Is nurses’ clinical competence associated with their compassion satisfaction, burnout and secondary traumatic stress? A cross‐sectional study

Abstract Aim The current study aimed to investigate the relationship between clinical competence and subscale of professional quality of life (ProQOL). Methods This cross‐sectional study was conducted from November 2018 to May 2019 on 291 nurses working in public hospitals in south Iran (Rafsanjan). The nurses were selected by convenience sampling method. Data were collected using the ProQOL questionnaire that included three subscales: compassion satisfaction, secondary traumatic stress and burnout and the Competency Inventory for Registered Nurse (CIRN) that measured clinical competence. Results A significant positive relationship was observed between compassion satisfaction and clinical competence. A significant negative association was found between compassion satisfaction and secondary traumatic stress/burnout and also between secondary traumatic stress and clinical competence. The results of regression analysis indicated that compassion satisfaction was the best predictor of secondary traumatic stress (R 2 = 65%), burnout (R 2 = 40%) and clinical competence (R 2 = 12%). Moreover, secondary traumatic stress was found to be the best predictor of compassion satisfaction (R 2 = 53%).


| Background
Nurses' clinical competence is one of the essential requirements for providing safe and effective caregiving (Kim et al., 2015) and is one of the main elements in providing nursing care based on professional performance standards (Bahreini et al., 2010). Nurses need high-level clinical expertise to accurately assess the patient's condition and deal with problems that may occur during treatment (Park & Kim, 2009). Aued et al. (2016) showed that identifying clinical competence and nurses' access to this competence were important achievements for managing individuals. Nurse managers can use them to allocate nurses better and provide opportunities for their professional development (Aued et al., 2016). The recognition of various factors affecting the development of clinical competence is very important (Bench et al., 2003). Assessing and improving clinical competence is an ongoing and dynamic process and many factors can affect the level of competence of nurses (Yanhua & Watson, 2011). A study by Mirlashari et al. on nurses in the intensive care unit (ICU) found that factors such as marital status, employment status and interest in working in the ICU should be taken into consideration for inducing the highest level of clinical competence in nurses (Mirlashari et al., 2016).
A study by Memarian et al. (2007) showed that factors such as effective communication, career interest, accountability work experience and personal factors such as ethical and professional principles, knowledge and skills affect the competence of nurses.
Professional factors such as effective management, control and monitoring and external environmental factors such as an efficient education system and providing technology are other factors affecting the competence of nurses. Yanhua and Watson (2011) review showed that there is a growing concern about the competence of nurses, which has led nursing managers to pay special attention to it and related factors.
Nurses' clinical competence must be assessed regularly because of the ongoing changes in therapeutic settings. However, nurses may have a low quality of life, which can affect their clinical competence (Kim et al., 2015). Recently, the focus has been shifted on concepts related to the professional quality of life (ProQOL) and job performance of nurses, including their clinical function and competence (Vagharseyyedin et al., 2011). Nurses are exposed to occupational stress and they experience the highest levels of stress in the workplace (Sonke et al., 2015). Nayomi's (2016) review revealed emergency cases, high workload, understaffing, lack of support or positive feedback from senior nursing staff, poor working relationship, demanding communication and relationships with patients and relatives have been the main sources of stress for nurses.
Thus, workplace stress has caused job dissatisfaction and burnout for nurses (Commission, 2012). Given that nurses are the main health providers who observe pain and suffering (Farhadi et al., 2013), job-related stress responses such as compassion fatigue and occupational burnout have a negative impact on the nurses' ProQOL, clinical decision-making and patient care quality (Thomas, 2012) and hence, affecting the clinical competence of nurses.
The term "professional quality of life" or ProQOL with three components of compassion satisfaction, secondary traumatic stress and occupational burnout, refers to the positive and negative emotions that a person describes in his/her job as a contributor and a rescuer (Stamm, 2002;Stamm, 2010). Compassion satisfaction occurs when altruistic empathy behaviours are used to reduce a patient's suffering and cause the caregiver to deal with the negative aspects of his or her work life (Sacco & Copel, 2018). Burnout is a negative alternative to the patient's suffering, which can be seen in the achievements of patient care (Hinderer et al., 2014).
ProQOL is an important concept for the health system and healthcare providers and is associated with personality traits and the occupational environment (Pashib et al., 2016). Kim and Choi found that over 50% of emergency nurses had a poor quality of life at work and low ProQOL (Kim & Choi, 2012). It has been shown that employees with higher ProQOL, organizational identity, higher satisfaction and job performance were less willing to leave a job (Lee et al., 2007). In particular, nursing practice is a compassion-based satisfaction experience, which can have a negative impact on nurses' physical and mental health and care performance (Kim et al., 2015).
Satisfaction with compassion and related avoidance behaviours can prevent nurses' empathy for patients and ultimately reduce their competence and quality of clinical practice (Boyle, 2011;Kim & Choi, 2012).
Given that the goal of nursing training is to work in complex and unpredictable clinical settings, special attention should be paid to the complicated nature of the competency and the characteristics required for it (Levett-Jones et al., 2011). Nonetheless, few studies have examined the effect of ProQOL on the clinical competence of nurses. On the other hand, studies have identified factors influencing nurses' clinical performance and competence such as job stress, job satisfaction and demographic characteristics (Boyas et al., 2012).
Since the ProQOL is also related to job performance, this study aimed to determine the relationship between clinical competence and the

| Sample size and sampling
This cross-sectional study was conducted on all 340 nurses working in public hospitals in southern Iran (Ali-Ibn Abi-Talib Hospital and Moradi Hospital of Rafsanjan). The nurses were selected by the convenience sampling method. The inclusion criteria were as follows: nurses working in the healthcare sector that provide direct care for patients; with at least one year of experience; and no management position and the willingness to participate in the study. The exclusion criteria were as follows: the respondents who were not nurses; pregnant or breastfeeding nurses; and those with a history of mental illness and those who did not complete the questionnaire (even one question left unanswered).

| Data Collection
A total of 300 nurses working in the two hospitals who met the inclusion criteria entered the study by the census method. Three hundred questionnaires were distributed over six months (November 2018 -May 2019) among the nurses and they were asked to return the questionnaires after completing them and 291 copies were returned (response rate: 97%).

| Socio-demographics
A socio-demographic information questionnaire was also completed by the respondents. The questionnaire assessed the respondents' age, gender, level of education, marital status, number of children, nursing service records, work shift, income level, working hours per month, overtime, the number of overtime hours per month, a second job (if any), the department, job satisfaction and satisfaction with colleagues, absenteeism, adaptation of the programme to the person's tendency, diseases or specific problems and a history of drug use.

| Competency Inventory for Registered Nurses
The Competency Inventory for Registered Nurses (CIRN) was developed in the mainland China for assessing the clinical competency of nurses in different clinical settings. This 55-item questionnaire was validated by Liu et al. (2009) in Macao, China. It consists of seven aspects of nursing competence: clinical care (10 items), leadership (9 items), interpersonal relationships (8 items), ethical/legal performance (8 items), professional development (6 items), coaching/training (6 items) and the desire for research/critical thinking (8 items).
The internal consistency of the questionnaire with Cronbach's alpha coefficient was 0.91, ranging from 0.72-0.90 (Liu et al., 2009).
This questionnaire was translated into Persian by Ghasemi et al. (2014) for use in Iran and its reliability (internal consistency) was confirmed with a total Cronbach's alpha coefficient of 0.87 for the whole questionnaire (with the corresponding values of the subscales ranging from 0.88-0.97). The items in this questionnaire are scored on the five-point Likert scale ranging from 0-4 (0 = lack of competence, 1 = low competence, 2 = limited competence, 3 = sufficient competence and 4 = very high competence). The total score varies from 0-220 points and the higher the total score, the higher the competences (scores ranging from 165-220 show high competence, scores ranging from 110-165 show moderate competence and scores less than 110 show low competence). In the present study, Cronbach's alpha coefficient for the whole questionnaire was 0.93. Moreover, the reliability of the nursing competence tool was 0.97 using Cronbach's alpha coefficient. Cronbach's alpha coefficients for clinical care, leadership, interpersonal relationships, ethical/legal performance, professional development, coaching/training and the desire for research/critical thinking were 0.88, 0.86, 0.85, 0.82, 0.84, 0.83 and 0.84, respectively. Pashib et al. (2016) translated the ProQOL questionnaire for use in Iran and assessed its validity and reliability. The questionnaire consists of three subscales as follows: compassion satisfaction, secondary traumatic stress and burnout. This questionnaire contains 30 items scored on a 5-point Likert scale (from never = 1 to always = 5).

| The ProQOL Scale, version 5
Each subscale consists of 10 items with an independent score that is calculated as the sum of the relevant items. In addition, in some studies, the concept of compassion fatigue has been conceptualized through burnout and secondary traumatic stress, which refers to the negative effects of care (Stamm, 2002;Stamm, 2010).
High scores of compassion satisfaction indicate one's satisfaction with his/her ability in providing services and care and high scores of burnout and secondary traumatic stress indicate that the person is at a high risk of compassion fatigue. Furthermore, high scores on secondary traumatic stress indicate that a person is vulnerable to stress symptoms such as hopelessness and discomfort. In all three domains, the standard scoring is based on high (above 42), moderate (23-41) and low scores (below 22). The validity of the ProQOL questionnaire was assessed via the content validation method and its reliability was established through Cronbach's alpha coefficient in Pashib et al.'s study. The Cronbach's alpha coefficients for compassion satisfaction, compassion fatigue and burnout were 0.82, 0.8 and 0.47, respectively (Pashib et al., 2016). The answers to items (1, 4, 15, 17 and 29) in the secondary traumatic stress scale must be scored inversely. In the present study, the reliability of the ProQOL scale was 0.80 using Cronbach's alpha coefficient and the corresponding values for compassion satisfaction, secondary traumatic stress and burnout were 0.87, 0.76 and 0.57, respectively.

| Statistical analysis
Descriptive statistics (means, standard deviation, minimum and maximum scores) were used to analyse the participants' demographic data. Besides, bivariate correlations and regression analyses were used to examine the relationships between the variables (CI = 95%, p = .05). All statistical procedures were performed using ibm spss22.

| Ethical Considerations
This study was conducted after obtaining the code of ethics (IR.

RUMS.REC.1397.213) from the Ethics Committee of Rafsanjan
University of Medical Sciences. The nurses were asked to complete the questionnaire after obtaining written consent and explaining the goals and importance of the study. To comply with ethical requirements, the participation was voluntary and the participants' information was kept confidential and was used only for the purpose of this study.

| Participants
The sample in this study consisted of 291 nurses with a mean age of 33.24 (SD 6.2) years.  Table 2 shows the distribution of the participants' scores on the ProQOL scales. The highest mean value was related to the compassion satisfaction (38.89 SD 6.49) and the lowest mean value was found in secondary traumatic stress (26.02 SD 5.66).

| Regression analysis
Multiple regression models were tested to explore how ProQOL underlying variables and clinical competence can predict compassion satisfaction, secondary traumatic stress and burnout. As shown in Table 6, 65% of the variance of secondary traumatic stress is predicted by compassion satisfaction and burnout (R 2 = 65%) and the best predictor is compassion satisfaction (p < .001). Secondary traumatic stress, clinical competence and burnout predict 53% of the variance of compassion satisfaction (R 2 = 53%) and the best predictor is secondary traumatic stress (p < .001). Compassion satisfaction and secondary traumatic stress predict 40% of the variance of burnout (R 2 = 40%) and based on β, the best predictor is compassion satisfaction (p < .001). Finally, compassion satisfaction predicts 12% of the variances of clinical competence (R 2 = 12%) and the best predictor is compassion satisfaction (p < .001).

| D ISCUSS I ON
Few studies have directly measured ProQOL, clinical competence and related factors. The results of this study showed that clinical competence was associated with the ProQOL. Specifically, it was found that compassion satisfaction induced by helping patients was associated with clinical competence. This is consistent with a study by Kim et al. that showed nurses with higher compassion satisfaction had a high level of clinical competence in their work and that they were less prone to compassion fatigue and burnout (Kim et al., 2015). According to Soroush et al., (2016)   Understanding these stressors may help nurses and nursing managers to improve competence levels of nurses. Health organizations need to improve the physical and mental health of nurses by increasing the general well-being of nurses and implementing training courses such as resilience training and using systems and methods to empower nurses to increase compassion satisfaction and prevent the incidence of cumulative burnout (BO) and compassion fatigue (CF) in the healthcare workforce. As a result, they improve nurses'  with similar studies. However, some studies found a significant relationship between clinical competence and demographic factors (Han & Park, 2013;Kang et al., 2011;Meretoja et al., 2015;Slåtten et al., 2010). These results can highlight many factors affecting the competence of nurses, including family support, religious practices and professional work that need further exploration concerning their influence on clinical competence.
The continual increase of clinical competence among nurses is consistent with the rapid changes in the healthcare setting.
Nurses' ProQOL can influence their clinical competence. Kim et al. (2015) showed that technical factors such as competence in providing nursing care and supporting patients increased ProQOL.
The results of this study concerning ProQOL score showed that compassion satisfaction had a protective effect on the compassion fatigue, as highlighted in previous studies Craigie et al., 2016;Hegney et al., 2015;Heritage et al., 2018;Ray et al., 2013;Sansó et al., 2015). Some studies did not show any negative effects of compassion satisfaction and compassion fatigue (Duarte et al., 2016;Durkin et al., 2016). This is because individuals can regulate their negative states (Lynch et al., 2018). Hegney et al. (2014) found no correlation between compassion satisfaction and secondary traumatic stress.
Intervention programmes are necessary in the future to enhance compassion satisfaction and target burnout and secondary traumatic stress. Since secondary traumatic stress involves more acute and disabling symptoms that are too hard to treat (Gentry et al., 2002), we need to set goals and plans to deal with secondary traumatic stress more precisely.
Although the current study found significant correlations be- skills and set their own professional boundaries (Yılmaz & Üstün, 2018). Meadors et al. (2010) proposed that the terms secondary traumatic stress and compassion fatigue not be used interchangeably.
We should examine secondary traumatic stress and compassion fatigue as separate but related constructs and focus on nurses' awareness of the factors associated with secondary traumatic stress that may help them reduce secondary traumatic stress. Individual-level protective factors, a strong social support system outside of work and the frequent use of positive coping mechanisms are recommended to reduce secondary traumatic stress (Brady, 2017).
In this study, more than half of the nurses (57.0%) had an average level of competence that was slightly lower than the level reported in Mirlashari et al.'s (2016) (Bahreini et al., 2011).
This difference can be due to factors such as better educational facilities, more frequent in-service training programmes and the organization of educational processes.

| LI M ITATI O N S
There were several limitations in this study. The cross-sectional nature of this study did not allow the assessment of cause and effect relationship between ProQOL and clinical competence. In addition, the data were collected from two governmental hospitals using a self-report questionnaire that can restrict the generalizability of the findings. Concerning nurses' clinical competence at the national and international levels, the socio-cultural differences should be examined in subsequent studies.

| CON CLUS ION
Clinical competence is an essential requirement for the provision of safe and effective care for the patient. This study demonstrated that nurses' compassion satisfaction could increase their clinical competence. It seems that compassion satisfaction can be improved by decreasing the level of secondary traumatic stress and burnout.

ACK N OWLED G M ENTS
The authors would like to thank the Clinical Research Development Center of Ali-Ibn Abi Talib Hospital, the Rafsanjan University of Medical Science for its supports.

CO N FLI C T O F I NTE R E S T
No conflict of interest was found for this paper.

DATA AVA I L A B I L I T Y S TAT E M E N T
All results of data analysed during this study are included in this published article and its supplementary files. The data set analysed during the current study are available from the corresponding author on reasonable request.