Background
Primary Health Care (PHC) is at the forefront of any healthcare system. According to the World Health Organization (WHO), “Primary health care forms an integral part of both the country’s health system, of which it is the central function and main focus, and the overall social-economic development of the community. It is the first level of contact of individuals, the family and the community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process” [1]. Primary health care encompasses a wide array of health services delivered by healthcare professionals (e.g. physicians, nurses, and pharmacists) within the community [2], including non-communicable diseases management, health awareness, communicable diseases, immunization, mother and child health services [3‐5]. There is irrefutable evidence at the macro level (e.g., policy, regulations) showing countries with a strong primary health care service to have improved health outcomes at a lower cost [6]. Studies revealed that stronger PHC is crucial in accomplishing the health-related Sustainable Development Goals and universal health coverage [7, 8].
In order for PHC to be capable of leading the health system and producing high quality care, health specialist training is a prerequisite [9]. For example, Saudi Arabia’s special efforts in training and teaching their health professionals, improved their skills and raised the quality of health care which led this country to rank higher than many other international ones [10].
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In Lebanon, where this study was conducted, the primary health care system follows the multidisciplinary team-based model, often involving physicians, nurses, social workers, and other allied health professionals in the management and delivery of services. Some of the PHCs are governmental, but most are non-governmental organizations (NGOs) that secure their own funding and provide services at minimal cost to the patients. At the time when the study was conducted in late 2018, there were 220 PHCs that were part of the national network of PHCs spread across the country. In addition to dispensing essential drugs, the package of services offered included but were not limited to general medical care, pediatrics, dental and oral health care, reproductive health care, and cardiovascular medical care.
Nurses play an essential role in providing community care, which demands a comprehensive set of core competencies to effectively meet the needs of community residents [11, 12]. Core competencies encompass a wide range of skills, including health promotion, illness prevention, health education for community residents, and fostering behavioral changes that empower individuals to manage their own health [13, 14]. Effective communication is another critical area, involving proficient written, oral, and electronic communication with clients and interprofessional teams [14, 15]. Despite the clear importance of these competencies, the degree to which PHC nurses master and maintain these skills, along with the necessary support for their ongoing development, has yet to be thoroughly examined. In fact, in 2017, a report from the Ministry of Public Health (MOPH), in collaboration with the Order of Nurses in Lebanon (ONL) and with the support of United Nations International Children’s Emergency Fund (UNICEF) included a recommendation to conduct an assessment of the PHC nurses’ learning needs [16]. Practicing nurses were best positioned to provide information on their own experiences, to identify their own needs, and to distinguish between top priority and trivial clinical issues [17, 18]. It was important to involve them in setting priorities for their training within the health community and; hence, the motivation for this study.
Study purpose
To our knowledge, this study was the first to assess the range of the core competencies of the nurses and the level of training support needed to fulfill and improve these competencies. Using a survey approach, the primary purpose of this study was to assess the current use of core competencies required by community-based nurses. The secondary purpose was to assess the learning needs of nurses working in the national network of PHCs, where the results of the current survey could serve as a baseline for exploring future trends and learning needs. Additionally, the study aimed to assess the factors associated with nurses’ training needs, clustered within centers.
Methods
Design
CHANCE study was conducted using a cross-sectional quantitative survey design.
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Population
We invited all 220 PHCs spread across the country to participate in this study [19]. We included all PHC community nurses. At the time of the study, we were not able to identify the exact number of registered nurses working in PHCs, hence, we mailed all 220 PHCs’ administrators and those who agreed to allow their nurses to participate in the study were prompted to share the consent form and the survey amongst all their registered nurses.
Questionnaire packets were mailed to PHCs in September 2018 and received by November 2018.
Data collection
Survey instrument
The survey instrument used in this study was adapted from a tool developed by Ruta, based on the Canadian Community Health Nurses’ standards of practice. The original tool contained 88 items organized under five core standards and was validated with test-retest reliability scores of r = 0.890 (p < 0.01) for the learning need scale and r = 0.889 for the activity performed scale (p < 0.01) [20]. While the original tool demonstrated strong validity and reliability, our adaptation was not revalidated in the Lebanese context. However, it was translated into Arabic and piloted with a group of community health nurses to assess clarity, flow, and cultural appropriateness. After piloting, no changes were deemed necessary, and the instrument was used as adapted.
The instrument was structured into two parts. Part A had 11 questions and focused on the demographic characteristics of the participants. The demographic data included continuous and categorical variables. The continuous variables were age in years, number of years since graduation, and number of years in practice in PHCs. The categorical variables were gender (male, female), level of education (baccalaureate technique, technique superior, Bachelor of Science degree in Nursing (BSN) and Master’s degree in Nursing (MSN) or higher), job designation (practical nurse, registered nurse, senior nurse/head nurse, other), accreditation status of the PHCs (yes, no, in process), number of patients seen every day (< 10, 10–25, 25–50, > 50), and participation in the range of services offered at the PHCs.
In Lebanon, there are two parallel educational systems: General Education and Technical Education. In this study, the Baccalaureate Technique is a college degree, after completing three years at a technical secondary school. In contrast, nurses with a bachelor’s or master’s degree have completed a university-level education in nursing, which typically involves three to five years of study.
Part B assessed the use of nurses’ competency and their level of need for developing this competency. PART B was divided into five sections: (1) direct clinical practice (patient-centered care, clinical nursing assessment skills) (2) non-communicable diseases practice (continuity of care, patient education, self-management), (3) comprehensive care (preventive and screening services, community health promotion), (4) inter-professional collaboration and (5) electronic technology adoption. (Appendix 1: Survey instrument)
The use of the competencies was measured as follows: 1 = not applicable, 2 = occasionally (once per month), 3 = frequently (daily or at least once weekly). The training needs were measured as follows: 1 = not applicable, 2 = not needed, 3 = needed.
A mean percentage score was developed for each participant by grouping related items (see Appendix 2) under specific competency categories and calculating an average percentage score for each category. This mean percentage score was calculated based on the total number of items within each competency or training need category. For each participant, we excluded items marked as ‘not applicable’ or with missing responses from the denominator, tailoring it to each participant’s valid responses.
To analyze competency use, we created a binary variable: 0 = low competent and 1 = high competent, where a participant is considered ‘highly competent’ if they apply at least 75% of the competencies within a category. For training needs, a binary variable was similarly created, with 0 = less needed and 1 = more needed, designating participants as ‘more needed’ if they required at least 25% of the training needs within a competency.
We applied a 25% threshold for competency need to maximize the pool of participants identified as requiring further training. For high competency, we set a more stringent 75% threshold, classifying participants as highly competent if they reported using at least 75% of the competencies, due to the self-reported nature of the study.
Data collection approach
We mailed sealed envelopes containing both the consent forms and survey instruments to PHCs that had agreed to participate in the study. Initial approval was obtained from the PHC directors before distributing these materials to individual nurses. A mailing organization associated with the Order of Nurses in Lebanon (ONL) handled the distribution. This organization returned to the PHCs six weeks after the initial mailing to collect the completed surveys.
Phone reminders
We used the Dillman’s approach of making three consecutive contacts to maximize the response rate [21]. In addition to the first contact by mail, two phone reminders to each PHC were made. The first phone reminder was one week after the delivery of the package and the second was five weeks after the package delivery. Therefore, every center received one invitation and two reminders.
Ethical considerations
The Institutional Review Board (IRB) at the American University of Beirut reviewed and approved all the procedures and protocols of this study (IRB approval number: NUR.GH.05). Further, we sought approval from the MOPH through the Department of Public Health Care to approach the PHCs. Special precautions were taken to protect participant confidentiality, safety, and autonomy. Precautions included informing participants (nurses) of the aims of the study and their right to decline to participate, seeking consent, and protecting confidentiality through password-protected files and locked storage of the available data. Written informed consent to participate was obtained from all participants. This study adhered to the Declaration of Helsinki guidelines for human participant research.
Data analysis/statistical methods
For descriptive statistics, mean, standard deviation (SD), frequency and percentage data were reported (Tables 1, 2 and 3). Since our aim was to assess the level of need for development in each core competency, only the “need for training” outcome was presented. Generalized estimating equation (GEE) was used to assess the factors associated with nurses’ training needs clustered within centers. This is a popular technique for handling such data. It was first introduced by Zeger and Liang in 1986 [22] as an extension to Generalized Linear Models. Since the outcomes are binary, Logistic GEE regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) taking into consideration the cluster effect. The independent variables included levels of education, job designation, years of experience, and accreditation status of centers. Because we cannot assume that the responses are correlated, the independent model is chosen as the working correlation treating responses as if they were independent [23]. Zeger et al. in their study also showed that high efficiency of GEE estimates are maintained under the independence model [24].
Table 1
Socio-demographic characteristics of the participating nurses, the services they conducted, and the accreditation status of the PHCs (N = 139)
Characteristics | n | (%) | Mean | SD | Missing | |
|---|---|---|---|---|---|---|
Age | 35.41 | 8.92 | 5 | |||
Gender | ||||||
Males | 5 | (3.6) | ||||
Females | 134 | (96.4) | ||||
Highest Education Level | ||||||
Baccalaureate Technique | 18 | (12.9) | ||||
Technique Superior | 76 | (54.7) | ||||
Bachelor’s degree in nursing | 39 | (28.1) | ||||
Master’s degree in nursing or higher | 6 | (4.3) | ||||
Year of Graduation | 12.67 | 9.19 | 6 | |||
Years in practice in PHCs | 6.65 | 6.42 | 11 | |||
Job Designation | ||||||
Practical nurse | 13 | (9.4) | ||||
Registered nurse | 38 | (27.3) | ||||
Senior nurse/Head nurse | 76 | (54.7) | ||||
Other* | 12 | (8.6) | ||||
Accreditation Status of the PHCs | ||||||
Yes | 47 | (33.8) | ||||
No | 35 | (25.2) | ||||
In process | 54 | (38.8) | ||||
Missing | 3 | (2.2) | ||||
Numbers of Patients Seen Everyday | ||||||
Less than 10 | 16 | (11.5) | ||||
Between 10–25 | 55 | (39.6) | ||||
Between 25–50 | 39 | (28.1) | ||||
More than 50 | 28 | (20.1) | ||||
Missing | 1 | (0.7) | ||||
Services | ||||||
Universal Health Coverage | 73 | (52.5) | ||||
Immunization | 125 | (89.9) | ||||
Essential drugs | 98 | (70.5) | ||||
Mother and child health | 108 | (77.7) | ||||
Prevention and treatment programs | 113 | (81.3) | ||||
Communicable diseases | 86 | (61.9) | ||||
Mental health | 67 | (48.2) | ||||
Malnutrition | 105 | (75.5) | ||||
Other | 41 | (29.5) | ||||
Nurses working at the center | 3.13 | 2.30 | ||||
Table 2
Frequency of competency use and training needs after dichotomization
Competency | Need for Training | |||||
|---|---|---|---|---|---|---|
Dependent variables | n | Low competency (< 75%) n (%) | High competency (≥ 75%) n (%) | n | Less needed (< 25%) n (%) | More needed (≥ 25%) n (%) |
Patient Centered Care Missing or NA | 139 0 | 88(63.31) | 51(36.69) | 137 2 | 58(41.70) | 81(58.30) |
Clinical Nursing Skills Missing or NA | 137 2 | 63(45.99) | 74(54.01) | 132 7 | 84 (63.64) | 48(36.36) |
Continuity of care Missing or NA | 135 4 | 54(40.00) | 81(60.00) | 129 10 | 77(59.69) | 52(40.31) |
Patient Education Missing or NA | 138 1 | 85(61.59) | 53(38.41) | 130 9 | 69(53.08) | 61(46.92) |
Self-management Missing or NA | 138 1 | 86(62.32) | 52(37.68) | 131 8 | 63(48.09) | 68(51.91) |
Preventive Screening Services Missing or NA | 135 4 | 69(51.11) | 66(48.89) | 130 9 | 73(56.15) | 57(43.85) |
Community Health Promotion Missing or NA | 123 16 | 91(73.98) | 32(26.02) | 129 10 | 45(34.88) | 84(65.12) |
Interprofessional Collaboration Missing or NA | 135 4 | 65(48.15) | 70(51.85) | 132 7 | 62(46.97) | 70(53.03) |
Electronic Technology Adoption Missing or NA | 118 11 | 53(44.92) | 65(55.08) | 122 17 | 61(50.00) | 61(50.00) |
Table 3
Factors associated with training needs using GEE-based logistic regression model estimates
Variables | Patient-centered care | Clinical nursing skills | Continuity of care | Patient education | Self-management | Preventive and screening services | Community health promotion | Inter-professional collaboration | Electronic technology adoption | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
OR(95%CI) | p-value | OR(95%CI) | p-value | OR(95%CI) | p-value | OR(95%CI) | p-value | OR(95%CI) | p-value | OR(95%CI) | p-value | OR(95%CI) | p-value | OR(95%CI) | p-value | OR(95%CI) | p-value | |
Highest Education Level | ||||||||||||||||||
Baccalaureate Technique | 1.65(0.30–9.25) | 0.566 | 3.87(0.88–17.11) | 0.074 | 5.78(1.23–27.23) | 0.026* | 6.07(1.81–31.16) | 0.031* | 1.50(0.36–6.28) | 0.577 | 4.84(0.97–24.08) | 0.050* | 2.10(0.50–8.84) | 0.311 | 1.73(0.31–9.47) | 0.530 | 7.16(1.51–34.07) | 0.013* |
Technique Superior | 1.72(0.67–4.38) | 0.260 | 2.50(0.95–6.63) | 0.065 | 3.37(1.25–9.11) | 0.017* | 3.12(1.27–7.70) | 0.013* | 2.32(0.99–5.44) | 0.050* | 2.60(0.92–7.35) | 0.072 | 1.99(0.85–4.65) | 0.111 | 1.28(0.49–3.30) | 0.615 | 2.70(1.03–7.07) | 0.043* |
Bachelor’s degree in nursing and above(Ref = 3) | ||||||||||||||||||
Job Designation | ||||||||||||||||||
Practical Nurse | 1.13(0.20–6.39) | 0.888 | 2.00(0.46–8.69) | 0.352 | 1.95(0.31–12.33) | 0.477 | 1.95(0.23–16.91) | 0.544 | 0.67(0.13–3.56) | 0.640 | 0.75(0.15–3.65) | 0.719 | 4.14(0.43–39.42) | 0.217 | 0.41(0.79–2.16) | 0.294 | 1.18(0.20–6.88) | 0.856 |
Registered Nurse | 0.30(0.11–0.80) | 0.016* | 0.85(0.33–2.21) | 0.745 | 0.64(0.26–1.60) | 0.343 | 0.66(0.28–1.59) | 0.356 | 1.10(0.48–2.53) | 0.815 | 0.48(0.18–1.30) | 0.149 | 0.80(0.31–2.08) | 0.650 | 0.60(0.23–1.55) | 0.293 | 0.865(0.33–2.29) | 0.771 |
Senior Nurse/Head Nurse(Ref = 3) | ||||||||||||||||||
Other | 0.67(0.17–2.69) | 0.572 | 0.31(0.06–1.56) | 0.156 | 0.18(0.03–0.97) | 0.047* | 0.13(0.03–0.67) | 0.015* | 0.72(0.18–2.91) | 0.645 | 0.26(0.05–1.40) | 0.117 | 1.86(0.34–10.14) | 0.474 | 0.42(0.12–1.48) | 0.178 | 0.93(0.23–3.67) | 0.914 |
Years in practice in PHCs (rs) | 0.97(0.90–1.04) | 0.413 | 0.96(0.89–1.03) | 0.248 | 0.93(0.87-1.00) | 0.050* | 0.96(0.89–1.02) | 0.189 | 1.02(0.95–1.10) | 0.588 | 0.98(0.92–1.05) | 0.630 | 0.99(0.92–1.06) | 0.724 | 0.93(0.86–1.01) | 0.080 | 1.00(0.93–1.09) | 0.812 |
Accreditation Status of the PHCs | ||||||||||||||||||
Yes (Ref = 1) | ||||||||||||||||||
No | 2.23(0.73–6.79) | 0.158 | 0.51(0.17–1.55) | 0.235 | 1.03(0.31–3.44) | 0.961 | 1.07(0.33–3.46) | 0.912 | 1.12(0.33–3.80) | 0.854 | 0.96(0.28–3.31) | 0.947 | 1.12(0.31–4.07) | 0.868 | 0.83(0.24–2.88) | 0.767 | 0.29(0.09–0.92) | 0.036* |
In process | 3.39(1.26–9.13) | 0.016* | 0.83(0.30–2.28) | 0.720 | 1.62(0.60–4.45) | 0.343 | 1.64(0.61–4.38) | 0.325 | 2.30(0.89–5.88) | 0.085 | 2.46(0.87–6.96) | 0.090 | 1.66(0.59–4.66) | 0.338 | 1.47(0.56–3.86) | 0.429 | 0.63(0.21–1.90) | 0.852 |
Some respondents had 50% or more missing values. Therefore, the most common approach used in the literature was to delete these observations [25].
Merged responses
Since some response categories had small counts, some groups were merged for analysis purposes. For example, the level of education originally consisted of seven categories and was grouped into three for the final GEE model.
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All data analyses were conducted with STATA 15. A p-value less than 0.05 was considered to have statistical significance.
Results
Description of sample
The total number of PHCs that agreed to participate was 206, of which 173 returned completed surveys. Given that we do not have an accurate number of the population of nurses working in those centers, we assumed that there would be two nurses in each PHC. Thus, for a total of 251 surveys completed by nurses, the response rate is estimated to be 61%. Of the 173 surveys, 139 were included in the final analysis after deleting those that were incomplete. The various reasons for excluding the surveys are reported in Fig. 1 (Fig. 1: Prisma chart of the survey participants). Table 1 summarizes the nurse’s characteristics, including their age, gender, year of graduation, education level, years of experience, job designation, and the accreditation status of the PHCs. The mean (SD) age was 35.41 (8.92) years. The vast majority of nurses (96.0%) were females. Half of them had a Technique Superior degree, and around 30% had at least a bachelor’s degree in nursing. As for their job position, half of them were senior/head nurses. About 40% of the nurses cared for 10 to 25 patients daily. The mean (SD) number of their professional experience in PHCs was 6.65 (6.42) years. Results showed that 33% of the centers were accredited, with an average (SD) of 3 (2.30) nurses per center. In addition, the top three services provided by nurses at PHCs were immunization (89.9%), preventive and treatment programs (81.3%), and maternal and child healthcare (77.7%).
Fig. 1
Prisma chart of the survey participants
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Frequency distribution of competencies and needs
Frequencies and percentages for the use of competencies and the needs for training, as per the survey, are detailed in Appendix 2. Table 2 displays frequencies and percentages for both competencies’ and needs’ main variables after dichotomizing them. Descriptive results showed that more than half of the nurses were highly competent in continuity of care (60.0%), electronic technology adoption (55.08%), and clinical nursing skills (54.01%). Meanwhile, nurses appeared to be in need of more training in community health promotion (65.12%), patient-centered care (58.30%), and self-management (52.0%).
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Factors related to the training needs using GEE estimates of the logistic regression models
Several associations were found between the nurses’ education levels, job designations, years in practice in PHCs, accreditation status of the PHCs and the training needs to develop certain competencies, taking into consideration the cluster effect of PHCs (Table 3).
In patient-centered care, nurses working in centers that were in the process of becoming accredited required three times more training to develop this competency than those working in accredited ones (OR = 3.39, 95% CI: 1.26–9.31, p = 0.016). Compared to senior/head nurses, registered nurses reported three times less need for training in this area (OR = 0.30, 95% CI: 0.11–0.80, p = 0.016).
Most outcomes, including continuity of care, patient education, self-management, preventive and screening services, and electronic technology adoption, appeared to be statistically significant associated with the education level of the nurse. The results revealed that nurses holding Baccalaureate and Technique Superior degrees required more training to develop these competencies than nurses with bachelor’s or master’s degrees in nursing. For example, nurses with a Baccalaureate technique degree required six times more training in patient education than nurses with BSN or MSN degree (OR = 6.07, 95% CI: 1.81–31.16, p = 0.031). In addition, when compared to nurses with BSN and MSN degrees in nursing, nurses with a Technique Superior degree required three times more training (OR = 3.12, 95% CI: 1.27–7.70, p = 0.013). These numbers were nearly identical across all the outcomes mentioned above and strongly linked to the education level.
Midwives, on the other hand, who are classified as “other” and fall under the job designation, appeared to have an inversely statistically significant relationship with continuity of care and patient education. As a result, midwives required less training than senior/head nurses in terms of providing continuity of care (OR = 0.18, 95% CI: 0.03–0.97, p = 0.047) and patient education (OR = 0.13, 95% CI: 0.03–0.67, p = 0.015).
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Continuity of care was inversely associated with the years of practice. Nurses were found to require less training to develop this competency as their years of experience increased (OR = 0.93, 95% CI: 0.87-1.00, p = 0.050). Furthermore, regarding the use of electronic technology, nurses working at non-accredited PHCs required less need for training than nurses working at accredited PHCs (OR = 0.29, 95% CI: 0.09–0.92, p = 0.036). Finally, no associations were found between clinical nursing skills, community health promotion, and inter-professional collaboration outcomes and exposures.
Discussion
The research aimed to assess data on community-based nurses’ use of core competencies and to assess their learning needs from their perspective within Lebanon’s national PHC network. The secondary purpose was to assess the learning needs of nurses working in the national network of PHCs.
The findings highlighted that the community nurses’ highest learning needs were centered on health promotion. Although the debate and research that health policies can guide nurses’ efforts to improve health around the world have been highly focused, health policies have shown little impact on nursing practices [26, 27].
Nurses in the healthcare system appear to play a vital role in the implementation of PCC [28], which is a complex process involving the patient and the nurse that takes place in multiple care settings [29, 30]. Patient-centered care was ranked second among the top training needs of PHC nurses in our study, indicating that they are not confident in their ability to acquire this competency.
Factors associated with nurses’ training needs
The level of education, job designation, years in practice and PHC accreditation status of nurses clustered within centers were found to be statistically significant factors associated with their training needs. Nurses with a Baccalaureate technique degree, for example, required six times more patient education training than nurses with an undergraduate or graduate degree in nursing. The impact of education on nursing practices and needs has been highlighted in research studies [31] which, in turn, appear to have a positive effect on the patient outcomes. Studies have shown that junior registered nurses need more training on knowledge, care and skills management to strengthen their competencies, whereas senior registered nurses required more training in the development of individuals and services [32, 33]. In addition, our findings showed that nurses working in PHCs that are in the process of becoming accredited require more training than nurses working in accredited centers. This is due to the fact that in order for PHCs to be accredited, working nurses must master certain core competencies.
Strengths and limitations
Our study has several strengths. First, this is the first to assess the range of the core competencies of the nurses and the level of training support needed to fulfill and improve these competencies in Lebanon. Second, this study targeted PHCs spread over the whole country, giving us the opportunity to assess information from nurses working in different communities. The findings of this study have influenced the development of a capacity-building program in collaboration with WHO Beirut Office, which is currently being piloted and will eventually be disseminated across Lebanon. Additionally, this study can provide a basis for the development of a nursing education program that is tailored to the nursing competencies and educational requirements of nurses.
This study has some limitations. First, the survey’s self-administered paper-and-pencil format contributed to a lower completion rate, as many responses were excluded due to incomplete fields. Second, self-reported data may be influenced by social desirability bias, leading nurses to overstate certain skills. Third, the data were collected in 2018, and significant changes have occurred since then, particularly due to the COVID-19 pandemic and related shifts in healthcare needs. Competencies are built and refined over time, so the need for training may have increased in certain areas and shifted focus in others, influenced by these evolving contextual factors. For example, the need for training in Patient Education likely increased during the pandemic as nurses had to educate patients about the virus, prevention measures, and public health guidelines. The need for training in Self-Management during the pandemic had shifted to immediate self-care during the crisis as people prioritized urgent care needs over long-term patient support. Hence, these contextual changes have definitely affected the findings, which is a limitation, but eventually the need for training remained relevant regardless of the situation.
Study implications and recommendations for future research
This study provides a baseline for nursing competencies that can be used to develop interventions later. The next step is to provide a certificate to empower primary health care nurses around those competencies. Future research can target a certain competency and test the effect of this nursing competency on patient outcomes.
Conclusions
This cross-sectional study revealed that community-based nurses are highly skilled in clinical nursing skills, continuity of care, and the use of electronic technology. Nurses appear to require additional training in community health promotion, patient-centered care, and self-management. Nurses’ educational levels, job designation, years of experience working in PHCs, PHC accreditation status, and the training needed to develop specific competencies were all found to be linked. This study can serve as a foundation for developing a nursing education program based on the nurses’ nursing competencies and educational needs.
Acknowledgements
Not applicable.
Declarations
Ethics approval and consent to participate
The Institutional Review Board (IRB) at the American University of Beirut reviewed and approved all the procedures and protocols of this study (IRB approval number: NUR.GH.05). Written informed consent to participate was obtained from all participants in the study. This study adhered to the Declaration of Helsinki guidelines for human participant research. Clinical trial number: not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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