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Journal of Public Health Research logoLink to Journal of Public Health Research
. 2021 Dec 1;11(2):2736. doi: 10.4081/jphr.2021.2736

Nurses' efforts to maintain competence: A qualitative study

Nur Miladiyah Rahmah 1, Rr Tutik Sri Hariyati 2,, Junaiti Sahar 3
PMCID: PMC8941307  PMID: 35244357

Abstract

Background: The clinical competence of nurses should be maintained to ensure patient safety. Competence is the integration of knowledge, skills, and attitudes. Nurse competency also improves the quality of nursing care and reduces the incidence of missed nursing care. This study aimed to explore the experiences of nurses maintaining a nurse competence system in hospitals through continuing education.

Design and Methods: The research method used was qualitative phenomenological research, and the data was collected through an in-depth interview which was consist of six participants.

Results: The results of the research were 1) continuing professional development to maintain the competence, 2) credentialing system in the career ladder system, 3) missed care still occurred in the implementation of nursing services 4) nurses had hopes that managers supported the efforts to maintain competence through continuing professional development.

Conclusions: Nurse managers are expected to improve the supervision program to maintain clinical competence and decrease missed care.

Significance for public health.

The results showed that maintaining nursing competence through continuous professional development can improve the quality of nursing care. In addition, support from the leadership is also needed in enhancing the competence of nurses. Competent nurses can improve quality nursing care and increase patient satisfaction.

Key words: Clinical competence, Continuing professional development, Missed care

Introduction

Nurse competence maintenance is a continuous process of improving knowledge, attitudes, and skills. The competence of nurses can be improved through continuous professional development. 1 The level of education attained by nurses is essential to the development of nursing competency. Nursing competency remains a significant issue in health care. Hariyati et al. stated that continuing nurse education was a program that aimed to develop nurse professional competence, which could not be separated from nursing career advancement. The core competence of clinical nursing staff can directly influence the quality of clinical nursing practice and clients’ care outcomes.2

In addition, when a nurse already working need to get career certainty. A career can be interpreted as an award and an effort to increase competence. Without a career, a nurse will be in a stagnant and undeveloped position.3,4 The program of nurse career path is designed to reward nurses who have clinical expertise. Nursing practice and education to be credentialed to demonstrate that an authorized standard has been met.5 Hariyati et al., 2017 stated that the nursing career ladder could enhance nurse capabilities, which leads to position compatibility and improved the quality of care.1 The career ladder has been commonly used in many health care organizations to identify and recognize those who exceed expectations. Hospitals have started to adopt a clinical career ladder for nurses, offering them clinical promotions for their clinical excellence and performance rather than seniority to improve recruitment, increase satisfaction and retention.1,6 This method includes enhancing competence, taking training, and giving responsibility.5,7,8

Continuing professional development (CPD) as part of the career ladder system is related to maintaining nurse competencies. Continuing professional development can be defined as the pursuit of knowledge and skills that help nurses achieve career advancement and enhance their effectiveness at work.2 It enables nurses to acquire competence concerning safe and effective person- centered care. Registered professional nurses need to possess the necessary skills and competencies in executing their duty. These skills are acquired through professional development, clinical experience, and education level. The future of nursing in healthcare is becoming multifaceted. Nurses must be given advanced pieces of training that enable them to meet people’s needs in the healthcare industry.9,10

Nurses must acquire their skills to develop and integrate with these emerging technologies. Without pursuing their further education, this problem will pose a significant challenge to nursing leaders. Higher competency and satisfaction with the quality of care are associated with more positive perceptions of the work environment, ethics, greater empowerment, and occupational commitment.11 Most nurses in Indonesia only have a diploma education, so Indonesia has much homework to improve and maintain the competence of nurses. The need for a highly educated nursing workforce is evident in the positive patient perceptions.3A clinical nurse is a person who has direct experience of a patients’ needs. According to Rizany et al., it was crucial for nurses to improve their competence, although several factors hinder it, also along with work experience, personal factors such as knowledge, attitudes, self-confidence, and nurse health would impact the development of a nurses’ talent.12

The research aimed to explore the efforts of nurses continuing education to maintain their competency in a clinical area.

Design and Methods

This study described nurses’ experiences maintaining competencies and getting continuing professional as part of career ladder implementation in hospitals. This research used a qualitative phenomenology to acknowledge the participants’ subjective experiences and allow insights into how individuals understood and construct their lives. While using a phenomena qualitative design, the researchers uncovered participants’ everyday experiences by remaining close to their reported or observed events.4 The participants recruited by using purposive sampling of nurses were eligible to participate in the study based on some criteria. They had at least one year of service, had experience as a clinical nurse, had experience in nursing career ladder implementation, and got continuing professional development. The snowballing approach was used to be the supplement purposive sampling. Sampling continued until the researchers reached data saturation to complete the categories and subcategories and answered the study question. The sample selection variation was to obtain a diverse study population regarding gender, age, work experience, and education level. The researchers extracted information until data saturation and was reached from the six participants. Data was collected through semi-structured in-depth interview. It was conducted from January to March 2021. The interview question focused on nurses’ experiences when maintaining competence on their career ladder. The questions contain open-ended questions, such as 1) How are your experiences about competence in nursing care? 2) What are the obstacles faced during the implementation of the authority? 3) Have you carried out the authority according to your competence? 4) What is the significance and hope to participate in nursing CPD as an effort to maintain competence? All participants were interviewed using the local language (Indonesian). The transcripts were translated from Bahasa Indonesia to English by one of the researchers and an experienced nurse who was fluent in both languages. Demographic data of participants was obtained using a demographic form during individual interviews.

Results

Characteristics of participants

The nurses who participated in this study were four females and two males. Participants’ ages ranged from 24 to 40 years old. Work experiences in a nursing role for participants were between two until 18 years. Three participants were RNs, and three participants were diplomas. One participant had a career ladder in level 1, three were on a career ladder in level 2, and two had a career ladder in level 3.

Themes

Four themes described various experiences of associated nurses in following the experiences nurse conducted on competence maintenance. The themes were: 1) continuing professional development, 2) credentialing by a career ladder system, 3) missed care still occurs in the implementation of nursing services, and 4) nurses have hopes that managers support efforts to maintain competence through CPD.

The themes described the various experiences of nurses participating in the maintenance of competencies. The details of 4 themes and supporting extracts from participants’ interviews were subsequently presented as follows:

Theme 1: Continuing professional development

An overview of participant’s understanding of the maintaining process and advancing their competencies by continuing professional development was based on the interview as follows:

“Currently, nursing science is getting more innovative, so I have to pursue my study, so my career ladder will go up. Besides, I have to attend nursing conferences or pieces of training to update my skill” (P1)

We are forced to continue our study so that I can feel the knowledge difference between a diploma and registered nurse” (P3)

“I have to continue my study because my education is still on Diploma, at least I can continue my nursing education as a Registered nurse so that I can improve my competence as a nurse” (P5)

“I try to join any training, especially in orthopedic one, because I like it, and hopefully, my career path can improve” (P6)

Based on data from six participants, four participants stated that one of the efforts to maintain competence was to continue nursing education both formally and informally.

Theme 2: Credentialing by a career ladder system

This theme was originated from the question of how nurses experience maintaining competency. The description of the credentialing career ladder were as follows:

“We have our logbook as a guidebook for clinical skills (P1).”

”There is a logbook, and exam questions too, the competency to give nursing care should be following the logbook, but its rarely done too”(P3)

”I prepare my assessment. Thus I got a notice from the nursing committee about the result of credentialing” (P4)

Participants said the way to maintain competencies was to reassess the competency according to the logbook and exam question to credentialing nurses.

Theme 3: Missed nursing care still occurred in the implementation of nursing service

This theme originated from whether you have carried out the authority according to your competence in nursing care in hospitals. The transcripts were as follows:

“….understaffed so that some nursing care is missed” (P1)

“well basic human needs such as personal hygiene, oxygenation, nutrition, but they are rarely done” (P2)

”We do not have time treating a patient with basic human needs, because we have many things to do during our shift, and we have better priority to give medicine or doing another intervention for patients” (P4)

“Sometimes we do not perform well (missed care) on our clinical task like doing it not up to a standard operational procedure’ (P5)

Participants stated that missed nursing care still occurred in the implementation of nursing services. Most of the clinical nurses in level 1 could not finish the primary human need nursing care or lacked time to do the nursing care because of understaffed human resources.

Theme 4: Nurses had hopes that managers supported efforts to maintain competence through CPD

The transcript was as follows:

“There is no difference in remuneration between clinical nurse 1, 2, or 3, so maybe someday if career ladder can influence the remuneration, we might be motivated to increase our career ladder (P1)

“My supervisor does not provide any examples and does not supervise my job. He or she never asks regarding the update of my career path as a clinical nurse. Increasing my career path depends on me when I am ready; I will apply to improve my clinical task“ (P2)

”My head nurse always supports me when I have exams with the committee; it means a lot for me“(P5)

”Sometimes, I need supervision from my supervisor; I think that he or she does not oversee my task“ (P3)

Participants stated that they needed support and supervision from the manager to maintain nursing competence.

Discussion

Professional development comprised formal and non-formal learning methods. Professional development was one of the main phases in the nursing career ladder.11 Other studies stated that continuing professional development could improve competency, increase knowledge, and develop professionalism in providing nursing care. Continuing professional development was one way to improve the competence of nurses. Pursuing nurse education was a program that aims to develop nurse professional competence, which could not be separated from nurse career advancement.12-14 It was the first step for nurses in preparing for their next career. The findings revealed that professional development required a robust knowledge base on nursing and its application. Professional development had a crucial part in practitioners’ proficiency in delivering safe and effective care.14–16

The second theme regarding the credentialing system which was evaluate nurse competencies and stated the clinical appointment. The nursing committee conducted the credentialing to guarantee and evaluate knowledge, skill, attitude, and portfolio. Credentialing also guaranteed quality and safety because the placement was followed by clinical privilege.17 The nursing career ladder program in Indonesia, including the CPD program and nursing credentials, began in 2006 with some hospitals that differ from one to another. Hariyati et al. stated that the career ladder system, including credentialing in Indonesia, was still far from being optimal. Nurse credentials that had not run optimally would impact the implementation of nursing care that was not optimal. Missed nursing care often relates to basic needs, where many nurses still emphasized collaborative and invasive actions.1 This research followed the results of previous research, which conveyed that actions that were often forgotten in nursing care were monitoring and assisting with personal hygiene and nursing documentation.18

Nursing manager support was needed in the implementation of credential processes and CPD improvement. Not only nurses carried out evaluations and credentials, but nurses needed to get direction and supervision and continue developing CPD. The role of the nurse manager included (a) patient nursing care management, (b) supervising staff providing care, (c) evaluating performance and development of staff competencies, (d) ability to create a safe and comfortable work environment.9,19 According to Cottingham et al., mentoring programs could boost career development, professional development, increase competence and improve retention.20–22 Nursing supervision was a process designed to develop leadership ability to deliver good professional health services. The career ladder implementation would be more optimal once it is underpinned with higher-ups’ better management and supervision system.7 The career path system, including improving CPD, should include greater support from the leadership, improvement of nursing care services, a decrease of slipups towards patients and their families, and an increase of clinical competence in collaboration with other medical teams. The elements that support the value of professionalism were care, provision of quality nursing care, and nursing leadership. The core areas included supportive practice, empathetic care, family care, and emotional and spiritual support. Professional nursing care could also look at the whole picture of the patient and communicate the overall care plan to the patients and their families.16,23,24 The professional would decrease missed nursing care and reduce patient safety incidents.1,18 The study’s limitations are that the number of participants is too small and cannot describe the nurse’s efforts in maintaining competence. Further study is needed with a large number of samples to describe the nurse efforts by nurses in improving their competence

Conclusions

Continuing professional development and credentialing systems helped maintain nurse competence. The support from nurse managers was needed to improve quality and safety and reduce missed nursing care.

Acknowledgments

The author would like to thank the Lembaga Pengelola Dana Pendidikan (LPDP)/Education Fund Management Institute and nurse’s in Chasbullah Abdul Madjid Hospital who participated in the study and openly shared their experiences.

Funding Statement

Funding: This work is supported by Hibah Riset WCU Publikasi Doktor 2021 funded by Directorate of Research and Development Universitas Indonesia with number NKB-482/UN2.RST/ HKP.05.00/2021.

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