nursing education research articles

Open access
Published: 03 June 2024

Continue nursing education: an action research study on the implementation of a nursing training program using the Holton Learning Transfer System Inventory

MingYan Shen 1 , 2 &
ZhiXian Feng 1 , 2

BMC Medical Education volume 24 , Article number: 610 ( 2024 ) Cite this article

Metrics details

To address the gap in effective nursing training for quality management, this study aims to implement and assess a nursing training program based on the Holton Learning Transfer System Inventory, utilizing action research to enhance the practicality and effectiveness of training outcomes.

The study involved the formation of a dedicated training team, with program development informed by an extensive situation analysis and literature review. Key focus areas included motivation to transfer, learning environment, and transfer design. The program was implemented in a structured four-step process: plan, action, observation, reflection.

Over a 11-month period, 22 nurses completed 14 h of theoretical training and 18 h of practical training with a 100% attendance rate and 97.75% satisfaction rate. The nursing team successfully led and completed 22 quality improvement projects, attaining a practical level of application. Quality management implementation difficulties, literature review, current situation analysis, cause analysis, formulation of plans, implementation plans, and report writing showed significant improvement and statistical significance after training.

The study confirms the efficacy of action research guided by Holton’s model in significantly enhancing the capabilities of nursing staff in executing quality improvement projects, thereby improving the overall quality of nursing training. Future research should focus on refining the training program through long-term observation, developing a multidimensional evaluation index system, exploring training experiences qualitatively, and investigating the personality characteristics of nurses to enhance training transfer effects.

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Introduction

The “Medical Quality Management Measures“ [ 1 ] and “Accreditation Standards for Tertiary Hospitals (2020 Edition)” [ 2 ] both emphasize the importance of using quality management tools in medical institutions to carry out effective quality management [ 3 ]. However, there is a notable gap in translating theoretical training into effective, practical application in clinical settings [ 4 ]. This gap is further highlighted in the context of healthcare quality management, as evidenced in studies [ 5 ] which demonstrate the universality of these challenges across healthcare systems worldwide.

Addressing this issue, contemporary literature calls for innovative and effective training methods that transition from passive knowledge acquisition to active skill application [ 6 ]. The Holton Learning Transfer System Inventory [ 7 ] provides a framework focusing on key factors such as motivation, learning environment, and transfer design [ 7 , 8 , 9 ]. This study aims to implement a nursing training program based on the Holton model, using an action research methodology to bridge the theoretical-practical gap in nursing education.

Quality management training for clinical nurses has predominantly been characterized by short-term theoretical lectures, a format that often fails to foster deep engagement and lasting awareness among nursing personnel [ 10 ]. The Quality Indicator Project in Taiwan’s nursing sector, operational for over a decade, demonstrates the effective use of collective intelligence and scientific methodologies to address these challenges [ 11 ]. The proposed study responds to the need for training programs that not only impart knowledge but also ensure the practical application of skills in real-world nursing settings, thereby contributing to transformative changes within the healthcare system [ 12 ].

In April 2021, the Nursing Education Department of our hospital launched a quality improvement project training program for nurses. The initiation of this study is underpinned by the evident disconnect between theoretical training and the practical challenges nurses face in implementing quality management initiatives, a gap also identified in the work [ 13 ]. By exploring the efficacy of the Holton Learning Transfer System Inventory, this study seeks to enhance the practical application of training and significantly contribute to the field of nursing education and quality management in healthcare.

Developing a nursing training program with the Holton Learning Transfer System Inventory

Establishing a research team and assigning roles.

There are 10 members in the group who serve as both researchers and participants, aiming to investigate training process issues and solutions. The roles within the group are as follows: the deputy dean in charge of nursing is responsible for program review and organizational support, integrating learning transfer principles in different settings [ 14 ]; the deputy director of the Nursing Education Department handles the design and implementation of the training program, utilizing double-loop learning for training transfer [ 15 ]; the deputy director of the Nursing Department oversees quality control and project evaluation, ensuring integration of evidence-based practices and technology [ 16 ] and the deputy director of the Quality Management Office provides methodological guidance. The remaining members consist of 4 faculty members possessing significant university teaching experience and practical expertise in quality control projects, and 2 additional members who are jointly responsible for educational affairs, data collection, and analysis. Additionally, to ensure comprehensive pedagogical guidance in this training, professors specializing in nursing pedagogy have been specifically invited to provide expertise on educational methodology.

Current situation survey

Based on the Holton Learning Transfer System Inventory (refer to Fig. 1 ), the appropriate levels of Motivation to Improve Work Through Learning (MTIWL), learning environment, and transfer design are crucial in facilitating changes in individual performance, thereby influencing organizational outcomes [ 17 , 18 ]. Motivation to Improve Work Through Learning (MTIWL) is closely linked to expectation theory, fairness theory, and goal-setting theory, significantly impacting the positive transfer of training [ 19 ]. Learning environment encompasses environmental factors that either hinder or promote the application of learned knowledge in actual work settings [ 20 ]. Transfer design, as a pivotal component, includes training program design and organizational planning.

To conduct the survey, the research team retrieved 26 quality improvement reports from the nursing quality information management system, which were generated by nursing units in 2020. A checklist was formulated, and a retrospective evaluation was conducted across eight aspects, namely, team participation, topic selection feasibility, method accuracy, indicator scientificity, program implementation rate, effect maintenance, and promotion and application. Methods employed in the evaluation process included report analysis, on-site tracking, personnel interviews, and data review within the quality information management system [ 21 ]. From the perspective of motivation [ 22 ], learning environment [ 23 ], and transfer design, a total of 14 influencing factors were identified. These factors serve as a reference for designing the training plan and encompass the following aspects: lack of awareness regarding importance, low willingness to participate in training, unclear understanding of individual career development, absence of incentive mechanisms, absence of a scientific training organization model, lack of a training quality management model, inadequate literature retrieval skills and support, insufficient availability of practical training materials and resources, incomplete mastery of post-training methods, lack of cultural construction plans, suboptimal communication methods and venues, weak internal organizational atmosphere, inadequate leadership support, and absence of platforms and mechanisms for promoting and applying learned knowledge.

Learning Transfer System Inventory

Development of the training program using the 4W1H approach

Drawing upon Holton’s Learning Transfer System Inventory and the hospital training transfer model diagram, a comprehensive training outline was formulated for the training program [ 24 , 25 ]. The following components were considered:

(1) Training Participants (Who): The training is open for voluntary registration to individuals with an undergraduate degree or above, specifically targeting head nurses, responsible team leaders, and core members of the hospital-level nursing quality control team. Former members who have participated in quality improvement projects such as Plan-Do-Check-Act Circle (PDCA) or Quality control circle (QCC) are also eligible.

(2) Training Objectives (Why): At the individual level, the objectives include enhancing the understanding of quality management concepts, improving the cognitive level and application abilities of project improvement methods, and acquiring the necessary skills for nursing quality improvement project. At the team level, the aim is to enhance effective communication among team members and elevate the overall quality of communication. Moreover, the training seeks to facilitate collaborative efforts in improving the existing nursing quality management system and processes. At the operational level, participants are expected to gain the competence to design, implement, and manage nursing quality improvement project initiatives. Following the training, participants will lead and successfully complete a nursing quality improvement project, which will undergo a rigorous audit.

(3) Training Duration (When): The training program spans a duration of 11 months.

(4) Training Content (What): The program consists of 14 h of theoretical courses and 18 h of practical training sessions, as detailed in Table 1 .

(5) Quality Management Approach (How): To ensure quality throughout the training process, two team members are assigned to monitor the entire training journey. This encompasses evaluating whether quality awareness education, quality management knowledge, and professional skills training are adequately covered. Additionally, attention is given to participants’ learning motivation, the emphasis placed on active participation in training methods, support from hospital management and relevant departments, as well as participants’ satisfaction and assessment results. Please refer to Fig. 2 for a visual representation.

In-house training model from Holton Learning Transfer

Implementation of the nursing project training program using the action research method

The first cycle (april 2021).

In the initial cycle, a total of 22 nurses were included as training participants after a self-registration process and qualification review. The criteria used to select these participants, elaborated in Section Development of the training program using the 4W1H approach, ‘Development of the Training Program,’ were meticulously crafted to capture a broad spectrum of experience, expertise, and functional roles within our hospital’s nursing staff. The primary focus was to investigate their learning motivation. The cycle comprised the following key activities:

(1) Training Objectives: The focus was on understanding the learning motivation of the participating nurses.

(2) Theoretical Training Sessions: A total of 7 theoretical training sessions, spanning 14 class hours, were completed. The contents covered various aspects, including an overview of nursing quality improvement projects, methods for selecting project topics, common tools used in nursing quality improvement projects, effective leadership strategies to promote project practices, literature retrieval and evaluation methods, formulation and promotion of project plans, and writing project reports. Detailed course information, including the title, content, and class hours, is listed in Table 1 . At the end of each training session, a course satisfaction survey was conducted.

(3) Assessment and Reporting: Following the completion of the 7 training sessions, a theoretical assessment on quality management knowledge was conducted. Additionally, nurses were organized to present their plans for special projects to be carried out during the training. Several issues were identified during this cycle:

Incomplete Literature Review Skills: Compared to other quality control tools, nursing quality improvement project places more emphasis on the scientific construction of project plans. The theoretical evaluation and interviews with nurses highlighted the incomplete and challenging nature of their literature review skills.

Insufficient Leadership: Among the participants, 6 individuals were not head nurses, which resulted in a lack of adequate leadership for their respective projects.

Learning environment and Support: The learning environment, as well as the support from hospital management and relevant departments, needed to be strengthened.

Second cycle (may-october 2021)

In response to the issues identified during the first cycle, our approach in the second cycle was both corrective and adaptive, focusing on immediate issues while also setting the stage for addressing any emerging challenges. The team members actively implemented improvements during the second cycle. The key actions taken were as follows:

(1) Establishing an Enabling Organizational Environment: The quality management department took the lead, and multiple departments collaborated in conducting the “Hospital Safety and Quality Red May” activity. This initiative aimed to enhance the overall quality improvement atmosphere within the hospital. Themed articles were also shared through the hospital’s WeChat public account.

(2) Salon-style Training Format: The training sessions were conducted in the form of salons, held in a meeting room specifically prepared for this purpose. The room was arranged with a round table, warm yellow lighting, green plants, and a coffee bar, creating a conducive environment for free, democratic, and equal communication among the participants. The salon topics included revising project topic selection, conducting current situation investigations, facilitating communication and guidance for literature reviews, formulating improvement plans, implementing those plans, and writing project reports. After the projects were presented, quality management experts provided comments and analysis, promoting the transformation of training outcomes from mere memory and understanding to higher-level abilities such as application, analysis, and creativity.

(3) Continuous Support Services: Various support services were provided to ensure ongoing assistance. This included assigning nursing postgraduates to aid in literature retrieval and evaluation. Project team members also provided on-site guidance and support, actively engaging in the project improvement process to facilitate training transfer.

(4) Emphasis on Spiritual Encouragement: The Vice President of Nursing Department actively participated in the salons and provided feedback on each occasion. Moreover, the President of the hospital consistently commended the training efforts during the weekly hospital meetings.

Issues identified in this cycle

(1) Inconsistent Ability to Write Project Documents: The proficiency in writing project documents for project improvement varied among participants, and there was a lack of standardized evaluation criteria. This issue had the potential to impact the quality of project dissemination.

(2) Lack of Clarity Regarding the Platform and Mechanism for Training Result Transfer: The platform and mechanisms for transferring training results were not clearly defined, posing a challenge in effectively sharing and disseminating the outcomes of the training.

The third cycle (November 2021-march 2022)

During the third cycle, the following initiatives were undertaken.

(1) Utilizing the “Reporting Standards for Quality Improvement Research (SQUIRE)”, as issued by the US Health Care Promotion Research, to provide guidance for students in writing nursing project improvement reports.

(2) Organizing a hospital-level nursing quality improvement project report meeting to acknowledge and commend outstanding projects.

(3) Compiling the “Compilation of Nursing Quality Improvement Projects” for dissemination and exchange among nurses both within and outside the hospital.

(4) Addressing the issue of inadequate management of indicator monitoring data, a hospital-level quality index management platform was developed. The main evaluation data from the 22 projects were entered into this platform, allowing for continuous monitoring and timely intervention.

Effect evaluation

To assess the efficacy of the training, a diverse set of evaluation metrics, encompassing both outcome and process measures [ 26 ]. These measures can be structured around the four-level training evaluation framework proposed by Donald Kirkpatrick [ 27 ].

Process evaluation

Evaluation method.

To assess the commitment and support within the organization, the process evaluation involved recording the proportion of nurses’ classroom participation time and the presence of leaders during each training session. Additionally, a satisfaction survey was conducted after the training to assess various aspects such as venue layout, time arrangement, training methods, lecturer professionalism, content practicality, and interaction. On-site recycling statistics were also collected for project evaluation purposes.

Evaluation results the results of the process evaluation are as follows

Nurse training participation rate: 100%.

Training satisfaction rate (average): 97.75%.

Proportion of nurses’ participation time in theoretical training sessions (average): 36.88%.

Proportion of nurses’ participation time in salon training sessions (average): 74.23%.

Attendance rate of school-level leaders: 100%.

Results evaluation

Assessment of theoretical knowledge of quality management.

To evaluate the effectiveness in enhancing the trainees’ theoretical knowledge of quality management, the research team conducted assessments before the training, after the first round of implementation, and after the third round of implementation. Assessments to evaluate the effectiveness of the training program were conducted immediately following the first round of implementation, and after the third round of implementation. This dual-timing approach was designed to evaluate both the immediate impact of the training and its sustained effects over time, addressing potential influences of memory decay on the study results. The assessment consisted of a 60-minute examination with different question types, including 30 multiple-choice questions (2 points each), 2 short-answer questions (10 points each), and 1 comprehensive analysis question (20 points). The maximum score achievable was 100 points.

The assessment results are as follows:

Before training (average): 75.05 points.

After the first round of implementation (average): 82.18 points.

After the third round of implementation (average): 90.82 points.

Assessment of difficulty in quality management project implementation

To assess the difficulty of implementing quality management projects, the trainees completed the “Quality Management Project Implementation Difficulty Assessment Form” before and after the training. They self-evaluated 10 aspects using a 5-point scale, with 5 indicating the most difficult and 1 indicating no difficulty. The evaluation results before and after implementation are presented in Table 2 .

Statistically significant differences were found in the following items: literature review, current situation analysis, cause analysis, plan formulation, implementation plan, and report writing. This indicates that the training significantly enhanced the nurses’ confidence and ability to tackle practical challenges.

Evaluation of transfer effect

To assess how effectively the training translated into practical applications. The implementation of the 22 quality improvement projects was evaluated using the application hierarchy analysis table. The specific results are presented in Table 3 .

In addition, the “Nursing Project Guidance Manual” and “Compilation of Nursing Project Improvement Projects” were compiled and distributed to the hospital’s management staff, nurses, and four collaborating hospitals, receiving positive feedback. The lecture titled “Improving Nurses’ Project Improvement Ability Based on the Training Transfer Theory Model” shared experiences with colleagues both within and outside the province in national and provincial teaching sessions in 2022. Furthermore, four papers were published on the subject.

The effectiveness of the training program based on the Holton Learning transfer System Inventory

The level of refined management in hospitals is closely tied to the quality management awareness and skills of frontline medical staff. Quality management training plays a crucial role in improving patient safety management and fostering a culture of quality and safety. Continuous quality improvement is an integral part of nursing management, ensuring that patients receive high-quality and safe nursing care. Compared to the focus of existing literature on the individual performance improvements following nursing training programs [ 28 , 29 , 30 ], our study expands the evaluation framework to include organizational performance metrics. Our research underscores a significantly higher level of organizational engagement as evidenced by the 100% attendance rate of school-level leaders. The publication of four papers related to this study highlights not only individual performance achievements but also significantly broadens the hospital organization’s impact on quality management, leading to meaningful organizational outcomes.

Moreover, our initiative to incorporate indicators of quality projects into a hospital-level evaluation index system post-training signifies a pivotal move towards integrating quality improvement practices into the very fabric of organizational operations. In training programs, it is essential not only to achieve near-transfer, but also to ensure that nurses continuously apply the acquired management skills to their clinical work, thereby enhancing quality, developing their professional value, and improving organizational performance. The Holton learning Transfer System Inventory provides valuable guidance on how to implement training programs and evaluate their training effect.

This study adopts the training transfer model as a framework to explore the mechanisms of “how training works” rather than simply assessing “whether training works [ 31 ].” By examining factors such as Motivation to Improve Work Through Learning (MTIWL), learning environment, and transfer design, the current situation is analyzed, underlying reasons are identified, and relevant literature is reviewed to develop and implement training programs based on the results of a needs survey. While individual transfer motivation originates from within the individual, it is influenced by the transfer atmosphere and design. By revising the nurse promotion system and performance management system and aligning them with career development, nurses’ motivation to participate and engage in active learning has significantly increased [ 32 ]. At the learning environment level, enhancing the training effect involves improving factors such as stimulation and response that correspond to the actual work environment [ 33 ]. This project has garnered attention and support from hospital-level leaders, particularly the nursing dean who regularly visits the training site to provide guidance, which serves as invaluable recognition. Timely publicity and recognition of exemplary project improvement initiatives have also increased awareness and understanding of project knowledge among doctors and nurses, fostering a stronger quality improvement atmosphere within the team.

Transfer design, the most critical component for systematic learning and mastery of quality management tools, is achieved through theoretical lectures, salon exchanges, and project-based training. These approaches allow nurses to gain hands-on experience in project improvement under the guidance of instructors. Throughout the project, nurses connect project management knowledge and skills with practical application, enabling personal growth and organizational development through problem-solving in real work scenarios. Finally, a comprehensive evaluation of the training program was conducted, including assessments of theoretical knowledge, perception of management challenges, and project quality. The results showed high satisfaction among nurses, with a satisfaction rate of 97.75%. The proportion of nurses’ participation time in theoretical and practical training classes was 36.88% and 74.23%, respectively. The average score for theoretical knowledge of quality management increased from 75.05 to 90.82. There was also a significant improvement in the evaluation of the implementation difficulties of quality management projects. Moreover, 22 nurses successfully led the completion of one project improvement project, with six projects focusing on preventing the COVID-19 pandemic, demonstrating valuable crisis response practices.

Action research helps to ensure the quality of organizational management of training

Well-organized training is the basis for ensuring the scientific and standardized development of nursing project improvement activities. According to the survey results of the current situation, there is a lot of room for improvement in the training quality; since it is the first time to apply the Holton training transfer model to the improvement training process of nurses in the hospital, in order to allow the nurses to have sufficient time to implement and evaluate the improvement project, the total training time Set at 11 months, a strong methodology is required to ensure training management during this period. Action research is a research method that closely combines research with solving practical problems in work. It is a research method aimed at solving practical problems through self-reflective exploration in realistic situations, emphasizing the participation of researchers and researchees. Practice, find problems in practice, and adjust the plan in a timely manner. According to the implementation of the first round, it was found that nurses had insufficient literature review skills, insufficient leadership, and lack of support from hospital management and related departments [ 32 ]. In the second round, the training courses were carried out in the form of salons. The project team members went deep into the project to improve on-site guidance, arranged graduate students to assist in document retrieval and evaluation, and promoted the transfer of training; the “Hospital Safety and Quality Red May” activity was carried out, and the vice president of nursing Regularly participate in the salon and make comments. The problems exposed after this round of implementation are the low quality of the project improvement project document, and the unclear platform and mechanism for the transfer of training results. In the third round, the “Reporting Standards for Quality Improvement Research (SQUIRE)” was used to standardize the writing of the report [ 33 ], and the “Compilation of Nursing Project Improvement Projects” was completed, and the main evaluation data of 22 projects were entered into the hospital-level quality index management platform for continuous monitoring and intervention. As of May 2022, the effect maintenance data of each project has reached the target value. It can not only produce useful improvement projects, but also help to promote the dissemination and penetration of quality awareness.

Future research directions

Drawing on the Holton training evaluation model, this study implemented nurse quality improvement project training using action research methodology, resulting in a successful exploration practice, and achieving positive transfer effects. To further advance this research area, the following future research directions are recommended:

Summarize the experiences gained from this action research training and continue to refine and enhance the training program. Through ongoing practice, reflection, and refinement in subsequent training sessions, long-term observation of the transfer effects can be conducted to establish an effective experiential model that can serve as a reference for future initiatives.

Develop a multidimensional evaluation index system for assessing transfer effects. A comprehensive framework that captures various dimensions of transfer, such as knowledge application, skill utilization, and behavior change, should be established. This will enable a more holistic and accurate assessment of the training program’s impact on the participants and the organization.

Conduct qualitative research to explore the training experiences of nurses. By gathering in-depth insights through interviews or focus group discussions, a deeper understanding of the nurses’ perceptions, challenges, and facilitators of training transfer can be obtained. This qualitative exploration will provide valuable information to further refine and tailor the training program to meet the specific needs and preferences of the nurses.

Investigate the personality characteristics of nurses who actively engage in training transfer and consider developing them as internal trainers. By identifying and cultivating nurses with a proactive attitude and a strong inclination towards knowledge application and skill development, the organization can enhance employee participation and initiative. These internal trainers can play a crucial role in motivating their colleagues and driving the transfer of training outcomes into daily practice.

By pursuing these future research directions, the field of healthcare and nursing care can continue to advance in optimizing training programs, enhancing transfer effects, and ultimately improving the quality of care and patient outcomes.

Limitations

The research was conducted with a cohort of 22 nurses and a 10-member research team from Grade 3, Class A hospitals in China Southeast. This specific composition and the relatively small sample size may affect the generalizability of our findings. The experiences and outcomes observed in this study might not fully encapsulate the diverse challenges and environments encountered by nursing professionals in varying healthcare settings. The significant improvements noted in the capabilities of the participating nursing staff underscore the potential impact of the training program. However, the study’s focus on a specific demographic—nurses from high-grade hospitals in a developed urban center—may limit the external validity of the findings.

Conclusions

This study affirms the efficacy of the Holton Learning Transfer System Inventory-based training program, coupled with action research, in significantly advancing nursing quality management practices. The strategic incorporation of motivation to improve work through learning, an enriched learning environment, and thoughtful transfer design significantly boosted the nurses’ engagement, knowledge acquisition, and practical application of quality management tools in their clinical work.

It highlights the importance of continuous learning, organizational support, and methodological flexibility in achieving sustainable improvements in healthcare quality and safety. Future endeavors should aim to expand the scope of this training model to diverse nursing contexts and evaluate its long-term impact on organizational performance and patient care outcomes.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to hospital policy but are available from the corresponding author on reasonable request.

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This study was funded by Department of Education of Zhejiang Province, Grant Number jg20220475.

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School of Nursing, Zhejiang Shuren University, 8 Shuren Road, 310015, Hangzhou, ZheJiang, China

MingYan Shen & ZhiXian Feng

Department of Nursing, Shulan (Hangzhou) Hospital, Shulan International Medical College, Zhejiang Shuren University, 310022, Hangzhou, China

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Contributions

The following statements specify the individual contributions of each author to the manuscript titled “Continue Nursing Education: An Action Research Study on the Implementation of a Nursing Training Program Using the Holton Learning Transfer System Inventory”:ZhiXian Feng conceived and designed the analysis; led the research team and coordinated the project; critically reviewed and revised the manuscript for important intellectual content; oversaw the implementation of the training program; MingYan Shen conducted the research; collected and organized the data; analyzed and interpreted the data; contributed to the statistical analysis; wrote the initial draft of the manuscript; managed logistics and operational aspects of the study.

Corresponding author

Correspondence to ZhiXian Feng .

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Ethics approval and consent to participate.

Approval of this study was granted by the Research Ethics Committee of Shulan Hospital (Approval no. KY2021042).

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Not applicable.

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Shen, M., Feng, Z. Continue nursing education: an action research study on the implementation of a nursing training program using the Holton Learning Transfer System Inventory. BMC Med Educ 24 , 610 (2024). https://doi.org/10.1186/s12909-024-05552-6

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New role to boost research and education in social care nursing

28 May, 2024 By Steve Ford

A nurse has become the first to be appointed to a new academic role created to support the development of nursing in social care settings, which those behind the move have called a “milestone” for the sector.

The University of Salford and the RCN Foundation have jointly announced that Dr Claire Pryor will become the inaugural RCN Foundation chair in adult social care nursing.

“There is an absolute need to ensure our nurses working in social care settings are recognised, supported, and developed” Claire Pryor

The university said the new role had been created to take a “strategic lead in shaping research and education in adult social care nursing at a local, national and international level”.

Dr Pryor will “translate research into professional practice” to improve nursing care and develop the evidence-base to support the “current and next generation of nurses” in adult social care, it added.

She will be based at Salford’s nursing and midwifery directorate in the School of Health and Society, which is the largest specialist provider of nursing and midwifery education in the North West region.

The university noted that it was a UK focused role and Dr Pryor would work closely with England’s chief nurse for adult social care, Professor Deborah Sturdy.

Dr Pryor’s appointment represents the latest in a series of developments in recent weeks that aim to support social care nursing and raise its profile in the profession.

Earlier this month, Northumbria University launched the UK’s first new specialist practice qualification in community adult social care nursing.

In addition, guidelines were launched to encourage and support the development nationally of placements for student nurses and nursing associates in social care settings.

The government arms’-length body Skills for Care published the guidance in collaboration with Professor Sturdy and the Department of Health and Social Care.

Meanwhile, a nurse from a Bristol-based charity carried the ceremonial lamp at the annual Florence Nightingale Commemorative Service, the first to do so from the adult social care sector.

Emily Pimm, who qualified as a nurse in 2006, works as a social care deputy manager at John Wills House Care Home in Westbury-on-Trym, which is run by the St Monica Trust .

“This appointment marks a significant milestone for the nursing profession and the wider social care sector” Deepa Korea

The appointment also follows the government earlier this year embarking on a campaign to boost the domestic pipeline into adult social care nursing.

The DHSC unveiled a package of measures, backed by £75m funding, to recruit new talent to the sector , including investment in adult social care nursing apprenticeships.

Separately, higher education institutions were encouraged to expand placement opportunities in social care to encourage more nurses into such settings.

Dr Pryor will start her new role on 31 July. She is currently assistant professor of adult nursing at Northumbria, where she specialises in frailty, social care nursing and non-medical prescribing.

She began her career as a nursing assistant in care homes prior to becoming a staff nurse in medical assessment and critical care, and then a nurse practitioner for older people in mental health settings.

Commenting on her appointment, Dr Pryor said: “I am excited and passionate about the new role, and the significant impact the focus on adult social care will bring.

“There is an absolute need to ensure our nurses working in social care settings are recognised, supported, and developed throughout their careers,” she said.

“We need to work toward recognition of social care nurses as a highly skilled, autonomous clinicians, and empower them to use specialist and advanced skills, leading and shaping high quality care across the sector.”

Professor Margaret Rowe, dean of the school of health at Salford, said: “The chair role will drive changes to adult social care across the UK in terms of education, professional practice and research.

“We look forward to the benefits her role will no doubt bring to our students as we continue to develop and educate the next generation of nurses in adult social care,” she said.

The RCN Foundation said it chose the University of Salford to host the role following a competitive process.

Dr Claire Pryor

Deepa Korea, RCN Foundation director, said “We are delighted that the inaugural RCN Foundation chair in adult social care nursing has been appointed at the University of Salford.

“This appointment marks a significant milestone for the nursing profession and the wider social care sector,” she said.

“Having a dedicated chair will not only further advance the academic and practical knowledge in adult social care nursing that it so vitally needed, but also ensure that the important work of this part of the nursing workforce is highlighted.

“The role will also develop further the clinical expertise and leadership needed across the sector to meet the complex needs of those accessing social care,” she added.

The RCN Foundation, chaired by former chief nursing officer for England Professor Jane Cummings, is an independent charity whose purpose is to support and strengthen nursing and midwifery.

It does this by providing grants to nurses and midwives facing hardship or who want to enhance their skills and develop their practice, and by funding nursing and midwifery-led projects.

Assessing nurses’ professional competency: a cross-sectional study in Palestine

Rasha Abu Zaitoun 1 , 2

BMC Nursing volume 23 , Article number: 379 ( 2024 ) Cite this article

Metrics details

Evaluating nurses’ professional competence is critical for ensuring high-quality patient care. Therefore, this study aimed to evaluate the nurses’ professional competence level and to identify differences based on demographics in three West Bank hospitals.

A cross-sectional design was used, and a convenient sample of 206 nurses participated in the study. The Nurse Professional Competence (NPC) Scale was used to assess the competency level. The investigator distributed the questionnaire and explained the aim of the research. Consent forms were signed before the data collection.

The average competency level was 79% (SD = 11.5), with 90% being professionally competent nurses. The average “nursing care” competency was 79% (SD = 12.98), and the competency level in providing value-based care was 80% (SD = 13.35). The average competency level in technical and medical care was 78% (SD = 13.45), whereas 79% (SD = 12.85) was the average competence level in “Care Pedagogics” and “Documentation and Administration “. The average competence level in the development and leadership subscale was 78% (SD = 12.22). Nurses who attended three to five workshops had a higher level of Nursing Care Competency, (H = 11.98, p = 0.003), and were more competent in value-based care (H = 9.29, p = 0.01); in pedagogical care and patient education (H = 15.16, P = 0.001); and in providing medical and technical care (H = 12.37, p = 0.002). Nurses attending more than five workshops were more competent in documentation and administration (H = 12.55, p = 0.002), and in development and leadership subscale ( H = 7.96, p = 0.20).

The study revealed that participants lacked development and leadership skills. Engagement in workshops positively impacted the level of competencies among nurses. Notably, those attending more than five workshops exhibited greater competence in documentation, administration, development, and leadership in nursing care.

Implications

This study emphasized the role of continuing education in improving nurses’ competencies and highlighted the need to conduct the study at a wider aspect to involve more hospitals with various affiliations to help structure more sensitive professional development and adopt the competencies as an integral part of staff development.

Peer Review reports

In the contemporary world, scholars prioritize the significance and function of human resources in the progress of nations; furthermore, they assert that an organization’s most critical asset is its human capital [ 1 ]. Nurses play a critical role as the primary and most valuable human resource in healthcare organizations [ 2 ]. With significant advancements in science and technology, cost control measures, and limited time for building therapeutic patient relationships, nurses are increasingly concerned about patient safety and quality of care and are committed to improving and maintaining their competencies [ 3 ].

Contemporary perspectives on professionalism underscore that enhancing the quality of healthcare is a moral and professional obligation of all medical practitioners, especially nurses. Thus, they must exhibit dedication to professional competence, transparency with patients, and improvement of care quality [ 4 ]. Professional competency is crucial in providing nursing care, and it involves adhering to professional standards [ 5 ]. The literature extensively addresses nursing competency in terms of patient safety and the quality of care provided [ 6 ].

The Novice to Expert Theory by Patricia Benner emphasizes the importance of nursing competency. Benner’s theory supports the formation of competent and trained nurses who can address the various problems of modern healthcare by offering a developmental framework, encouraging experiential learning, promoting mentorship, and improving patient safety.

skilled and knowledgeable nurses who provide high-quality care, advance patient safety, and influence good outcomes in healthcare delivery. This study is supported by Benner’s theory that emphasizes the effect of nurses’ competency on patient outcomes [ 7 ] Identifying the level of professional competency could help categorize nurses based on their level of practice and determine the proper approach to move nurses from novice to expert.

Professional competency in nurses is defined as a combination of skills, knowledge, attitudes, values, and abilities that facilitate effective performance in occupational and professional roles [ 8 ]. It involves using knowledge, technical skills, clinical reasoning, communication, emotions, and values and rethinking daily activities to provide services to individuals and society, reflecting sound judgment and habits [ 9 ].

Globally, the professional empowerment and competency of nurses are a focus of human resource management in healthcare systems, and the World Health Organization mandates that member countries report and implement plans to strengthen nurses’ competencies [ 10 ]. Nursing competency leads to improving the quality of care, increasing patient satisfaction, enhancing nursing education, and promoting nursing as a profession [ 11 ]. Patients expect competent behavior from nurses, and following the high prevalence of medical incidents, the public and media have become concerned about clinicians’ competency [ 12 ]. Thus, professionals must demonstrate their clinical competence to perform specific roles [ 13 ]. Neglecting nursing competency can cause problems for organizations, resulting in frustration, job dissatisfaction, and attrition [ 14 ].

Professional skills and competency have an impact on job attitudes, including organizational commitment and professional affiliations [ 15 ]. To achieve the goals of the healthcare system, manpower requires not only expertise, empowerment, and competency but also high levels of organizational attachment and commitment, as well as a willingness to participate in activities beyond their predetermined duties; hence, the levels of attachment and commitment of nurses to their affiliated organizations can affect the promotion of their clinical competency [ 1 ].

Nursing competency is a fundamental skill that is essential for meeting nursing obligations; hence, it is crucial to have a clear understanding of the nursing competency level to establish the basis for nursing education programs, and professional development planning and it is vital to recognize the process of nursing competency development to ensure ongoing professional growth following the acquisition of a nursing license [ 5 ]. The fundamental concept of professional competency in nursing has a direct correlation with enhancing patient care quality and safety [ 1 ].

Currently, in Palestine, there exist various levels of nurses who have graduated from a variety of nursing schools within and outside the country. Consequently, there is a diversity in their practices both at an individual and institutional level, posing a challenge to both evaluating the quality of care delivered and standardizing nursing practices nationwide. One proposed strategy to address these obstacles involves conducting an initial assessment of nurses’ competencies to establish a foundation, followed by devising a standardized professional development scheme informed by the gathered data. Unfortunately, there is a notable absence of studies that have investigated the professional competencies of nurses across different nursing specialties, leading to the absence of a comprehensive national framework for appraising nursing competencies and a lack of a standardized approach for assessing competencies.

Given that nurses are frontline healthcare providers delivering population-based health services and gatekeepers for maintaining patient safety their competency level is critical to ensure their ability to perform their daily duties effectively and efficiently to maintain high-quality care also it is an important objective method to help the nursing administrative to assess their employees level of practices and set suitable improvement plans Therefore, it is essential to measure nurses’ competency and, once measured, to establish a standard against which practice domain and performance can be evaluated. This approach provides a framework for ensuring nurses possess the necessary knowledge and skills to carry out their responsibilities effectively.

The Joint Commission Accreditation requires measuring different types of competencies based on the main patient safety goals such as infection control practices and recommends health institutions align with an organization’s strategies, business objectives, and culture for success [ 16 ]. Most commonly measured competencies verify specific nursing skills and practices and tho, but, there are limited efforts to assess the overall nursing professional competence level.

To the best of our knowledge, this study represents the first attempt to assess the level of professional competence among nurses. The choice was made to carry out this investigation within a tertiary hospital that holds accreditation from JCI. This decision was based on the premise that nurses in such settings have been immersed in a system of competency-based evaluation, potentially yielding more insightful responses compared to their counterparts in non-JCI-accredited hospitals. Furthermore, JCI-accredited hospitals typically offer ongoing professional development initiatives. The advancement of these programs requires a thorough understanding of the overall professional competence level, which is essential for structuring purposeful developmental activities.

Therefore, this study aimed to assess the level of professional competence among nurses in a tertiary hospital in the West Bank using the Nurse Professional Competence (NPC) Scale, which evaluates self-reported professional competence.

Study design and settings

A cross-sectional descriptive-analytic design was used to recruit the targeted participants from academic, private, and Ministry of Health hospitals. The data were collected from April to July 2023.

Research procedure and sample

The sample was convenient to reach nurses in their place of work easily during their working time. The sample size was calculated using a Raosoft calculator ( http://www.raosoft.com/samplesize.html ) with a confidence level of 95%, a marginal error of 5%, and a response distribution of 50%. The estimated sample size was 286, with an attrition rate of 5%. The sample included registered nurses who provided direct patient care and had at least one year of experience in their current workplace. Head nurses, nurses who worked in the administrative field, nurses on maternal, annual, and unpaid leave, and aid nurses were excluded. Questionnaires that were completed by less than 60% of the participants were excluded from the study according to the recommendation of the original author of the tool [ 17 ]. A total of 206 nurses responded and were actively engaged in the study.

Data were gathered over a single month through the use of a self-reported, paper-based questionnaire. The questionnaire was administered in the English language because the intended participants consisted of nurses who predominantly used English for documentation and communication purposes. The questionnaires were directly distributed to the participants, allowing them to peruse the consent form, research objectives, and ethical considerations while simultaneously being encouraged to submit any inquiries they may have had. The initial page of the instrument included a description of the research aim, a consent form, and the contact information of the author.

Research instrument

The data collection questionnaire consisted of two parts: the first part included demographic and workplace information, and the second part included the short version of the Nurse Professional Competence Scale (NPC), which was utilized to assess self-reported professional competence among nurses [ 18 ]. The Nurse Professional Competence Scale was developed by Jan Nilsson and colleagues [ 17 ] in Sweden based on Swedish national guidelines and the World Health Organization’s European Strategy for Nursing and Midwifery [ 19 ]. The original NPC scale comprises eight competency domains and a total of 88 items grouped into eight competence areas, namely, nursing care, value-based nursing care, medical and technical care, teaching/learning and support, documentation and information technology, legislation in nursing and safety planning, leadership in and development of nursing care, and education. For this study, the short version of the NPC was used [ 17 ]. The reliability and validity of the NPC Scale have been confirmed in previous studies, and the Cronbach’s alpha values of all the domains were > 0.70 [ 18 ]. .

The Nurse Professional Competence Scale has been validated and shown to have good reliability and validity in various studies conducted in the Swedish language version [ 20 ]. Responses are given on a seven-point scale ranging from a very low degree (1) to a very high degree (7), with “either high or low degree” coded as (4) [ 21 ]. The competency levels were classified into four categories based on the average score of the scale and subscales: low level (0–25), rather good level (> 25–50), good level (> 50–75), and very good level (> 75–100) [ 22 ].

For this study, Permission was obtained from the authors to use the instrument and they gave instructions to analyze the scale the instrument was piloted on 10 nurses who were excluded from the study. Some modifications were made based on the results to enhance the readability and readability of the study. The needed completion time was from 10 to 15 min.

The Statistical Package for the Social Sciences (SPSS) version 21 was used to analyze the data. Descriptive statistics in terms of percentage, mean and standard deviation were used to describe the demographic and work environment factors. The competency subscale scores were calculated following the formulas recommended by the author of the short version of the NPC. The nursing care competence level was calculated by summing item numbers one through 5 divided by 25 and multiplied by 100. The value-based nursing care competence level was obtained by summing the items ranging from six to ten divided by 35 and multiplied by 100. The medical and technical care competence level was estimated by summing the results of items 11 to 16 divided by 42 and multiplied by 100. The competence level in the care pedagogic was the result of summing the items ranging from 17 to 21 divided by 35 and multiplied by 100. The documentation and administrative competence level was calculated by summing the items ranging from 22 to 29 dividing by 56 and multiplying by 100; finally, the leadership and organization subscale was assessed by summing the items from 30 to 35 dividing by 42, and multiplying by 100 [ 17 ]. Moreover, the data were not normally distributed; thus, the Mann‒Whitney test and the Kruskal‒Wallis test were used to analyze the associations between demographic information and professional competency subscale scores. A p -value < 0.05 was considered to indicate statistical significance.

Ethical considerations

The institutional review board of the Arab American University (AAUP) IRB NO. 2023/A/59. All nurses were given both verbal and written information about the aim and objectives of the study, and informed consent was obtained from all participants. Participants were assured that their confidentiality and anonymity would be preserved, that their participation was voluntary, and that they could withdraw at any time without any penalties.

Demographics and work environment factors

A total of 206 nurses, with a response rate of 72%, participated in this study to assess their professional competence level. The mean age of the participants was 29.5 years, with a minimum of 21 years and a maximum of 45 years. Male nurses represented 52.4% of the participants ( n = 108). The majority held a bachelor’s degree in nursing ( n = 168), and 22 (10.7%) nurses held postgraduate certificates. 57% of the nurses earned a monthly income of 500–1000 JD ( n = 57.8). 94% of the respondents received up to five courses per year. Nearly half ( n = 94) of the participants worked as instructors for nursing students. Among those with less than six years of experience, 97 (47.1%) and 11.7% ( n = 24) had 12 or more years of experience, respectively (Table 1 ).

The professional competence level and subscales

Table 2 showed that the average professional competence level was 79% (SD = 11.5), with a median of 80, a minimum of 45% and a maximum of 100%. A total of 90% of the nurses were professionally competent, while 15 nurses had a competence level of less than 60%. The average “nursing care” competency was 79% (SD = 12.98), with a minimum of 34% and a maximum of 100%. The competency level of providing value-based care was 80% (SD = 13.35), with a minimum of 20% and a maximum of 100%. An average of 78% (SD = 13.45) of the participants were competent at providing technical and medical care, for a minimum of 21%. The nurses also showed an average competence level of 79% (SD = 12.85) in “Care Pedagogics”, with a minimum score of 34% and a maximum of 100%. Similarly, 79% (SD = 12.15) of the participants had an average competence level in “documentation and administration of nursing care”, for a minimum of 39%. Finally, the average competence level of the “Development, leadership and organization of Nursing Care” factor was 78% (SD = 12.22), with a minimum score of 48% and a maximum of 100% (see Table 2 ).

The difference in competency subscale scores among nurses

A significant relationship was found between the number of workshops attended by nurses and their level of competence in all competency areas. In Nursing Care, nurses who attended between three and five in-service education workshops had a higher level of Nursing Care Competency, with a mean rank of 122.39 (H = 11.98, p = 0.003) (see Table 3 ). Table 4 indicated that nurses who attended three to five workshops had a higher level of competency in applying value-based care, with a mean rank = 119.65 (H = 9.29, p = 0.01); in pedagogical care and patient education, with a mean rank of 123.1 (H = 15.16, P = 0.001) (see Table 5 ); and in providing medical and technical care, with a mean rank of 121.88 (H = 12.37, p = 0.002) (see Table 6 ).

Table 7 revealed that nurses who attended more than five workshops were more competent in documenting and administering nursing care, with a mean rank of 130.0 (H = 12.55, p = 0.002), and in developing and leading nursing care (mean rank = 121.7, H = 7.96, p = 0.20) (see Table 8 ). Similarly, Table nine shows that attending three to five workshops was associated with a higher total professional competence level, with a mean rank of 121.05 (H = 12.11, p = 0.002). However, there were no significant differences in the total professional competency level or other professional competency subscale scores among other demographic and work environment factors (see Table 9 ). The reliability of the short version of the questionnaire in this study was excellent, with a Cronbach’s alpha of 97%.

This study aimed to assess the level of professional nursing competency of nurses who work at a tertiary hospital. Using the NPC Scale, the study’s findings shed light on the degree of self-reported professional competence among nurses working in a tertiary hospital in the West Bank. The results could be applied to raise the standard of patient care and healthcare services by pointing out areas that need improvement in the nursing clinical field, education, and training programs. This study contributes to the existing body of knowledge on the level of professional competence among nurses on the West Bank.

A total of 206 nurses participated in the study. Most of the respondents were male. The study showed no significant differences between males and females in terms of their level of professional competence; this was also noted in a study in which gender was not significantly related to professional competence [ 23 ]. In contrast, a study conducted on nurses’ competency in the Saudi Arabian healthcare context showed that male participants demonstrated superior self-reported competency assessment compared to female participants [ 24 ].

On the other hand, this study showed that years of experience do not affect the competency level, in contrast to a Japanese study in which the nursing competence levels are affected by the clinical experience. high competency level among newly hired nurses and junior nurses [ 25 ]. Also, a systematic review in Iran indicated that clinical experience of more than nine years affects the competency level [ 26 ].

The educational level of nurses in this study revealed no discernible relationship with their competence, and this is supported by the study of S-O Kim and Y-J Choi [ 27 ] contradicting the study of Z Nabizadeh-Gharghozar, NM Alavi and NM Ajorpaz [ 28 ] that correlates the educational level with competence level This discrepancy in results underscores the necessity for further exploration to understand the nuanced relationship between education levels and nursing competencies [ 29 ]. While a notable correlation emerged in this study between the number of workshops attended by nurses and their competence levels across all competency domains, a recent study in Japan showed that attending a two-day international outreach seminar provided participants with valuable and current knowledge regarding the competency of nurse educators. They developed a heightened awareness of the shifts in their self-efficacy as educators [ 30 ]. Additionally, Egyptian studies concluded that workshops had a beneficial impact on enhancing the knowledge, collaboration skills, and overall performance of both head and staff nurses [ 31 ].

According to our study, nurses exhibited a very good level of the total professional competency level. This result was supported by a study conducted in Iran which reported that nurses had a very good competency level [ 32 ]. Delving into the assessment of competency sub scores our study excelled in evaluating the competency of providing nursing care and helping patients was very good and the same with the result of a Turkish study that assessed the caring and helping competency level of 243 nurses in a university hospital [ 33 ],. Similarly, participants showed a very good competency level in handling technology and advanced medical machines, which affirms the growing integration of technology in nursing practice [ 34 ]. The “Care Pedagogics” competency underscores the crucial role of nurses in educating and supporting patients and their families, which is consistent with the findings of other related research [ 32 , 35 ] These results emphasize the ongoing need to prioritize clinical proficiency in nursing education and practice [ 17 ].

Moving into the sphere of “Documentation and Administration of Nursing Care”, nurses in our study had a very good competency level in developing a collaborative care plan and documentation skills echoing the significance of nursing documentation and administration for ensuring high-quality patient care [ 36 ], Additionally, the participant’s had very good competency in “Development, Leadership, and Organization of Nursing Care” which underscored the nursing abilities to lead and supervise teamwork and prioritize care aligning with the findings of various studies supporting this notion [ 37 , 38 , 39 ].

According to the study’s findings, nurses generally do well in areas including nursing care, value-based nursing care, technical and medical treatment, and administration and documentation. In contrast, a study highlighting possible areas for focused improvement in nursing practice and education found that nurses tended to report lower competence scores in the areas of development, leadership, organization of nursing care, and care pedagogy [ 40 ].

Furthermore, it’s critical to stress how important it is for nurses to maintain quality of life. To guarantee that high-quality care is provided, initiatives to enhance the quality of life for nurses must be initiated. When creating projects and programs to improve nurses’ competence, nurse managers should take the results into account [ 41 ] and use reflective learning, which can help both new and novice nurses because it will help them develop a good self-perception of their competence [ 42 ].

Theoretical implication

The results of this study contributed to the theoretical understanding of factors affecting the professional competencies of nurses. The notable correlation between the number of continuing education activities attended by nurses and the level of nurses’ performance implies that professional development programs have a pivotal role in enhancing and improving nurses’ competency in several domains. This result goes in alignment with the “ Novice to Expert” theory of Benner and empirically supports the crucial role of ongoing education in improving and supporting nurses to advance their professional competencies and growth. On the other hand, the multidimensional aspects of the applied professional competency in this study such as the documentation, value-based, and technical aspects all act as factors that shape the wholistic approach to nursing care and the nature of the nurse’s practices which require more wholistic evaluation method for nurses competencies.

Managerial implications

The majority of nurses in this study were professionally competent which indicates that available ongoing educational activities were valuable and effective opportunities to promote nurses’ competencies. However, having 15 nurses with a 60% competency level highlights the importance of structuring more need-sensitive ongoing education programs and interventions. On the other side, the strong relationship between attending continuing education activities and a higher level of nurses competencies across various domains underscores the pivotal role of offering equal and efficient opportunities for attending and joining the available activities, also health care institutions may need to invest more effectively in promoting and supporting goal-based, and need-sensitive professional development programs in their setting to get more competent and qualified nurses and subsequently high-quality patient care.

Additionally, the study findings highlight that subdomains and sub-dimensions of nurses’ practices such as care and value-based aspects and documentation and administration have essential roles in formulating the overall professional competency level of nurses. This guides the nurse managers and leaders to establish a more uniform performance appraisal process to evaluate nurses’ practices. This would enable nurse leaders to effectively identify any practice gaps and areas for improvement and this helps them to efficiently utilize resources to provide the required learning activities and offer equal chances for improving nurses’ performance. Determining a nurse’s areas of competence can serve as a reference to guide the hiring process of new staff.

The outcome of this study can steer the adoption of robust ongoing education such as mentorship and preceptorship programs, cross-training programs, in-service clinical training, and other professional development opportunities to facilitate the rapid transition of newly hired nurses from beginner level to more competent and proficient nurses.

A trustworthy tool that recognizes a nurse’s level of professional competency can assist policymakers, managers, and nurse educators in defining the skills, knowledge, and attitude necessary for nurses to perform their jobs. The findings of this research can also be used to create more customized and goal-oriented professional development programs, pinpointing areas of best practices that require improvement and investigating the necessary methods and resources to improve nurses’ competencies while emphasizing evidence-based practices. Additional research examining the relationships between nursing competence and patient outcomes may be beneficial in enhancing best practices for nurses.

Limitations

The sample was convenient with 206 nurses participating in the study, which potentially limits the generalizability of the findings to a broader nursing population. Additionally, the overrepresentation of male respondents might skew the results and not accurately reflect the gender balance in nursing.

The data primarily relied on self-reported measures, which might introduce response bias and subjectivity. Objective assessments or external evaluations of competence could enhance the validity of the findings.

The study utilized a cross-sectional design, providing a snapshot of competence at a specific time. Longitudinal studies tracking nurses’ competence over time could offer a more comprehensive understanding of competence development.

The study did not comprehensively explore other potential influencing factors, such as workload, staffing ratios, or specific training programs attended by participants. These factors can significantly impact nursing competence and have not been thoroughly investigated.

Conclusions

In this study, we meticulously evaluated the professional competence levels of 206 nurses employed in a tertiary hospital setting. The findings revealed that the professional competence level was moderately high among the participants. However, it is noteworthy that while a significant portion of nurses demonstrated high levels of competency, a considerable number still exhibited competence levels below the desired threshold, with 15 nurses scoring below 60%.

Our comprehensive assessment encompassed various competency areas, shedding light on specific domains where nurses warrant focused attention. Notably, the domain of “Development, Leadership, and Organization of Nursing Care” exhibited a slightly lower average competency level (78%). Therefore, it is important to promote nurse’s knowledge and skills in the domain of leadership and management principles.

Attending workshops plays a significant role in improving nurses’ competencies, especially the competency in documentation, management, and leadership skills. So, investments in providing a well-designed workshop with a clear outcome are essential to affect the level of competence among nurses. Moreover, the findings underscored the importance of continuing education and training programs to foster nurses’ competency, and subsequently, improve the quality of patient care.

In conclusion, this study provides valuable insights into the nuanced landscape of nursing competence, highlighting both areas of strength and opportunities for improvement. Moving forward, healthcare institutions and educational bodies must prioritize ongoing education and targeted interventions aimed at fortifying nursing competencies for the betterment of patient care.

Recommendations

Healthcare institutions should invest in continuous training programs, and make sure they are goal-directed and have outcomes related to improving the staff knowledge as well as the skills and contributing to improving the competency level.

More emphasis needs to be placed on the development of leadership and management abilities. The ongoing educational initiatives should arrange more organized and impactful workshops and training programs to enhance this particular aspect, which in turn will have a direct impact on the competencies of nurses.

Encourage collaboration between academia and healthcare institutions to conduct research focused on nursing competence to disseminate competency development to regional policymakers and initiate training programs and the potential implementation of a “clinical ladder” system for nurses.

Future studies should involve larger and more diverse samples across various healthcare settings to capture a more representative picture of nursing competence. Ensuring a balanced gender representation among participants would yield more comprehensive insights.

Complementing self-reported measures with objective assessments or observations of nursing practices could enhance the robustness and validity of the findings. Qualitative interviews or focus groups might provide richer insights into the factors affecting nursing competence.

Conducting longitudinal studies to track nurses’ competence development over time would offer a deeper understanding of competency growth and fluctuations throughout a nurse’s career trajectory.

Future research should further explore the various factors influencing nursing competence, including workload, staffing, continuing education programs, and the impact of specific training initiatives on competence levels.

Implementing targeted interventions or training programs and evaluating their impact on nursing competence could provide valuable insights into effective strategies for enhancing nursing competency.

Collaborating with multiple healthcare facilities or employing a multicenter approach would provide a more extensive dataset and facilitate comparisons between institutions, enriching the understanding of nursing competence on a broader scale.

Data availability

Primary research article or the corresponding author are the sources of all data. Data that supports the results of the manuscript is provided within the manuscript.

Abbreviations

Arab American University

Institutional Review Board

An-Najah-National University Hospital

Nurse Professional Competence Scale

Statistical Package for the Social Sciences

World Health Organization

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Acknowledgements

I would like to express my gratitude and acknowledgment to the Research Centre especially Prof. Saed Zyoud and Prof. Ramzi Shawahneh for their support in providing resources and facilitating the research process.

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Rasha Abu Zaitoun

Department of Nursing, An-Najah National University Hospital, Nablus, 44839, Palestine

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Zaitoun, R.A. Assessing nurses’ professional competency: a cross-sectional study in Palestine. BMC Nurs 23 , 379 (2024). https://doi.org/10.1186/s12912-024-02064-y

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The experiences of nurse educators in implementing evidence-based practice in teaching and learning

Gloria n. mthiyane.

1 Department of Health Studies, University of South Africa, South Africa

Debbie S. Habedi

Nurse educators have a vital role to mentor student nurses in relation to developing evidence-based practice (EBP) skills, accessing research products and participating in research projects. This requires more innovative teaching approaches that promote active participation, creativity and critical thinking in students such as online teaching and learning, accessing electronic resources, video conferencing and research-based teaching and learning.

To determine the nurse educators’ experiences in implementing EBP in teaching and learning, and to describe the importance and benefits of EBP teaching and learning to the nursing profession, especially for nurse educators and student nurses.

Two chosen campuses from Umgungundlovu Health District under the KwaZulu-Natal College of Nursing (KZNCN) and offering a 4-year R425 training programme.

Qualitative research design and methods were followed in conducting the study. A non-probability purposive sampling technique was used to access the sample of 12 nurse educators. Data were collected using semi-structured interviews, the interview guide, and the digital voice recorder.

Data were analysed manually, following a content thematic approach and two themes emerged as challenges experienced by nurse educators with the implementation of EBP in teaching and learning and benefits and value of EBP in teaching and learning. Findings revealed that, although most of the nurse educators are supportive and displayed a positive attitude towards implementing EBP in teaching and learning, the level of knowledge and skills was questionable. This was coupled with a lack of motivation and commitment towards research.

Conclusions

Evidence-based practice has an essential potential role to play through incorporating more practice-based evidence of nurse educators in teaching and learning implementation. The nurse educators should use EBP to ensure that student nurses receive high-quality nursing education.

Introduction

Evidenced-based practice (EBP) is described by Melnyk et al. ( 2012 :410) as a problem-solving approach to clinical decision-making in health care. Evidence-based practice integrates the best evidence from well-designed studies with the clinicians’ expertise, including internal evidence from patient assessments and practice data, and patients’ preferences and values. Melnyk et al. ( 2012 :410) further revealed that implementation of EBP leads to a higher quality of care, improved patient outcomes, and decreased health care costs.

Evidence-based practice teaching and learning has become an important function for nursing education. Research is used as an instrument in developing new teaching and learning strategies. Nurse educators are guided by evidence-based practice in teaching and on research reports. Evidence-based practice in learning is also based on research, meaning that students learn by using research findings. Research-based teaching and learning encourages and stimulates critical thinking for students (Felicilda-Reynaldo & Utley 2015 :91).

Although EBP is known to improve health care quality, decreasing costs and empowering nurses, the challenge is the way in which it ensures successful implementation by the nurses (Levin et al. 2011 :21). The implementation of successful EBP education serves the function of developing practitioners who value EBP and have the knowledge and skills to implement such practice (Lehane et al. 2017 :8).

Nurse educators play a key role in creation of opportunities for implementing EBP and in facilitating the implementation process. The question now is how to foster implementation of EBP. The most important factor that is likely to help nurses and nurse educators to adopt EBP is the provision of adequate training in EBP (Heikkila et al. 2017 :3). The importance of embedding EBP in nurse education programmes cannot be underestimated if EBP and its positive patient outcomes are to be realised in health care settings. According to Felicilda-Reynaldo and Utley ( 2015 :93), one nurse educator noted that ‘nurse graduates will be prepared to facilitate a transformation of the health care system culture by implementing practice review and revision consistent with evidence-based nursing (EBN) research’. The above-mentioned statement highlights the importance of incorporating EBP throughout the curriculum to prepare students for future success in using EBP in their professional nursing practice (Felicilda-Reynaldo & Utley 2015 :93). Mackey and Bassendowski ( 2016 :54) indicated that utilising nursing best practice guidelines, reviewing and implementing applicable research evidence, and taking advantage of technological advances are ways in which nursing can move forward as a well-informed discipline.

Malik, McKenna and Griffiths ( 2015 a:158) in Australia reported that integrating EBP into undergraduate nursing education and preparing future nurses to embrace EBP into clinical practice becomes crucial in today’s complex and evolving health care environment. The study further implies that the role that EBP plays in the practical lives of student nurses will depend on the degree to which it is promoted by academics; the extent to which it is incorporated in course objectives, content and assessments; and its application within the clinical setting (Malik et al. 2015 a:158). In this way, nurses’ willingness to carry out research projects, as well as to utilise the research findings effectively in practice is enhanced.

Traditional teaching methods and learning styles still dominate in nursing education and these strategies do not encourage critical thinking among the nursing students; therefore, these methods will not prepare student nurses to make sound clinical judgements in practice (Subhan 2014 :35). With the nursing profession experiencing many changes on contemporary issues, nursing students need to be prepared for these challenges. Using EBP as one of the teaching and learning strategies will qualify student nurses to become excellent critical thinkers and solve problems in the clinical area. However, EBP remains a relatively new concept to nursing, and there is limited literature available addressing the incorporation of EBP into nursing curricula, especially at the undergraduate level (Malik et al. 2015 a:158). In South Africa, there is a dearth of literature in the implementation of EBP in nursing education.

To determine the experiences of nurse educators in implementing EBP in teaching and learning, and to describe the importance and benefits of EBP in teaching and learning in the nursing profession, especially for nurse educators and student nurses.

What are the experiences of nurse educators regarding implementation of EBP in teaching and learning?
What recommendations may be made for nurse educators to implement EBP in teaching and learning?

Design and methods

A qualitative, explorative, descriptive research design, using non-probability purposive sampling, focusing on understanding the social settings, facilitating the exploration of relationships and human experience within the research setting was followed. It also enabled face-to-face, personal contact in data collection (Moule & Goodman 2014 :175). Participants selected and interviewed were individuals who were more knowledgeable about the phenomenon and qualified enough to answer the question at hand.

The total target population was 62 nurse educators in June 2017.The sample comprised 12 nurse educators in possession of a nursing education qualification, registered by South African Nursing Council (SANC) as nurse educators and employed by the KwaZulu-Natal Department of Health. The focus of the study was on nurse educators involved in classroom teaching at the two chosen campuses from Umgungundlovu Health District under the KwaZulu-Natal College of Nursing (KZNCN) and offering a 4-year R425 training programme.

Sampling method

The sampling process followed the non-probability method using a purposive sampling technique to select the participants. This type of sampling assisted the researcher to select those homogeneous participants who knew most about the phenomenon under study (Brink, Van der Walt & Van Rensburg 2012 :139). All nurse educators who met the inclusion criteria were requested to volunteer for participation in the study. Clinical nurse educators were excluded from the study. The sample size was 12 participants and was based on collecting detailed data to address the research questions, objectives, and the purpose of the study.

Data collection

Data were collected in June 2017 using semi-structured interviews, interview guide and the digital voice recorder. To ensure anonymity, code numbers were allocated to each participant. The researcher kept all collected and private information shared safely locked and/or encrypted in the researchers’ computer for 5 years. Participants were informed of the presence of the research assistant during the interview process and all participants granted the researcher permission to record interviews.

Semi-structured individual interviews were conducted using the self-developed interview guide and digital voice recorder as data-collection instruments. The interview guide was developed in English based on the research purpose, research objectives, research questions and literature review. It comprised predetermined open-ended questions to get in-depth information about participants’ experiences and was pre-tested before conducting the main study to determine the feasibility of the instrument. All interviews were captured on the digital voice recorder with the help of the research assistant who had training in doing qualitative interviews prior to data collection.

Data analysis

Data were analysed manually following a content thematic analysis approach which involved a thorough review of all recorded information that the researcher obtained during data collection (Brink et al. 2012 :194). The researcher listened to recorded interviews repeatedly. All recorded data were transcribed into written format. Transcriptions were read thoroughly and repeatedly; common themes and categories of information were identified and grouped together. Electronic files for each theme were created and labelled, allowing for ease of access and management of data. Discussion and interpretation of the findings commenced thereafter.

Trustworthiness

Strategies employed to ensure the quality of data included the following measures of trustworthiness as suggested by Lincoln and Guba’s framework (Polit & Beck 2017 :560).

Credibility : Data were collected through face-to-face interviews, directly from the participants using a digital voice recorder and they were given a chance to confirm data before the final written report. Participants were provided with the opportunity to review the researchers’ interpretation of data.

Transferability : Sufficient description and interpretation of data was supported by the relevant literature so that it can be easily transferrable and applicable to other settings.

To ensure dependability , the researcher ensured that data collected remained stable over a period of time; meaning that information related to data collected would remain unchanged over time. Therefore, data were collected using the digital voice recorder with a memory card and all other information were properly stored and kept safely.

The use of actual quotations from the participants in the discussion of the report supports the confirmability of data.

Ethical considerations

Ethics approval certificate (reference number HSHDC/537/2016) was obtained from the Research Ethics Committee of the Department of Health Studies, University of South Africa (UNISA). Permission to conduct the study was granted by the KwaZulu-Natal Department of Health, KwaZulu-Natal College of Nursing, and both principals of the colleges. Participants were informed about the study and that their participation was voluntary and they were advised of their rights to withdraw at any time. All participants signed informed consent forms, their responses were kept confidential and anonymous and their identities were not divulged or disclosed during reporting of the findings.

Biographical data of the participants

Participants were from three race groups: African, Indian and Coloured. 1 They were all women. Their years of experience ranged between 5 and 30 years, occupying the ranks of junior nurse educator, senior nurse educator and Head of Department. The highest qualifications were a Bachelor’s, Honour’s or Master’s degree in Health and Nursing Science Studies as indicated in Table 1 .

Demographic information of the sample.

Themes, categories and findings

The following themes and categories emerged during data analysis and are summarised in Table 2 .

Themes and categories.

EBP, evidence-based practice.

Theme 1: Challenges with implementation of evidence-based practice in teaching and learning

The findings revealed that nurse educators are experiencing certain challenges with the implementation of EBP in teaching and learning. They include time constraints, lack of and poor access to relevant resources, the use of traditional teaching approaches which are still dominant, nurse educators’ lack of or poor knowledge and skills, and the quality of nursing students. Emmanuel et al. ( 2011 :22) in their study on developing EBP among student nurses in the United Kingdom identified similar challenges that prevented the nurses from successfully using EBP, which included poor access to facilities and information, lack of experience and little confidence in using computers.

Schoonees, Rohwer and Young ( 2017 :11) reported that the challenges experienced by lecturers at a sub-Saharan African academic institution were a lack of time by the programme to dedicate to evidence-based health care, lack of evidence related to a specific field, lack of student motivation and the students’ schooling background.

Category 1.1: Time constraints

This study indicated that, for the nurse educators to successfully implement EBP in teaching and learning, more time is required in the library to search for information, for reading the literature, and for preparation and presentation of the content. This applied to both the nurse educators and student nurses. This statement is supported in the study conducted by Emmanuel et al. ( 2011 :22), which indicated that the use of EBP by the professionals requires accessing and integrating a number of different resources which could be time consuming. Lack of time was also mentioned as a major barrier when trying to access and review any of the evidence (Emmanuel et al. 2011 :22).

Nurse educators indicated that time is not allocated or distributed fairly between library, theory and practice. The prescribed time in the curriculum does not provide sufficient time for students to visit the library to search for information. The location of the library also contributed to time limits, neither campus under study having a library on site. On one campus, the library is 8 km away from the campus. At the other campus, the library is within the hospital premises and not on the campus. These are both medical libraries, which means that they are accessed by all hospital staff. The following statements were reported by the participants with regard to time allocation, prescribed time, and preparation time:

‘Yes, yes, the students have library, the problem that we encounter when they are in block is that they do not have enough time to go to the library because the libraries are not situated in the facilities, like colleges they must go out and find information that is our challenge for now.’ (Participant 1, Junior, 40 years old) ‘So, you find that even the time that is allocated for library the moment they walk out to go to the library, you find that library is in use full of doctors then that is a challenge and you find that now when they come back they are somehow late for classes so that is a challenge.’ (Participant 2, Junior, 42 years old) ‘Maybe we can move from what we have already, because you know generally there is allocated time for clinical exposure, allocated time for theory. Maybe we can look at both these components and also allocate time for self-directed learning so that it comes in as part of the curriculum, like a prescribed kind of thing, like for example saying that the students must have so many assignments, must have so much library time.’ (Participant 3, Senior, 50 years old)

A study conducted by Malik et al. ( 2015 b:50) on nurse educators and clinical nurse coaches and specialists regarding their perceived knowledge, skills, attitudes and contextual factors affecting EBP, revealed that insufficient time prevented appraisal of literature on a regular basis and the searching of research reports. There is no time to find and read research articles. Again, in circumstances where shortages of staff exist, allowing staff adequate time to complete the requisite reading to update their clinical or EBP knowledge or to attend continuing nursing education is not always possible (Boswell & Cannon 2017 :20).

Category 1.2: Lack of and poor access to relevant resources

It is clear that for the nurse educators to implement EBP in teaching and learning, special resources must be available and accessible to both nurse educators and student nurses for successful implementation. Evidence is available in various forms, such as books, videos, journals, and articles. Access to evidence comes through the libraries, computer laboratories with Internet access and mobile technology.

Participants responded this way when asked about their resources:

‘For instance, if you look at the in-house, what you need to make your teaching learning process smarter, is sometimes not available.’ (Participant 11, Senior, 48 years old) ‘It could be available but you cannot access it easily.’ (Participant 8, Junior, 53 years old) ‘No not easily especially with the IT, we are limited for resources; I would have to go to the library to use it.’ (Participant 10, Senior, 59 years old) ‘Eh I don’t think especially with our college, I do not think that we do not, I mean we have enough resources, like for instance we need to have enough resources, the most recent textbooks you know, even the library should make sure that it is well equipped with most recent textbooks, we have the computers so that they have access to the internet which is the problem that we are experiencing that we don’t have with our campus.’ (Participant 4, HOD, 56 years old)

Hussein and Hussein ( 2014 :870) agree with the statements above in their study conducted in Egypt. Nursing education must be committed to the principles of EBP and critical thinking. Such education must provide resources and create a supportive environment for the implementation of EBP in teaching and learning. The fundamentals of teaching student nurses must be based on the best available evidence to recognise and deliver high-quality patient care (Emmanuel et al. 2011 :21).

Insufficient financial resources as well as journals, reports and computers for making EBP a reality in theoretical and clinical teaching could affect negatively the nurse educators’ ability to access evidence from various sources. It has been discovered that when nurses are provided with the necessary tools such as smart phones and computers inter alia, they are much more likely to access relevant information and best practice guidelines (Mackey & Bassendowski 2016 :53).

Category 1.3: Current teaching approaches

The study revealed that, currently, traditional teaching approaches are still dominant in nursing education. The participants identified the following current teaching strategies used for teaching and learning: facilitation, group discussion, simulation, assignments, role play, case study, clinical debates, lecture, self-activities, demonstrations, peer group teaching, problem-solving, group presentations, games, case-based research, videos, reflective journals, portfolio of evidence, and learning package. Most of these approaches lead to technical skills mastery but they do not stimulate the development of critical-thinking skills, as one participant stated that:

‘They promote psychomotor skills; the students get technical skills to do the procedures and more.’ (Participant 9, HOD, 59 years old)

Felicilda-Reynaldo and Utley ( 2015 :94) recommended a change in educational technology for nurse academics, which include the teaching approaches that facilitate critical thinking and provide opportunities for practising evidence-based patient care. The study by Leufer and Clearly-Holdforth ( 2015 :6) mentions that the continuous assessment element of the module comprising an EBP project and the lectures must provide ongoing support to student nurses throughout the research module as they develop their project. Tailored teaching and assessment methods must be implemented within the academy to foster a culture of EBP at undergraduate level and beyond (Leufer & Clearly-Holdforth 2015 :7). Teaching of student nurses must be based on the best available evidence to recognise and deliver high-quality patient care (Emmanuel et al. 2011 :21).

Category 1.4: Lack of knowledge and skills by nurse educators

Other challenges experienced by nurse educators on EBP implementation in teaching and learning were expressed by some of the participants as lack of confidence, lack of motivation, and lack of relevant knowledge and skills about EBP teaching. The following quotes were stated:

‘I think educators need to know how to use EBP research, I think that research for educators is something very important. I am not really completely involved with research, I think they got to understand research, they got to practice research and then, we can bring it to the students.’ (Participant 8, Junior, 53 years old) ‘Maybe the in-service or the education of the staff themselves, the information that they have regarding what problem-based practice or research is all about. They need to be in serviced as well.’ (Participant 10, Senior, 59 years old) ‘The first challenges will be the lack of motivation if they have not been motivated that’s a challenge, because there need to be like more workshops on evidence-based and the importance of using evidence-based, which is the challenge at the present moment because it is not everybody that is well tuned with evidence-based that is the challenge.’ (Participant 4, HOD, 56 years old) ‘Research is very good, it is good and as much as this off the topic you know we hate research, nurses hate research but I think they should be encouraged so we have more EBP and you know encourage the students.’ (Participant 6, Senior, 56 years old)

Although various studies indicate that nurse educators have a positive attitude towards EBP, it has been reported that a positive attitude is increased with advanced educational level, higher academic ranking, years of experience, and a teaching and research role (Hussein & Hussein 2013 :609). Therefore, findings suggest that continuing education for nurse educators on the EBP process is necessary to enhance their knowledge and skills in acquiring appropriate research and analytic skills relevant to their teaching specialties (Hussein & Hussein 2013 :617).

In an Australian study on integration of EBP into the curriculum, Malik et al. ( 2015 a:158) mention that there is lack of clarity on EBP content and process. Clarity is frequently blurred with research processes and outcomes, which often results in continuation of traditional nursing research courses in the hope of preparing EBP practitioners. Leufer and Clearly-Holdforth ( 2015 :11) state that if optimal patient outcomes are to be maximised, practitioners’ skills and knowledge base must be fostered and enhanced through ongoing education, training and support.

Category 1.5: Student characteristics

Nurse educators had a challenge with students’ attitude and perceptions towards EBP, and their lack of computer skills. According to participants, students appear to have preconceived ideas about research in general. These perceptions are negative and overwhelming for students. A negative attitude develops among the student nurses, because students do not understand the importance of EBP. Nurse educators felt that students’ lack of confidence, motivation, and commitment to perform and use research contributed to misperception and their resultant negative attitude. The nursing programme R425 is perceived as being full, overwhelming, with competing priorities of research, clinical, and theoretical workloads.

‘Students feel that it is an added responsibility.’ (Participant 7, Junior, 49 years old) ‘Students that we are teaching, they look at this research as a monster.’ (Participant 12, Senior, 60 years old) ‘So, the experience that I am coming across when I teach is that these students they do not like it.’ (Participant 12, Senior, 60 years old) ‘These students, they think that no eh eh we are overloading them.’ (Participant 5, Junior, 50 years old) ‘Yah there are challenges because at times the learners are lazy, they do not want to do work.’ (Participant 11, Senior, 48 years old)

Students’ attitudes and perceptions can influence EBP learning either positively or negatively. Should students’ roles be clearly defined early during training, so that they understand the importance of EBP, a positive attitude develops within them. According to Malik et al. ( 2015 a:158), the role that is played by EBP in the practical lives of nursing students depends on the degree to which it is promoted by academics, the extent to which it is incorporated into course objectives, content and assessments; and its application to clinical practice.

In a study by Hickman, Kelly and Phillips ( 2014 :603) on exploring ways to optimise the uptake of EBP to undergraduate nurses, findings indicated that students were initially hesitant and reluctant towards the subject of research. However, as they advanced with the subject their perceptions and beliefs changed to understanding the relevance of the research subject and its importance in improving patient outcomes.

Students’ lack of computer skills is another challenge that nurse educators encountered. Students are fully dependent on them for these skills and more time is needed to orientate students on how to use the computers. The use of EBP requires searching of information from the Internet. To accomplish this one must be able to use computers to search for information. These are the quotes from participants:

‘When you ask students for instance, initially we had challenges with them not knowing, because you find that at school they never did anything that has to do with computers, like any classes and now when they come here they have to sit in front of the computer, they do not even know what the mouse is, you know.’ (Participant 3, Senior, 50 years old) ‘So, I would love to see in the initial stage of training, this newly employed student nurses to have a basic course in computer literacy so that when we send them to fish information or explore they have the skills on how to like do internet surfing, go through the specific web, SANC web and etc., so that we are offload with them relying on us with computer skills.’ (Participant 9, HOD, 59 years old)

Increasing competence in information literacy is the foundation for EBP; this provides nurses with the skills to be literate consumers of information in an electronic environment (Emanuel et al. 2011 :22). According to Emmanuel et al. ( 2011 :23), advances in IT have had a radical impact on health care delivery and nurse education. The use of sophisticated equipment and electronic assessment care packages requires nurses to be competent in IT skills.

For students to be ready for EBP learning, they need to have good basic computer skills and to develop the right attitude towards learning using EBP. Their learning styles must support the inculcation of EBP. Fostering a culture of EBP in student nurses is essential to delivering effective health care (Leufer & Clearly-Holdforth 2007 :4) and it is also important that student nurses be equipped with EBP knowledge and skills to encourage evidence-informed decision-making after graduation (Schoonees et al. 2017 :1). Students should have the right attitude for functioning as independent health care providers (Young et al. 2015 :354). Nursing education institutions (NEIs) have a responsibility to provide support to student nurses in the development of relevant IT skills. This calls for services of the librarian to provide skills to student nurses in searching electronic databases for evidence. Clinical librarians in health services have to promote information literacy in the workplace. Health-related degree programmes need to adopt and incorporate EBP methods into their curricula to prepare practitioners in training for their future professional roles and responsibilities (Spring & McCuskey 2010 :249).

The recommendations that were made by the participants concerning student nurses were about creating good networking between the clinical practitioners and nurse educators to support the student nurses, providing students with basic computer skills so that they can work independently, and introducing a reward system as motivation for student nurses who are doing well.

Theme 2: Benefits and value of evidence-based practice in teaching and learning

Although some studies indicated that the main barrier to EBP is lack of value for EBP (Melnyk et al. 2012 :415), this study revealed that participants also believed that integration of EBP in teaching and learning as the best way to follow. It showed ways in which EBP teaching and learning could benefit the nurse educator, the nursing education discipline, student nurses, patients, and the employer or institution. Evidence-based practice is associated with critical-thinking skills which must be developed among the student nurses, and lifelong learning for nurses, to expand their knowledge and quality of care related to patient and health care facilities (Felicilda-Reynaldo & Utley 2015 :91-92). The following categories of information offer the benefits that come with implementation of EBP in teaching and learning.

Category 2.1: Keeping up to date with current information

Participants believed that EBP empowers and enriches the nurse educators and student nurses with up-to-date information, thus keeping their knowledge current. They also believe that EBP is based on researched international studies, and grounded on expert knowledge. These remarks were made by participants:

‘I think it is the best way to do your teaching and learning because you have evidence to base your information on.’ (Participant 1, Junior, 40 years old) ‘The other thing, you will find that you do not have to waste more time trying to give information to the students because everything is there.’ (Participant 1, Junior, 40 years old) ‘Again, that are not going to be having people that would be having something that is outdated, again when we actually engage in that we also update ourselves as lecturers.’ (Participant 12, Senior, 60 years old)

Nurse educators displayed a positive attitude and appeared to be very supportive of EBP teaching and learning. Reinforcing this statement, Mehrdad et al. ( 2012 :507) reported that nurses’ knowledge and attitude towards EBP contribute to its implementation in health care. Therefore, nurse educators and nursing students need to keep up to date with current evidence for use in practice. Current practices relied on by senior nurses and nurse educators are frequently based on personal experience, tradition, intuition, and organisational policies or protocols, rather than on evidence (Malik et al. 2015 b:47).

There is a belief that the use of up-to-date scientific findings will improve the quality of care for patients and fill the gap between research, theory, and practice (Mehrdad et al. 2012 :509). It is important that nurses use evidence to ensure their practice is up to date and based upon the best available research (Hickman et al. 2014 :604). Malik et al. ( 2015 a:159) emphasise that the health professionals are required to be using up-to-date knowledge and evidence to guide their decisions, hence improving patient care. In order for nursing education to keep up with the changes in nursing and health care, such professionals should be immersed in EBP (Felicilda-Reynaldo & Utley 2015 :92).

Category 2.2: Preparing student nurses to engage in evidence-based practice

According to the nurse educators, student nurses lack interest in research. However, once they become involved with research activities, the tendency is for students gradually to develop more interest and a concomitantly positive attitude towards research. Equally, increased motivation and eagerness to learn is noticed. The following statement was reported:

‘But when they come back from the library with those articles you could see that they are now developing interest you know, they are developing interest, they seem to understand it is like now there is that curtain that has fallen away so they can see now the light in this research.’ (Participant 6, Senior, 56 years old)

Hickman et al. ( 2014 :603) agree that developing the EBP capabilities of the emerging nursing workforce is essential in improving patient outcomes, promoting organisational efficiencies and creating a satisfying work environment. Engaging students in applying evidence into professional practice is a critical role of nursing faculties. This results in student nurses gaining confidence in the use of research and EBP to inform decision-making. Hickman et al. ( 2014 :603-604) further reveal that students demonstrated the ability to identify, criticise, and translate research to practice owing to the increased understanding. Students also understood the difference between research and EBP and how one informs the other. Therefore, teaching concepts of EBP to student nurses to enable them to recognise and deliver high-quality care that is evidence-based is a key outcome of all nurse education programmes (Leufer & Clearly-Holdforth 2015 :4).

Category 2.3: Improvement to quality care for patients

Evidence-based practice allows for individualised care, improvement in quality care leading to quick recovery of patients and shortened period of hospitalisation which saves money for patients. Participants stated the following:

‘Research helps in the improvement in the quality of care and in how quick the patient recovers or how long he stays ill in the ward.’ (Participant 3, Senior, 50 years old) ‘I think the benefits, the benefits are, because EBP is more patient centered I think and therefore it is beneficial and also sometimes it becomes meaningful, you can even individualize the care to the patient based on that EBP and the outcome of that so I think it is beneficial in that way but eh those are the benefits I think and also improvement, improvement in patient care.’ (Participant 8, Junior, 53 years old)

When patient care is informed by sound evidence, it results in better and more affordable care towards people and the community. Nursing evolved from a series of dictated tasks to a holistic care approach which requires evidence that is developed into guidelines. These guidelines support nurses to promote individualised care (Emmanuel et al. 2011 :22).

Evidence-based practice is a patient-centred approach as it influences patient care and minimises the theory-practice gap with nursing (Mackey & Bassendowski 2016 :53). The main aim of EBP is to optimise outcomes for patients and clients by selecting interventions that have the greatest chance of success (Leufer & Clearly-Holdforth 2015 :4).

Category 2.4: Reducing health care delivery cost

The use of EBP leads to improvement in the quality of care, thus reducing patient stay in hospital. Although quality is sometimes expensive, it comes with positive implications for health care facilities, for example, when patients receive quality care, their recovery is quicker and the numbers of days spent in hospital are reduced, resulting in reduction of patient-care costs. Therefore, the employer and institutions benefit positively from the use of EBP because of the end result, which is improvement in the patient outcomes. One participant reported that:

‘You know I feel like with EBP teaching and learning, it will be more important to use more in the clinical area.’ (Participant 10, Senior, 59 years old)

For the health institutions to provide effective services, their functioning, planning, policies, and guidelines are informed by researched evidence. The following statements were reported:

‘I think EBP will be an excellent way to have proficient and efficient nurses in the ward.’ (Participant 5, Junior, 50 years old) ‘You get in improvement, quality improvement in nursing care and you find that with research, research helps in the improvement in the quality of care and in how quick the patient recovers or how long he stays ill in the ward.’ (Participant 4, HOD, 56 years old)

Reducing health care costs requires that nursing and health care services be based on best current available evidence. Improved cost-effectiveness of the health institutions allows the administrators the ability to negotiate for better sponsorship and incentives from health care funders and insurers (Levin et al. 2011 :22).

Evidence-based practice teaching and learning is not explicitly implemented. The current curriculum (R425) does not have any specific guidelines for EBP teaching and learning; it only requires that research processes and steps to conduct research projects be taught to student nurses. For KZNCN, the research module is taught at third-year level, and it is covered under the Community Nursing Science component. The learner study guide only requires the nursing students to conduct and present a mini research project. There is no mention of EBP skills or competencies that must be acquired or achieved.

The researchers concluded that the information generated as experiences of nurse educators is not directly linked to EBP in teaching and learning: it was more about teaching and learning of research in general. Nevertheless, EBP depends for its success on researched information. Research is conducted to develop evidence that may be used for EBP. The utilisation of researched evidence in practice is known as EBP. It is never easy to separate research from EBP because one complements the other. However, it remains the responsibility of the NEIs to encourage student nurses to promote and deliver EBP from the onset of training; therefore, the principles of EBP should be introduced to students as part of pre-registration education (Emmanuel et al. 2011 :21).

Lack of resources was one of the challenges mentioned by most of the nurse educators, mainly the physical resources like lack of or poor access to computers and libraries. Non-availability of Internet access, current books, journals, and articles also contributed to poor access to relevant evidence needed for successful implementation of EBP teaching and learning.

From the list of teaching strategies identified by nurse educators, it was clear that traditional teaching strategies are still dominant in nursing education. Such strategies do not promote or stimulate critical-thinking skills and EBP competencies to student nurses. A teaching method is understood to be a particular technique a teacher uses to help learners gain the knowledge which they need and to achieve a desired outcome. A desired outcome in this context is the development of critical thinking, problem-solving and good decision-making skills for student nurses, which can be achieved by the use of EBP in teaching and learning as one of the innovative teaching strategies.

Though it transpired that most nurse educators were supportive and had a positive attitude towards the implementation of EBP in teaching and learning, their level of knowledge and skills was questionable; there was uncertainty in understanding the use of EBP in teaching and learning; and a lack of motivation and commitment towards research was evident. Malik et al. ( 2015 b:46), in a tertiary health care facility in Victoria, Australia, investigated the perceptions of nurse educators on factors promoting EBP and perceived barriers to facilitating EBP in a clinical setting before developing an educational programme. The findings revealed that nurse educators had positive attitudes towards EBP implementation. However, they demonstrated a lack of knowledge and skills in appraising and incorporating evidence into practice. Nurse educators cannot be expected to teach what is not known to them, therefore; they must be equipped with knowledge and skills so that they can teach EBP to produce professional nurses who are competent in evidence-based care (Melnyk et al. 2012 :416).

Limitations

It may not be possible to generalise the findings to all nurse educators because the study was limited to nurse educators who work in the public institutions under Umgungundlovu Health District, and who only provide R425 comprehensive 4-year programmes at two campuses. Therefore, findings cannot be generalised to private institutions like universities, other districts, provinces or even nationally and for other nursing programmes.

Recommendations

The current curriculum (R174) should be reviewed and restructured to allow for early introduction of EBP principles at the onset of training. In addition, online and telematics studies together with the use of mobile technologies should be included in the curriculum.

Relevant adequate resources should be made available and accessible to nurse educators and nursing students. Access to sufficient clinical facilities that are appropriate for the achievement of the outcomes of the programme should also be considered.

Nurse educators should be supported through in-service training, workshops and affiliation to journal clubs to improve their knowledge and skills regarding EBP competencies.

The findings revealed both the challenges and benefits that come with the use of EBP in teaching and learning skills for the nursing education discipline, thus paving the way for the implementation of the suggested recommendations. Evidence-based practice has an essential potential role to play through incorporating more practice-based evidence of nurse educators in teaching and learning implementation. Therefore, nurse educators should use EBP to ensure that student nurses receive high-quality nursing education.

Acknowledgements

Thanks to Dr D.K.S. Habedi for her assistance and supervision in writing this article. I am also thankful to the participants for their willingness to contribute in the study.

Competing interests

The authors declare that there are no competing interests with regard to the writing of this article.

Authors’ contributions

G.N.M. is the author of the article and conducted the research. D.S.K.H. provided guidance and assisted with the writing of the manuscript.

How to cite this article: Mthiyane, G.N. & Habedi, D.S., 2018, ‘The experiences of nurse educators in implementing evidence-based practice in teaching and learning’, Health SA Gesondheid 23(0), a1177. https://doi.org/10.4102/hsag.v23i0.1177

1 The author understands and acknowledges the sensitivity of the terms used and prefers to use as classified according to the Republic of South Africa’s Government Application Form for Employment in order to avoid misinterpretation of the study results.

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The experiences of nurse educators in implementing evidence-based
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Continue nursing education: an action research study on the implementation of a nursing training program using the Holton Learning Transfer System Inventory

Introduction

Developing a nursing training program with the Holton Learning Transfer System Inventory

Current situation survey

Development of the training program using the 4W1H approach

Implementation of the nursing project training program using the action research method

Second cycle (may-october 2021)

Issues identified in this cycle

The third cycle (November 2021-march 2022)

Effect evaluation

Process evaluation

Evaluation results the results of the process evaluation are as follows

Results evaluation

Assessment of difficulty in quality management project implementation

Evaluation of transfer effect

The effectiveness of the training program based on the Holton Learning transfer System Inventory

Action research helps to ensure the quality of organizational management of training

Future research directions

Limitations

Conclusions

Data availability

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

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Assessing nurses’ professional competency: a cross-sectional study in Palestine

Implications

Study design and settings

Research procedure and sample

Research instrument

Ethical considerations

Demographics and work environment factors

The professional competence level and subscales

The difference in competency subscale scores among nurses

Theoretical implication

Managerial implications

Limitations

Conclusions

Recommendations

Data availability

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

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Conclusions

Introduction

Design and methods

Sampling method

Data collection

Data analysis

Trustworthiness