A survey of clinical competence of new nurses working in emergency department in Iran: A descriptive, cross‐sectional study

Abstract Aims This article reports on a study investigating the self‐assessed clinical competence of new nurses working in emergency departments. Design A quantitative approach using descriptive cross‐sectional survey design was employed. Methods The clinical competency of the participants was assessed using the Competency Inventory for Registered Nurse questionnaire, which contains the seven dimensions of clinical care, leadership, interpersonal relations, legal/ethical, professional development, teaching/coaching and critical thinking/research aptitude. Data from 115 new nurses employed in emergency departments of nine selected university hospitals in the northwest of Iran were collected by the Competency Inventory for Registered Nurse (CIRN) from December 2018–May 2019 and analysed. Results The mean clinical competency for the total scale was 155.7 (SD 32.9), indicating a moderate competency. The most highly self‐rated competency was legal/ethical practice, and the least rated was critical thinking–research aptitude.

the effective application of knowledge, skills and judgments" (International Council of Nurses, 1997).

| BACKG ROU N D
Consistent with many other countries in the world, nursing shortage is a challenging issue for the healthcare system of Iran. According to the national code of ethics, nurses are expected to be competent, have sufficient knowledge and skills to provide safe and quality care independently and assume accountability for their actions (Zahedi et al., 2013). Globally, newly graduated nurses perceive low competency to work independently, requiring support and mentoring within the first a few months of their practice as a registered nurse (Baumann, Crea-Arsenio, Hunsberger, Fleming-Carroll, & Keatings, 2019;Spence Laschinger et al., 2019). In Iran, nurses should have at least three years of work experience as a nurse to be able to work in the EDs. However, due to the nurse shortage, this employment requirement is not always met, jeopardizing patient safety in the EDs. Indeed, the phenomenon of new nurses commencing their professional career in an emergency department is relatively new in the nursing world (Kary, 2012).

| Design
This was a descriptive cross-sectional survey design study.

| Method
Nurses with equal or less than 3 years of work experience in the EDs of nine selected university hospitals in the northwest of Iran were invited to participate in the study (N = 132), of whom two nurses declined to participate in the study, for reasons, such as having a busy workload and being tired. Participant recruitment took place using convenience sampling.
Overall, 130 new emergency nurses completed the survey, 15 questionnaires were removed due to incomplete data, leaving 115 questionnaires for analysis. Data were collected by a paper-pencil questionnaire from December 2018-May 2019.
The study tool consisted of a self-administered survey containing a section on demographic and professional characteristics and the Competency Inventory for Registered Nurses (CIRN) questionnaire (Liu et al., 2009). The CIRN is a standardized questionnaire consisted of 55 items and the seven dimensions of clinical care, leadership, interpersonal relations, legal/ethical, professional development, teaching/coaching and critical thinking/research aptitude. The CIRN uses a 5-point Likert scale ranging from 0 (not competent at all)-4 (very competent). The scores for the total scale can range from 0-220. The Content Validity Index of the CIRN was 0.85 in the original study (Liu et al., 2009). It has been translated into Persian and psychometrically tested in Iran on a sample of registered nurses (Ghasemi, Janani, Dehghan Nayeri, & Negarandeh, 2014). The Cronbach's alpha coefficient of the

| Analysis
The data were analysed using SPSS software (IBM SPSS software (version 24; SPSS)) with the assistance of the research team statistician. Descriptive statistics, including frequency distribution, mean, standard deviation, range were used to summarize the data.

| Ethics
Before collecting the data, the Regional Research Ethics Committee of Tabriz University of Medical Sciences issued permission for conducting the study (IR.TBZMED.REC.1397.395). All participants received oral and written information about the study and its objectives and were informed that the participation was voluntary, and they were free to withdraw from the study at any time. Those who were interested in participating in the study signed a consent form. The participants' confidentiality was ensured throughout the research process. Table 1 summarizes the sociodemographic and professional characteristics of the participants. The participants' age ranged between 21-50 years, with a mean of 29.47 (SD 5.92). Most participants were female (64.8%), married (66.1%) and had a bachelor degree in nursing (94.8%). More than half of the participants (57.45) had less than five years work experience as a registered nurse, 21.7% commenced their first nursing job in the EDs and 29.6% had <1 year of work experience in the ED (Table 1).

| Self-assessed clinical competence
The total mean score for the CIRN was 155.7, with a standard deviation of 32.9, indicating an overall moderate competency. Slightly above half of the participants (53%) self-rated their competency level as moderate. The normalized mean scores in the seven competency domains ranged from 66.6-76.6. The most highly rated clinical competency domain was related to legal/ethical practice (76.6), followed by leadership (72.0), interpersonal relation (70.5) and clinical care (70.4). The least highly rated domains included critical thinking-research aptitude (66.6) and teaching-coaching (66.6) ( Table 2).

| D ISCUSS I ON
In this study, nurses self-rated their overall competence at a moderate level. No prior study has been carried out in Iran to investigate the clinical competence of new nurses in the EDs. In a study by Hassankhani et al. (2017), Iranian emergency nurses, including both new and experienced, self-rated their competency level as good (Hassankhani et al., 2017). Mirlashari et al. (2016) studied the clinical competence of Iranian nurses employed in the neonatal intensive care units and reported that 65.8% of these nurses had a moderate clinical competency (Mirlashari et al., 2016), as opposed to 53% in our study. The higher percentage of nurses with a moderate clinical competency level in Mirlashari et al.'s (2016) study can be due to recruiting both highly experienced and less experienced nurses (Mirlashari et al., 2016). Outside Iran, nurses in different clinical settings often self-assess their competence as good or high. In Salonen et al.'s (2007) study, registered nurses with less than three years of work experience and employed in intensive and emergency settings in Finland rated their competence as good (Salonen et al., 2007). Nurses' competency in teaching and coaching may be improved by providing opportunities to be engaged in patient education and mentoring and precipitating of novice nurses (Liu et al., 2009).
Education is an essential part of nursing's role involving individuals and groups, patients and coworkers. Nursing curriculums should ensure that nurse students are given adequate opportunities to learn and practice effective patient education and presentation skills.
In addition, nurses should be supported to be engaged in research projects to develop competency in advancing the nursing and diversity of patient care needs create significant competence challenges for emergency nurses and they need to be aware of the impact of optimal competence on patient care outcomes (Meretoja & Koponen, 2012). Patient safety may be compromised if a nurse cannot provide clinically competent care (Fero et al., 2009). For example, the critical thinking ability of a nurse can directly affect patient safety. Nurses must have the skills to recognize variations in patient conditions, perform independent nursing interventions, anticipate orders and prioritize care based on the circumstances.
These actions require critical thinking ability, advanced problem-solving skills and the ability to communicate clearly (Buerhaus et al., 2005;Fero et al., 2009). The new nurse preceptorship programs provide novice nurses with opportunities to enhance competence in different domains, including critical thinking and clinical skills (Gorman, 2019;Ke, Kuo, & Hung, 2017;Rush et al., 2019).
Strategies such as in-services and problem-solving workshops may also improve the critical thinking skills of beginner nurses (López et al., 2020).

| Limitations
The sample size of this study is small, yet, the participants were recruited from the emergency departments of nine teaching hospitals.
In addition, subjectivity and response bias are inherent challenges in self-assessment of competence (Meretoja & Koponen, 2012).

| CON CLUS ION
New nurses, working in the EDs, in Iran self-assessed their competence as moderate. The results indicate the need for improving new nurses' competence in the EDs, with a particular focus on their teaching/coaching and critical thinking/research aptitude skills. This is the first report on the competence of new nurses working in the EDs.

| Recommendations for practice and further research
The findings of this study provide implications for nursing administration, nursing practice and nursing education. The findings provide evidence to nursing mangers on the level of competency perceived by new nurses in the EDs and the potential patient safety issues.
New nurses may be provided with an opportunity to develop their competency in a slow-paced care setting, before working in the EDs.

ACK N OWLED G EM ENTS
The present study is a part of the emergency nursing M.S. dissertation. Hence, the researchers feel obliged to appreciate all authorities of Tabriz University of Medical Sciences and Faculty of Nursing and