Exploring the core competencies of clinical nurses in chinese tertiary hospitals: a qualitative content analysis

Core competency is defined as the essential minimum set of attributes, such as applied knowledge, skills, and attitudes, that enable an individual to perform a set of tasks effectively and follow appropriate standards [1]. Core competencies serve as a common language for all healthcare professions, defining what all people are expected to be able to do to the best of their abilities. There is currently no international standard for defining the concept of nursing core competency (NCC), the International Nurses Association and individual national nursing associations define core competencies for nurses differently based on nursing practice and nursing developments in their respective countries [2‐7]. The NCC has been defined by international nursing associations and national nursing associations by national nursing practice and developments. As nurses struggle to adapt to standard definitions of competency, nursing practice and public expectations continue to change, and these factors make defining competencies in practice an ongoing challenge [8]. NCC, while defined differently, must be an integrated and dynamically evolving competency. It combines multiple competencies such as knowledge, skills, talents, and personal characteristics and should be updated as a society, the healthcare environment, and the nursing profession change. Because of an aging population and changes in the disease spectrum, the healthcare environment has changed dramatically. Simultaneously, as medical care improves, people’s health needs and concepts evolve, and people are increasingly concerned not only with their physical health, but also with spiritual, psychological, social, environmental, and other factors [9]. The demand for social health has contributed to the development of nursing competency. The health needs of society have contributed to the development of nursing competency while also raising the bar for the renewal and expansion of nursing competency and roles. Nurses are gradually moving from the subordinate role of physicians to independence [10], they are unstoppable forces shaping global healthcare, providing better care and attention to individuals and families all over the world. In China, nurses’ attempts to enforce prescriptive authority are also enhancing nurses’ abilities to “be at the table”, which is a significant step forward in the renewal of nurses’ competency and roles [11]. Nursing services are being extended from institutions to communities and families through the development of new nursing service models such as “Internet + nursing services,“ with nurses playing an important role in providing professional care, health management, rehabilitation promotion, and other comprehensive nursing services. Nurse competency development must reflect the current state of health care [12] and in an ever-changing world, new competencies are required [13].

Some studies have shown that China has a chronic shortage of nursing human resources and that nurses’ competencies vary, meeting the current social demand for high levels of care more difficult. Chinese nursing managers have long struggled with the issue of how to use effective methods to promote nurse competency development [14].To better seek ways and strategies to enhance nurses’ competency, it is critical to understand the hierarchy of the nurse’s competency needs. Competency models have been used in job analysis, performance management, and human resource training and development as important tools in human resource development [15]. The onion model, a classic competency model, has been widely used in competency assessment and measurement. the onion model categorizes competence into three layers: the inner layer, the middle layer, and the outer layer. The inner layer consists of motivation and characteristics, the middle layer of attitudes, values, and self-image, and the outer layer of knowledge and skills [16]. The inner layer’s competency is less likely to be trained, developed, and measured, whereas the outer layer’s competency is more likely to be acquired and assessed through training.

Although many core competency structures existed in China in the past, with the passage of time and the renewal of society’s health needs, nurses have been assigned new roles and responsibilities in the new health development strategy, and the renewal and development of core competencies for nurses is an unavoidable trend [17]. Because of its rich hierarchical features, the onion model better explains the embodiment of nurses’ core competencies at different levels. This study is based on the general layout of social health strategies and the actual needs of nurses, as well as a qualitative study based on the theoretical foundation of the onion model, which can provide rich theoretical guidance for future CBE for nurses.

Semi-structured interviews were used in this study to identify different layers and content elements of core competencies for nurses based on the onion model, which can better reveal the hierarchical structure and connotation of NCC. In addition, WHO proposes that the world is currently witnessing an unprecedented contribution of nursing to universal health coverage, and there is a need to invest in capacity building [28]. In the next decade, there must be a rapid development of nursing education to cultivate nurses capable of addressing future challenges [29]. The NCC identified in this study is based on the genuine needs of nurses under China’s new era of health development strategy. Using the onion model, the NCC has been divided into three distinct levels based on their level of difficulty, providing a reference for managers in different countries to better understand the requirements of NCC at different levels and develop the nursing profession’s capabilities.

The most central level of need in the NCC is motivation and traits, which are the intrinsic, difficult-to-measure aspects of people that are the most difficult to uncover and change. It is undeniable that nurses’ sense of responsibility for the safety of their patients’ lives remains the nursing profession’s most fundamental mission commitment. Nurses’ competency to continually improve and develop is driven by enterprise, and both execution and adaptability are traits possessed by a highly qualified nurse.

Professional philosophy and values are both the foundation of nursing practice and the cornerstone of nurses’ ability to provide high-quality nursing care [30]. Perceptions of the nursing profession directly influence individual behavior and performance, and by being sensitive to changes and trends in the nursing field, they can have a clearer understanding of their career plans. Furthermore, some participants mentioned that choosing to nurse is a choice of dedication. Dedication, as a professional spirit rooted in the nursing profession, is at the heart of a nurse’s profession [31].

Clinical nursing competency, leadership and management competency, humanistic practice competency, and professional development competency are the most accessible and cultivated competencies. The majority of this related knowledge and skills are similar to the competencies in the previously developed core competency framework for nurses in China [6]. In this study, the real needs of nurses and reflections on competency development were included, and these differences and additions may reflect the new preferences and needs of nurses in the context of times and social developments that are shaped by the various values and strategic goals of society and the health care system. Nurses require a diverse set of skills to provide quality care to patients in an ever-changing clinical environment. Because of the development of nursing specialization in China, common knowledge and nursing skills in specialties such as hospice care, chronic disease management, TCM, and maternal and child health must be gradually learned and applied in addition to basic nursing knowledge and skills. In the same way, a multidisciplinary understanding of the disease, such as anatomy, physiology, biochemistry, and pathology, is better suited to providing quality patient care. Even though not all participants held leadership positions, the majority of participants mentioned this important competency. Leadership and management competency is not unique to nursing managers, in addition to administrative competencies, nurses’ leadership can provide quality care to patients by infecting the surrounding healthcare professionals and patients through their own professional and personal charisma [32]. All nurses play an important role in leadership and are encouraged to learn more about it in the ever-changing healthcare field [33, 34].

Person-centered care and respect for the patient’s feelings and needs as a “human” are more important in the new health development strategy, and humanistic practice competencies, which include legal and ethical, interpersonal communication, humanistic care, and other related competencies, are being raised by an increasing number of nurses. Surprisingly, almost all nurses mentioned the difficulty of communication. One of the causes of communication barriers could be a mismatch in information [35]. The question of how to communicate effectively with patients and colleagues in a high-stress clinical situation remains unanswered. The biomedical model, which focuses on diagnosis and treatment, continues to heavily influence how healthcare professionals view patient care in most clinical settings in China. Nurses are more likely to be concerned with the patient’s physical condition and less concerned with psychological care, which contradicts the holistic nature of care to some extent [36, 37]. The importance of communication in humanistic care cannot be overstated; however, good interpersonal communication in clinical situations necessitates a significant amount of effort, and empathy and patience may be important ways to achieve comfortable and acceptable communication.

Professional development skills are the knowledge and skills that nurses should have to improve and develop their clinical professionalism. It is not only a technical tool, but it is also the most effective method of obtaining scientific information, which is a necessary skill for nurses. Many nurses in research have suggested that the ability to use information is important. The rapid advancement of information technology is gradually transforming the medical and nursing care delivery model [38]. Nurses should fully utilize information technology tools to expand their service areas to adapt to this new model of care. Furthermore, the shift in mindset aids in the development of competencies and increases motivation for behavior change. As a result, the future focus and difficulty will be how to fully use critical thinking in nursing decision-making and train the shift in mindset [39].

Both the “Healthy China 2030” Strategy and the 20th Communist Party of China Report advocate for a people-centered approach to health maintenance in all aspects and cycles. In light of the people’s growing health needs, the development of nursing capabilities must be integrated with the current social context, expanded the scope of nursing services, and integrated with the people’s health needs. As patients’ individual needs, disease complexity, and treatment modalities evolve, the development of nurses’ core competencies must become more varied depending on the stage.

According to the findings of this study, the majority of nurses believe that their competencies are still lacking in many ways and that they should constantly improve and update their professional knowledge and skills to meet the health needs of patients. The nurses’ ability to integrate and apply their knowledge is limited, and they have a fixed mindset, making it difficult to apply their learning. This could be due to a mismatch between what nurses learn in school and the clinic, as well as a gap between what they learn in training and clinical practice. Furthermore, the supervising teacher influences the working style and attitude of the new nurses and may have a significant impact on their professional perceptions [40]. Moreover, not all nurses consider their competence development deeply, and they are frequently accustomed to accepting passive learning, settling for the status quo, and being less self-driven. In China, the Confucian educational ideology handed down through history, as well as the modern education system that mimics the former Soviet Union’s classroom style, have severely limited the development of students’ creative ways of thinking [41, 42], therefore, a change in the traditional educational model should be considered. Competency-based education for nurses may be an effective way to enhance the thinking and developmental skills of nurses [43]. Competency-based education (CBE) broadens the theoretical and practical training content, and this study has identified three levels of nurses’ core competencies using the onion model. Going forward, CBE will be an important approach for enhancing nurses’ comprehensive competencies, such as problem-solving and critical thinking, and improving the quality of nursing services [44‐46].

Based on the onion model, three layers of core competencies for nurses in Chinese tertiary hospitals were identified. Under the new health development strategy, nurses need not only comprehensive knowledge and skills such as clinical nursing competencies, management and leadership competencies, humanistic practice competencies, and professional development competencies but also positive professional perceptions and values. More importantly, strong motivation and good traits are significant internal motivators for nurses to improve their competencies. The different layers of NCC identified by the study can serve as a theoretical reference for nursing managers to better understand nurses’ various levels of competency and conduct CBE based on their layers. In future studies, relevant measurement tools can be developed to assess and identify weaknesses in NCC based on the model, and then construct targeted competency enhancement strategies based on assessment results.

This study has one limitation: using the onion model as a deductive method for data analysis may result in some biases. To minimize the potential bias, inductive and deductive methods were used to analyze the data.