PROFESSIONAL COMPETANCIES

Professional competence of practising nurses

Olivia Numminen, Riitta Meretoja, Hannu Isoaho and Helena Leino-Kilpi

Aims and objectives. To compare nurse competence in terms of its quality and frequency of action in medical, surgical,
paediatric/obstetric/gynaecological and psychiatric clinical fields.
Background. One challenge of current health care is to target practising nurses competencies to optimal use. Therefore, a
systematic assessment of nurse competence is justified. Studies using the Nurse Competence Scale have found that nurses
competence is on a good or very good level and it increases with age and work experience.
Design. A cross-sectional comparative survey using the Nurse Competence Scale.
Methods. A purposive sample of 2083 nurses in a major University Hospital in Finland participated in this study in 2007
2008. Descriptive statistics and inferential statistics ANOVA with Bonferroni correction, and Pearson/Spearman correlation
coefficients were used to analyse the data.
Results. The overall level of competence of nurses was good, and the quality of action correlated positively with the fre-
quency of action. Nurses in the psychiatric field reached somewhat higher overall mean scores than nurses in other clinical
fields. On item level, nurses seemed to be the most competent in actions related to immediate individualised patient care, the
maintenance of their own professional competence and commitment to nursing ethics. Age and particularly work experience
were positively correlated with the competence.
Conclusion. Findings from this large data corroborate previous study results on the category level assessment of nurse com-
petence using the Nurse Competence Scale indicating a good level of competence. On item level, findings revealed more
detailed themes of nurse competence, which complements earlier knowledge retrieved from the category level analysis and
could be used to target nurses competencies to even more optimal use.
Relevance to clinical practice. Competence assessment and targeted interventions are recommended as tools for the manage-
ment for planning nurses career development and continuing education to ensure competent and motivated work force and
high-quality care.

Key words: evaluation research, Nurse Competence Scale, nursing competencies, practice development, professional
development

Accepted for publication: 04 July 2012

become an important issue in todays health care. Several

Introduction
Professional competence of nurses refers to expected levels
of knowledge, attitudes, skills, and values of the nurse (e.g.
Meretoja et al. 2004a, Cowin et al. 2008). Competence has
factors have given rise to the ongoing discussion on nurse
competence. Nurses increasing migration within Europe
and globally has raised the question of the comparability of
nurses competence requirements in practice and education

Authors: Olivia Numminen, PhD, RN, Clinical Researcher,
Corporate Headquarters, Hospital District of Helsinki and
Uusimaa, Helsinki; Riitta Meretoja, PhD, RN, Adjunct Professor,
Corporate Headquarters, Hospital District of Helsinki and
Uusimaa, Helsinki and Department of Nursing Science, University
of Turku, Turku; Hannu Isoaho, MSc, Statistician, Statcon Ltd,
Salo; Helena Leino-Kilpi, PhD, RN, Professor and Chair/Nurse
Manager, Department of Nursing Science, University of Turku,
Turku and Hospital District of Southwest Finland, Turku, Finland
Correspondence: Olivia Numminen, Clinical Researcher, Corporate
Headquarters, Hospital District of Helsinki and Uusimaa, PO Box
100, Helsinki FI-00029, Finland. Telephone: +358445277654.
E-mail: j.o.numminen@welho.com

2013 Blackwell Publishing Ltd

Journal of Clinical Nursing, 22, 14111423, doi: 10.1111/j.1365-2702.2012.04334.x 1411
O Numminen et al.
(EU Council Directive 1977, European Healthcare Training
and Accreditation Network 2005, European Commission
2007, WHO 2009, FEPI, http://www.fepi.org; accessed 5
October 2011). The increase in the share of ageing popula-
tions in well-fare countries is generating bias in nurse/
patient ratio in that a smaller number of nurses have to
care for the increasing number of ageing patients. Recent
financial crises resulting in national and global economic
recessions have had an adverse impact on possibilities to
allocate needed resources to health care and education
(ICN 2007, OECD 2011, WHO 2011). Furthermore,
nurses increasingly demanding work load in terms of phys-
ical, emotional and moral stress, combined with compara-
tively low wages and devaluation of the profession have
caused nurses to leave the profession (Simoens et al. 2005,
Allen et al. 2008). Finally, nurses as the largest group of
healthcare professionals have a great impact on human
health, and consequently, it is important that the care
provided by nurses fulfils the competence requirements of
high-quality nursing care (ICN 2006). Thus, one of the
challenges of current health care is to target practising
nurses competencies to their optimal use. To achieve this
target, a systematic assessment of nurse competence and its
critical appraisal are justified. This study focuses on nurse
competence in the Finnish healthcare context comparing
nurse competence in four clinical fields.
Background
Various international and national bodies have addressed
the question of nurse competence. World Health Organisa-
tion has issued reports on nursing education to meet the
competence requirements of quality nursing care (WHO
2001, 2009). The European Union and the Council of
Europe have issued nurses qualification standards for educa-
tion and practice defining the knowledge and skills required
for registration as a professional practitioner (EU Council
Directive 1977, EU 2005, Ministry of Education 2006).
International Council of Nurses (2006) calls for continuing
competence as a professional responsibility and public right
naming public and patients, governments, nurse regulators,
individual nurses, employers, education communities and
national nurses associations as key stakeholders in contribut-
ing to the competence of the practitioner (ICN 2006). Nurse
competence is also addressed by national legislations.
Several instruments and competence indicators have
been developed and tested to measure nurse competence
(Meretoja & Leino-Kilpi 2001, Robb et al. 2002, Watson
et al. 2002, Cowan et al. 2008, Yanhua & Watson 2011).
Although many instruments have indicated acceptable
1412
degree of validity and reliability, development of compe-
tence instruments has also proven to be challenging.
Finding a consensus on the concept of nurse competence
has been difficult, which has raised the question of the
validity of the studies and interpretation of the findings
(McMullan et al. 2003, Cowan et al. 2005, 2008). Many
psychometric properties of the instruments have been found
to be at the early stage of development (Meretoja & Leino-
Kilpi 2001, Robb et al. 2002, Watson et al. 2002, Dolan
2003, Hamilton et al. 2007), although there is some evi-
dence of progress (Yanhua & Watson 2011).
In the following, the focus is on studies in which the Nurse
Competence Scale (NCS; Meretoja et al. 2004a) has been
used. The sensitivity of the instrument to discern nurse
competence has been studied in different nursing contexts in
medical, surgical, ambulatory surgical, perioperative, neuro-
logical, intensive and emergency care, and psychiatric care in
Finnish studies (Meretoja et al. 2004a, Heikkila et al. 2007,
Makipeura et al. 2007, Salonen et al. 2007, Meretoja &
Koponen 2011) and in international studies (Cowin et al.
2008, Hengstberger-Sims et al. 2008, Dellai et al. 2009,
Finotto & Cantarelli 2009, Istomina et al. 2011, Kudoh
et al. 2011). Participants in these studies have varied from
recently graduated to very experienced nurses.
The findings of these studies indicate that experienced
nurses level of competence is in general on a good or on a
very good level regardless of their clinical field (Meretoja
et al. 2004b, Dellai et al. 2009, Istomina et al. 2011, Mere-
toja & Koponen 2011). However, comparison between
nurses working in different clinical fields show that there
are differences between the fields (Meretoja et al. 2004a,
Heikkila et al. 2007, Makipeura et al. 2007, Salonen et al.
2007, Istomina et al. 2011, Meretoja & Koponen 2011).
Moreover, the optimal level of nurse competence defined by
a multidisciplinary group of healthcare experts is signifi-
cantly higher than nurses self-assessed actual competence
level (Meretoja & Koponen 2011). On category level of the
NCS, the highest competence scores were found in helping
role, managing situations, diagnostic functions and work
role categories and lowest in ensuring quality, therapeutic
interventions and teaching/coaching categories (e.g. Mere-
toja et al. 2004a, Salonen et al. 2007, Istomina et al.
2011). Relationship exists between perceived competence
and frequency of action in that the scores of quality of
action correlate positively with the frequency of action
(Meretoja et al. 2004a, Salonen et al. 2007, Hengstberger-
Sims et al. 2008, Istomina et al. 2011). Age and work
experience correlate positively with the level of competence
assessment, particularly very experienced nurses assess
themselves more competent than do less experienced
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Journal of Clinical Nursing, 22, 14111423
Professional competancies
nurses (Meretoja et al. 2004a, Salonen et al. 2007). Also
independence in work and personal job satisfaction has a
positive impact on competence (Istomina et al. 2011).
Aims
The purpose of this study was to compare the current com-
petence of nurses practising in medical, surgical, paediatric/
obstetric/gynaecological (henceforth paediatric/obstetric)
and psychiatric clinical fields. These clinical fields comprise
all four profit units of the studied University Hospital. The
aim of the study was to produce knowledge for planning
future nursing action in a way that nurses individual com-
petences can be used in an optimal way. In the NCS (Mere-
toja et al. 2004a), nurse competence is defined as the
nurses capability to act as well as her capacity to integrate
knowledge, skills, attitudes and values in a certain contex-
tual nursing situation. Measurement of competence is two-
pronged focusing on both quality and frequency of action.
Research questions:
1 What is the level of competence of practising nurses as
assessed by nurses themselves?
2 What are the differences in competence between nurses
working in different clinical fields?
3 Do nurses quality and frequency of action correlate with
each other?
4 Which demographic variables are associated with nurse
competence?
Methods
Study design and instrument
A descriptive, cross-sectional, comparative survey study
design and the NCS instrument (Meretoja et al. 2004a)
were used in this study. The NCS is a generic instrument to
assess nurse competence identifying the attributes that are
crucial to effective nursing care. The instrument consists of
seven action-oriented competence categories composed of
73 items measuring competence: Helping role (seven items),
Teaching-coaching (16 items), Diagnostic functions (seven
items), Managing situations (eight items), Therapeutic inter-
ventions (10 items), Ensuring quality (six items) and Work
role (19 items). The instrument is based on Benners (1984)
work From novice to expert in which the nurses career
development is described as a sequence from the novice
level through advanced beginner, competent and proficient
levels to the expert level. The psychometric properties of
the NCS instrument have been scientifically tested and it
has been proved to be valid, reliable and sensitive to mea-
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 14111423
Nurse competence
sure nurse competence at the generic level in a wide range
of work experience and clinical care contexts (Meretoja
et al. 2002, Meretoja & Leino-Kilpi 2003, Meretoja et al.
2004a,b, Heikkila et al. 2007, Makipeura et al. 2007, Salo-
nen et al. 2007, Cowan et al. 2008, Hengstberger-Sims
et al. 2008, Dellai et al. 2009, Istomina et al. 2011, Mere-
toja & Koponen 2011). In each item of the NCS, nurses
assess the quality of action using Visual Analogy Scale
(VAS) from 0100. VAS points from 025 indicate low
quality of action, points >2550 rather good quality of
action, >5075 good quality of action and >75100 very
good quality of action. The frequency of action is assessed
using a four-point scale (0 = not applicable, 1 = very sel-
dom, 2 = occasionally and 3 = very often). Demographic
variables in this study were the following: clinical field, age,
education in health care, work experience in health care
and work experience in current work unit.
Participants
A purposive sampling of registered nurses (n = 2699) was
recruited from one of the five University Hospitals in Finland
providing specialised healthcare services to 1
5 million peo-
ple in its region (HUS 2010). Only registered nurses with the
minimum work experience of three months and nurses with
more than six months to their retirement were included in
the sample. They represented all four clinical fields in the uni-
versity hospital (i.e. medical, surgical, paediatric/obstetric
and psychiatric). Nurses from a total of 125 clinical specialty
units participated on a voluntary basis. Nurses were
informed about the purpose, aim and implementation of the
assessment procedure and familiarised with the NCS.
Data collection
The data for this study were collected between 1 January
200730 October 2008 electronically and reported using
DIGIUM ENTERPRISE (version 3.2) software program (http://
www.digium.fi/en/). An e-mail consisting of the NCS ques-
tionnaire, and a cover letter was sent to 2699 nurses. The
cover letter included information about the purpose of the
study, issues related to research ethics and how to access
the electronic questionnaire.
Data analysis
The data were analysed using SPSS (15.0) software (SPSS
Inc., Chicago, IL, USA). Descriptive statistics frequency
distribution, mean, range and standard deviation were used
to summarise the data of the variables. An individual VAS
1413
O Numminen et al.

score of competence of a nurse was calculated as a mean Table 1 Participants demographics (n = 2083)
value of average competencies assessed for the seven cate- Variables n (%)
gories. Inferential statistics one-way and two-way analyses
of variance (ANOVA) were used to estimate the significance Participant nurses in clinical fields
Medical 259 (12
5)
of differences of means of nurses self-assessments between
Surgical 458 (22
0)
the four clinical fields. Post hoc Bonferroni correction was Paediatric/obstetric 1015 (48
7)
applied to estimate and specify the significance of the differ- Psychiatric 346 (16
6)
ences of means between single clinical fields (Burns & Missing 2 (0
2)
Grove 2009). Pearsons and Spearmans correlation coeffi- Age (years)
2025 150 (7
2)
cients were used to estimate correlation between the quality
2629 296 (14
2)
and frequency of action, and associations between demo- 3039 688 (33
0)
graphic variables and competence. 4049 562 (27
0)
 50 356 (17
1)
Missing 31 (1
5)
Ethical considerations Education
Nurse (college level) 1278 (38
0)
The approval to carry out the study was obtained from the
Bachelor of health care (polytechnic level) 792 (61
4)
hospital administration. According to national standards, Master of nursing science (university level) 13 (0
6)
permission of the ethical committee of the hospital was not Work experience in health care (years)
required, because participants represented healthcare profes- <1 45 (2
2)
sionals. Nurses were given a full explanation of the purpose 13 280 (13
4)
49 590 (28
3)
of the study and informed about researchers adherence to
1015 348 (16
7)
protocols of research ethics. Ethical consideration con- >15 788 (37
8)
cerned confidentiality and anonymity of the participants Missing 32 (3
8)
and restoration of information. Participants were recruited Work experience in current work unit
voluntarily, and they gave their verbal consent to partici- <1 298 (14
3)
pate in the study (Burns & Grove 2009, ETENE, http:// 13 587 (28
2)
49 618 (29
7)
www.etene.org; accessed 20 October 2011).
1015 208 (10
0)
>15 340 (16
3)
Missing 32 (3
8)
Results

Sample characteristics
From the total of 2699 nurses included in the study, 2083
(77%) nurses returned a completed questionnaire (Table 1).
The largest number of participants represented the paediat-
ric/obstetric clinical field (n = 1015; 49%). The majority of
nurses were aged 3049 years (n = 1250; 60%). Nurses rep-
resented both college and polytechnic level education. In
1990s, basic nurse education was gradually transferred from
college level to polytechnic level in Finland. The nurses had a
long work experience in health care, over a half of them
(n = 1136; 55%) had a work experience of more than
10 years. Nearly, three quarters of the nurses (n = 1503;
72%) had worked in their current work unit for <10 years.
The level of nurse competence in terms of quality of
action
In all seven competence categories, nurses quality of action
was at a good level, the category means of VAS scores
ranging from 58
175
7. Nurses assessed themselves as
most competent in helping role category (overall VAS mean
71
9; SD 15
03) and the least competent in ensuring quality
(overall VAS mean 59
7; SD 19
38) and therapeutic inter-
ventions categories (overall VAS mean 60
3; SD 18
24).
The overall VAS mean of all categories for all nurses was
66
0; SD 14
92.
In item level analysis, the highest VAS scores were related
to individualised patient care, maintenance of professional
competence and adherence to ethics (VAS > 80). The low-
est scores were related to development tasks, multidisciplin-
ary team work and use of research-based knowledge
(VAS < 50). Nurses in psychiatric field reached the highest
mean scores in all categories (VAS mean 69
4; SD 13
91)
compared with other clinical fields (Fig. 1). The competence
scores of nurses in paediatric/obstetric (VAS mean 66
3; SD
14
33), medical (VAS mean 65
2; SD 16
05) and, surgical
(VAS mean 63
3; SD 15
81) clinical fields were somewhat
lower.

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1414 Journal of Clinical Nursing, 22, 14111423
Professional competancies
80
75
70
65
VAS point
60
55
50 Medical
Surgical
45 Paed-obs
Psychiatric
40
1 2 3 4 5 6 7 0
047. There were significant differences between clinical
1. Helping role 2. Teaching-coaching
3.Diagnostic functions 4. Managing situations
5. Therapeutic interventions
6. Ensuring quality 7. Work role
Figure 1 Nurse competence in clinical fields.
In about one-third (32
9%) of all single items measuring
quality of action nurses assessed themselves to be at very
good level of competence (VAS mean 75100) and in about
a half (56
2%) of the items at good level (VAS mean
5075). Only in 10
9% of the items nurses assessed their
competence to be at rather good level (VAS mean 2549).
None assessed themselves to be at low level of competence.
The range of item level VAS mean scores was from
43
184
8 (Table 3).
Comparisons showed several statistically significant dif-
ferences in quality of action between nurses working in
the four clinical fields in all competence categories at the
significance level p  0
05 (ANOVA). P-values ranged from
p = 0
0000
047. There were significant differences
between clinical fields in 76
7% (n = 56) of the single items
of the NCS. Bonferroni correction revealed that the largest
number of statistically significant differences in relation to
other clinical fields were found in psychiatric field
(n = 111), which is 51% of all 219 possible differences
between the four clinical fields. The smallest number of dif-
ferences was found in medical field (n = 48, 22%). This
indicates that nurses self-assessment of their competence in
psychiatric field differed most from the other three fields.
Most of the significant differences were found between
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 14111423
Nurse competence
psychiatric and surgical fields (n = 49, 22%) and least
between medical and surgical fields (n = 6; 3%; Table 3).
The level of nurse competence in terms of frequency of
action
In Helping role category, nurses from all clinical fields
assessed themselves to act occasionally (Mean  2
0)
(Table 2). In three categories, psychiatric nurses reached
the highest scores of frequency. Means of single item fre-
quencies ranged from 1
62
9 (Table 3). Highest frequen-
cies (  2
5) were found in 31
5% (n = 23) and the lowest
frequencies (<2) in 27
4% (n = 20) of all single items. None
of the nurses reported actions which were never
implemented.
Comparisons showed several statistically significant dif-
ferences in frequency of action between nurses in the four
clinical fields in all competence categories at the significance
level p  0
05 (ANOVA). P-values ranged from p = 0
000
fields in 72
6% (n = 53) of the single items of the NCS.
Bonferroni correction revealed that the largest number of
statistically significant differences in relation to other clini-
cal fields were found in psychiatric field (n = 81), which is
37% of all 219 possible differences between the four clini-
cal fields, and the smallest number in medical field (n = 47,
21%). This indicates that nurses assessment regarding their
frequency of action in psychiatric clinical field differed most
from the other three clinical fields. Most of the significant
differences were found between psychiatric and surgical
fields (n = 30, 14%) and least between medical and surgical
fields (n = 3; 1%).
Correlation between quality and frequency of action
The correlation between nurses VAS scores and frequency
of action was tested with Pearsons correlation coefficient at
the significance level of p  0
01. The category level mean
scores of all clinical fields revealed a statistically significant
positive correlation between the quality and frequency
of action, Pearsons r-values ranging from 0
4500
733
(p = 0
000) indicating strong correlation (r  0
5) between
the quality and frequency of action (Fig. 2).
Demographic variables and their association with nurse
competence
The correlation between demographic variables and quality
and frequency of action was tested with Spearmans corre-
lation coefficient at the significance level of p  0
01. The
1415
O Numminen et al.

Table 2 Cronbachs (a) and means of nurses VAS and frequency of action scores

All Medical Surgical Paediatric/Obstetric Psychiatric

Competence category Cronbachs a value n = 2083 n = 259 n = 458 n = 1015 n = 346

I. Helping role
Q 0
84 71
9 (15
03) 69
7 (16
49) 68
4 (16
21)* 72
8 (14
29) 75
7 (13
15)
F 0
68 2
5 (0
33) 2
5 (0
34) 2
5 (0
36) 2
5 (0
31) 2
5 (0
31)
II. Teaching-coaching
Q 0
93 67
1 (16
21) 64
8 (17
41) 63
0 (16
78)* 68
5 (15
64) 69
9 (15
04)
F 0
88 2
3 (0
39) 2
2 (0
39) 2
2 (0
38) 2
4 (0
38) 2
3 (0
41)
III. Diagnostic functions
Q 0
85 68
7 (17
27) 68
2 (18
67) 65
3 (19
31)* 69
1 (16
36) 72
2 (15
13)
F 0
75 2
3 (0
41) 2
3 (0
44) 2
3 (0
42) 2
3 (0
39) 2
4 (0
39)
IV. Managing situations
Q 0
87 68
8 (17
30) 68
1 (19
82) 67
5 (18
25)* 68
8 (16
58) 70
8 (16
04)
F 0
80 2
3 (0
46) 2
3 (0
42) 2
3 (0
44) 2
3 (0
45) 2
1 (0
50)
V. Therapeutic interventions
Q 0
90 60
3 (18
24) 60
9 (18
79) 59
1 (18
63)* 59
9 (18
17) 62
7 (17
39)
F 0
81 2
1 (0
39) 2
1 (0
39) 2
1 (0
40) 2
1 (0
38) 2
1 (0
41)
VI. Ensuring quality
Q 0
85 59
7 (19
38) 58
1 (20
09) 56
8 (19
79)* 59
8 (19
02) 64
5 (18
53)
F 0
77 2
0 (0
46) 2
0 (0
46) 2
0 (0
45) 2
0 (0
45) 2
1 (0
48)
VII. Work role
Q 0
92 65
1 (16
30) 65
2 (17
06) 62
9 (16
42)* 64
6 (16
09) 69
5 (15
49)
F 0
87 2
2 (0
36) 2
2 (0
38) 2
2 (0
34) 2
2 (0
35) 2
3 (0
38)
Overall mean
Q 66
0 (14
924) 65
2 (16
05) 63
3 (15
81)* 66
3 (14
33) 69
4 (13
91)
F 2
2 (0
32) 2
2 (0
32) 2
2 (0
32) 2
3 (0
31) 2
3 (0
35)

Q, VAS mean (standard deviation); F, mean of frequency of action (standard deviation); VAS, Visual Analogy Scale.
*Lowest value of all four clinical fields in each category.

Highest value of all four clinical fields in each category.

category level mean scores of all clinical fields revealed
positive correlations between demographic variables of age,
work experience in health care and in current work unit
both in quality and in frequency of action. Spearmans
-values ranged from 0
1440
353 with significance values
from p = 0
0000
030. Nevertheless, all these correlations
were moderate or weak ( < 0
5).
Comparison between clinical fields showed that in terms
of age, length of work experience in health care and in cur-
rent work unit there were statistically significant differences
(ANOVA, p  0
05) between nurses in all competence
categories both in quality and in frequency of action (all
p = 0
000). Bonferroni correction revealed that the most
significant differences concentrated on nurses representing
groups in the middle of the response scales and the least
significant differences concentrated on nurses in both ends
of the response scales regarding both age and work experi-
ence. Nurses self-assessed competence showed a general
tendency to increase with age and with work experience,
both in health care and in the current work unit. However,
the competence level seemed to remain the same in older
age groups and in nurses with long work experience in
medical and surgical clinical fields (Figs 3 and 4).
Discussion
Findings
The purpose of this study was to describe and to compare
nurse competence of practising nurses of four clinical fields
and to identify which demographic variables were associ-
ated with the competence. Nurses self-assessments repre-
sented good level of competence in all clinical fields
throughout all competence categories. This finding is in
accordance with earlier Finnish studies in similar clinical
fields (Meretoja et al. 2004b, Heikkila et al. 2007, Salonen
et al. 2007, Meretoja & Koponen 2011) and international
studies using the NCS (Dellai et al. 2009, Istomina et al.
2011). Despite the generally high level of competence, there
were differences between categories in which nurses
assessed themselves most and least competent. In this data,
nurses were most competent in Helping role, Diagnostic

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1416 Journal of Clinical Nursing, 22, 14111423
Professional competancies Nurse competence

Table 3 Single item means of nurses quality (VAS) and frequency of action scores of all four clinical fields (n = 2083)

NCS items and categories (1 = Helping role, 2 = Teaching/coaching, 3 = Diagnostic functions, VAS ANOVA Frequency ANOVA
4 = Managing situations, 5 = Therapeutic interventions, 6 = Ensuring quality, 7 = Work role) mean p < 0
05 mean p < 0
05

Decision-making guided by ethical values (1) 84
8 0
000 2
8 *

Providing individualised patient education (2) 83
4 0
000 2
9 0
000
Planning own activities flexibly according to clinical situation (5) 82
9 0
001 2
8 0
001
Making decisions concerning patient care taking the particular situation into account (5) 82
4 0
000 2
8 0
000
Analysing patients well-being from many perspectives (3) 82
4 0
001 2
9 *
Modifying the care plan according to individual needs (1) 81
8 0
000 2
8 *
Prioritising my activities flexibly according to changing situations (4) 81
5 0
015 2
8 0
001
Professional identity serves as resource in nursing (7) 80
0 0
000 2
7 *
Mastering the content of patient education (2) 79
5 0
000 2
7 0
000
Committed to my organisations care philosophy (6) 79
1 0
002 2
7 *
Acting autonomously (7) 78
8 0
000 2
7 *
Aware of the limits of my own resources (7) 78
8 0
031 2
6 0
008
Planning patient care according to individual needs (1) 78
4 0
000 2
8 0
017
Supporting patients coping strategies (1) 78
4 0
000 2
8 0
000
Able to identify patients need for emotional support (3) 77
9 0
000 2
7 0
000
Acting appropriately in life-threatening situations (4) 77
8 * 2
4 0
000
Using information technology in my work (7) 77
3 * 2
6 0
027
Arranging expert help for patient when needed (3) 76
4 0
000 2
4 0
000
Taking care of myself in terms of not depleting my mental and physical resources (7) 76
4 0
000 2
6 *
Supporting student nurses in attaining goals (2) 76
4 0
002 2
4 0
006
Acting autonomously in guiding family members (2) 75
9 0
000 2
5 0
000
Planning care consistently with resources available (4) 75
4 0
000 2
6 0
003
Taking active steps to maintain and improve my professional skills (2) 75
1 * 2
6 0
004
Able to recognise situations posing a threat to life early (4) 75
1 * 2
3 0
000
Able to recognise colleagues need for support and help (7) 74
6 * 2
5 0
000
Finding optimal timing for patient education (2) 74
1 0
000 2
6 0
000
Mapping out patient education needs carefully (2) 71
8 0
000 2
6 0
000
Able to identify family members need for emotional support (3) 70
8 0
000 2
4 0
001
Able to recognise family members needs for guidance (2) 70
7 0
000 2
4 0
000
Taking student nurses level of skill acquisition into account in mentoring (2) 69
8 * 2
3 0
005
Co-ordinating patients overall care (7) 69
5 0
000 2
4 0
000
Familiar with my organisations policy concerning division of labour and 68
4 * 2
3 0
007
co-ordination of duties (7)
Evaluating critically own philosophy in nursing (I) 67
7 0
001 2
3 *
Able to identify areas in patient care needing further development and research (6) 66
9 0
001 2
2 0
009
Coaching others in duties within my responsibility area (2) 66
3 * 2
2 0
026
Promoting flexible team co-operation in rapidly changing situations (4) 66
1 * 2
2 *
Keeping nursing care equipment in good condition (4) 66
0 0
000 2
3 0
000
Co-ordinating multidisciplinary teams nursing activities (5) 64
3 0
000 2
3 0
019
Coaching other staff members in patient observation skills (3) 63
0 * 2
1 *
Acting responsibly in terms of limited financial resources (7) 61
5 * 2
2 0
000
Coaching the care team in performance of nursing interventions (5) 61
2 0
011 2
0 0
000
Giving feedback to colleagues in a constructive way (7) 61
1 0
001 2
1 *
Co-ordinating student nurse mentoring in the unit (7) 60
8 0
000 1
9 0
005
Mentoring novices and advanced beginners (7) 60
7 0
048 1
9 *
Providing expertise for the care team (7) 60
3 0
000 2
0 0
000
Evaluating patient education outcome together with patient (2) 60
0 0
000 2
1 0
000
Orchestrating the whole situation when needed (7) 60
0 0
001 1
9 *
Ensuring smooth flow of care in the unit by delegating tasks (7) 59
9 0
000 2
1 0
001
Evaluating critically my units care philosophy (6) 59
9 0
000 2
0 0
000
Coaching other staff members in use of diagnostic equipment (3) 58
9 * 2
0 0
000
Evaluating systematically patients satisfaction with care (6) 58
5 0
008 1
9 0
010
Developing the treatment culture of my unit (1) 58
4 0
000 2
0 0
002

2013 Blackwell Publishing Ltd

Journal of Clinical Nursing, 22, 14111423 1417
O Numminen et al.

Table 3 (Continued)

NCS items and categories (1 = Helping role, 2 = Teaching/coaching, 3 = Diagnostic functions, VAS ANOVA Frequency ANOVA
4 = Managing situations, 5 = Therapeutic interventions, 6 = Ensuring quality, 7 = Work role) mean p < 0
05 mean p < 0
05

Evaluating patient education outcome with care team (2) 58
3 0
000 2
1 0
000
Evaluating systematically patient care outcomes (5) 58
0 0
008 2
1 *
Co-ordinating patient education (2) 57
6 0
000 2
1 0
003
Guiding staff members to duties corresponding to their skill levels (7) 56
5 * 1
9 0
000
Coaching other team members in mastering rapidly changing situations (4) 55
8 0
033 1
9 *
Providing consultation for the care team (5) 55
4 * 2
0 0
004
Using nursing research findings in relationships with patients (1) 54
7 * 2
0 *
Evaluating patient education outcomes with family members (2) 54
1 0
000 1
9 0
000
Developing work environment (7) 53
1 0
003 1
8 *
Incorporating relevant knowledge to provide optimal care (5) 53
0 0
010 1
9 0
037
Developing patient care in multidisciplinary teams (7) 52
2 0
000 1
8 0
000
Using research findings in further development of patient care (6) 51
0 0
009 1
8 0
031
Arranging debriefing sessions for the care team when needed (4) 50
0 0
000 1
6 0
000
Developing documentation of patient care (3) 50
0 * 1
8 *
Developing orientation programmes for new nurses in my unit (2) 50
0 * 1
8 *
Updating written guidelines for care (5) 49
6 0
000 1
7 0
000
Using research findings in nursing interventions (5) 49
5 0
002 1
8 0
014
Developing patient education in my unit (2) 49
3 0
000 1
8 0
005
Incorporating new knowledge to optimise patient care (7) 49
3 0
000 1
8 0
004
Contributing to further development of multidisciplinary clinical paths (5) 45
2 0
000 1
6 0
000
Making proposals concerning further development and research (6) 43
1 * 1
6 *

NCS, Nurse Competence Scale; VAS, Visual Analogy Scale.

*Not significant.

Medical Paed-obs 80
Surgical Psychiatric

75

70

65
VAS point

60

55
Medical
50 Surgical
Paed-obs
45
Psychiatric

40
1 2 3 4 5
Age
ping role Teaching- Diagnostic Managing Therapeutic Ensuring W
coaching functions situations interventions quality 1. 20-25, 2. 26-29, 3. 30-39, 4. 40-49, 5. > 50

Figure 2 Correlations between quality and frequency of action Figure 3 Correlations between age and competence.
between clinical fields.

Salonen et al. 2007, Dellai et al. 2009, Istomina et al.

functions and Managing situations categories, and least 2011, Meretoja & Koponen 2011).
competent in Ensuring quality and Therapeutic interven- However, an analysis of the results on a single item level
tions categories. This finding gets support from earlier revealed interesting findings. The differences between the
studies (Meretoja et al. 2004b, Heikkila et al. 2007, highest and the lowest mean VAS scores were striking,

2013 Blackwell Publishing Ltd

1418 Journal of Clinical Nursing, 22, 14111423
Professional competancies
80
75
70
65
VAS point
60
55
Medical
50 Surgical
Paed-obs
45
psychiatric
40
1 2 3 4
Work experience in years
1. < 1, 2. 1-3, 3. 4-9, 4. 10-15, 5. > 15
Figure 4 Correlation between work experience in health care and
competence.
the maximum difference being 41
7 points. It stresses the
importance of item level analysis and interpretation. More-
over, the highest single item means (VAS mean > 75) came
from all seven categories, while the lowest means (VAS
mean < 50) came from all but Helping role and Managing
situations categories. The content of the single items with
the highest VAS scores could be crystallised into four
themes: Actions related to immediate individualised patient
care and care environment, actions that were guided by
commitment to nursing ethics, actions related to close
nurse-patient relationship and actions related to the nurses
personal professional development. The three themes of sin-
gle items with the lowest scores described nurses profes-
sional uncertainty in actions which concern professional
development tasks, working in multidisciplinary teams, and
using research-based knowledge in their work. Low scores
relating to the use of research-based knowledge have been
found earlier (Hengstberger-Sims et al. 2008, Chang et al.
2011, Meretoja & Koponen 2011). Thus, viewing nursing in
wider professional contexts seemed limited. These findings
suggest that the traditional nurses role and approach to
care still has footing in nursing. This tendency has been
found in studies focusing on specific topics, such as ethics
(Numminen et al. 2009). The item level analysis may also
imply that mere category level interpretation of nurse com-
petence may hide individual low item level competencies
found even in categories with relatively high mean VAS
scores. For example, low scores of single items concerning
using research-based knowledge were included in the com-
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 14111423
Nurse competence
petence categories in which nurses overall competence level
was assessed fairly high.
And again, although some nurses described their compe-
tence to be on the moderate level in some items, none
regarded their overall level of competence low. It suggests
that basic nursing education provides students with
competencies to meet the basic requirements needed in
actual nursing practice, also at the University Hospital level
which provides highly specialised care and requires particu-
larly competent nurses. The good competence level of
experienced nurses in this study could be seen as a natural
finding. Registration as a nurse in itself requires qualifica-
tions which the nurse has to meet to provide competent
and safe care. It is further complemented with accumulating
experience, annual manager reviews, continuing education
5
and other supportive interventions. However, nurses self-
assessed professional uncertainty in multidisciplinary team
work and modest use of research knowledge raise the
question whether interventions supporting competence are
targeted optimally.
However, there are some issues which should be consid-
ered when using self-assessment instruments. First, social
desirability bias may be present in the responses. Admitting
inferior competence to carry out nursing actions might
cause embarrassment. Second, there is an inherent element
of subjectivity in all self-assessments. Closely related to this
is also the question, how subjectively individual nurses
define what is meant by a competent nurse, how it is
related to their own care context, and whether the meaning
of each individual item is understood unambiguously. It is
also recognised that a multi-method approach to nurse
competence may provide new knowledge of competence
assessment (Hamilton et al. 2007).
The positive correlation between quality and frequency
of action, also found in earlier studies (Meretoja et al.
2004a,b, Salonen et al. 2007, Hengstberger-Sims et al.
2008) may, on one hand, indicate a responsible approach
to care in that nurses commit to actions which they con-
sider to be within their competence. On the other hand, the
constrained resources of current health care may force
nurses to concentrate on actions related only to immediate
and necessary patient care. Thus, nurses have to practise
these actions frequently and consequently their feeling of
competence in these actions may increase. And vice versa,
the lack of resources limits nurses opportunities to engage
in other areas of nursing, such as development work, which
may result in low frequency of such actions and low feeling
of competence.
There were differences also between nurses working in
different clinical fields. In this study, psychiatric nurses
1419
O Numminen et al.
excelled in competence in terms of quality and
frequency, particularly in relation to surgical nurses.
Demographic variables did not explain this difference.
Although in this data age and long work experience
were positively correlated with nurse competence,
psychiatric nurses age structure and length of work
experience were not different from those of nurses
working in other clinical fields so as to explain psychiat-
ric nurses overall higher level of competence. And
moreover, although the positive correlation between age
and competence was found, this correlation was weak
and therefore does have but a negligible impact on com-
petence in the real life nursing context.
Associations between demographic variables and compe-
tence showed that most of the significant differences con-
centrated on age groups over 30 and <50 years, thus
representing generations that were born between 1955
1975. Changes in societal values and considerable changes
in nurse education in Finland to some extent provide expla-
nation to differences between younger and older nurses.
Like this study and earlier studies indicate, nurse compe-
tence seems to increase with age and work experience
(Meretoja et al. 2004a, Salonen et al. 2007), which
describes a rather natural tendency in career development
in general and gets support from Benners (1984) theory as
well. However, in this study, the competence development
of medical nurses in this respect seems to differ from other
groups by being more fluctuating in the beginning and
seeming to cease fairly early in terms of age. Also surgical
nurses competence development remains unchanged after
about 10 years work experience. It is also interesting, that
the youngest surgical nurses with little work experience
assess their competence fairly low. Finding reason for these
findings might need further competence assessment paying
attention to other factors related to competence, such as
motivation, work environment or management support,
and the differences in specific skill requirements in different
clinical fields.
Study limitations
From the viewpoint of validity and reliability of this
study, the following two limitations have to be taken into
account in interpreting the results. First, self-assessment
lends itself to the subjectivity of participants responses.
This limits the generalisation of the findings. However, the
representative power of the large number of participants
representing all clinical fields in a University Hospital set-
ting in this study mitigates this limitation. Second, there
are differences in healthcare systems and nursing cultures
1420
between countries and this may limit the generalisation of
these findings.
Validity and reliability of the study
The NCS is a scientifically developed instrument and its
ability to discern differences in nurses competence level has
been tested in different clinical contexts and different coun-
tries (e.g. Meretoja et al. 2004b, Heikkila et al. 2007, Co-
win et al. 2008, Hengstberger-Sims et al. 2008, Dellai et al.
2009, Istomina et al. 2011). In this study, the high number
of participants combined with the high response rate sup-
port the generalisation of the findings in similar care con-
texts. Moreover, taking into account the natural differences
between individual studies, the findings of this study are in
accordance with earlier studies using the NCS.
Conclusion
Findings of this study are in accordance with earlier studies
using the NCS indicating that experienced nurses level of
competence is good. However, in this study based on a
large data, item level analysis revealed new themes for com-
petence development. Nurses seem to be the most compe-
tent in actions related to immediate patient care rather than
viewing competence in a wider professional context. This
suggests that nurse competence assessment using the NCS
could benefit from item level analysis in providing more
accurate knowledge for the assessment and development of
individual nurse competence and continuing education.
Relevance to clinical practice
For retaining the current work force and attracting new
recruits to nursing, it is important that nurses work experi-
ences are both positive and rewarding. Job satisfaction is
related to the employees possibilities to influence her own
work and to use her own personal abilities in the best possi-
ble way. Motivated and competent work force is also a way
to ensure high-quality nursing care (Tzeng 2004). The use of
competence assessment is recommended when planning indi-
vidual nurses career development. It is one way for the man-
agement to ensure competent and motivated work force, and
to maintain nurses work satisfaction and high quality of
care. In addition, based on the findings of this study, nursing
management should pay particular attention to developing
interventions which enhance nurses use of research knowl-
edge and their opportunities to engage in multi-professional
team work. For example, recruiting nurses with high aca-
demic degrees (PhD) competent in research to guide staff
2013 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 14111423
Professional competancies Nurse competence

nurses to interpret and apply research knowledge in their

daily practice should be considered.
Acknowledgements
Basic nurse education backed by official documents con- This study was supported by the Joint Authority of
cerning the minimum competence requirements guarantee Hospital District of Helsinki and Uusimaa, Finnish Nurses
that graduating nurses have the required level of compe- Association and Finnish Association of Nurse Education.
tence to work as a qualified nurse. Findings of practising
nurses competence assessments should be one element in
guiding the development of competence based nursing cur-
Contributions
ricula. However, longitudinal studies on how nurses com- Study design: ON, RM, HL-K; data collection and analysis:
petence develops with time and work experience and which RM, ON, HI and manuscript preparation: ON, RM, HI,
factors are associated with it needs further research. Nurse HL-K.
competence research would benefit from taking into
account other aspects influencing nurse competence, such as
work motivation and career orientation. Various triangula-
Conflict of interest
tion designs might also provide more profound knowledge None declared.
of this highly important but complex phenomenon.

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