Nurses’ viewpoints on nursing competencies during epidemics: A Q methodology study

Abstract

BACKGROUND:

Epidemics create chaotic situations in health services. Understanding different perspectives about nursing competencies during epidemics can help designing better educational and interventional programs to prepare nurses for future epidemics. The aim of the present study was to investigate nurses’ perspectives on required competencies of nurses during epidemics using Q methodology.

MATERIALS AND METHODS:

The present cross-sectional study was conducted using Q methodology and carried out from September 2023 to February 2024 in general hospital of Kashan, IRAN. Twenty-four nurses who were involved in management of COVID-19 patients were recruited to the study by purposive sampling. Participants sorted 72 statements from -6 to + 6 that showed their viewpoints about the least to the most important required nursing competencies during epidemics. The Q factor analysis was used to cluster the distinguished viewpoints with PQ-Method 2.35 and KADE software using centroid factor analysis and Varimax rotation.

RESULTS:

Considering eigenvalues and factor loadings, the 3-factor solution was recognized as the best fit for the data that represented 3 viewpoints of competencies related to working in ICUs, competencies related to infection control and basic skills, and competencies based on dedication and working beyond the routine duties.

CONCLUSIONS:

This study showed that nurses require wide range of competencies during epidemics such as ability to work in ICUs, basic nursing skills, and working in hard conditions. Nurses have different viewpoints about the importance of these competencies. These viewpoints can help nurse managers and instructors to prepare nurses for future epidemics.

Introduction

Clinical competency has been an important issue in nursing education and practice. Clinical competence has been defined as the ability to function effectively in the area of practice, using skills, knowledge, and clinical reasoning.[1]

In a qualitative study, nursing clinical competency had personal, social, and professional dimensions. Personal competence refers to characteristics such as patience, secrecy, anger management, effective coping, punctuality, and discipline. Social competence means nurses’ ability to establish effective communication with their colleagues, patients, and patients’ families to provide quality care through teamwork. Professional competence means providing effective and evidence-based care with combination of knowledge and skills and clinical judgment to make the best decisions based on their patients’ conditions and take the best actions in patient care.[2] Factors such as age, work experience, educational degree, and work stress can affect nurses’ clinical competence.[3]

Enhancing competencies through education could positively influence patient outcomes. A study in Iran showed that education through telenursing could improve the quality of life of COVID-19 patients.[4] Telenursing education also could reduce the burden of care in family caregivers for COVID-19 patients.[5] An empowerment program including educational workshop, tabletop, and operational maneuvers improved nurses’ competence in all domains of management, ethics, personal, teamwork, and technical, immediately and 3 months after the intervention.[6]

Nursing managers have a crucial role in improvement of nursing competencies and increasing their motivations to efficiently apply their competencies. In participatory management, nurses can decide about their educational programs according to their needs in different situations such as epidemics. This will improve the quality of care, and job satisfaction.[7] A study in Iran showed that nurses caring for COVID-19 patients selected democratic leadership as the preferred model for nursing managers. This model makes nurses feel more belonging and committed to the organization, which ultimately increases the quality of service and patient satisfaction.[8] COVID-19 pandemic has challenged the clinical competencies of nurses. There was overload of critical patients in emergency wards and ICUs, and considerable shortages in staff, space and equipment. Nurses should have taken care of patients and overcome their own concerns and fears.[9] A study in Iran showed high levels of occupational exhaustion and chronic fatigue in nurses providing care for COVID-19 patients.[10] Nurses also showed a high level of work–family conflict.[11] In a qualitative study, three categories of nursing competencies in epidemics were determined, including clinical nursing skills, knowledge of epidemics, and soft skills for nurses. Clinical nursing skills means, the psychomotor, and technical abilities of nurses to successfully manage patients during epidemics. Knowledge of epidemics refers to up to date information about infectious diseases, and epidemiology principals and soft skills include leadership, organizational, communication, critical thinking, conflict management, problem solving, resilience, stress management, high internal motivations, accountability, adaptability, and creativity.[9]

During COVID-19 pandemic, many changes were made in nursing workforce in hospitals. Many nursing students and retired nurses were volunteered as staff nurses, and many nurses were transferred to emergency wards, ICUs, and COVID-19 wards without adequate preparation.[12] Changing the clinical practice setting without appropriate preparation has been contributed to an increased sense of inadequacy and perceived lack of competence in providing care. On the other hand, nurses in new units increased their efforts in self‐directed learning and establishing partnerships with their new colleagues with the purpose of helping each other. Therefore, nurses reported to experience the expansion of the professional nursing role by gaining new competencies, such as working with noninvasive ventilation devices, improving their decision‐making abilities, and strengthening their professional role identity.[13] In a qualitative study, male nurses who volunteered for working in COVID-19 wards noted that this experience had changed their way of thinking at work to more humanistic care, helped them to identify their life goals, and helped them grow as individuals. They believed that male nurses have more advantages over female nurses during epidemics. They are stronger, firm in making decisions, and more suitable in some departments such as the operating room and emergency department.[14]

Nurses’ positions can also influence their perspectives regarding competence. In a study clinical nurses mostly emphasized on abilities such as cardiopulmonary resuscitation, client safety, and implementation of procedures, while academic nurses emphasized on assessing the client’s needs and physiological integrity.[15] These studies show that there are different perspectives about clinical nursing competencies during epidemics. Understanding different perspectives and viewpoints within healthcare system is an important issue because individuals’ and groups’ perception of these subjects would affect their behaviors.[16]

Exploring these perspectives can help managers designing better educational and interventional programs to prepare nurses for future epidemics. An approach that has gained recognition in healthcare research for identifying and comparing individuals’ and groups’ contrasting viewpoints is Q-methodology. As far as we reviewed the literature, this is the first research with the aim of exploring different viewpoints about nurses’ competencies during epidemics using Q methodology.

Materials and Methods

Study design and setting

This cross-sectional, Q methodology study was carried out from September 2023 to February 2024 in general hospital of Kashan, Iran. This hospital has 740 beds that provides health care services to 400000 residents. During the COVID-19 pandemic, this hospital was the center for providing services to patients. This study was conducted in six stages according to Q methodology phases.

Stage 1: Develop the Q-statements

The Q methodology process, started with defining and collecting statements that could represent the entire spectrum of viewpoints within the topic, which is called Q-set.[17] The objective of this step was to extract the competencies that nurses should have to manage the infectious outbreaks successfully. For this purpose, a qualitative study was carried out from October 2022 to March 2023, and 12 nurses who were engaged in patients’ management during COVID-19 pandemic were interviewed about the nursing competencies during the epidemic. The statements about the competencies were categorized into 11 subcategories and 3 categories of clinical nursing skills in epidemics, knowledge of epidemics, and soft skills for nurses in epidemics. The 159 competencies were extracted from the interviews, and then after removing and integrating similar competencies, the 72 statements were piloted. This qualitative study has been published elsewhere.[9]

Piloting

The comprehensibility of the statements and instructions and how easy participants can sort the statements were ensured in this stage.[16] In this study, 10 experts in nursing and infectious diseases evaluated the statements. The experts were requested to revise the statements or add new ones if they thought the statements could not cover the subject adequately. Qualitative content analysis and quantitative content analysis including Content Validity Index (CVI) and Content Validity Ratio (CVR) also were calculated.[18] CVR and CVI scores of the statements were calculated 0.976 and 0.996 respectively, that showed an acceptable content validity. No statement was deleted in this stage.

Study participant and sampling (P-sample)

In this stage, participants who were able to articulate viewpoints on the topic were recruited to the study by purposive sampling. The set of participants was referred to as a P-set.[17] The number of participants is usually less than the number of statements, using a statement–participant ratio of 3:1 is suggested.[19] Twenty-four nurses providing nursing care during COVID-19 pandemic were recruited to the study using purposive sampling considering diversity of gender, education, work experience, hospital departments, and thick experience during pandemic according to suggestions by colleagues and hospital nursing managers. The inclusion criteria were having at least 6 months’ of work experience during COVID-19 pandemic and willingness to participate in the study.

Data collection tools and technique

In this stage, statements were written in similar cards and participants sort them (Q-sorting) according to some level of judgment.[16] In this study, for the Q-sorting process a forced distribution was chosen on a scale from -6 to + 6 (least important to most important competence), as seen in Figure 1. The number of statements that could be in each group was specified, so the participants had to made the decision about the importance of the competencies. The manual sorting was performed in a quiet room in the hospital during a time that was proper for the participants. During sorting, the participants were questioned about why they thought a statement is less important or very important, and their answers were recorded to help the researchers during the interpretation stage. The demographic variables of each respondent and the number of each statement according to his/her Q-sorting were also recorded.

Figure 1.

Q sorting grid used in the present study

Data analysis

Data were analyzed using PQMethod 2.35 and KADE software. The centroid factor analysis and Varimax rotation with the Horst 5.5 method were used for Q factor analysis. Factors were extracted using following criteria: the total amount of variability has been explained, at least two participants had similar viewpoints per factor, and the eigenvalues were greater than 1.

Interpretation

This stage included qualitative interpretation of the viewpoints according to the most negative and most positive statements in every factor and developing narratives for each factor that represent a viewpoint.[16] In this study, participants with similar opinions were grouped as a factor. The most and less important and distinguished statements for every factor were interpreted qualitatively, and narrative explanations were provided for every factor. Distinguished statements are statements which rank in a position that significantly differs from the rank in other factors.

Ethical considerations

The research protocol was independently reviewed and approved by ethics committee of Kashan University of Medical Sciences with ethical code of: IR.KAUMS.NUHEPM.REC.1401.030. The research objectives were explained to all the participants, and written informed consent was obtained. The confidentiality of the participants and their views were respected. Participants had the right to withdraw from the study at any desired time. This research has been conducted in accordance with Declaration of Helsinki ethical principles.

Results

A total of 24 nurses participated in the study. The average age of participants was 35.6 ± 6.2 (range 25–46) years, and their work experience was 12.1 ± 6 (range 3–25 years). Sixteen (66.7%) participants were female, and 17 (70.8%) were married. The hospital departments of the participants were internal (6, 25%), surgical (8, 33.3%), ICU (6, 25%), and emergency (4, 16.7%).

The Kade software suggested 3 factors for the data, but the researchers examined 8 factors and reduced the factors one by one, and finally, considering eigenvalues and factor loadings, the 3-factor solution was recognized as the best fit for the data. The scree plot also approved the three factors [Figure 2]. Each factor was considered as a viewpoint in this study. From 72 statements, 55 ones showed significance on at least 1 viewpoint that could be seen in Table 1. The three viewpoints explained 32% of clinical competency variance. The viewpoints were named:

Figure 2.

The scree plot showed that 3 factors were appropriate for the data

Table 1.

Statement scores ranking per viewpoints about the nursing competencies in epidemics

Statements		Viewpoints
		1		2		3
Having courage		1		-1**»		3
Think positive		3«**		1		-2**»
Being well-mannered		5		-3**		-2**»
Having a sense of sacrifice and selflessness		2**		-5**»		6«**
Being patient		2		-5**»		1
Being kind		3		-1**»		2
Ability to work beyond the duty		0**		-6**»		4«**
Being organized		-1**»		4		2
Having work conscience		6«**		-2*»		0*
Ability to work despite thirst and hunger		-5**»		-1**		5«**
Volunteering to work in hazardous conditions		0		-6**»		1
Being critical		-2**»		4		4
Ability to work with media and social networks		-4**»		3«*		1*
Patient education skills		1«**		-1		-2
Ability to manage his/her fear and stress		5«**		-3**»		0**
Ability to manage bad memories		-1		0		-3*»
Being smart		0**»		6«**		4**
The need to be sharp		0		0		5«**
Having accuracy and concentration		3«*		1		-1
Ability to work with a ventilator		2«**		-3		-4
Oxygen therapy ability		0«**		-4		-5
Ability to recognize breathing sounds		-2**»		1		2
Ability to do chest physiotherapy		-1		4«**		0
The skill of recording nursing charts		-2		5«**		-3
Ability to correctly collect clinical information		2**		5«**		-2**»
Basic nursing skills		4*		5«*		-4**»
Having the ability of clinical decision-making		2		3		-2**»
Ability to provide nursing care beyond routine duties		0**		-2**»		4«**
Ability to take appropriate actions in an emergency		-6**»		2«*		-1*
Basic and advanced resuscitation skills		4«**		-3		-2
Skill of isolation		-2**»		3«*		1*
Wearing and removing personal protective devices		-4		2«**		-4
Disinfection and infection control skills		-4		2«**		-3
Ability to perform care despite the presence of protective devices		-3		-2		0«*
Ability of working in ICUs		1«**		-4		-3
Critical patient management skills		6«**		-5		-6
Ability to work in different departments		-1		-2		-5**»
Ability to perform the triage process in suspected epidemic cases		-2*»		0		0
Ability to use up to date information for optimal care of patients		1*		3«*		-5**»
Having information about legal issues		-3**»		2		-1
Ability to provide home care		-3**»		2«*		-1*
Ability to conduct telephone consultations		-6**»		4«**		-1**
Ability to prioritize problems		5«**		-1		-1
Knowledge of traditional and complementary treatment methods		-3**»		0*		2«*
Knowledge of dealing with superstitions and unscientific methods		-4**»		0**		6«**
Knowing the basics of epidemics		-5		-4		0«**
Knowledge of infectious diseases and antibiotics		0		-1		-4*»
Trustworthiness		-1**»		6«**		2
Ability to act as the patient’s accompany to perform basic care		-5**»		0*		1«*
Community education skills		0		-1		3«**
Knowing the principles of crisis management		1		-3**»		0
Ability to participate in hospital management and reorganization		0«*		-2*		-6**»
Ability to use information from experienced nurses		-1**»		2		3
Having a sense of altruism		4		-4**»		5
Having a sense of aesthetics and artistic understanding		-3**»		0		0
Having creativity in care		-2**»		3«*		0*

*Distinguished statement at P<0.05. **Distinguished statement at P<0.01. ^«Z-score higher than other factors. ^»Z-score lower than other factors

• Competency of working in ICUs, and managing critically ill patients.

• Competency of infection control and basic nursing skills.

• Competency based on dedication and working beyond the routine duties.

Viewpoint 1: Competency of working in ICUs, and managing critically ill patients

Ten participants shared this viewpoint, from which 8 were female, and their age and work experience were 37.6 ± 6.5 and 14 ± 6.6 years, respectively. Their hospital departments were 5 in surgical, 4 in ICU, and 1 in emergency wards. This viewpoint explained 16% of variance, with eigenvalue of 3.76. In this viewpoint, the most important competency for nurses during epidemics was the ability to manage critical patients. They also gave the higher rank to the skills related to this competency such as the basic and advanced resuscitation, working with ventilators, ability to work in ICUs, oxygen therapy, ability to prioritize problems, patient education, and basic nursing skills. Some personal characters that are important in managing critical patients also received higher ranks in this viewpoint such as having work conscience, the ability to manage fear and stress, thinking positively, and having good manners. The ability of hospital management was also important in this viewpoint.

On the other hand, the competencies of telephone counseling, working with media and social networks, and isolation were not important for nurses who made this viewpoint.

Viewpoint 2: Competency of infection control and basic nursing skills

Three participants shared this viewpoint, 2 of them were female, and their age was 28 ± 2.6 years, and work experience was 5.6 ± 2.3 years. They were working in medical and surgical departments. This viewpoint explained 9% of variance, with eigenvalue of 2.14. In the eyes of these nurses, some personal characters including being smart and trustworthiness were most important competencies for nurses in epidemics. They also gave higher ranks to some nursing skills such as chest physiotherapy, documentation, gathering clinical information, basic nursing skills, telephone counseling, working with media and social networks, isolation, using Personal Protective Devices (PPD), disinfection, being up to date, home care, and having creativity. On the other hand, the characters such as working beyond duties, being dedicated and altruism, managing fear and stress, and being compassionate were not important competencies for these nurses.

Viewpoint 3: Competency based on dedication and working beyond the routine duties

Four nurses made this viewpoint from which, 2 were female, and average age and work experience were 38 ± 2.5 and 14 ± 3.3 years, respectively. Two were working in ICUs, 1 in medical, and 1 in emergency wards. This viewpoint explained 7% of variance with eigenvalue of 1.6. The knowledge of dealing with superstitions and unscientific methods, being dedicated to the patients, being sharp, working in spite of hunger and thirst, working beyond duties, and working like the patients’ companions were the most important competencies for the nurses that made this viewpoint. On the other hand, the competencies of hospital management, being up to date, ability to work in different wards, the knowledge of infectious diseases, and antibiotics were not important competencies for these nurses.

Discussion

This study was carried out to show nurses’ viewpoints about the required competencies of nurses during epidemics. The findings of the current study showed that there were three viewpoints about nursing competencies during epidemics, which could be categorized as competency of working in ICUs, and managing critically ill patients, competency of infection control and basic nursing skills, and competency based on dedication and working beyond the routine duties. Nursing as a profession has an extensive body of knowledge in basic sciences, medicine, pharmacology, and nursing, along with very specialized skills in different fields. Nurses should manage patients during their most vulnerable times. Hence, this profession combines science, skills and art. That is why the concept of “good nurse” is still unclear.[20] In crisis, such as epidemics, the concept is even more difficult to define.

Competency of working in ICUs and managing critically ill patients: The finding of the current study showed that some nurses believed that the ability to work in ICUs and manage critically ill patients were the most important competencies that nurses require during epidemics. This includes basic and advanced resuscitation skills, working with ventilators, oxygen therapy, and prioritizing problems. During COVID-19 pandemic, many patients required intensive cares, so the nurses’ competencies to work in ICUs showed priority in this viewpoint. These findings align with previous studies that have emphasized the importance of specialized skills and knowledge in managing severe cases during health crises.[21,22] In a study, the competencies of therapeutic management of the disease, clinical decision making, end of life care, working with ventilators, and advance life support were some competencies that have been defined for ICU nurses.[23] Providing comprehensive care for a critically ill patient, the ability to prioritize, getting support from colleagues with more experience to solve problems in complex situations, and ability to act quickly in the event of patient deterioration were some other required competencies for ICU nurses.[24] Performing cardiopulmonary resuscitation, cardioversion, tracheal intubation, tracheal suction, obtain appropriate microbiological samples, interpreting the results of blood gas samples, management of coma patients, and sepsis were some clinical core competencies for practitioners in ICUs.[25] In Australia, the ability to take care of critically ill patients, appropriate use of personal protective equipment in the intensive care unit, use of specialized equipment, and basic mechanical ventilation were defined as the required competencies for managing COVID-19 patients.[22] However, this viewpoint contrasts with studies that place less emphasis on ICU-specific skills and more on general public health competencies, such as community education and media communication.[26,27] This discrepancy could be due to the specific context of this study being conducted in a hospital that was a COVID-19 treatment center, thus prioritizing ICU-related competencies over broader public health skills.

Competency of infection control and basic nursing skills: In the current study, some nurses believed that competency of infection control and basic nursing skills were more important. This viewpoint prioritized competencies such as chest physiotherapy, documentation, isolation techniques, and working with media and social networks. This aligns with the findings of other studies. Liu believe that during epidemics and infectious outbreaks, the nurses should have adequate knowledge of infection control, basic microbiology, hand hygiene, standard precautions and additional precautions, using personal protective equipment, proper cleaning, disinfection, and sterilization.[28] Nurses are working closely with patients; therefore, they can directly impact infection control, so they should be equipped with the latest knowledge and skills for infection control and assessment of patients’ infection symptoms and providing education.[29] However, there is a divergence from studies that emphasize advanced clinical skills over basic nursing skills.[22,30] This could be explained by the varying roles and responsibilities nurses might have during different phases of an epidemic. In initial outbreak phases, infection control and basic care are paramount, while advanced clinical skills may become more critical as the epidemic progresses and more severe cases arise.

Competency based on dedication and working beyond the routine duties: The findings of the current research showed that some nurses believed that competencies based on dedication and working beyond the routine duties were most important ones during epidemics. This includes being dedicated to patients, working despite personal discomforts, and going beyond standard duties. This perspective underscores the importance of altruism, resilience, and a strong commitment to patient care, which have been supported by other studies.[9,20] Nursing as a profession has strong humanitarian roots.[20] Nurses have experienced difficult times during COVID-19 pandemic. In a qualitative study nurses reported uncertainty, lack of training, social stigma by society, and physical and psychological challenges while providing nursing care during COVID-19 pandemic.[31] The COVID-19 pandemic placed nurses on the treatment frontline and increased their managers’ expectations. The managers expected standard care from nurses despite shortages. Therefore, nurses had to linger their stay in the hospital to cover personnel shortages. During the pandemic, nurses experienced workload, fear, high pressure, anxiety, helplessness, sleep disorders, and depression.[32] Nurses in Turkey noted challenging working conditions, tiredness, isolation and loneliness, fear, and helplessness, and lack of management support as their experience during COVID-19 pandemic.[21] These experiences have made some nurses believe that dedication and working beyond the routine duties were the most important nursing competencies during epidemics. This viewpoint differs from studies that have focused more on technical and procedural competencies.[21,29] The emphasis on dedication and personal sacrifice might be influenced by cultural and contextual factors specific to the study setting, where personal commitment and sacrifice were highly visible and valued during the COVID-19 pandemic.

Limitations and recommendation

This study had some limitations. First, all the nurses who ranked the statements were staff nurses working in hospital. The study on community health nurses might have different perspectives. Second, the nurses used the traditional method for ranking the statements, using computer-based ranking could be more feasible for the participants. For Health Policy Makers: Develop policies that would support ongoing training and simulation exercises for nurses, focusing on both ICU-specific skills and general infection control measures. Ensure that adequate resources and support systems are in place to foster a work environment that values and supports nurses’ dedication and resilience. For Nursing Managers: Implement continuous education programs that would cover a broad range of competencies, from technical skills to personal development. Create a supportive workplace culture that recognizes and rewards dedication and going beyond routine duties. Facilitate peer support groups and stress management workshops to help nurses cope with the pressures of working during epidemics. By addressing these areas, healthcare systems can better prepare nurses for future epidemics, ensuring they are equipped with the necessary skills and attribute to manage such crises more effectively.

Conclusion

In conclusion, this study identified three main viewpoints on nursing competencies during epidemics: managing critically ill patients in ICUs, infection control and basic nursing skills, and dedication and working beyond routine duties. These findings suggest that a comprehensive competency development program for nurses during epidemics should include advanced clinical skills, robust infection control measures, and fostering personal attributes such as dedication and resilience.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.