Introduction
The current state of the healthcare system is marked by a notable increase in the need for enhanced service quality and improved patient outcomes [1]. In this context, nurses play a crucial role in providing high-quality care and ensuring patient safety [1]. Their notable advantage lies in the significant amount of time they dedicate to interacting with patients, which sets them apart from other healthcare professionals. As such, they hold a vital position within the healthcare system [2]. It is estimated that approximately 80% of healthcare services in hospitals are delivered by nurses, underscoring the critical need for these services to be of the highest quality—the evaluation of nursing care quality hinges upon meticulous and comprehensive nursing [3]. Given this critical role, it becomes essential to examine the proficiency in the nursing process, which directly influences the quality of care provided [4].
To effectively provide patient care, nurses must demonstrate proficiency in nursing, including thorough assessment, accurate diagnosis, comprehensive planning, precise implementation, and careful evaluation [5]. These abilities directly influence the quality of care, resulting in increased patient satisfaction and decreased complications [6]. Competency in the nursing process refers to a nurse’s confidence in their knowledge, skills, and attitudes to perform the five steps of the nursing process with individual patients [7]. The nursing process is the appropriate method to explain the essence of nursing, scientific bases, technologies, and humanist assumptions that encourage critical thinking and creativity in professional practice, focusing on care as a reflective practice [8]. Practical application of the nursing process leads to improved outcomes in critical illnesses and enhances overall patient well-being [9]. Mastery of this process is essential for delivering quality care, as it allows nurses to identify patient needs, develop appropriate interventions, and evaluate the effectiveness of their actions [5]. By focusing on each nursing process step, nurses can ensure patients receive the best possible care and achieve optimal outcomes [4]. Understanding nurses’ work environment is crucial as it significantly impacts their ability to execute essential competencies and emphasizes their value in the healthcare system [10].
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The work environment of nurses encompasses various factors, including the physical layout of the workplace, social dynamics among colleagues and patients, and the organizational structure of healthcare institutions [11]. A supportive work environment significantly enhances nurses’ performance and boosts their confidence in delivering quality care. Conversely, an unsupportive work environment can lead to increased stress, burnout, and decreased quality of nursing services [12]. The interplay between these factors can create either an empowering or a detrimental atmosphere for nursing professionals [13].
Previous research has highlighted the significance of several key factors within the work environment that can influence nurses’ competencies. One crucial aspect is managerial support, which encompasses the presence and availability of supervisors who provide guidance and mentorship to nursing staff. This support often includes acknowledging and recognizing nurses’ contributions to patient care and fostering a sense of value and motivation among the team [14]. Another important factor is the quality of teamwork and collaboration among nursing staff. Effective communication is essential for seamless interactions and the successful exchange of vital information, while shared decision-making processes empower staff members to contribute their insights and expertise. This collaborative approach enhances patient care and promotes a positive workplace culture. Furthermore, access to necessary resources, such as medical supplies and advanced technology, is critical in nurses’ ability to perform their duties efficiently. The availability of up-to-date equipment and sufficient supplies ensures that nurses can provide high-quality care without unnecessary delays or complications. These elements contribute significantly to nursing professionals’ overall competency and effectiveness in delivering patient-centered care [10].
Many studies have focused on specific aspects of the work environment or nursing competencies, yet a critical gap persists in our understanding of their interrelationship [10, 14, 15]. This gap is crucial because individual competencies do not solely determine the effectiveness of nursing practice but are also significantly influenced by the work environment in which nurses operate. An unfavorable work environment can hinder even the most skilled nurses, leading to increased stress, burnout, and ultimately, compromised patient care. Conversely, a supportive work environment can empower nurses to utilize their competencies fully and provide high-quality care. This study aimed to identify the relationship between nursing process competency and the work environment among Iranian clinical nurses. By exploring this interconnection, we sought to illuminate how deficiencies in one area can exacerbate issues in the other. The findings of our study have the potential to significantly inform the development of policies and procedures that enhance training and support systems for nursing professionals. A deeper understanding of how these factors interact is essential for healthcare administrators to implement targeted interventions that substantially improve nursing practice. By addressing this critical gap, our study provides insights that can lead to the creation of tailored training modules that effectively address gaps in nursing competencies.
Furthermore, we advocate for policies that cultivate a supportive work environment—including appropriate staffing ratios and mental health resources. This comprehensive approach will form a robust framework for future studies examining specific interventions and their impacts on nurse satisfaction and patient care quality. Ultimately, by emphasizing the necessity of understanding the interplay between nursing competencies and the work environment, the initiatives proposed here are intended to improve workplace conditions and enhance nursing competencies. This, in turn, will lead to better patient outcomes and increased job satisfaction among nurses.
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a study investigated the relationship between nursing process competency and work environment among clinical nurses. The research utilized a quantitative approach aligned with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
Participants and setting
The data were collected from five teaching hospitals in Ardabil, northwest Iran. This study involved clinical nurses with at least six months of nursing experience who volunteered to participate. Any incomplete questionnaire responses were excluded from the analysis to ensure data independence. The sample size of 289 was determined using a confidence level of 1.96, a proportion (p) of 0.5, a complementary proportion (q) of 0.5, and a margin of error (d) of 0.05.
$$\:n=\frac{{z}^{2}.p.\:(1-p)}{{d}^{2}}$$
The final sample consisted of 321 participants, accounting for an anticipated non-response rate of 10%. Proportional stratified sampling was employed to ensure representation aligned with hospital populations. Specifically, 140 nurses were selected from Imam Khomeini Hospital (A major teaching hospital known for its comprehensive medical services and high patient volume), 65 from Fatemi Hospital (The trauma center of the province and a psychiatric facility in Ardabil, recognized for specialized care and advanced treatment options), 40 from Alavi Hospital (A center for neurosurgery and obstetrics, focusing on community health and providing a range of outpatient and inpatient services), 35 from Imam Reza Hospital (A center for ophthalmology and urology, offering a wide array of medical specialties with an emphasis on emergency and critical care), and 41 from Boo Ali Hospital (A specialized and super-specialized pediatric center, catering to a unique patient population).
A power analysis was conducted to ensure the sample size was adequate for detecting meaningful relationships between the variables. This analysis estimated the probability of correctly rejecting the null hypothesis when false, thereby confirming the likelihood of detecting an effect if one exists. A power level of 0.80 was targeted, which indicated an 80% chance of detecting a true effect at a significance level of 0.05. Given the calculated sample size of 321, the study was sufficiently powered to detect moderate effect sizes (Cohen’s d = 0.5) between the variables of interest. Simple random sampling was applied within each stratum. Eleven questionnaires were excluded from the analysis due to incomplete responses. Data collection took place from April 10 to June 2024, following an introduction from the researchers to nursing offices, where they explained the study’s objectives and procedures.
Data collection and tools
Data were collected using the Competency of Nursing Process Questionnaire (CNPQ), the Work Environment Questionnaire, and a demographic characteristics form.
Demographic characteristics form
The demographic characteristics include several items: age, work experience (in years), ward distribution, gender, marital status, education level, position, employment status, monthly salary, and overtime. The questionnaire also inquired about the implementation of the nursing process in daily patient care (yes, no) and previous education on the nursing process (yes, no).
Competency of nursing process questionnaire (CNPQ)
The Competency of Nursing Process Questionnaire (CNPQ) was designed by Koy et al. to evaluate the competency of registered nurses in Cambodia in the nursing process [7]. This questionnaire is an essential tool for nurses to assess their skills. It provides valuable data for nursing managers to create policies to enhance nursing competencies and the quality of patient care. It comprises 24 items divided into five dimensions: assessment, diagnosis, planning, implementation, and evaluation. Responses are rated on a five-point Likert scale, with scores ranging from 1 (not confident at all) to 5 (proficient), where higher scores suggest greater perceived competency [7]. The CNPQ has displayed strong reliability, with a Cronbach’s α coefficient of 0.963 and a content validity index of 1.00, confirming the relevance of its items [7].
The study received permission from CNPQ before collecting data. The questionnaire underwent a thorough evaluation for content validity, with items reviewed by experts in the field to ensure their relevance and clarity. The content validity index (CVI) was calculated to confirm the appropriateness of these items. Additionally, face validity was established through feedback from a small group of clinical nurses. To assess the content validity of the tool, a panel of 12 nursing professionals was convened, each bringing diverse professional backgrounds and expertise. This panel included a Nurse Educator specializing in training and mentoring nursing students with over 10 years of teaching experience, a Clinical Nurse Specialist focused on improving patient outcomes through advanced clinical practice, and a Nurse Practitioner providing primary and specialized care with a background in family medicine. Other members included a Public Health Nurse, who promotes health and prevents disease in community settings; a Pediatric Nurse, specializing in critical care for children; and an Oncology Nurse, who offers care for cancer patients emphasizing pain management and palliative care. Additionally, a Mental Health Nurse, trained in therapeutic communication and crisis intervention, and a Geriatric Nurse, experienced in managing chronic illnesses in elderly patients, contributed their insights. The panel also featured a Surgical Nurse skilled in preoperative and postoperative care, a Nurse Researcher focusing on evidence-based practice, an Informatics Nurse integrating nursing with information technology, and a Nurse Administrator overseeing nursing departments and healthcare management. The collective feedback from these professionals was instrumental in ensuring that the questionnaire’s content accurately reflected the measured constructs, thereby enhancing its overall validity.
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Furthermore, the face validity was confirmed through expert review, validating that the items were appropriate and relevant for the intended purpose. This comprehensive evaluation process significantly contributed to increasing the overall reliability and validity of the tool. This questionnaire’s CVI and CVR coefficients were reported as 0.90 and 0.88%, respectively. The reliability of the CNPQ was evaluated using Cronbach’s alpha, obtaining a coefficient of 0.97, which signifies a high level of internal consistency, further reinforcing the tool’s reliability.
Work environment questionnaire
The work environment questionnaire, developed by Saiga et al. [10], evaluates various factors related to the working conditions of nurses, focusing on both objective and subjective elements. According to definitions provided by Saiga et al., the work environment encompasses physical aspects such as working hours and lighting, interpersonal relationships, and stress levels [10]. In our study, we identified seven key items related to the work environment, which we assessed using a four-point Likert scale: 1 = disagree, 2 = slightly disagree, 3 = slightly agree, and 4 = agree. The selected items for evaluation were carefully chosen based on their relevance to nursing practice and their potential impact on job satisfaction and performance. The items included are:
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Support from superiors or senior colleagues: Recognizing the importance of mentorship and guidance in enhancing professional growth and job satisfaction.
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Amicable interpersonal relationships: Highlighting the significance of positive relationships among colleagues in fostering a collaborative and supportive work atmosphere.
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Clarity about the organization’s vision: Ensuring employees understand the organizational goals helps align individual efforts with broader objectives, enhancing motivation and focus.
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Fairness and objectivity in personnel evaluation and treatment: Emphasizing the necessity of transparent evaluation processes to promote trust and equity within the workplace.
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Satisfactory education and training: Addressing the need for ongoing professional development to equip staff with the necessary knowledge and skills, improving overall service quality.
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Established and easily accessible support system for taking time off for childcare and caregiving: Recognizing the importance of policies that support work-life balance, which is crucial for employee well-being and retention.
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Ease of taking time off: Acknowledging that the ability to take vacations and personal time as needed contributes significantly to job satisfaction and overall mental health.
Using these items in the questionnaire aimed to capture a comprehensive view of the work environment as it relates to nursing practice, thereby facilitating a better understanding of factors that influence nurses’ experiences and well-being.
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The decision to include these seven factors was based on a thorough review of existing literature and consultations with nursing professionals to identify the most pressing issues impacting their work environment [10]. Each factor was selected for its direct relevance to nursing practice and potential influence on job satisfaction and performance. While the scale developers focused on these seven key items, several other factors were considered but ultimately omitted from the scale. These omitted factors include:
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Workload management: Although crucial, they determined that workload management could be indirectly assessed through the ease of taking time off and support from superiors.
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Physical work conditions: While important, they felt that the physical aspects of the work environment (e.g., workplace safety, ergonomics) were sufficiently covered under the broader category of support systems and interpersonal relationships.
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Access to mental health resources: Although essential for overall well-being, they believed this factor could be indirectly captured by evaluating interpersonal relationships and the support system.
By focusing on these seven items, we aimed to capture a comprehensive view of the work environment as it relates to nursing practice, thereby facilitating a better understanding of factors that influence nurses’ experiences and well-being.
This questionnaire’s CVI and CVR coefficients were reported as 0.92 and 0.89%, respectively. The internal consistency of these items was confirmed by Saiga et al., with a Cronbach’s alpha coefficient of 0.846 [10]. In our study, the Cronbach’s alpha coefficient for this questionnaire was 0.87.
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Data analysis
This study utilized descriptive and analytical statistical methods, employing the Statistical Package for the Social Sciences (SPSS) version 14. Descriptive statistics, including mean, median, standard deviation, and frequency distributions, were used to summarize the demographic characteristics of the study participants. For our analytical approach, we employed independent sample t-tests, analysis of variance (ANOVA), Pearson correlation, hierarchical regression analysis, and correlation tests. These methods enabled us to thoroughly investigate the relationships between variables and assess the influence of various factors on the competency of nursing processes.
Hierarchical regression analysis was performed to investigate the factors influencing nursing process competency while controlling for the demographic characteristics of the participants. This method was selected because it allows for examining the incremental value of adding variables to the model, providing insights into how different factors contribute to nursing process competency. By entering variables in a specified order, we can assess each factor’s unique contribution while controlling for others’ effects. Prior to conducting the multiple linear regression, we assessed multicollinearity by examining the variance inflation factor (VIF) and tolerance levels. Typically, a tolerance value below 0.1 and a VIF value exceeding 5 suggest potential multicollinearity issues. However, according to these criteria, none of the variables examined in this study showed significant signs of multicollinearity.
Results
In our study, the mean age of participants was 33.51 years (SD = 8.05), with an average work experience of 9.74 years (SD = 7.56). 76.1% were female, and 67.7% were married. A significant portion (90.3%) held a bachelor’s degree, and 91.9% implemented the nursing process in daily patient care. Additionally, 87.7% of participants had received prior education on the nursing process (Table 1).
Table 1
Frequency distribution of participants’ demographic characteristics (𝑛 = 310)
Variables | Mean | SD |
|---|---|---|
Age (years) | 33.51 | 8.05 |
Work experience (years) | 9.74 | 7.56 |
Frequency | Percentage | |
Ward | ||
Emergency | 81 | 26.1 |
Surgery | 52 | 16.8 |
ICU | 59 | 19.0 |
Pediatrics | 29 | 9.4 |
Internal | 89 | 28.7 |
Gender | ||
Male | 74 | 23.9 |
Female | 236 | 76.1 |
Marital status | ||
Single | 100 | 32.3 |
Married | 210 | 67.7 |
Education level | ||
Bachelor’s degree | 280 | 90.3 |
Master’s degree | 30 | 9.7 |
Position | ||
Nurse | 280 | 90.3 |
Head nurse | 17 | 5.5 |
Staff | 13 | 4.2 |
Employment status | ||
Official | 150 | 48.4 |
Contract | 25 | 8.1 |
Contractual | 30 | 9.6 |
Project-based | 105 | 33.9 |
Annual income (US$) | ||
3200–3800 | 16 | 5.2 |
3800–4400 | 53 | 17.1 |
4400–5000 | 179 | 57.7 |
> 5000 | 62 | 20.0 |
Overtime (hours per month) | ||
Less than 40 | 84 | 27.1 |
40 to 80 | 156 | 50.3 |
81 to 120 | 44 | 14.2 |
More than 120 | 26 | 8.4 |
Implementation of the nursing process in daily patient care | ||
Yes | 285 | 91.9 |
No | 25 | 8.1 |
Previous education on the nursing process | ||
Yes | 272 | 87.7 |
No | 38 | 12.3 |
The mean score for the assessment dimension was 3.83 (SD = 0.80), while the diagnosis dimension achieved a mean score of 3.89 (SD = 0.78). The planning dimension recorded a mean of 3.85 (SD = 0.78), and the implementation dimension also had a mean score of 3.83 (SD = 0.74). The evaluation dimension reached a mean score of 3.87 (SD = 0.80). Overall, the CNPQ yielded a mean score of 3.86 (SD = 0.71), reflecting a generally high level of competency across all dimensions (Table 2).
Table 2
Nursing process competency dimensions’ scores (n = 310)
Dimensions | Possible Range | Min | Max | Mean | SD |
|---|---|---|---|---|---|
Assessment | 1–5 | 1.50 | 5.00 | 3.83 | 0.80 |
Diagnosis | 1–5 | 1.40 | 5.00 | 3.89 | 0.78 |
Planning | 1–5 | 1.00 | 5.00 | 3.85 | 0.78 |
Implementation | 1–5 | 1.00 | 5.00 | 3.83 | 0.74 |
Evaluation | 1–5 | 1.00 | 5.00 | 3.87 | 0.80 |
Overall CNPQ | 1–5 | 1.23 | 5.00 | 3.86 | 0.71 |
The findings of Table 3 highlight both strengths and areas needing improvement. Most nurses (67.5%) felt supported by their superiors and senior coworkers, and 75.1% had positive interpersonal relationships. However, some areas required attention, such as a clearer vision (52%) and improved fairness and equality in evaluations (59.4%). These areas presented significant opportunities for improvement. Most nurses (66.8%) were satisfied with training and learning opportunities, but it was crucial to address the issue of available childcare leave support, as 46.8% indicated a lack of this support.
Table 3
Status of the working environment dimensions among clinical nurses (n = 310)
Dimensions | Disagree | Somewhat disagree | Somewhat agree | Agree |
|---|---|---|---|---|
(n, %) | ||||
Support from superiors and senior coworkers | 27 (8.7%) | 74 (23.9%) | 149 (48.1%) | 60 (19.4%) |
Good interpersonal relationship | 21 (6.8%) | 56 (18.1%) | 160 (51.6%) | 73 (23.5%) |
Clarity about the organization’s vision | 31 (10.0%) | 118 (38.1%) | 118 (38.1%) | 43 (13.9%) |
Fairness and objectivity in personnel evaluation and treatment | 29 (9.4%) | 97 (31.3%) | 131 (42.3%) | 53 (17.1%) |
Satisfactory education and training to gain necessary knowledge and skills | 23 (7.4%) | 80 (25.8%) | 149 (48.1%) | 58 (18.7%) |
Established and easily accessible support system for taking time off for childcare and caregiving | 31 (10.0%) | 114 (36.8%) | 115 (37.1%) | 50 (16.1%) |
Ease of taking time off | 33 (10.6%) | 95 (30.6%) | 120 (38.7%) | 62 (20.0%) |
Table 4 illustrates the correlation between the nursing process competency and various aspects of the work environment among clinical nurses. The results indicated several significant positive correlations, particularly between Overall CNPQ and fairness and equality in evaluation (r = 0.388, p < 0.001), as well as with support from superiors and senior colleagues (r = 0.306, p < 0.001). Additionally, strong correlations were observed between good interpersonal relationships and support from superiors and senior colleagues (r = 0.628, p < 0.001), suggesting that supportive relationships within the workplace enhanced interpersonal dynamics. The dimension of clarity about the organization’s vision also showed significant positive correlations with various items, particularly with fairness and equality in evaluation (r = 0.639, p < 0.001), indicating that a clear organizational vision may have contributed to perceptions of fairness. These findings underscored the importance of a supportive work environment in fostering nursing competency. They also suggested that improvements in these areas could have significantly enhanced nurse satisfaction and patient care quality, thereby emphasizing the practical implications of this research.
Table 4
Association between nursing process competency and work environment dimensions among clinical nurses (n = 310)
Variables | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
|---|---|---|---|---|---|---|---|---|
1. CNP | 1 | 0.306** | 0.302** | 0.272** | 0.388** | 0.292** | 0.197** | 0.119* |
2. SSSC | 0.306** | 1 | 0.628** | 0.390** | 0.525** | 0.412** | 0.347** | 0.324** |
3. GIR | 0.302** | 0.628** | 1 | 0.496** | 0.550** | 0.467** | 0.380** | 0.373** |
4. FOPET | 0.272** | 0.390** | 0.496** | 1 | 0.639** | 0.546** | 0.448** | 0.400** |
5. FEE | 0.388** | 0.525** | 0.550** | 0.639** | 1 | 0.633** | 0.505** | 0.460** |
6. SETGNKS | 0.292** | 0.412** | 0.467** | 0.546** | 0.633** | 1 | 0.480** | 0.362** |
7. EEASSTTCC | 0.197** | 0.347** | 0.380** | 0.448** | 0.505** | 0.480** | 1 | 0.513** |
8. ETT | 0.119* | 0.324** | 0.373** | 0.400** | 0.460** | 0.362** | 0.513** | 1 |
Table 5 presents the relationship between nursing process competency and various demographic characteristics among clinical nurses. Significant differences were observed based on position, where head nurses scored the highest at 4.28 (SD = 0.49), leading to a statistically significant result (F = 4.75, p = 0.009). Additionally, participants who implemented the nursing process in daily care had a mean score of 3.91 (SD = 0.69), significantly higher than those who did not (3.29, SD = 0.72; t = 4.27, p < 0.001). Furthermore, previous education in the nursing process also revealed a significant difference, with educated participants scoring 3.90 (SD = 0.68) compared to 3.55 (SD = 0.86) for those without prior education (t = 2.86, p = 0.004). Other variables, such as age, work experience, gender, marital status, employment status, annual income, and overtime hours, did not show statistically significant associations with CNPQ scores.
Table 6 presents the results of hierarchical regression analysis aimed at identifying predictors of nursing process competency among clinical nurses. In model 1, which included demographic variables, the analysis revealed several predictors of nursing process competency among clinical nurses. The variable “position” had a significant positive effect, with a Beta of 0.21 (p = 0.03). “overtime” also showed a significant positive relationship (Beta = 0.13, p = 0.01). The variable “implementation of the nursing process in daily patient care” demonstrated a strong negative impact (Beta = -0.56, p < 0.001). Additionally, “previous education on the nursing process” was significant, with a Beta of -0.26 (p = 0.03). The model explained 12% of the variance in nursing process competency (R² = 0.12, Adjusted R² = 0.08), with an F statistic of 3.29 (p < 0.001).
The predictors of nursing process competency were assessed in model 2, which included work environment dimensions. The variable “FEE” (Fairness and Equality in Evaluation) had a significant positive effect (Beta = 0.22, p < 0.001). The model accounted for 27% of the variance in nursing process competency (R² = 0.27, ΔR² = 0.14, Adjusted R² = 0.22), with an F statistic of 5.37 (p < 0.001).
Table 5
The relationship between nursing process competency and demographic characteristics of the participants (n = 310)
Variables | Mean | SD | Coefficient | p-value |
|---|---|---|---|---|
Age (years) | 3.86 | 0.71 | r = 0.05 | p = 0.30 |
Work experience (years) | 3.86 | 0.71 | r = 0.05 | p = 0.30 |
Ward | F = 0.114 | p = 0.978 | ||
Emergency | 3.87 | 0.77 | ||
Surgery | 3.84 | 0.80 | ||
ICU | 3.90 | 0.63 | ||
Pediatrics | 3.87 | 0.76 | ||
Internal | 3.82 | 0.65 | ||
Gender | t = -1.37 | p = 0.17 | ||
Male | 3.76 | 0.70 | ||
Female | 3.89 | 0.70 | ||
Marital status | t = -0.10 | p = 0.91 | ||
Single | 3.85 | 0.71 | ||
Married | 3.86 | 0.71 | ||
Education Level | t = -0.72 | p = 0.46 | ||
Bachelor’s degree | 3.85 | 0.70 | ||
Master’s degree | 3.95 | 0.84 | ||
Position | F = 4.75 | p = 0.009 | ||
Nurse | 3.82 | 0.71 | ||
Head nurse | 4.28 | 0.49 | ||
Staff | 4.17 | 0.80 | ||
Employment status | F = 0.40 | p = 0.50 | ||
Official | 3.91 | 0.71 | ||
Contract | 3.85 | 0.57 | ||
Contractual | 3.88 | 0.65 | ||
Project-based | 3.77 | 0.76 | ||
Annual income (US$) | F = 2.38 | p = 0.07 | ||
3200–3800 | 3.42 | 0.66 | ||
3800–4400 | 3.80 | 0.78 | ||
4400–5000 | 3.89 | 0.69 | ||
> 5000 | 3.92 | 0.69 | ||
Overtime (hours per month) | F = 2.13 | p = 0.09 | ||
Less than 40 | 3.85 | 0.72 | ||
40 to 80 | 3.82 | 0.68 | ||
81 to 120 | 3.78 | 0.75 | ||
More than 120 | 4.19 | 0.76 | ||
Implementation of the nursing process in daily patient care | t = 4.27 | p < 0.001 | ||
Yes | 3.91 | 0.69 | ||
No | 3.29 | 0.72 | ||
Previous education on the nursing process | t = 2.86 | p = 0.004 | ||
Yes | 3.90 | 0.68 | ||
No | 3.55 | 0.86 | ||
Table 6
The results of hierarchical regression to determine the predictors of nursing process competency among clinical nurses (n = 310)
Predictor variables | Model 1 | Model 2 | |||||
|---|---|---|---|---|---|---|---|
Beta | VIF | p | Beta | VIF | p | ||
Age | -0.00 | 1.05 | 0.57 | -0.01 | 1.10 | 0.15 | |
Work experience | -0.01 | 1.02 | 0.45 | -0.00 | 1.03 | 0.67 | |
Ward | 0.01 | 1.10 | 0.62 | -0.01 | 1.12 | 0.55 | |
Gender | 0.05 | 1.03 | 0.61 | 0.06 | 1.04 | 0.48 | |
Marital status | -0.09 | 1.08 | 0.39 | -0.09 | 1.09 | 0.34 | |
Education level | 0.02 | 1.07 | 0.88 | 0.08 | 1.08 | 0.49 | |
Position | 0.21 | 1.06 | 0.03 | 0.10 | 1.07 | 0.25 | |
Employment status | -0.04 | 1.04 | 0.30 | -0.05 | 1.05 | 0.13 | |
Annual income | 0.11 | 1.09 | 0.09 | 0.18 | 1.10 | 0.01 | |
Overtime | 0.13 | 1.06 | 0.01 | 0.11 | 1.07 | 0.02 | |
Implementation of the nursing process in daily patient | -0.56 | 1.15 | < 0.001 | -0.44 | 1.16 | 0.01 | |
Previous education on the nursing process | -0.26 | 1.08 | 0.03 | -0.09 | 1.09 | 0.42 | |
SSSC | 0.08 | 1.05 | 0.16 | ||||
GIR | 0.06 | 1.06 | 0.29 | ||||
FOPET | 0.02 | 1.07 | 0.66 | ||||
FEE | 0.22 | 1.08 | < 0.001 | ||||
SETGNKS | 0.05 | 1.09 | 0.40 | ||||
EEASSTTCC | 0.00 | 1.10 | 0.88 | ||||
ETT | -0.09 | 1.57 | 0.11 | ||||
Model characteristics | R2 = 0.12, Adj R2 = 0.08, F = 3.29, p < 0.001 | R2 = 0.27, ΔR2 = 0.14, Adj R2 = 0.22, F = 5.37, p < 0.001, DW = 1.76 | |||||
Discussion
Understanding the correlation between nursing process competency and the work environment is crucial, as it profoundly impacts shaping nurses’ competencies. A supportive work environment can significantly enhance nurses’ capabilities, improving patient outcomes and job satisfaction. The primary aim of this research is to investigate the intricate ways in which various aspects of the work environment influence nurses’ proficiency in the nursing process. Key findings reveal significant positive correlations between overall nursing process competency and factors such as evaluation fairness and colleague support. Additionally, differences in competency were noted based on position and prior education in the nursing process. This investigation will yield valuable insights that can be used to develop targeted interventions and formulate policies, thereby improving nursing practice and fostering a positive work atmosphere within clinical settings.
In our research, clinical nurses demonstrated a strong competency in the diagnosis dimension, reflecting their ability to accurately identify patient conditions. However, their performance in the assessment dimension was slightly lower, suggesting that while they are competent, there are areas that require improvement. In contrast, Koy et al.‘s study indicated an even higher level of perceived competency across all dimensions, particularly in intervention, where participants felt exceptionally confident, and slightly less so in evaluation [4]. This comparison highlights that both studies reveal a high level of nursing process competency, but Koy et al.‘s participants generally viewed their skills as more robust. This discrepancy may stem from various factors, including differences in educational training, clinical experience, or the conditions of their work environments [9, 16]. The nursing process is crucial for professionalism in modern nursing practice, as it employs scientific reasoning, critical thinking, and problem-solving to facilitate effective patient care [17]. By engaging in this process, nurses significantly contribute to identifying health problems, implementing interventions, and evaluating the outcomes of their care [4, 18]. Our study emphasizes the need for specific and targeted training programs that focus on areas with lower competency scores, such as assessment. To enhance nursing competency, it is essential to implement targeted training initiatives and foster a supportive work environment, which can ultimately boost the confidence and skills of nursing staff.
Our study has confirmed a strong connection between fairness and objectivity in personnel evaluations and the competency of clinical nurses in the nursing process. Consistent with our findings, Koy’s study clarified that fair and objective assessments of personnel significantly contribute to enhancing clinical nursing competency [4]. Personnel evaluation is a critical factor in the working environment and plays a pivotal role in shaping nurses’ experiences [19]. A stressful work environment often diminishes nurses’ willingness to effectively engage with the nursing process [20, 21]. Lack of fair personnel evaluations can exacerbate workplace stress, as nurses may feel undervalued or uncertain about their performance [22]. This stress can hinder their ability to apply the nursing process competently, as they may lack confidence in their skills and decision-making abilities [4, 22]. Conversely, effective and fair evaluations boost nurses’ confidence by affirming their knowledge, skills, attitudes, and clinical judgment—key components of nursing process competency. When nurses perceive their evaluations as just and unbiased, they are more likely to feel valued and secure in their roles. This recognition empowers them to enhance their expertise and fosters a sense of job security [19]. Additionally, fair evaluations promote open communication and collaboration among colleagues, creating a supportive work environment. When nurses recognize and appreciate their contributions, they are motivated to improve their performance and engage more fully in the nursing process [23]. Continuous monitoring, fair follow-up, and a just environment are essential for the effectiveness and competency of the nursing process.
The findings indicated that nurses achieved higher competency scores when implementing the nursing process in daily patient care. It was found that nurses with prior education in the nursing process demonstrated significantly greater competency than those without such training. These results highlight the importance of initial education and ongoing training and support. Addressing barriers to effective implementation is crucial to transforming theoretical knowledge into practical skills, ultimately improving patient care and nurse confidence. Findings from a survey by Hagos et al. indicated that although the majority of nurses were trained in the implementation of the nursing process (90.5%), only a tiny percentage felt confident in their knowledge about it (2.5%) [8]. Another research conducted by Rajabpoor et al. showed that 90% of the nurses reported concerns about the lack of control and ongoing oversight in the implementation of the nursing process, as well as insufficient training during their education [19]. The study points out that nursing education often focuses more on theoretical knowledge than practical skills, leaving students unprepared for real-world clinical settings [24]. The hospital environment significantly influences how the nursing process is carried out [19]. To address these challenges, we can create thorough training programs integrating theoretical learning with practical hands-on experience in real-life situations. These programs should offer mentorship opportunities, regular workshops, and simulations to connect theoretical knowledge with practical application, ultimately boosting nurse confidence and enhancing patient care outcomes.
The willingness of nursing staff to work overtime was another factor that affected the competency of the nursing process. According to Tan et al.‘s study, challenging job roles, such as overtime, that promote growth can positively influence nurses’ motivation. Engaging in work tasks can enhance employees’ self-efficacy and motivate them to improve their competencies and skills [25]. However, it is essential to recognize that excessive overtime can lead to burnout, negatively impacting nurse well-being and patient care. Effective workload management is crucial in supporting nurses’ willingness to work overtime while mitigating the risks associated with burnout. Healthcare facilities should foster a supportive culture that views overtime as an opportunity for growth rather than a burden. To achieve this, organizations can implement strategies such as training programs: offer targeted training to help nurses acquire new skills during overtime shifts, making the experience more rewarding; workload management: ensure that workloads are balanced, allowing nurses to manage their time effectively and reduce the strain of excessive hours; incentives for overtime: provide financial or non-financial incentives for nurses who take on additional shifts, reinforcing the value of their extra efforts; communication channels: establish open lines for feedback, enabling nurses to share their experiences and challenges related to overtime work [4, 22]. By adopting these strategies, healthcare facilities can boost motivation, enhance nurses’ competencies, and ultimately improve the overall quality of nursing care while reducing the risk of burnout associated with excessive overtime.
Our study indicated that the income of nursing staff can significantly impact their work processes and the quality of care they provide. Factors such as job satisfaction, motivation, and the ability of nurses to deliver better care to patients may be influenced by their income [26]. Nurses with adequate income are likely to feel more valued, leading to improved care quality and reduced job-related stress [27]. Conversely, low income may result in dissatisfaction and burnout, ultimately diminishing the quality of patient care [28]. Therefore, addressing the economic and livelihood factors affecting nurses can improve nursing processes and the quality of healthcare services.
Based on the results of our study, there was a relationship between position and competency in the nursing process, and Head nurses were more competent in this area than staff and nurses. Nursing has many challenges that often grow as people progress to higher positions [29]. These challenges can encourage people to acquire the necessary qualifications and skills [30]. In addition, supervisors may feel a greater need to expand their knowledge and abilities because of their managerial responsibilities. As a result, they are often more likely than nurses to develop skills that can enhance their competency in the nursing process.
Limitations
Despite its strengths, this study has several limitations. The cross-sectional design, while helpful, limits the ability to establish causal relationships between nursing competency and work environment factors. Longitudinal studies could provide deeper insights into how these variables interact over time. Additionally, the data was collected from a specific geographic area (Ardabil City, Iran), which may limit the generalizability of the findings. Further research is needed in regions or countries with different healthcare systems and cultural contexts. Furthermore, the self-reported measures used in the study, such as the Competency of Nursing Process Questionnaire and the work environment questionnaire, may be subject to response bias, as participants may overestimate their competencies or the quality of their work environment. Future studies could explore alternative methods of data collection to mitigate this bias.
Conclusion
This study reveals a significant relationship between nursing process competency and the work environment for clinical nurses. The key findings suggest that supportive work conditions—such as fair evaluations and strong colleague support—positively influence nurses’ competencies. Higher competency scores were associated with the effective implementation of the nursing process in daily care and with prior education on the subject. Furthermore, factors such as job position and the willingness to work overtime were significant predictors of competency. These insights highlight the importance of healthcare institutions offering targeted training programs. Such initiatives would enhance nursing competencies, improve patient care outcomes, and foster greater motivation and commitment among nurses toward this vital endeavor.
Acknowledgements
The authors would like to thank all the clinical nurses and the officials of the public hospitals affiliated with the Ardabil University of Medical Sciences, the Student Research Committee of Ardabil University of Medical Sciences, the Vice Chancellor for Research of Ardabil University of Medical Sciences, and all those who helped us in this study.
Declarations
Ethics approval and consent to participate
Before commencing the study, we obtained ethical approval from the Ethics Committee and the Research of Ardabil University of Medical Sciences (Approval ID: IR.ARUMS.REC.1402.395). This involved submitting a detailed proposal outlining the study’s objectives, methods, and ethical considerations, which the committee reviewed and approved. Participants were fully informed about the study’s goals and significance, and their consent was obtained voluntarily. Throughout the research process, we maintained confidentiality to ensure that participants’ identities remained anonymous. Participants had the right to withdraw from the study at any stage without any consequences. Additionally, we provided a summary of the results to university authorities upon request and strictly adhered to all ethical guidelines in the publication of the study findings.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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