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Nurse Competence Scale: Development and psychometric testing

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METHODOLOGICAL ISSUES IN NURSING RESEARCH

Nurse Competence Scale: development and psychometric testing

Riitta Meretoja MNSc PhD RN
Nursing Director, Department of Nursing Science, University of Turku and Corporate Headquarters, Hospital District of
Helsinki and Uusimaa, Helsinki, Finland

Hannu Isoaho MSc

Statistician, Department of Education, University of Turku, Turku, Finland

Helena Leino-Kilpi PhD RN

Professor, Department of Nursing Science, University of Turku, Turku, Finland

Submitted for publication 29 May 2003

Accepted for publication 12 January 2004

Correspondence: MERETOJA R., ISOAHO H. & LEINO-KILPI H. (2004) Journal of Advanced

Riitta Meretoja,
Department of Nursing Science,
University of Turku and Corporate
Headquarters,
Hospital District of Helsinki and Uusimaa,
Helsinki,
Finland.
E-mail: riitta.meretoja@hus.fi
Nursing 47(2), 124–133
Nurse Competence Scale: development and psychometric testing
Background. Self-assessment assists nurses to maintain and improve their practice
by identifying their strengths and areas that may need to be further developed.
Professional competence profiles encourage them to take an active part in the
learning process of continuing education. Although competence recognition offers a
way to motivate practising nurses to produce quality care, few measuring tools are
available for this purpose.
Aim. This paper describes the development and testing of the Nurse Competence
Scale, an instrument with which the level of nurse competence can be assessed in
different hospital work environments.
Methods. The categories of the Nurse Competence Scale were derived from
Benner’s From Novice to Expert competency framework. A seven-step approach,
including literature review and six expert groups, was used to identify and validate
the indicators of nurse competence. After a pilot test, psychometric testing of the
Nurse Competence Scale (content, construct and concurrent validity, and internal
consistency) was undertaken with 498 nurses. The 73-item scale consists of seven
categories, with responses on a visual analogy scale format. The frequency of using
competencies was additionally tested with a four-point scale.
Results. Self-assessed overall scores indicated a high level of competence across
categories. The Nurse Competence Scale data were normally distributed. The higher
the frequency of using competencies, the higher was the self-assessed level of
competence. Age and length of work experience had a positive but not very strong
correlation with level of competence. According to the item analysis, the categories
of the Nurse Competence Scale showed good internal consistency.
Conclusion. The results provide strong evidence of the reliability and validity of the
Nurse Competence Scale.

Keywords: nurse competence, performance, competence assessment, measurement,

validity, reliability

124
2004 Blackwell Publishing Ltd

Methodological issues in nursing research
Introduction
Assessing the competence of practising nurses is crucially
important in identifying areas for professional development
and educational needs, and also in making sure that nurse
competencies are put to the best possible use in patient care.
Competence assessment of practising nurses should be a core
function in quality assurance systems, workforce planning and
human resource management. Competence is defined as the
ability to perform a task with desirable outcomes (Benner
1982, While 1994, Nagelsmith 1995), as the effective appli-
cation of knowledge and skills (Del Bueno 1990), and as
something that a person should be able to do (Mansfield &
Mitchell 1996). It is the interplay of interpersonal and
technical skills with critical thinking, and it integrates the
cognitive, affective and psychomotor domains of practice (Del
Bueno et al. 1987, Gurvis & Grey 1995, Jeska 1998). In spite
of attempts to clarify the meaning of nurse competence, debate
on this still continues (Girot 2000, McMullan et al. 2003).
Several reviews have revealed that competence is closely
related to performance, and that these concepts are associ-
ated with much confusion (Messick 1984, While 1994,
Ramritu & Barnard 2001). There has also been much
controversy in the literature about the type of instrument
needed to assess competence or performance, for example
trait-based, behaviour-based, qualitative or quantitative
(Springer et al. 1998). United Kingdom (UK) studies have
adopted a more qualitative approach to the assessment of
competence (Bartlett et al. 2000), and this may explain the
trend towards phenomenology and multiple assessments
(Girot 1993a, While et al. 1995).
Self-assessment allows nurses to consider their practice
within their own environments, and assists them to maintain
and improve their practice (Campbell & Mackay 2001). By
using the process of reflection, nurses gain insight into their
practice in order to identify strengths and areas that may need
to be further developed (Campbell & Mackay 2001,
Hannigan 2001). Reflective practice has a role to play at all
stages of the ‘novice to expert’ continuum (Paget 2001). Self-
assessment provides a way to produce a professional profile
of an experienced nurse’s competence (Campbell & Mackay
2001). Professional profiles encourage practitioners to take
an active part in the learning process and facilitate continuing
education (Richardson 1998). A self-assessment tool serves as
a learning and career planning tool (Campbell & Mackay
2001). Critical in promoting professional practice is the need
for effective dialogue between nurses, managers and edu-
cators (Richardson 1998).
Instruments for competence assessment of practising nurses
are a relatively new field of study and several researchers have

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 47(2), 124–133
Nurse Competence Scale
criticized the validity and reliability of current instruments
(Coates & Chambers 1992, Girot 1993b, Chambers 1998,
Meretoja & Leino-Kilpi 2001, Robb et al. 2002).
The study
Aim
The study reported here was aimed at developing the Nurse
Competence Scale (NCS), an instrument to be used by nurses
and managers to assess the level of nurse competence.
Phase I: instrument development
The first task in the process of developing the NCS was a
review of current literature to find how the concept of
competence had been used in existing instruments and
instruments closely related to this concept (Meretoja &
Leino-Kilpi 2001). The review revealed that all instruments
had different definitions for the categories of nurse compe-
tence. Many were still in their early stages of development,
and there was hardly any instrument that provided a reliable
and accurate measure of practising nurses’ level of compet-
ence. The Six-Dimension Scale (6D Scale) of Nursing
Performance (Schwirian 1978) had been extensively tested
for validity and reliability (McCloskey & McCain 1988,
Myric & Awrey 1988, Battersby & Hemmings 1991,
Gardner 1992, Witt 1992, Bartlett et al. 2000). Although
originally developed to assess performance of graduating and
recently graduated nurses, the 6D Scale we used it in this
study to test concurrent validity of the NCS as the closest
existing instrument.
Development of the content validity of the NCS involved
six steps. Firstly, in 1997 a semi-structured questionnaire was
used to collect data on indicators of nurse competence from
the Clinical Ladder Development Project Group at the major
Finnish university hospital. The questionnaire consisted of
three levels of nursing practice (beginner, advanced beginner
and competent) and seven competence categories adapted
from Benner (1984). The domains for nursing practice were
selected to represent the categories of the scale due to their
frequent use and good validation (Fenton 1985, Shuldham
1993, Krichbaum et al. 1994, Krichbaum 1994, Cash 1995,
Benner et al. 1996, Maynard 1996, Buchan 1997, 1999,
Bryckzynski 1998, Shapiro 1998, Priest 1999). A total of
122 nurses and managers from all medical specialities at the
hospital were used as 25 expert groups in different work
environments. In a period of 3 months, they produced as
many descriptions as they considered necessary for each level
and each category of competence, and created a total of 1308
125
R. Meretoja et al.
descriptions. The database of these descriptions was analysed
by deductive content analysis (Krippendorf 1986). This
resulted in identification of 193 indicators for competent
nursing practice.
Secondly, the logical consistency of the competence categ-
ories was evaluated by 12 doctoral students in nursing
science. They were asked to review the indicators having
‡50% inter-rater agreement among the 122 experts. The
content analysis was continued and 20 overlapping indicators
were deleted.
Thirdly, a 173-item set of clinical indicators of nurse
competence was critically reviewed to evaluate their rele-
vance by using a self-administered questionnaire submitted to
26 nurses and nurse managers in 1999. They were asked to
judge and quantify the validity of the items individually and
as a set to suggest revisions and to identify areas that were
missing, as recommended by Lynn (1986) and DeVellis
(1991). Relevance was validated using a 4-point scale, where
0, not relevant; 1, relevant at novice level; 2, relevant at
advanced beginner level and 3, relevant at competent level.
Items with inter-rater agreement of ‡50% were accepted for
inclusion in the scale, and this produced 75 items.
Fourthly, this first version of the NCS was pilot tested in
2000 in conditions similar to those anticipated in subsequent
trials (see DeVellis 1991, Burns & Grove 1997). Thirty
nurses and nurse managers from medical–surgical settings
were asked to test the scale by using an adapted version of the
content validity testing method of Perälä (1995). They were
asked to judge the validity of indicators and categories on a
scale from 1 to 4 for clarity; from 1 to 4 for concreteness;
from 1 to 2 for whether the indicator measured competence;
from 1 to 2 for whether any other indicator measured the
same indicator; from 1 to 2 for whether the indicator
belonged to this category; from 1 to 4 for relevance; from 1 to
4 whether the category measured competence; and from 1 to
4 whether the indicators cover the category. A Likert-type
scale (1–10) was used for assessment of the level of
competence. Cronbach’s a coefficients of the NCS categories
in the pilot test ranged from 0Æ67 to 0Æ95. These reliability
estimates were encouraging, and so no changes were made to
the scale. While the nurses had no problems in responding to
the items, they did suggest some changes for greater clarity.
Fifthly, the relevant wordings were reviewed by the expert
group of nurse managers and administrators working to
implement the Clinical Ladder System in the hospital (n ¼ 5).
When the clarity of the expressions of the scale was reviewed,
six items were excluded, three were divided and one was
added to the scale. Because the median of the assessed level of
competence was very high (median 9, quartile range 8–10),
the visual analogue scale (VAS 0–100) format was regarded
126
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 47(2), 124–133
as a more appropriate response format to increase response
precision (Wewers & Lowe 1990).
Sixthly, to evaluate the applicability of the VAS scale, it
was further pilot tested with three nurses, who found it easy
to use. This work finally yielded the 73-item scale that was
then used for subsequent data collection.
Description of the NCS
The NCS is a 73-item scale distributed into seven categories:
helping role (seven items), teaching–coaching (16 items),
diagnostic functions (seven items), managing situations (eight
items), therapeutic interventions (10 items), ensuring quality
(six items) and work role (19 items) (Table 1). Each item is
rated by using a VAS (0–100), with the ends labelled 0 for
very low level and 100 for very high level of competence. The
frequency with which individual items are actually used in
clinical practice is indicated on a four-point scale (0, not
applicable in my work; 1, used very seldom; 2, used
occasionally and 3, used very often in my work. Background
factors are also investigated, and include the respondent’s
age, educational preparation, length of work history and
work environment.
The 6D Scale
The 6D Scale (Schwirian 1978) consists of 52 items grouped
into six subscales: leadership (five items), critical care (seven
items), teaching/collaboration (11 items), planning/evalua-
tion (seven items), interpersonal relations/communications
(12 items) and professional development (10 items). The scale
was translated into Finnish, back-translated into English and
the two versions were compared and the necessary revisions
made to the Finnish version (Jones 1987, Varricchio 1997).
The Finnish version was pilot tested by the 26 experts used in
the third step described above. In order to compare level of
competence to level of performance, an identical VAS scoring
system was adapted for the 6D Scale.
Phase 2: testing the validity and reliability of the NCS
Participants
A cluster sample of 593 Registered Nurses working at the
major Finnish university hospital (total number of beds 3800)
was selected to represent medical and surgical work environ-
ments of the hospital (total number of medical and surgical
nurses 1547). Nineteen environments (wards, emergency/
outpatient departments, intensive care units, operating rooms)
were selected, and data collection took place in 2001. The
NCS, along with the 6D Scale, was mailed to the nurses.
Methodological issues in nursing research Nurse Competence Scale

Table 1 Items of the Nurse Competence Scale Table 1 (Continued)

Item Item
number Items number Items

Helping role Therapeutic interventions

1 Planning patient care according to individual needs 39 Planning own activities flexibly according to clinical
2 Supporting patients’ coping strategies situation
3 Evaluating critically own philosophy in nursing 40 Making decisions concerning patient care taking the
4 Modifying the care plan according to individual needs particular situation into account
5 Utilizing nursing research findings in relationships with 41 Co-ordinating multidisciplinary team’s nursing activities
patients 42 Coaching the care team in performance of nursing
6 Developing the treatment culture of my unit interventions
7 Decision-making guided by ethical values 43 Updating written guidelines for care
Teaching–coaching 44 Providing consultation for the care team
8 Mapping out patient education needs carefully 45 Utilizing research findings in nursing interventions
9 Finding optimal timing for patient education 46 Evaluating systematically patient care outcomes
10 Mastering the content of patient education 47 Incorporating relevant knowledge to provide optimal
11 Providing individualized patient education care
12 Co-ordinating patient education 48 Contributing to further development of
13 Able to recognize family members’ needs for guidance multidisciplinary clinical paths
14 Acting autonomously in guiding family members Ensuring quality
15 Taking student nurse’s level of skill acquisition into 49 Committed to my organization’s care philosophy
account in mentoring 50 Able to identify areas in patient care needing
16 Supporting student nurses in attaining goals further development and research
17 Evaluating patient education outcome together with patient 51 Evaluating critically my unit’s care philosophy
18 Evaluating patient education outcomes with family 52 Evaluating systematically patients’ satisfaction
19 Evaluating patient education outcome with care team with care
20 Taking active steps to maintain and improve my 53 Utilizing research findings in further development of
professional skills patient care
21 Developing patient education in my unit 54 Making proposals concerning further development and
22 Developing orientation programmes for new nurses in research
my unit Work role
23 Coaching others in duties within my responsibility area 55 Able to recognize colleagues’ need for support and help
Diagnostic functions 56 Aware of the limits of my own resources
24 Analysing patient’s well-being from many perspectives 57 Professional identity serves as resource in nursing
25 Able to identify patient’s need for emotional support 58 Acting responsibly in terms of limited financial
26 Able to identify family members’ need for emotional resources
support 59 Familiar with my organization’s policy concerning
27 Arranging expert help for patient when needed division of labour and co-ordination of duties
28 Coaching other staff members in patient observation 60 Co-ordinating student nurse mentoring in the unit
skills 61 Mentoring novices and advanced beginners
29 Coaching other staff members in use of diagnostic 62 Providing expertise for the care team
equipment 63 Acting autonomously
30 Developing documentation of patient care 64 Guiding staff members to duties corresponding to
Managing situations their skill levels
31 Able to recognize situations posing a threat to life early 65 Incorporating new knowledge to optimize patient care
32 Prioritizing my activities flexibly according to changing 66 Ensuring smooth flow of care in the unit by
situations delegating tasks
33 Acting appropriately in life-threatening situations 67 Taking care of myself in terms of not depleting my
34 Arranging debriefing sessions for the care team when mental and physical resources
needed 68 Utilizing information technology in my work
35 Coaching other team members in mastering rapidly 69 Co-ordinating patient’s overall care
changing situations 70 Orchestrating the whole situation when needed
36 Planning care consistently with resources available 71 Giving feedback to colleagues in a constructive way
37 Keeping nursing care equipment in good condition 72 Developing patient care in multidisciplinary teams
38 Promoting flexible team co-operation in rapidly 73 Developing work environment
changing situations

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 47(2), 124–133 127
R. Meretoja et al.

Twenty-three had been participating in the pilot test 3 months
earlier but, because of the time lapse, they were not excluded
from the sample.
The return rate for was 86Æ5%. Fifteen questionnaires had
to be rejected because of major missing data (half of the items
not answered), giving the final number of 498 analysed
questionnaires. The mean age of respondents was 37 years
(range 23–60 years). The average number of years in nursing
was 11 years, in the current position 8 years and in health
care 13 years. Only 3% of the nurses had less than 1 year’s
experience in health care and 7% had graduated within the
past year.
Ethical considerations
The hospital ethics committee gave permission to carry out
the study. All data were collected and handled anonymously.
Respondents agreed to participate after receiving a written
description and further verbal information about the study.
The copyright holder of the 6D Scale (Lippincott Williams &
Wilkins) gave permission to translate and use the scale.
good (VAS 75–100). Nurses’ self-assessed overall VAS-mean
scores indicated a high level competence across categories
(range 56–69, Table 2). Self-assessed frequency of using
competencies revealed a high relevance for the NCS items.
The data matrix showed that 77% of the competence items
were used frequently (occasionally or very often). Self-
assessed level of competence increased in direct proportion
to the self-assessed frequency of using competencies
(Figure 1). Age and length of work experience had a positive
but not very strong correlation with overall level of compet-
ence (r ¼ 0Æ303–0Æ339, P < 0Æ001) (Table 3).
Principal component analysis provided some support for
the structure of Benner’s domain categories, although some
items loaded on more than one factor. This could account for
the relatively low correlation between the items. The average
inter-item correlation was 0Æ300. This was expected because
Table 2 Level of self-assessed competence and frequency of using
Nurse Competence Scale – competencies occasionally or very often
(n ¼ 498)

Level of
Data analysis competence
Statistical analysis was carried out using Statistica ’99 and Frequency of using
Competence category Mean SD competencies (%)
SPSS 10.0 software. The data were first analysed using des-
criptive statistics. Sum variables were formed out of the seven Helping role 67Æ7 14Æ3 89Æ0
competence categories. An individual overall VAS-score of Managing situations 69Æ4 14Æ7 82Æ9
Diagnostic functions 67Æ7 16Æ6 82Æ2
competence of a nurse was calculated as the mean value of the
Work role 63Æ3 16Æ2 78Æ5
average competencies assessed for the seven competence Teaching–coaching 62Æ8 15Æ9 71Æ5
categories. Linear correlation analysis was used to compare Therapeutic interventions 59Æ5 17Æ5 73Æ8
overall VAS-mean competence (NCS) and overall VAS-mean Ensuring quality 55Æ6 19Æ1 67Æ4
performance (6D Scale). In all analyses statistical significance Overall competence 63Æ7 13Æ7 77Æ3
was set at 0Æ05. Linear regression analysis was used to correlate
the background factors with overall level of nurse competence.
Information on individual item characteristics was obtained by
inter-item correlation and item-to-total correlation. Lilliefors’ 100
Level of competence, VAS 0–100

test was used to test the normal distribution of the data.

80
Internal consistency of the categories was analysed using
Cronbach’s a coefficients. The construct validities of the NCS
60
and the 6D Scale were analysed using factor analysis. Principal
component analysis with varimax and oblique rotations were
40
used to examine which factors of the scale were comprised of
coherent groups of items (Knapp & Brown 1995). The analysis
20
was performed without mean substitution of missing values,
that is, any missing item response eliminated a case.
0
Not applicable Very seldom Occasionally Very often
Frequency of using competencies
Results
Figure 1 Level of self-assessed nurse competence related to frequency
For descriptive purposes, the VAS 1–100 was divided into of using different competence items.
four parts to represent level of nurse competence as low (VAS Note: Bars denote SD . Competence levels in each frequency category
0–25), quite good (VAS 25–50), good (VAS 50–75) and very differ from all other levels of competencies (P < 0Æ05).

128
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 47(2), 124–133
Methodological issues in nursing research Nurse Competence Scale

Table 3 Correlation coefficients between

Years in current
nurse background factors and scores on the
Age environment Years as Registered Years in health
Nurse Competence Scale and 6D Scales
Scale (n ¼ 468/474) (n ¼ 462/464) Nurse (n ¼ 436/439) care (n ¼ 375/377)

NCS 0Æ339 0Æ336 0Æ303 0Æ337

6D Scale 0Æ238 0Æ265 0Æ230 0Æ264

n, Number of nurses with the information.

All correlation coefficients are significant (P < 0Æ001).

Table 4 Development of items and testing internal consistency reliability of the Nurse Competence Scale (NCS)

Primary set of The set of 173 Pilot test with 75-item The 73-item NCS
1308 indicators clinical indicators scale (n ¼ 30) (n ¼ 498)

Domain category Items Items Items Cronbach a Items Cronbach a

Helping role 168 28 6 0Æ82 7 0Æ79

Teaching–coaching 193 23 17 0Æ93 16 0Æ91
Diagnostic functions 165 28 8 0Æ70 7 0Æ79
Managing situations 190 17 8 0Æ77 8 0Æ83
Therapeutic interventions 217 31 10 0Æ68 10 0Æ88
Ensuring quality 119 14 6 0Æ88 6 0Æ82
Work role 256 32 20 0Æ89 19 0Æ91

n, Number of nurses providing information.

140 160

120 140
120
Number of nurses

100
100
80
Figure 2 Distributions of the assessed levels 80
60
of overall competence on the Nurse 60
Competence Scale (NCS) and overall 40
40
performance on the 6D Scale. 20
20
Note: Distributions of the data of 498
0 0
nurses differ significantly (P < 0Æ001) and <35 <45 <55 <65 <75 <85 <95 ≥95 <35 <45 <55 <65 <75 <85 <95 ≥95
only the data of the NCS are distributed Level of overall competence Level of overall performance
normally. on the NCS on the 6D Scale

of the large number of expert groups that had been used in
the item validation phase to reduce overlap between items
and categories. However, the items of the NCS fitted into the
expected factors and the total variance accounted for was
52Æ7%. Also the 6D Scale fitted into the expected factors and
the total variance accounted for was 55Æ3%.
Reliability of the NCS factors was estimated by determin-
ation of inter-item and item–total correlations, as well as
alpha-if-deleted values. Average inter-item correlation coeffi-
cients of the seven factors ranged from 0Æ353 to 0Æ442. Item–
total correlation coefficients ranged from 0Æ322 to 0Æ731. The
alpha-if-deleted values indicated that the scale would not be
improved by the removal of any items and, therefore, the
73-item scale was accepted. Cronbach’s a for the NCS ranged
from 0Æ79 to 0Æ91 and for the 6D Scale from 0Æ79 to 0Æ80
(Table 4).
Concurrent validity testing of the NCS and the 6D Scale
showed that the self-assessed VAS-mean scores indicated
good competence levels across categories (NCS, range 56–69)
and even higher performance levels across categories (6D
Scale, range 61–81). Lilliefors’ test for normality of the NCS
(P > 0Æ20) showed evidence of normal distribution of the
data (Figure 2). This was not the case with the data of the 6D
Scale (Lilliefors’ test for normality P < 0Æ01), which showed
skewness (Figure 2). There was a very strong correlation
between overall VAS-means of the NCS and 6D Scales
(r ¼ 0Æ829, P ¼ 0Æ00).
Discussion
This study involved developing and testing of a new
instrument, the NCS, for the self-assessment of competence

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 47(2), 124–133 129
R. Meretoja et al.
by practising hospital nurses. The results are discussed first
with the regard to content validity and the theoretical
framework selected for the study. We then discuss the
psychometric properties, relevance and utility of the NCS
and identify areas for further research.
Content validity of NCS
Content validity is the degree to which the items of an
instrument adequately represent the universe of the content.
This is the most important type of validity because it ensures
a match between research target and data collecting tool of
the study (Burns & Grove 1997). The evidence supporting
the content validity of the NCS was based, firstly, on
literature review and, secondly, on the judgements of six
expert groups. Face validity was verified by assessing that the
instrument truly measured the concept (Lynn 1986, Streiner
& Norman 1999). The information obtained from the expert
groups was used to delete or add items (see Lynn 1986, Berk
1990, Davis 1992, Strickland 2000). Selection of items for
the final version of the NCS was based on agreement among
experts on the relevance of the items (Lynn 1986). It was
highly important to incorporate a large number of nurses as
well as managers and directors in the processes to obtain a
wide perspective on the scale.
The theoretical framework adopted for the study specified
and limited the phenomenon under investigation and created
a basis for interpretation of the results (Burns & Grove
1997). Competence category identification was accomplished
by reviewing research instruments on nurse competence.
Benner’s (1984) competency framework was selected to
specify the content domain of nurse competence due to good
validation of these domains. Validity of the research process
was based on instrument development methodology (Waltz
et al. 1991, Streiner & Norman 1999). In the empirical part
of the study, descriptions of nurse competence were collected
from a large and representative sample of nurse experts and
analysed by deductive content analysis. A set of competence
indicators was identified and the scale was finally determined
to be content valid, with ‡50% agreement between the nurse
experts. The final scale consisted of 73 items distributed into
seven competence categories. The result that the competence
items were used frequently in clinical practice supports the
content validity of the NCS.
Psychometric properties of the NCS
Construct validity of the NCS was examined by collecting
empirical data. Construct validity indicates whether a meas-
ure relates to other observed variables in a way that is
130
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 47(2), 124–133
consistent with theoretically-derived predictions (Streiner &
Norman 1999). Initial testing focused on how easy it was for
respondents to understand and complete the questionnaire.
The factorial validity of Benner’s (1984) domain categories
was examined through factor analysis (see DeVellis 1991).
The expert groups had no problems in defining the scope of
competent nursing practice, although in the early phases of
indicator identification some overlap was detected between a
few categories. The deletion of overlapping items may have
resulted in low correlation between items. Therefore, the
factor analysis was not very useful in the instrument
development. However, it did provide some support for
Benner’s domain categories for nursing practice (Benner
1984, Benner et al. 1996), although the factors were not
identical to the theoretical categories. The result, that there
was little evidence of low or quite low level competence, can
be seen as little evidence of the existence in the sample of
novice and advanced beginner level practice, when related to
Benner’s competence framework. The distribution of
respondents’ overall competence levels shows evidence of
competent and proficient level practice and is similar to
findings in the study by Garland (1996).
Internal consistency of the NCS was tested by item analyses
to examine the extent to which all the items measure the same
construct. Items that do not show high correlation may be
deleted from the instrument (Streiner & Norman 1999). The
internal consistency of the NCS was found to be reasonable
good for a new instrument (see Nunally & Bernstein 1994).
However, internal consistency does not provide a sufficiently
sound basis upon which to judge reliability (Streiner &
Norman 1999). Indeed, all decisions about omission or
addition of items were based on agreement between experts.
Reliability and validity are essential characteristics of any
measuring device or method. Factors that may affect the
degree of consistency obtained for a given measure include
the manner in which it is scored, characteristics of the
measure itself, the physical and emotional state of the
respondent and the situation in which the measure is
administered. If a measure does not assign scores consistently,
it cannot be useful for the intended purposes (Waltz et al.
1991).
With concurrent validity, the scale is correlated with the
criterion measure, both of which are given at the same time
(Streiner & Norman 1999). The 6D Scale is one of the most
tested scales internationally and has endured the test of time.
Content validity of the Finnish version of the 6D Scale was
evaluated by experts and no revisions were made. Good or
reasonably good validity and reliability has been described in
earlier studies (McCloskey & McCain 1988, Myric & Awrey
1988, Battersby & Hemmings 1991, Gardner 1992, Witt
Methodological issues in nursing research
1992, Bartlett et al. 2000). However, the pilot test verified
that many of the items belonged to novice or advanced
beginner level of practice. This result was congruent with the
original purpose of the scale, which was to tap observable
nurse behaviours applicable to graduating or recently gradu-
ated nurses (Schwirian 1978). This is also corroborated by
the relatively low correlation coefficients between nurses’
background factors and level of performance in the present
study.
In the final testing phase of the study, the NCS was found
to be more sensitive for differentiating nurses on the novice to
expert continuum than the 6D Scale. Although the visual
analogue scales have some attractive features, problems with
participants’ ability to conceptualize the method have been
reported (Wewers & Lowe 1990). In this study nurses did not
report problems in using the VAS method in competence
assessment. Although Wood and Power (1987), While (1994)
and Worth-Butler et al. (1994) did not have empirical data,
they stated that competence does not correlate with perform-
ance. On the contrary, we found a close correlation between
these two concepts. Newble (1992) states that competence
can be seen as a prerequisite for performance in the real
clinical setting.
There are some limitations to this study. The literature
review conducted clearly highlighted the need to create a
valid, reliable and easy-to-use tool to assess the competence
of practising nurses on the novice to expert continuum. The
results indicate that the NCS is useful in the self-assessment of
competence. The operational definition of nurse competence
is the fundamental element for competence assessment. In
this study, Benner’s (1984) competency framework was
selected to define categories of nurse competence and,
therefore, deductive analysis was carried out to identify the
items to the scale. Although the framework showed useful
characteristics in defining the scope of clinical nursing
practice in acute care settings, gaining wider evidence could
broaden the definition of nurse competence. The sampling
limitation to surgical and medical specialities was imposed
due to the nature of the study. Therefore, the findings hold
for the particular sample and cannot be generalized without
further studies.
Conclusions
Practical implications
The results showed evidence that the NCS was more useful in
indicating different levels of nurse competence than was the
classical 6D Scale. Even novice nurses could perform at a very
high level of performance not distinguishable from more

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 47(2), 124–133
Nurse Competence Scale
experienced nurses. This has been also the result of most early
instruments aiming to quantify nurse competence or per-
formance due to the very young nursing groups on which the
scales were developed. It seems that the NCS may possess a
wider use for clinical practice and management in this
respect.
Evidence-based management to guarantee good clinical
nursing practice in the future depends on systematic evalu-
ations of caregiver processes in health care. Competence
assessment models should be integrated into quality assur-
ance systems and human resources management. Competence
recognition offers a way to develop workforce planning and
career opportunities of practising nurses. Instruments to
assess nurse competence should be relatively easy to use for
self-assessment and for managers to use in annual review
processes.
Suggestions for further research
The study highlights areas that need closer attention in the
future. Terminology appears to be a major obstacle to the
understanding of nurse competence and, therefore, limits
comparisons between research findings. In particular, concept
analyses of nurse competence and nurse performance should
be continued. Further research is also needed to develop both
the contextual and methodological areas of nurse competence
assessment. Peer and manager assessment should be included
in further testing of the level of nurse competence. Addition-
ally, patients’ perceptions of nurse competence should be
included in evaluation studies to gain evidence of patient
satisfaction and quality of nursing care. There is a need for
more research to explore the connection between nurse
competence, nursing outcomes and quality of care.
Content validity of the NCS was judged as satisfactory and
the probability of error because of the content sampling was
reduced. However, wider use of the NCS would offer
possibilities to test the scale in an even greater variety of
clinical environments than in this study. While the NCS
seems to have good internal consistency and good content
validity, concurrent and predictive validity testing with large
samples of diverse populations remains a research challenge
for the future. International co-operation in data collection
might be useful in discovering whether the concept of
competence is culturally affected and whether the NCS is
viable in other countries.
Author contributions
All authors contributed to the study conception and design.
RM was responsible for the data collection, and RM and HI
131
R. Meretoja et al.
What is already known about this topic
• Assessing the competence of practising nurses is cru-
cially important in identifying areas for professional
development and educational needs, and ensuring that
competencies are put to the best possible use in patient
care.
• Competence assessment of practising nurses should be a
core function in quality assurance systems, workforce
planning and human resource management.
• There is a lack of widely used valid and reliable
instruments for competence assessment of practising
nurses.
What this paper adds
• A 73-item Nurse Competence Scale instrument, devel-
oped and tested for validity and reliability.
• Evidence of the sensitivity and ease of use of the Nurse
Competence Scale in self-assessment of the competence
of practising nurses.
analysed the data. RM drafted the manuscript and all authors
carried out critical revisions of the paper. RM obtained
funding and HL-K provided supervision.
Acknowledgements
This project was supported by the Hospital District of
Helsinki and Uusimaa. We would like to thank all the
colleagues who took part during different phases of instru-
ment development and testing.
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