Meta competency, prerequisites improving the postgraduate psychiatric nursing students’ clinical competency: a qualitative study

Abstract

BACKGROUND:

Clinical education helps learners achieve the desired clinical competency. By identifying the influential factors, education will be more effective. One of the necessary prerequisites is meta-competency. Therefore, to improve education, this study aims to describe the meta-competencies required for postgraduate psychiatric nursing students.

MATERIALS AND METHODS:

A qualitative content analysis was conducted from November 2019 to August 2020 in the universities offering a postgraduate psychiatric nursing degree in Iran. Twenty-one participants were sampled purposefully, including postgraduate psychiatric nursing students and instructors, psychiatric nurses, psychologists, and psychiatrists with at least 2 years of experience working in psychiatric settings. It was performed to obtain data saturation. Data collected through individual semi-structured interviews were analyzed using conventional content analysis.

RESULTS:

Meta competency included three categories of “thinking and clinical reasoning skills”, “dynamic learning”, and “human and organizational management”.

CONCLUSION:

The findings of this study revealed that psychiatric nurses’ meta-competency concept was multidimensional. The findings of this study can be useful in educating and assessing psychiatric nursing students’ meta-competency. Further studies are required on psychiatric nurses’ meta-competency.

Introduction

“Competency” is a complex, ambiguous and controversial concept in healthcare.[1] “Nursing competency” is clinical, ethical and general competency,[2,3] which is important for various domains of education, practice, and management.[1] Clinical competency is closely related to care quality.[4] It results in safe and cost-effective healthcare services by reducing medical errors.[5] Clinical competency evaluation lets managers and nurses know caring problems and weaknesses.[6] Consequently, it provides an opportunity to develop the nursing profession.[1] Conversely, the lack of it causes problems in providing nursing services[4] and endangers patient safety.[7]

Clinical competency is visible abilities, consisting of the integration of knowledge, skills, values, and attitudes.[8] Nurses’ clinical competencies working in psychiatric settings involve the ability to perform tasks with desirable outcomes, the skill to implement knowledge effectively, and the contextualization of knowledge tailored to nursing care provision.[9] In other words, competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics through which a person can successfully perform his/her professional functions.[10] Thus, competencies are measurable and are expressed in the form of behavioral terms.[8] Theoretically, competency is based on positivism and behaviorism paradigms.[8,11]

One of the strategies through which nursing students achieve the desired clinical competency is clinical education.[12,13] Acquisition of competency in medical education, called “competency-based training”, has received much attention.[11] Nowadays, studies emphasize active and student-centered learning instead of teacher-centered teaching.[13] In fact, merely traditional training knowledge will not be implemented in practice, but, it will just bring competency a little.[14]

There is a prerequisite for getting higher qualifications, called “meta competency”, which must be acquired, not to be directly taught.[8,15] Meta competency was first used by Burgoyne in 1988. He introduced it as a special competency, which provides the possibility of adapting or even developing skills in special situations.[14] Meta-competencies are the set of competencies and skills that can be used effectively and manage constructively different types of conflict intelligence.[16]

In contrast, some studies have revealed a holistic approach to competency.[8] In this approach, competency is defined as a set of knowledge, skills, and attitudes, which are consistent with the context in which the interventions are provided. Also, ethics and values are considered as part of that.[17] As a sample, psychiatric nurses’ clinical competency concept was defined as thoughtfully and continually integrating therapeutic communication with technical skills, clinical knowledge plus reasoning, emotions, and values in the context of psychiatric nursing interventions,[18] including two interrelated dimensions: procedural competency and meta-competency. The former is related to the performance and ability to use procedures. The latter refers to a higher degree of competency, that is, cognitive, critical, and self-reflection abilities. Indeed, meta-competency is the development of capacities such as judgment, intuition, and intelligence about trained competencies stated it requisite for other competencies.[8] In nursing education, observable, measurable, and provable scientific techniques are merely taught, whereas creativity, excitement, and intuition are not taught.[19] Unlike other competencies, meta-competencies affect actions, but not immediately and directly.[20] Dharma and Suryadinatha.(2019) argued, that acquiring meta-competencies helps improve the quality of services. Competency alone does not matter; rather the development of meta competency in human resources makes services independent of a particular person. This can be achieved through promoting competency by in-service training of skills, increasing knowledge, as well as, learning to think and work together as a team.

Various categories of meta-competencies have been identified, including “learning[21] respect, and empathy; ability to self-direct and take risks; ability conceptualizing political and systemic issues; quick thinking; and commitment to social justice”.[20,21] Meta competency is considered the combination of individual knowledge, skills, and attitudes in socio-cultural contexts, which is necessary for proper and effective healthcare.[22] In some studies, its conceptual framework is explained in five systems thinking, temporal thinking, interpersonal literacy, ethical literacy and imagination/creativity.[23] Meta competencies affect other competencies and provide the opportunity to use competencies in new situations.[16,20,22] Nevertheless, many skills and competencies are not taught and there is no specific planning for teaching them.[24] Similarly, it is not highlighted in the curriculum,[25] which is traditional.[26] Given that psychiatric nurses should not only continuously adapt their interventions to the context and culture of the client, but also, assess their competency in accordance with the same context.[18,27] As a result, clarifying the required meta-competency is important. Because to the best of our knowledge, there is no study on postgraduate psychiatric nurses’ meta competency, thus, this study aims to explain the meta-competency required for postgraduate psychiatric nursing students.

Materials and Methods

Study design and setting

This study was part of a larger study on the MSc psychiatric nursing students’ clinical competency. This qualitative content analysis was conducted from November 2019 to August 2020 in the universities offering a postgraduate degree in psychiatric nursing in Iran.

Study participants and sampling

Purposeful sampling was performed to select the participants, including postgraduate psychiatric nursing students and professors, psychiatric nurses, psychologists, and psychiatrists with more than 2 years of experience.

Inclusion criteria

The participants in psychiatric settings and universities offering postgraduate psychiatric nursing internships are rich in information.

Data collection tool and technique

Data were collected by the first author. Through semi-structured interviews, demographic and occupational information of the participants, as well as their perception of the competencies required for postgraduate psychiatric nursing students were obtained. For deciphering, probing questions such as “Can you explain more about this?” were also asked. Interviews lasted 20–40 min. After interviewing 17 participants, data saturation was achieved, and no new data were obtained. Two more interviews were performed for sure. All interviews were conducted in a calm and agreed-upon place.

Ethical considerations

This study was part of a larger study approved by the Ethics Committee of Islamic Azad, TehranMedical Science University (IR.IAU.TMU.REC.1399.171). First, before data collection, the objectives of the study were explained to the participants. Informed written and oral consent was obtained from each participant. Participants were assured about the confidentiality of their information and the voluntary participation in the research.

Data analysis

The conventional content analysis suggested by Graneheim and Lundmann (2004) was used[28] [Table 1]. In the present study, each interview was transcribed verbatim by a computer. After reviewing the transcriptions several times, the initial codes were extracted. Then, subcategories and categories were formed based on the similarities of the extracted codes, and merging them. Disagreements were discussed to reach the final agreement with the research team.

Table 1.

Stages of Graneheim and Lundmans҆ method (1994)[28]

1. Implementation and reviewing of interviews 2. Extracting semantic units and assigning them to compile units 3. Summarizing the compiled units and selecting labels 4. Determining categories based on similarities and differences of subcategories 5. Choosing the appropriate title.

Trustworthiness

The trustworthiness was assessed using Lincoln and Guba’s (2004) criteria.[29] To ensure the credibility of the findings, the transcriptions were checked by a number of interviewees (member checking) and modified if necessary. In addition, prolonged engagement, continuous reviewing of transcriptions, as well as a comparison of data and categories in terms of similarities and differences were performed during data collection and analysis. Data triangulation (using different groups of participants, namely psychologists, psychiatrists, psychiatric nursing professors, psychiatric nurses, and psychiatric nursing students) was also used.

To meet confirmability criteria, methodological coherence, which involves ensuring the coherence between the questions and the research method, was assured and a complete audit trail was provided. The transferability of the findings was achieved through the provision of a detailed and rich description of the data. Dependability of the findings was obtained through implementing expert opinions and reviews performed by research participants as well as co-authors.

Results

Participants were 14 females (66.7%) and 7 males (33.3%). The mean and standard deviation of their age were 42.35 ± 10.08 years. They were 3 students, 16 psychiatric nurses with both teaching and practical experiences (with a mean and standard deviation of 3.90 ± 1.1 and 3.43 ± 1.53 years, respectively), 1 psychiatrist, and 1 psychologist [Table 2]. Based on the content analysis, it was found that meta-competency included the following categories: 1-thinking and clinical reasoning skills, 2-dynamic learning, and 3-human and organizational management. Each category involved several subcategories [Table 3].

Table 2.

Demographic information of participants (n=21)

Variable				Frequency (%)
Age (year)		25-30		2 (9.5)
		31-36		4 (19.0)
		37-42		5 (23.8)
		43-48		5 (23.8)
		49-54		3 (14.3)
		>55		2 (9.5)
Gender		Female Male		14 (66.7) 7 (33.3)
Marriage status		Married		20 (95.2)
		Single		1 (4.76)
		Divorced		0 (0)
Education		MSc		12 (57.1)
		Student		3 (14.3)
		PhD		4 (19.0)
		Others		2 (9.6)
				C		T
Experience (Clinical/Teach) (year)		1-5		3 (14.3)		3 (14.3)
		6-10		2 (9.5)		4 (19.0)
		11-15		7 (33.3)		3 (14.3)
		15-20		3 (14.3)		1 (4.8)
		>20		4 (19.0)		2 (9.5)
		<1		2 (9.5)		8 (38.1)
Total				21 (100)		21 (100)

C=Clinical, T=Teach

Table 3.

Categories and sub-categories of meta-competency

Category		Sub-category
Thinking and clinical reasoning skills		Critical and creative thinking Clinical decision making Holistic perspective.
Dynamic learning		Interest and motivation Lifelong learning.
Human and organizational management		Monitoring of patients with mental disorders Leadership and management of the psychiatric section and personnel
		Interpersonal relationship

Thinking and clinical reasoning skills

The first category extracted was “thinking and clinical reasoning skills”, which included the subcategories of “critical and creative thinking”, “clinical decision making” and “holistic perspective”. Through a holistic view, the students should consider all factors affecting the client and family’s health, critically review and analyze various challenging situations, search for creative solutions and interventions, solve problems with appropriate decisions, and provide appropriate healthcare services to the client and family in accordance with scientific reasoning. Through clinical reasoning, nurses will be able to investigate what is affecting the patient’s health, identify problems, and solve the problems with appropriate interventions. Clinical reasoning empowers the nurse in decision-making.

Critical and creative thinking

Most participants emphasized teaching critical and creative thinking is essential. They believed that knowing the details of a problem, evaluating various decisions before making them, and finally solving the problem would require critical and creative thinking. Each patient has his/her own needs; nursing care requires unique creative solutions that cannot be learned with traditional training. It is not enough for nurses to think critically; however, they should be able to implement their thoughts in practice. Thus, to implement psychiatric nursing care, an MSc psychiatric nursing student should identify situations, challenges, and problems by integrating innovation, flexibility, and sensitivity to health issues, analyzing information, designing a creative care program, implementing, and finally evaluating them. Critical thinking increases the power of clinical decision-making, identifying patients’ needs, and selecting the best nursing practice. A university faculty with 20 years of experience stated:

“Critical thinking and problem-solving skills should be learnt during internships. Students should be able to implement them. The critical thinking and problem-solving are really needed at higher levels (P₁₄, MSc, Female).”

Clinical decision-making

Clinical decision-making can be considered as interventions and strategies that affect the process of improving the patient’s clinical conditions, especially in psychiatric settings, where there are many ethical challenges. Decision-making under conditions of uncertainty is dangerous and difficult. For example, a psychiatric nursing student with 11 years of clinical experience stated:

“Since most patients have no abstract thought, we have to do decision for them. A wrong intervention can significantly harm the patient. Even their families are unable to make decisions due to stressful situations. Here, there are many conflicting situations where we have to choose an intervention that we are not sure is right or ethical or even appropriate for the patient. Because, we, specially, deal with signs and subjective problems (P₉, MSc student, Female).”

Holistic perspective

Psychiatric nursing students should plan interventions considering all inseparable and influential factors affecting the client’s health. The participants believed that MSc psychiatric nursing students would learn holistic perspectives not only through direct training but also with a presence in clinical settings. Most psychiatric nurses emphasize the holistic perspective. For example, participant 2 stated:

“Some psychiatric nurses think they just must assess patient psychologically or intervene merely psychiatric dimension. However, we must deal with all dimensions of patients such as social, psychological and physical continuously. “However, we just teach to consider different aspects of a problem (MSc, Female).”

Dynamic learning

The second category was “dynamic learning”, which was derived from “interest and motivation”, and ”lifelong learning”. The student’s interest and motivation in psychiatric nursing and helping the patient to serve and promote the health of the client and the community lead to the provision of compassionate nursing care. Also, students constantly attempt to improve their knowledge and update their scientific and professional information. The participants believed that postgraduate students, in addition to undergraduate nursing knowledge, should have sufficient knowledge about mental health, normal and abnormal personality traits and behaviors, and appropriate interventions to solve health problems. They should also be able to consciously implement their knowledge tailored to patients’ clinical conditions. Because the complexities of today’s world, as well as the aging of most societies, have caused many changes in life, and the high incidence of tensions and challenges, nursing interventions should also be updated appropriate to these changes. The more extensive the student’s knowledge, the more skills students will implement in practice. Thus, students need to learn continuously.

Interest and motivation

Participants considered their interest in the psychiatric nursing profession and satisfaction with helping human beings necessary for the provision of compassionate psychiatric nursing care. They believed that without interest and motivation, proper psychiatric nursing care would not be provided. The lack of interest in psychiatric nursing will also lead to tension and role conflict in psychiatric nurses. In this regard, a university instructor with more than 20 years of experience stated:

“The students should be interested in the patient, especially the patient with mental illness. They must really accept a mentally ill person as a human being. Sometimes you see someone is studying psychiatric nursing, but in practice, he/she does not like to work as a psychiatric nurse, so, they do not care about their responsibilities and duties, consequently they hurt not only themselves but also clients (P₁, MSc, Male).”

Lifelong learning

The participants stated that the MSc psychiatric nursing curriculum is incomplete and insufficient for students to become professionals. In addition, due to the complexity of modern life, the increase in diseases, novel interventions and treatments, and the development of information technology, students should constantly evaluate their knowledge and develop it. Regarding to insufficiency of curriculum a supervisor of the psychiatric setting, with 11 years of experience stated:

“In the psychiatric nursing syllabus, we learn about common psychiatric disorders. Well, these are all things that were taught during undergraduate courses. During postgraduate courses, there is not much discussion about treatments, especially about psychiatric settings. For example, MSc psychiatric nursing students are not taught about psychotherapy, couple therapy, or cognitive-behavioral therapy. They do not know CBT types. Some of us, ourselves take some courses on interventions after graduating when we understand to know nothing (P₁₃, Ph.D., Female).”

Regarding lifelong learning, an MSc student with 11 years of experience in a psychiatric setting stated:

“I feel that we need to know more, to discover more, and not to be satisfied with what we had learnt during MSc course. Sometimes, I feel I know nothing and I feel weak. Then, I try to find an article on that issue or ask a professor. (P₉, Female).”

Also, another participant stated:

”I’m very sensitive about decision-making in situations. Because, for example, I may see a new case, or I may face a new event that I cannot manage with my knowledge. Meanwhile I need to know how to manage these cases. I should have reasoning ability. (P₁₇, MSc, Male).”

Human and organizational management

The third category is derived from “monitoring of patients with mental disorders“, ” leadership and management of psychiatric section and personnel” and “interpersonal relationship”. Most participants stated the skills of controlling aggressive patients, those susceptible to self-harm or harming others, continuous monitoring of patients, guiding, cooperating, and controlling the quality of healthcare services provided by colleagues and treatment team, are necessary for students. Definitely, effective interpersonal relationships are definitely critical for controlling and managing patients and nursing personnel.

Monitoring of patients with mental disorders

Participants believed that although skills of communicating with aggressive patients, and patients with suicidal and delusional thoughts were taught, the skills of using communication techniques appropriately and implementing tailored interventions to achieve a satisfactory outcome were not instructed. Indeed, the skills of effective implementation of therapeutic communication knowledge, management of nursing care and psychiatric ward, and other interventions are required. Regarding the importance of continuously monitoring of patients, an instructor with 18 years of teaching and clinical experience stated:

“I have to learn how to behave with and calm down the patient who is now agitated, not to make her/his agitation worse (P₂, MSc, Female).”

Leadership and management of psychiatric section and personnel

Some participants believed that postgraduate psychiatric nurses specialized in psychiatric nursing should supervise the interventions made by other colleagues, especially undergraduate nurses, and direct the team. Thus, integrated care increases the quality of services. The head nurse of a psychiatric ward with 28 years of management experience in a psychiatric ward stated:

“Someone with a master’s degree is usually assigned managerial positions, such as a mentor or head nurse. So, he/she is supposed to manage perfectly (P₂₀, PhD, Male).”

However, some participants disagreed believing that a student could not acquire managerial skills simply by completing a 2-year master’s course. They believed that even an undergraduate nurse might have higher managerial skills through experiences gained in clinical settings One participant said:

“It depends on the individual’s efficiency. Sometimes the experience of a nurse with bachelor’s degree is so much that an MSc nurse cannot be replaced with her/him. There are many responsibilities in psychiatric settings. Due to these responsibilities, someone expert should be assigned as the head of the ward (P_20, Ph.D., Male).”

Interpersonal relationship

All participants believed that effective communication is significant. The art of effective interpersonal interaction and communication, including professional communication and inter-professional collaboration, is not able to teach. The participants emphasized that the knowledge of therapeutic communication is expected to be reflected in interpersonal relationships with others, including colleagues and other team members. In regard to it psychologists of the psychiatric setting mentioned:

“Should know how to report to a psychiatrist. Communication and cooperate with other members of treatment team (P_6, MSc, Female).”

Discussion

In the present study, “thinking and clinical reasoning skills”, dynamic learning”, and “human and organizational management” were extracted as categories of meta-competencies required for postgraduate psychiatric nursing students. MSc psychiatric nursing students are interested in and motivated to provide psychiatric nursing care and lifelong learning. Through a holistic perspective, students critically analyze situations and make creative clinical decisions. Also, they monitor patients, as well as, lead and manage psychiatric wards with effective interpersonal relationships.

Competency has become an important issue in health care.[30] Different competencies often overlap. They cannot be easily acquired.[10] The required competencies and meta-competencies are related to each other.[8] Studies have identified many factors influencing the acquisition and promotion of clinical competency, including experience, environment, taking advantage of opportunities, motivation, theoretical knowledge, demographic characteristics,[10] supportive visionary leadership, proper planning, education and training, availability of resources, effective management of resources, employees and processes, as well as collaboration and cooperation among providers.[31] However, according to Bogo et al.(2013), this list is a holistic view. Because meta competencies affect other competencies,[8] it should identify and update for each nursing domain.

In the present study, the first category of meta-competency required for MSc psychiatric nursing students was “thinking and clinical reasoning skills”. Most studies have also pointed to the importance of critical thinking such as Bogo et al.(2013) and Fukada (2018) study.[8,32] Jormfeldt et al. (2018[33] considered critical thinking as one of the individual characteristics, which is similar to the current study. Studies revealed that professional capabilities led to the development of individuals’ competency. They introduced cognitive ability as meta-competency. The use of cognitive skills and intellectual ability leads to development plus independence in a profession[20,14] and reduces stress.[34] Cognitive ability involves consciously using knowledge to understand practical phenomena, knowing the impact of subjective reactions on judgment, evaluating things critically and creatively, and making decisions with client participation.[8,32] Critical thinking is an essential component of clinical decision-making[4] and one of the factors influencing nurses’ clinical competency.[4,35] Even, the American Nurses Association considers critical thinking to be a mandatory criterion for obtaining an undergraduate nursing degree.[36] According to the results of a meta-analyzed study, Iranian nurses’ clinical competence was desirable; however, they were weak at critical thinking.[37] Azizi-Fini et al.(2015)[38] found that undergraduate nursing students’ critical thinking skills were poor in Iran. However, in some other studies such as Geok et al.’s (2019) study, the level of students’ skills in another country was reported to be high.[39] It shows that the education process in Iran needs to be revised to focus more on improving students’ critical and creative thinking skills.

Zafarnia et al.(2017) introduced moral competency as meta competency.[3] In our study, meta-competency was presented as the ability to criticize, analyze, and make comprehensive decisions for any complicated clinical situation including moral, ethical, professional, and skills challenges. Thus, one of the required meta-competencies for postgraduate students was to develop critical and creative thinking and clinical reasoning skills. However, one systematic review study stated, Iranian nurses were weak at ethical/legal practice, teaching–coaching, and professional development.[37]

The second category of meta-competency was “dynamic learning”. Dynamic learning can be achieved by being motivated to learn and enhancing knowledge and skills continuously. Due to the increasing production of knowledge, when attending graduate in a real clinical field, much of what students have learned at universities will become obsolete, and new methods will replace the old ones.[40] Further, the complexity of today’s life, the emergence of unforeseen problems, and the advancement of technology have shortened the life of knowledge. Thus, there will be a need for lifelong learning, impromptu decisions,[41] and retraining. Many studies have suggested that professional competency requires a commitment to lifelong learning,[41,42] which was extracted as dynamic learning in the present study. Yazdani and Farajpour (2018) revealed that meta-competency included lifelong learning, self-centered learning, rethinking and reflection, receiving internal and external feedback, and measurement of performance, as well as, consequences.[42] The mentioned domains in Yazdani and Farajpour’s study were a dynamic process to acquire knowledge and promote learning. The present study also emphasized dynamism. However, in the present study, participants did not mention reflection and receiving feedback (internal or external). A deeper consideration of the issue is necessitated. Bogo et al. (2013) and Yazdani and Yadollahi (2019)[8,17] considered continuous learning and review of theoretical knowledge as one of the domains of meta-competency, which are similar to this study.

Mohammadzadeh Zarankesh et al.(2019) addressed the lack of motivation for learning and the lack of lifelong learning in the educational program.[43] It is obvious that knowledge is associated with power, and knowledge about something or how to do something is a hidden factor in education.[19] A lifelong learner is an expert at that issue, has initiative, independence, curiosity, and self-confidence, enjoys learning, considers problems as challenges, and tries to promote.[44] The purpose of an education system should also be to teach learners how to continue learning after graduation.[45] The learning process during a professional life occurs through a self-centered learning process. The students should critically analyze situations and reflect to enhance their own knowledge and others. The students should also identify their own learning needs, based on internal and external feedback.[34] In the field of psychology, interpersonal communication and intelligence abilities, such as self-awareness, reflection, and self-assessment have gained great importance. Even the abilities to reflect, analyze, and modify the performance as well as self-development have been suggested as “super meta competency” because reflection and the process of modifying performance or experience gained are a series of mental reactions that lead to better understanding and learning.[8] In addition, in the present study, interest and motivation in healthcare delivery were introduced as a stimulus for learning, self-development, and improvement of the quality of healthcare services. Similarly, Fukada.(2018) also Yazdani and Yadollahi (2019) considered motivation as a necessary meta competency. Some researchers described competency as an iceberg composed of a visible tip above the water and an invisible part underneath.[32,17] Nevertheless, most studies on psychiatric nursing competencies have adopted a narrower definition of competency, focusing on its smaller tip. The iceberg is part of all competencies (e.g. knowledge, skills and abilities) and the larger underwater part is ignored, which is composed of relatively stable characteristics, such as attitudes, values, self-image, characteristics and motivations.[46,47,48]

Finally, the third category was “human and organizational management”, which was consistent with Brown’s (1993), Reis et al’s (2021) and Mathews’ (2013) study findings.[19,20,49] Management techniques and styles were teachable and measurable; however, higher aspects such as creativity, imagination, excitement, and intuition were not measurable. A manager can be trained to demonstrate his/her skills. Nevertheless, an intelligent person with his/her managerial knowledge, without any training and education, can acquire the meta competency and have better managerial ability.[19] Managerial competency as managerial distinctiveness and managerial resourcefulness, involves a higher-order performance that is not strictly based on skill and level, but it has clear action components. All processes that are unplanned, non-repetitive, unstructured, holistic and system-oriented require analysis and higher complex mental processes that fall under the definition of managerial competency or managerial resourcefulness.[49] Leadership, an essential component of management, plays an important role in managerial performance.[50] Leadership competencies include influencing others, learning and having knowledge of information processing, management talent, executive team development, and insight.[10] Nursing managers who have a decisive role in the mission and culture of the healthcare organization can promote the clinical competency of psychiatric nurses and hence the quality of care by resorting to leadership skills.[50] Thus, proper management and organization of different situations require knowledge and art. Studies state most novice nurses who face the challenges of the real nursing environment are not prepared.[51] As, studies stated Iranian nurses were weak at leadership, interpersonal relationships, teaching–coaching, and professional development dimensions.[37] Overall, all these skills are synergistic, and their combination can have a significant role in improving competencies.[52]

Limitations and recommendations

The main limitation of this research was few studies on the meta competency. Also, access to valid Embase and ISI sites was impossible. The literature review was limited to the Persian and English languages. As a result, further research is needed to decipher postgraduate psychiatric nurse meta-competency.

This study has strengths that outweigh the limitations of the study. This was one of the first studies to focus on meta competencies postgraduate psychiatric nurses’ competency to improve their services, especially in this decade when mental disorders have increased. By identifying the necessary meta-competency, the quality of education and evaluation of psychiatric nursing students meta-competency can be improved.

Conclusion

The findings of this study indicated that the meta-competency required for postgraduate psychiatric nursing students had three categories, including ”thinking and clinical reasoning skills“, “dynamic learning”, and “human and organizational management.” These findings may contribute to educating and evaluating psychiatric nursing students’ meta-competency. By acquiring this domain of competency, patients with mental disorders can receive better care. Further studies on required psychiatric nurses’ meta-competency, as well as the development of a valid and reliable tool for objectively evaluating psychiatric nurses meta-competency are recommended.

Authors’ contributions

First author: Concept and design of study -acquisition of data analysis and interpretation of data-drafting the manuscript-

The second and third authors are responsible the analysis and interpretation of data, and for revising and final approval of the version.

Ethics approval and consent to participate

This study is part of a larger study extracted from the PhD thesis and approved by the Ethics Committee of Azad Islamic University of Medical Sciences, Tehran (No: IR). IAU. TMU. REC.1399.171.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.