.683

Observe work-related risks and prevent them 0.586

Continuously engage in professional development 0.653

Lead and develop health staff teams 0.604 0.328

Development, leadership and organization of nursing care, 6 items 0.84

Act adequately in the event of unprofessional conduct among employees 0.535

Apply principles of disaster medicine 0.697

Search and review relevant literature for evidence-based nursing 0.690

Interact with other professionals in care pathways 0.721

Teach, supervise and assess students 0.795

Supervise and educate staff 0.786

α = Cronbach's alpha. Only loadings > 0.32 are presented in the table for ease of interpretation. Bold entries indicate items included in the respective factor. ⁎ _{Due to restriction of space, the items' content has been shortened for some items.}

Fig. 1. Flow chart presenting the underlying construct of the 35-item NPC-Scale (Error term [Er], item [I]).

J. Nilsson et al. Nurse Education Today 71 (2018) 233–239

3.3. Reliability

Reliability was measured as internal consistency for the six identi-fied factors and ranged from 0.71 to 0.86 (Table 1). Factor scores were calculated by summing up items in each factor and dividing by the highest possible score in the factor and then multiplied by 100. Thus, factor scores were transformed to 0–100 values.

4. Discussion

An initial analytic process resulted in a 35-item version of the NPC Scale. This article present the evaluation of the construct validity and internal consistency of this new 35-item NPC Scale – Short Form (NPC Scale-SF) to facilitate further use in evaluations and research regarding the self-reported professional competence of nursing students and RNs. On the basis of PCA, a theoretically sound six-factor structure for the NPC Scale-SF was obtained explaining 53.6% of the variance. This can be compared with the original 88-item version of the scale, which on the basis of an exploratory factor analysis resulted in eight factors ex-plaining 48% of the total variance (Nilsson et al., 2014a).

The factors of the original 88-item NPC Scale were also found in the NPC Scale-SF 35-items and all Cronbach's alpha-coefficients were > 0.70. In the original NPC Scale, factor 1 and factor 7 had alpha-coef-ficients above 0.90, which indicated that the number of items could be

reduced. The alpha-coefficients in the 35-item NPC Scale-SF were all between 0.71 and 0.86, which indicated that the number of items was satisfactory.

The new NPC Scale-SF with its six factors contained all eight factors from the original NPC Scale (Table 3). The six factors were named” Nursing Care”,” Value-based Nursing Care”,” Medical and Technical Care”, “Care Pedagogics”, “Documentation and Administration of Nursing Care”, and” Development. Leadership and Organization of Nursing Care”. These six factors corresponded well with the new competence description developed by theSwedish Society of Nursing (2017)which in turn is structured according to the core competencies described by the Quality and Safety Education for Nurses (Sherwood and Zomorodi, 2014): pa-tient-centered care, teamwork and collaboration, evidence-based prac-tice, quality improvement, safety, and informatics. In the Swedish competence description leadership and care pedagogics are added as additional competencies, which are highlighted in policy documents directing international nursing (WHO, 2016;American Association of Collage of Nursing, 2016). In the 35-item NPC Scale-SF, the six com-petencies as well as care pedagogics and leadership are visible and can be captured when using the scale.

Although the response rate has been high in studies using the ori-ginal NPC Scale with its 88-items, the NPC Scale-SF with its 35-items may further increase high response rates (Briller et al., 2012;Melnyk et al., 2012). Another advantage is that the NPC Scale-SF can be

Table 2

Estimates of factor loadings in the confirmative factor analyses. Items (n = 35)

Ability to… Factor loadings ML

a _{Factor loadings, Bayesian}

Nursing care, 5 items

Independently apply the nursing process 1.000 –

Meet patient's basic physical needs 0.886 0.886

Meet patient's specific physical needs 0.851 0.849

Document patient's physical status 1.021 1.013

Document patient's psychological status 0.987 0.979

Value-based nursing care, 5 items

Respectfully communicate with patients, relatives and staff 1.000 –

Show respect for patient autonomy, integrity and dignity 0.915 0.915

Enhance patients' and relatives' knowledge and experiences 0.878 0.884

Show respect for different values and beliefs 0.558 0.561

Contribute to a holistic view of the patient 1.079 1.079

Medical and technical care, 6 items

Manage drugs and clinical application of knowledge in pharmacology 1.000 –

Independently administer prescriptions 1.225 1.242

Pose questions about unclear instructions 1.145 1.150

Support patients during examinations and treatments 1.270 1.277

Follow up on patient's conditions after examinations and treatments 1.272 1.279

Handle medical/technical equipment according to legislation and safety routines 1.245 1.251 Care pedagogics, 5 items

Provide patients and relatives with support to enhance participation in patient care 1.000 –

Inform and educate individual patients and relatives 1.128 1.125

Inform and educate groups of patients and relatives 0.955 0.954

Make sure that information given to the patient is understood 1.087 1.085

Motivate the patient to adhere to treatments 0.873 0.869

Documentation and administration of nursing care, 8 items

Make use of relevant data in patient records 1.000 –

Use information technology as a support in nursing care 0.888 0.893

Document according to current legislation 0.888 0.900

Comply with current legislation and routines 1.219 1.228

Handle sensitive personal data in a safe way 1.245 1.257

Observe work-related risks and prevent them 0.952 0.962

Continuously engage in professional development 0.804 0.807

Lead and develop health staff teams 1.000 1.010

Development, leadership and organization of nursing care, 6 items

Act adequately in the event of unprofessional conduct among employees 1.000 –

Apply principles of disaster medicine 1.588 1.586

Search and review relevant literature for evidence-based nursing 1.257 1.251

Interact with other professionals in care pathways 1.283 1.276

Teach, supervise and assess students 2.331 2.331

Supervise and educate staff 2.224 2.227

combined with more background factors as well as other instruments, which enables further complex analyses.

As previously reported, the original NPC Scale has been used to assess the outcomes of nursing education programs (Gardulf et al., 2016;Nilsson et al., 2014b;Theander et al., 2016;Castrèn et al., 2017), and to assess the professional competences of nurses in relation to the needs of healthcare organizations (Leksell et al., 2015;Nilsson et al., 2016b), which is also a valid use for the NPC Scale-SF. Additional uses of the NPC Scale-SF include designing introduction programs for newly employed nurses and competence development programs for RNs. Among nursing students the NPC Scale-SF could be an asset in devel-oping self-regulated learning strategies. Using the NPC Scale-SF as a tool for self-evaluation and reflection could lead to it having an influ-ence on critical thinking and the development of clinical reasoning skills (Kupier and Pesut, 2004).

To further develop the NPC Scale-SF, changing the number of re-sponse alternatives has been considered. Using 4-point rere-sponse alter-natives might reduce variation and thus affect the CFA. For future use of the 35-item NPC Scale-SF, seven response alternatives for each item could be considered.Streiner and Norman (2008) recommended the minimum number of response alternatives to be 5–7 to increase variability and reliability. Changes in reliability with 7-point or 10-point response alternatives are small, while a change to 5-10-point re-sponse alternatives reduces reliability by about 12% (Streiner and Norman, 2008). Our results using 4-point response alternatives re-vealed high values for several items (median 3 for 29 items and 4 for 6 items).

A strength of the present study was the use of both PCA and CFA to evaluate construct validity. Furthermore, both maximum likelihood and Bayesian method of estimation were used for estimates of factor load-ings and showed, in general, stability in factor loadload-ings for the CFA. As with all instruments, the NPC Scale-SF needs to be tested further when used in a new context, for example in another country.

As discussed earlier (Nilsson et al., 2014a), the research group is aware of the fact that the use of a nurse professional competence in-strument will most probably result in the identification of competence gaps in nursing students and RNs. Making these gaps visible will result in the opportunity for both nurse educators and leaders of health care organizations to take action, which will contribute towards quality improvements to ensure quality of care and patient safety.

5. Conclusion

To conclude, the NPC Scale Short Form (NPC Scale-SF) 35-items revealed promising results with a six-factor structure explaining 53.6%

of the total variance. This 35-item scale can be an asset when used alone as it stimulates a high response rate or together with other instruments where it could provide the possibility of more complex analyses of the self-reported competence of nursing students and registered nurses.

Acknowledgements

We are grateful to all the nursing students who participated in the study, and to Gabrielle Mackay Thomsson for language revision. The research was conducted within the NPC-research network; www. npcresearchgroup.com

Author Contribution

Study conception/design: Jan Nilsson, Ann Gardulf, and Marianne Carlsson. Data collection: Jan Florin, Ann Gardulf, and Jan Nilsson. Drafting of manuscript and data analyses: Jan Nilsson, Ann Gardulf, Maria Engström, and Marianne Carlsson. Critical revisions for im-portant intellectual content: Jan Nilsson, Ann Gardulf, Maria Engström, Jan Florin, and Marianne Carlsson. Statistical advisors: Marianne Carlsson and Maria Engström.

Funding

This work was supported by grants from the Alice Lindström Fund, Sweden; and research allocations from the authors' universities.

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Table 3

A comparison between the original version of the NPC Scale 88-items and the new NPC Scale SF 35-items concerning factor structure and Cronbach's alpha (α) as measure of reliability/homogeneity.

NPC-88 α NPC-35 α

Factor 1

Nursing care; 15 items 0.90 Factor 1Nursing care; 5 items 0.76

Factor 2

Value-based nursing care; 8 items 0.85 Factor 2Value-based nursing care; 5 items 0.71

Factor 3

Medical technical care; 10 items 0.85 Factor 3Medical technical care; 6 items 0.79

Factor 4

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Factor 5

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Leadership in and development of nursing; 26 items 0.94 Items included in Factor 6 Factor 8

Education and supervision of staff/students; 5 items 0.88 Items included in Factor 4

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