Introduction
Clinical competence is regarded as the ultimate outcome of nursing education and defines as a person’s capability to apply their knowledge and skills in an independent and self-directed way [1].Nursing students’ clinical competency is their ability to demonstrate the required knowledge, skills, and attitudes in clinical settings and effectively communicate with staff while providing patient-centered care [2]. Clinical competency assessment is essential in nursing education, as it reveals students’ knowledge and attitudes relevant to patient care skills [3].
Competency is rooted in the curriculum, serving as a blueprint for the knowledge, skills, and attitudes that students are expected to develop and demonstrate [4].The Ethiopian nursing education program employs a four-year curriculum to prepare graduate-level nurses capable of providing holistic care to individuals, families, and communities.
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The healthcare system is facing increasing pressure due to the rise in chronic diseases and disabilities, along with demographic shifts [5]. The demand for skilled and capable professional nurses is on the rise due to the need to navigate the ever-changing and unpredictable healthcare landscape [6]. The international council of nursing has emphasized the importance of professional competence as both a professional obligation and a matter of public interest [7]. Clinical competence has been a much-discussed concept in nursing in the past decade, as it ensures that the public have access to quality nursing care [8].
The improvement of healthcare services requires professionals with adequate clinical competency, yet there is a global shortage of competent experienced nurses [9]. The development of an educated and clinically competent workforce is crucial for enhancing global health and providing effective care for disease patients [10].
Research findings indicate that many graduate nurses exhibit a reduced level of clinical competency. Study across ten European countries shows varying clinical competency levels, ranging from 50 to 60.1% [11]. Nursing graduates in Finland demonstrate 67.7% competency [12], while in Iran only half of students show competency [13]. Ethiopia reports low levels, ranging from 59.9 to 19.2% [14, 15].
Clinical competence of Nursing students can be influenced by various factors within the clinical setting, such as the competency of the educator, the interaction between staff and students, and the presence of clear assessment guidelines [16]. The quality of mentoring and feedback provided can also play a significant role in shaping the learning experience. However, students’ learning may be negatively impacted by poor relationships with clinical staff, insufficient support from educators, and a lack of stimulating learning opportunities [17].
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The health-care system in Ethiopia is facing a severe shortage of skilled health care workers, exacerbated by low clinical competency among providers [18]. This results in client dissatisfaction, highlighting the need for motivated and competent healthcare professionals [19, 20]. Health facilities need skilled, motivated providers with strong work ethics, but many recent graduates lack clinical competency [20]. Despite numerous studies on Ethiopian nursing students’ clinical competency, a comprehensive review synthesizing this literature is lacking. Given the importance of clinical competency and reported disparities studies result, this systematic review and meta-analysis aims to pool the levels of clinical competency, and the factors associated with it.
Theoretical framework
This systematic review and meta-analysis, utilizing Benner’s theory, Social Cognitive Theory, and Self-Efficacy Theory, highlights the significance of observational learning, modeling, and self-efficacy impacting students’ clinical competency. Benner’s Skill Acquisition Theory outlines the advancement of nurses through novice, advanced beginner, competent, proficient, and expert levels [21, 22] additionally, Social Cognitive Theory (SCT) underlines the importance of observation, modeling, and social interactions in learning and behavior change [23]. Furthermore, self-efficacy, or belief in one’s abilities, plays a key role in motivating nurses to develop competency, with factors like mastery experiences, vicarious learning, and social persuasion [24].
Review questions
What is the level of clinical competency of nursing students in Ethiopia?
What are the associated factors of clinical competency among nursing students in Ethiopia?
Methods
Study design and search strategy
The study was designed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist (PRISMA-Guidelines) [25]. We systematically searched the following databases: PubMed, HINARI and Google Scholar until December 22, 2023. The articles were searched using key terms developed according to Medical Subject Heading (MeSH) controlled vocabulary: (“competency”,“*competence”, “nursing”, “students”, “clinical competence”, “clinical competency”, “clinical skill”, and “Ethiopia”. The search process employed individual key terms and a combination of them using the Boolean operators “AND” and “OR”. The search was carried out by the two authors (SM and MW independently).
Study setting
This systematic review and meta-analysis only included studies conducted in Ethiopia.
Study selection
Inclusion criteria
This systematic review and meta-analysis follow PECOS framework in the context of observational studies as follow:
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Population: Studies conducted among nursing students in Ethiopia.
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Exposure : Factors that may influence the clinical competency of nursing students.
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Comparison: Clinically competent and not competent.
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Outcome: Clinical competency of nursing students.
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Study design: All observational studies were included.
Publication: Either published in peer-reviewed journals or unpublished studies, timeframe: All studies irrespective of data collection and publication year until March 22, 2024 and Language: Studies published only in English language were included in this review.
Exclusion criteria
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Those studies published repeatedly and/or those purely qualitative in designs were excluded from the review.
Measurement of outcome variable
The outcome variable (level of clinical competency) was measured on the basis of “YES” or “NO” responses. Accordingly, it was measured as “YES” if a student competent, or else, “NO”.
Data extraction and quality assessment
Those articles identified in all databases were exported to EndNote 20 and then duplicate files were omitted. Two reviewers (SMand MW) for inclusion in the full-text appraisal independently screened the remaining articles and abstracts. It was assessed using Joanna Brigg’s Institute (JBI) critical appraisal checklist according to the study design of each article [26]. Two independent authors (SM and MW) evaluated the quality of the records. Data were extracted using Microsoft excel 2016 sheet and the sheet contained the following list of variables: authors name followed by initials, year of study, study setting, sample size, response rate, level of clinical competency, study design, data collection tool, participants and quality score, and clinical competency. Two authors (SM and MW) extracted the data and any disagreements between the two reviewers during extractions were resolved through discussion and consensus, and the studies were then included in the analysis.
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Statistical analysis
We extracted the data in Microsoft Excel format and transferred it to RStudio Version 1.4.1106 software to perform the meta-analysis. The pooled effect of the estimate of level of clinical competency was calculated by DerSimonian & Liard’s method of random effect model at p-value less than 0.05 [27]. Sensitivity and subgroups analysis were conducted to investigate the sources of heterogeneity. A random effect model was employed to estimate the pooled level of clinical competency. Forest plot was used to present the combined estimate and odds ratio (OR) with the 95% confidence interval.
Publication Bias and Heterogeneity. We also assessed publication bias and heterogeneity. A funnel plot test was employed to evaluate publication bias, with a p-value of less than 0.05 indicating significant bias. Heterogeneity among studies was measured using the I² test statistic, with results of 25%, 50%, and 75% indicating low, moderate, and high heterogeneity, respectively. The random-effects model was applied for meta-analysis when significant heterogeneity was detected. Additionally, trim-and-fill analysis was performed using random-effects methods for studies that showed significant publication bias.
Results
Study selection
This study aimed to evaluate the clinical competency of students in Ethiopia by conducting a comprehensive review and meta-analysis of published studies. A total of 23 articles were identified through a search of various databases. Through careful examination of the titles, abstracts, and full papers, 7(seven) articles were ultimately chosen for inclusion in the meta-analysis (Fig. 1).
Fig. 1
PRISMA flow charts of Clinical competency and associated factors of nursing students in Ethiopia, 2024
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Study characteristics
Two studies were multicenter studies [28, 29]. Two studies reported the limitations, as it did not include qualitative research, which could provide a deeper understanding of the problem [15, 30]. Orienting students on assessment methods, supporting them during clinical practice, providing clinical preceptor support, being post-basic programs were statistically associated with the clinical competency [14, 31]. The study also revealed that providing logbooks, suitable clinical placement cases, and accommodating teaching techniques based on different learning styles during skills demonstration were associated to the clinical competency of the participants [29, 32].
Seven studies were included for the final analysis and all the included studies had employed cross-sectional study design. The mean age of the student’s included in the review ranged from 21.04 to 23.05 years, and the sample size ranged from 102 to 414. The publication year of the studies was from 2016 to 2023. For assessing the clinical competency of students, one study used Short Nursing Competencies Questionnaire (SNCQ) [32], and the rest of others studies used data collection tools prepared from relevant literature. Out of the seven studies included in the meta-analysis, two studies were multicenter studies [28, 33].
As depicted in the Table 1 the lowest (19.2%) level of clinical competency was observed in a study conducted in Dire Dawa, Ethiopia [14], whereas the highest level was observed in a study conducted in universities of the Southern regional state of Ethiopia [15]. All studies employed logistics regression to analyze the statistical association between the outcome variable and the independent variables.
Table 1
Basic characteristics of the studies included in the systematic review and meta-analysis, Ethiopia, 2023
First author/year | University | Total sample size | Response rate | Clinically competent | Study design | Data collection tool | Participants | Quality score |
|---|---|---|---|---|---|---|---|---|
Berhanu et al.,2016 | Amhara | 234 | 97.1 | 48.7% | Cross-sectional | Nursing Competencies Questionnaire (SNCQ) | 3rd and 4th year students | 8 |
Bonsa et al.,2020 | Oromia | 102 | 98.5 | 24.5% | Cross-sectional | Adapted questionnaire | 3rd and 4th year students | 6 |
Kebenesa et al.,2021 | Oromia | 147 | 100 | 44.2% | Cross-sectional | Adapted questionnaire | 3rd and 4th year students | 6 |
Getie et al.,2021 | Amhara | 307 | 90.1 | 33.6% | Cross-sectional | Adapted questionnaire | 4th year students | 6 |
Mickiale et al.,2022 | Dire Dawa | 318 | 100 | 19.2% | Cross-sectional | Adapted questionnaire | 2nd year and above students | 6 |
Tamene et al.,2023 | South region | 414 | 100 | 59.9% | Cross-sectional | Adapted questionnaire | 4th year students | 6 |
Telksew et al.,2023 | Bahir Dar | 403 | 99.8 | 36.5% | Cross-sectional | Adapted questionnaire | 3rd and 4th year students | 6 |
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Level of clinical competency
A wide-range of clinical competency of nursing students was observed across different studies included in this review. The overall pooled level of clinical competency of nursing students in Ethiopia from a random effect model was found to be 33% (95% CI:25 ;41) (Fig. 2). The I2 test result showed the presence of heterogeneity among the included studies (I2 93%; p = < 0.01), and because of this high heterogeneity, the random effect meta-analysis model was used (Fig. 2).
Fig. 2
The pooled proportion of nursing student’s clinical competency in Ethiopia
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Subgroup analysis based on sample size
The level of clinical competency was higher in studies having a sample size between (104–243] compared to those having a samples size between (243–403] (Fig. 3).
Fig. 3
Subgroup analysis based on sample size
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Subgroup analysis based on questionnaires type
The level of clinical competency was higher among studies employed questionnaire adapted from previous studies compared to a study employed Short Nursing Competencies Questionnaire(SNCQ) (Fig. 4).
Fig. 4
Subgroup analysis based on questionnaires type
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Sensitivity analysis
Following the existence of heterogeneity among studies, sensitivity analysis was performed; however, there was no single influential study that could attributed to source of heterogeneity (Fig. 5).
Fig. 5
Sensitivity analysis
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Trim and fill analysis
The trim and fill analysis added two studies on the left side of studies. The final pooled effect size after trim and fill analysis in the random effect model was found to be 28 (95%CI: 19, 37) (Fig. 6).
Fig. 6
Trim and fill analysis
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Publication biases
Despite the fact that the funnel plot by itself is subjective ways of estimating publication biases, the funnel plot of pooled magnitude of clinical competency looks asymmetrical (Fig. 7).
Fig. 7
Publication biases
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Factors affecting clinical competency of nursing students in Ethiopia
In order to analysis the associated factors of clinical competency in this review at least two studies were required for a factor to be included. The highest number of studies was found in the factor of the clinical conducive environment.
Clinical conducive environment
Three studies [14, 15, 19, 28] examined the association between clinical conducive environment and level of clinical competency of nursing students. The pooled odd ratio of clinical competency in Nursing students who had a conducive clinical environment for their clinical practice was 6.30 (95%CI: 3.470, 11.45) compared with nursing students who had no conducive clinical environment. Studies included in this meta-analysis were characterized by high heterogeneity (I2 = 76%), thus a random-effect model was applied to examine the association between clinical conducive environment and level of clinical competency of nursing students (Fig. 8A).
Student confidence during performing the procedure
Another factor is student confidence during conducting the procedure, and its effect size was examined from two studies [29, 30]. The pooled odd ratio of clinical competency in Nursing students who were confident in performing the procedure was 2.23(95%CI: 1.41, 3.50) compared with nursing students who were not confident in conducting the procedure. The effect size was calculated via the common-effect model as low heterogeneity (I2 = 20%) among the included studies was observed (Fig. 8B).
Staff-student interaction
Four studies [28, 30, 31, 33] examined the association between staff-interaction and clinical competency of nursing students. The pooled odd ratio of clinical competency in nursing students who had interaction with staff was 7.76 (95%CI: 3.69, 16.35) compared with nursing students who had no history of staff interaction (Fig. 8C).
Fig. 8
Forest plot of factors influencing level of clinical competency among nursing students in Ethiopia, 2024 A. Clinical conducive environment B. Student confidence during performing the procedure C. Staff-student interaction
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Discussion
The aim of this meta-analysis was to identify the level of clinical competency of nursing students and associated factors among university students in Ethiopia. The overall pooled level of clinical competency of nursing students in Ethiopia from a random effect model was found to be 33% (95% CI: 25; 41) while after the trim and fill analysis the pooled clinical competency was 28% [95% CI: (25.00, 41.00)]. The level of clinical competence in this study was lower than study conducted among nursing students in 10 European countries (50.0 to 69.1) [34]. The possible justification for this significant variation might be attributed to the apparent infrastructure differences present in the study setting and other factors including variations in educational systems, nursing curricula, and clinical training programs [35].
According to this meta-analysis result, three factors were associated with the clinical competency of nursing students. A positive and supportive clinical learning environment plays a crucial role in the development of clinical competency among nursing students [36, 37]. A conducive clinical learning setting plays a crucial role in attaining the necessary clinical skills. The clinical setting must offer students a conducive environment that facilitates optimal learning experiences [38] and plays a pivotal role in the educational journey and the realization of educational goals [39]. A favorable clinical learning environment plays a vital role in supporting and enhancing the educational experience of nursing students during their clinical placements [40, 41].
This meta-analysis was also identified student confidence during performing procedures as a significant factor in the clinical competency of nursing students. Confidence is a crucial element in providing nursing care, and it is imperative for nursing education to cultivate confidence in nursing students [42]. Nursing students who have confidence in their abilities often prevail in developing proficiency and creativity, making it effortless for them to achieve the required clinical competence.
Another factor is staff-student interaction, which has a significant effect on nursing student clinical competency. Staff-student is the cornerstone in the education of nursing students, as it not only enhances their clinical competency but also fosters professional growth and development [43]. By engaging with experienced staff members, students can acquire valuable knowledge, skills, and attitudes that are essential for successful nursing practice [44]. The development of clinical competency in nursing students is attributed to their self-confidence, which is acknowledged as a crucial component of their practice and education [45].
Conclusion
This meta-analysis depicted the pooled clinical competency of nursing students among Ethiopian Universities was 28%. Identified factors associated with this competency were a positive clinical learning environment, student confidence in performing procedures, and effective staff-student interaction. A conducive setting supports learning, student confidence boosts proficiency, and positive interactions aid professional growth and ultimately improve their clinical competence. Based on our results, we recommend that nursing education programs in Ethiopia focus on these factors to enhance the overall competency levels of their students.
Limitation of the studies
Small number of studies involved in the analysis. The study showed higher heterogeneity could have influenced the overall pooled estimate of clinical competency.
Recommendation
Future research should explore educational programs and interventions to enhance nursing students’ confidence in clinical skills, and create more conducive learning environments in Ethiopia.
Acknowledgements
Not applicable.
Declarations
Ethical approval
Ethical approval and informed consent are required for a systematic review and meta-analysis that solely relies on previously published data.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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