Relation between nurse educators' empowerment and nursing students' clinical competence

Introduction

The demographic changes of the population increased technological advancement, as well as the increased prevalence of chronic illness and disabilities have resulted in the need for changing the health care delivery systems ^{(1, 2)}. This dynamic and uncertain nature of health care environment requires competent professional nurse to manage the rapidly changing environment ⁽¹⁾.

Therefore, nurse educators play a vital role in ensuring that the new generation of nurses is prepared to meet the growing demand of health care services. Nurse educators are also instrumental in shaping the future of the nursing profession ⁽³⁾.They represent the spirits of the education process ^(4). So, many nurse educators have a dream to make a difference in the nursing profession, but this dream is challenging and faces many problems. One of these challenges is lack of nursing empowerment that nurses are still experiencing ⁽⁵⁾.

Empowerment is the process of increasing the capacity of individuals or group to make choices and to transform those choices into desired action and outcomes ⁽⁶⁾. It is considered a motivational process of enhancing feeling of self-efficacy among organizational members through the identification of conditions that foster powerlessness ^(7).

Moreover, the need to produce a competent, confident, critical thinker with the ability to lead, to question, and to be questioned is the core of modern preregistration in nursing educational programs .Despite the qualified professionals’ need, nowadays clinical competence of nurses in hospitals and other clinical environments are the concern and the center of attention for managers and the healthcare systems ⁽⁸⁾.

Thus, competence is a crucial attribute for assuring high-quality, ethical and safe nursing care ^{(9, 10)}. Nurse students’ clinical experience in nursing institutes has a long-term effect on their future competence ⁽¹¹⁾. They are required to master multiple task related skills during their education ⁽¹²⁾, to accurate determine patients' states and predict and cope with the problems that may occur during nursing care ^(13,14).

Currently, lack of nurses’ clinical competence is one of the most important issues in the provision of quality nursing care ^{(15, 16)}. The expectation of nursing education is to produce graduates who will be competent practitioners upon graduation ⁽¹⁷⁾. Therefore, nursing technical institutes are one of the organizations responsible to train nurses who have high level of clinical competence to satisfy the needs of all concerned bodies. For the preparation of these incompetent graduated nurses, literature revealed the contributions of different factors such role of the nurse educators as enabling the integration of theory and practice ⁽¹⁸⁾ .

In addition, the empowered nurse educator possesses the tools and resources that required developing instructional strategies; so students can attain successful mastery of the designated learning outcomes for the clinical course. With access to opportunity, resources, support, and information; nurse educators possesses the ability to engage in purposeful teaching, and enabling the student to integrate theoretical concepts into successful practice ^(19).

Significance of the study

Nurse educators have played a critical role in the professional development of nurses, and maintaining and advancing nursing practice standards. They are responsible for advancing practice development and student support ⁽²⁰⁾. Also, in the healthcare systems, nurse educators have the role for helping nursing students to become the type of practitioners who will positively impact patient care and satisfaction ⁽²¹⁾.

Aliakbari, and Amoli, 2016 ⁽²²⁾ found in their study that teacher empowerment important factor that enhance and improve student performance. Nurse educators who are empowered to make decisions are likely to have the ability to improve student achievement, as improving working condition will surely increase teaching quality which leads to positive effects on nursing student performance, learning, and academic performance.

Therefore, an effective role of nurse educators is the most important part in nursing education, because they considered as the change agent in the nursing education, in which, their role help nurse student to gain knowledge, skills, and attitudes, to enhance patient care. There are many researches that identify nurse educator empowerment as an important component to educator. But still now, there is no research that identifies a direct relation between nurse educators' empowerment and student clinical competence. Thus it is important to evaluate the relation between nurse educator empowerment and student clinical competencies

Aim of the study

The aim of the current study is to determine relation between nurse educators' empowerment and nursing students' clinical competence.                                       

Research questions

• What are the nurse educators' levels of empowerment at Minia Nursing technical institutes?
• What is the nursing students' clinical competence at Minia Nursing technical institutes?
• What is relation between nurse educators' empowerment and nursing students' clinical competence at Minia Nursing technical institutes?

Subjects and methods

Research design:

Descriptive correlational research design was used to achieve the aim of the current study.

Setting:

The study was conducted at Minia two nursing technical institute, one affiliated to university and another one affiliated to ministry of health.

Subjects:

The subject of study was include all nurse educators at Minia Nursing technical institute (n=15) and 50% of nursing students enrolled at 2nd academic year, 2018-2019 (n=165). And all nurse educators at Health Technical Institute (n=5) and 50% of nursing students enrolled at 2nd academic year, 2018-2019 (n=185). Total number of educators was (20) and total number of students was (350).

Data Collection Tools:

Data was collected by using three tools as follows: 

Tool (І) – Structural Empowerment Questionnaire it was included two parts:

Part 1: personal data; it was including information about nurse educators; such as: age, gender, residence, nursing qualification, and years of experience.

Part 2: Condition of Work Effectiveness Questionnaire (CWEQ) This tool was developed by Laschinger, et al., (2001) ⁽²³⁾ to assess nurse educators' structural empowerment. This tool was adopted and modified by the researcher to be compatible with the nursing institute environment. CEWQ included 19 item divided into 6 subscales components as follow: opportunity included (3 items), information included (3 items), support included (3 items), resources included (3 items), informal power included (3 items), and formal power included (4 items). Each Item was measured with five points Likert scale as (1 = never, 2 = seldom, 3 = sometimes, 4 = often, 5 = always). Scoring system was ranged from 19 to 95, and divided as follow:

• Low nurse educator structural empowerment from 19 to 44
• Moderate nurse educator structural empowerment from 45 to 69
• High nurse educator structural empowerment from 70 to 95

This scale was also, had two question measured by five point likert scale as (1 = strongly disagree, 2 = disagree, 3= agree, 4 = neutral, 5= strongly agree). These two items score were used to confirm construct validity with six components of structural empowerment

Tool (ІІ) – Psychological Empowerment Questionnaire: This tool was developed by Spreitzer (1995) ⁽²⁴⁾ and was adopted by researcher to assess nurse educators' psychological empowerment. It contained 12 item divided into four subscales as follow: Meaning, Competence, Self-determination, and Impact (3 items for each subscale). Each item was measured with five points likert scale as (1 = strongly disagree, 2 = disagree, 3= agree, 4 = neutral, 5= strongly agree). Scoring system of this tool was ranged from 12 to 60 and divided as follow:

v   Low nurse educator psychological empowerment from 12:28

v  Moderate nurse educator psychological empowerment from 29:44

v  High nurse educator psychological empowerment from 45:60

Tool (ІІІ) – Clinical Competence checklist: it was including three parts:

Part 1: Personal data; which included information about nurse students as age, gender, previous education and residence.

Part 2: this part was included the student score of final clinical exam during the time of data collection. The scoring system for this part was as follows:

Part 3:

This tool is developed by the researcher based on literature review ^{(25: 33)} to assess nursing student clinical competence. The final clinical competence observational checklistcontained (66) items divided into two subscales as follows:

• Subscale (I): Nursing Clinical Behaviors, Values and Attitudes: it included (19 items); each item measured with 3 point as (0=Unsatisfactory, 1= Need Improvement, 2= Satisfactory, and Not observed =-). This subscale was divided into 3 dimensions as follows:
  • Communication (6 items)
  • Responsibility and commitment (6 items)
  • Caring and ethics (7 items)
  • Subscale (II): Nursing Clinical skills: it included (47 items); each item measured with 3 point as (0= Not Done, 1= Done Incompletely, 2= Done Completely, and Not Applicable =--). This subscale was divided into 5 dimensions as follows:
    • General skills  (14 items)
    • Measuring vital signs skills (4 items)
    • Specific skills (11 items)
    • Safety and infection control skills (10 items)
    • Drug administration skills (8 items)

Scoring system of this part was ranged from 0 to 132 and divided as follows:

Validity of the tools:

Tools were tested for the content validity by a jury of 5 experts in the field of Nursing Administration and a necessary modification was done. The jury composed of two Assistant Professors from Faculty of Nursing, Minia University and three Assistant Professors from Faculty of Nursing, Assuit University. Each of the expert panel was asked to examine the instrument for content coverage, clarity, wording, length, format and overall appearance.

The tool І & ІІ of empowerment was not modified according to jury comments. Jury panel modified tool (ІІІ) clinical competence observational checklist; according to jury comments, there were (4) items that added to the tool related to student clinical area (pediatric unit) in which they were practiced during data collection. These four items were added to the specific skills dimension. The final format of the tool contained (70) items.  

Reliability of the tool

Reliability of the tools was performed to confirm consistency of tools. The internal consistency measured to identify the extent to which the items of the tools measure the same concept and correlate with each other by Cronbach’s alpha test; the reliability of the tools were structural empowerment (α=0.889), psychological empowerment (α=0.874), and clinical competence (α=0.791).

Pilot study:

A pilot study was conducted on 10% of student (35) and 10% of nurse educators (2) to ascertain the clarity, comprehensiveness and applicability of the tools as well as to estimate the appropriate time required to fill the questionnaire. The necessary modification was done.

According to the observation that was done for the students of the pilot; there were 4 items that all students had not performed and had score for ''not applicable'' for all of them; thus these 4 items were excluded from the final format of the tool. The final format of the tool contained (66 items). Thus, the tool (ІІІ) was modified and results of pilot study were not added to the final results.

Study procedure       

v  An official letters were granted from the Faculty Dean, the Director of both technical institute of nursing. This letter was included a brief explanation of the objectives of the study.

v   The researcher interviewed with nursing educators through morning during the working days of clinical rotation. 

v   The tools were handed to the nursing educators and researcher waited with them during their working hours to fill it and it was collected after filling. The time required for filling the tools was thirty minutes approximately.

v  For nursing students the researcher went to the hospital with nurse educators who supervised the nursing students to fill the observational checklist by asking the nurse educator to support and supplying general essential information and by observation, students were observed performing patient care duties during their clinical day, being limited interacts with the patients, visitors or other hospital personnel.

v  Data was collected from Nursing Technical Institute on Sunday per week during first semester of the academic year 2018-2019, it was lasted for three months, and each day, the researcher observed 15:16 students from 9:00 A.M to 1:00 pm.

v  Data was collected from Health Technical Institute on Tuesday per week during first semester of the academic year 2018-2019; it was also lasted for three months, and each day the researcher observed filled17:18 students from 9:00 A.M to 1:00 pm.

Ethical consideration

A written initial approval was obtained from the research ethics committee of the Faculty of Nursing, Minia University. Approval to conduct the study obtained from the Dean of faculty, as well from the Vice dean for education and students affairs in Faculty of Nursing at Minia University. The participants were informed that their participation in the study was completely voluntary and there will be no harm if they not participate in the study. Informed consent was obtained from participating after explaining the nature and benefits of the study. Each assessment sheet was coded and participants' names were not appearing on the sheets for the purpose of anonymity and confidentiality.

Statistical analysis:

Data entry was done using compatible personal computer. Statistical analysis done by using statistical package of social science (SPSS) version 25 and excel for figures. The content of each tool was analyzed, categorized and then coded. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. Statistical significance used at P value <0.05.

And comparison of means was performed using paired-sample t-test. Pearson’s chi square test (X2) is used to test for the association (or relationship) between the categories of two independent samples (row and column variables) to reflect a real association between these 2 variables in the population. Correlation is used to test the nature and strength of relation between two quantitative / ordinal variables.

Results:

Table (1): Percentage distribution of the nursing educators according to their personal data

Table (1) showed that, more than one third (40.0%) of nursing educators at Nursing technical institute and all (100) at Health technical instituteaged between 30- 34 years with mean age (32.3 + 3.9 and 32.0 +0.5 respectively). The majority (93.3%) of nursing educators at Nursing technical institute and all (100) at Health technical institute was female. Regarding the residence; two third (65.0%) and (60%) of nursing educators live in rural area. the majority (80.0%) of nursing educators at Nursing technical institute and all (100%) at Health technical institute had baccalaureate degree. Speaking about years of experiences, the majority (80%) of nursing educators at Nursing technical institute and (60%) at Health technical institute had (5 < 10) years of experience.

Table (2):  Percentage distribution of the nursing students according to their personal data

Table (2) presented that, near to two third (63.0%) of nursing students at Nursing Technical Institute aged between 19- 20 years with mean age (20.2 +0.970); more than half (52.1%) of them were female; the majority (82.4%) of them live in rural area, and all (100.0%) had high school.  Regarding to Health Technical Institute, table (2) shows that all (100.0%) of nursing students aged between 19- 20 years with mean age (19.5 +0.2); the majority (81.6%) of them were female; the majority (88.2%) of them lived in rural area; and  all (100.0%) of them had secondary nursing school.

Figure (1): Levels of total structure empowerment among nursing educators (n=20)

Figure (1) revealed that nursing educators had highest percentage for moderate level at Health Technical Institute (80%) and at Nursing Technical Institute (73.30%); also, there was (20%) of them at Health Technical Institute and (6.7%) at Nursing Technical Institute had high level of structure empowerment; with no statistically significant differences between them at two institutes; with no statistical significance difference. 

Figure (2): Levels of total Psychological empowerment among nursing educators (n=20)

Figure (2) displayed that nursing educators had highest percentage for high level as all (100%) at Health Technical Institute and neat three quarter (73.3%) at Nursing Technical Institute; also, no one (0%) of them at Health Technical Institute and at Nursing Technical Institute had low level of psychological empowerment; with no statistically significant differences between them at two institutes. 

Figure (3): Total level of empowerment among nursing educators (n=20)

Figure (3) showed that at Health Technical Institute, there was near to two third (60%) of nursing educators had high level and (40%) of them had moderate level of total empowerment; while at Nursing Technical Institute, there was two third of nursing educators (66.7%) had moderate level and only (20%) of them had high level of total empowerment; with no statistically significant differences between them at two institutes. 

Table (3): Mean scores of nursing students regarding their clinical competence

Independent t- test was used for quantitative data

 *: Significant difference in between groups (p value ≤ 0.05) **: Significant difference in between groups (p value ≤ 0.000)

Table (3) showed that nursing students at Health Technical Institute had higher mean score (7.9±1.9) for (communication dimension), and (10.9+2.0) for (Caring and ethics dimension), than nursing students at Nursing Technical Institute (7.7±2.3) and (10.6+1.6) respectively with no statistically significance difference (P=0.412) and (P=0.057) respectively. While, nursing students at Nursing Technical Institute (10.1±1.0) had higher mean score than nursing students at Health Technical Institute (9.1± 1.3) for (responsibility and commitment dimension) with highly statistical significance difference (P=0.000).

The nursing student at Nursing Technical Institute had highest mean score for ''General skills'' and ''Measuring Vital signs'' (14.7±1.2 and 2.8 ±0.7 respectively) than nursing student at Health Technical Institute; with statistical significance difference (P=0.015, and 0.034 respectively). While nursing student at Health Technical Institute had highest mean score for specific skills and Medication administration'' (9.0±1.5 and 8.8±1.4 respectively) than nursing student at Nursing Technical Institute; with highly statistical significance difference (P=0.000). No statistical significance differences founded between students for the safety and infection control dimension (p=0.861).

Regarding total mean score of subscale (I), there was no statistical significance difference between nursing students at two institutes (P=0.223). While; there was highly statistical significance difference between nursing students at two institutes (P=0.000) regarding the total mean score of subscale (II). Speaking about total clinical competence mean score, there was highly statistical significance difference (P=0.000) between nursing students at two institutes in favor to Health Technical Institute had higher mean score (82.7 ± 4.6).

Figure (4): Nursing students' final clinical exam scores according to their clinical institutes (n = 350)

Figure (4) illustrated that near to two third (62.4%) of nursing student at Nursing Technical Institute VS the majority (87.0) of nursing student at Health Technical Institute had excellent levels regarding their clinical area score. While more than one third (36.4%) of them VS (11.4%) had very good levels respectively.

Figure (5) Nursing students' levels regarding their total score levels of clinical competence (n=350)

Figure (5) displayed that, majority of nursing students (79.2%) at Nursing Technical Institute had fair level; while majority of nursing students (78.4%) at Health Technical Institute had good level regarding their total clinical competence; as well as no one (0%) had excellent level; with highly statistical significance differences between nursing students at two institutes (P=0.0001).

Table (4): Correlation between nursing students' clinical competence and their clinical score and nursing educators' empowerment

Table (4) presented that there were positive weak significant correlation between nursing student clinical competence and their final clinical exam score at Nursing Technical Institute which (r= 0.157 and P – value 0.04) and at health technical institute which (r= 0.187 and P – value 0.02).  Also, there were positive moderate significant correlation between nursing student clinical competence and nurses educator empowerment at Nursing Technical Institute which (r= 0.542 and P – value 0.01) and at Health Technical Institute which (r= 0.431 and P – value 0.05)