Introduction

Current views on professionalism emphasize that improving healthcare quality is both a moral and professional duty for all medical practitioners, particularly nurses [1]. Professional affiliations, organizational commitment, and job attitudes are influenced by professional competence and skills [2]. Nurses’ clinical competency is a major concern in all healthcare settings because of the requirement that nurses provide high-quality patient care and the strong correlation between nurses’ competency and the success of health organizations [3]. Research findings indicate that clinical competence is positively correlated with professional confidence, quality of working life, self-efficacy, and the efficient use of clinical abilities [4] and negatively correlated with job burnout [5]. Furthermore, patient safety and satisfaction are directly associated with clinical competence [6].

To meet population demands and safeguard the public, it is imperative to produce competent nursing staff [7]. Nurses are expected to provide qualified and safe care [8]. The need to provide safe and affordable services, raise community awareness of health issues, utilize competent staff by healthcare organizations, and adapt to rapid changes in health surveillance systems are just a few of the factors contributing to the increased focus on nurses’ clinical competence [9, 10]. Furthermore, healthcare settings have a responsibility to ensure that the nurses they employ possess the necessary skills to fulfill their professional obligations and to develop appropriate improvement plans [11–13].

Clinical competence refers to the attitudes, knowledge, and skills that a newly graduated nurse must possess to perform duties related to patient care appropriately and help maintain, restore, and advance patients’ health [14]. These skills are interrelated and relevant across various nursing practice environments [15, 16]. Competencies are divided into professional and clinical categories. Professional competency includes critical elements, such as compliance with ethical standards, a thorough knowledge of healthcare legislation, strong decision-making skills, expertise in professional development, and the ability to work collaboratively [17]. Clinical competency involves the fundamental principles of nursing care, adherence to clinical guidelines, and the implementation of effective nursing interventions [18]. It also encompasses the use of technical and communication skills, knowledge, clinical reasoning, emotions, and values within a clinical setting [19, 20].

Like other nations, Egypt has a long history of preserving and advancing the health of its residents as well as providing medical care for the sick. In Egypt, nurses are in high demand and serve as the backbone of both basic healthcare and hospital services. However, there is a persistent nursing shortage in Egypt. In 2020, Egypt had 201,623 registered nursing professionals in the governmental healthcare sector [21]. The Egyptian National Authority for Quality Assurance and Accreditation of Education emphasized the importance of nurses in the advancement, preservation, and restoration of health. As a result, the Egyptian healthcare sector determined that training competent nurses with advanced nursing competencies is essential. For nurses to fulfill their essential responsibilities as health promoters, educators, counselors, care coordinators, case managers, and researchers, they must possess these competencies [22].

Evaluating nurses’ clinical competence to identify their educational needs and taking appropriate action to improve are the most crucial elements in raising nurses’ professional competence and, as a result, improving the standard of nursing care [1, 17]. Furthermore, nurses must learn how to evaluate their knowledge and knowledge gaps to maintain their competence and safety in the workplace [23]. Additionally, through critical thinking, self-assessment empowers nurses to participate more actively in the learning process and promotes continuous learning [24, 25].

Various studies have examined nurses’ clinical competence worldwide. As far as researchers are aware, there is a notable lack of comprehensive published research specifically addressing the clinical competence of registered nurses within the healthcare context in Egypt. Most existing studies focus on inpatient care, leaving a gap in understanding how nurses perform in outpatient settings, particularly given the unique challenges and demands of outpatient care. This underscores the necessity of this study.

Materials and methods

Results

Participant characteristics

The study sample consisted of 450 nurses with a mean age of 28.7± 7.37 years, with more than three-quarters of them 76.7% being females. Additionally, 86.7% worked in government hospitals, and 80% held a bachelor’s degree in nursing sciences. Furthermore, less than two-thirds (61.3%) had more than 10 years of clinical experience, as shown in Table 1.

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. Distribution of the participants’ demographic and occupational data.

https://doi.org/10.1371/journal.pone.0314206.t001

Table 2 shows the distribution of participants based on their level of clinical competence. In terms of the domain of professional behaviors, the study found that 54.9% and 83.3% of the participants were competent enough to follow health and safety precautions and act to prevent or reduce the risk of infection for patients, respectively. However, only 2.2% of participants demonstrated competence in accepting cultural diversity. On the other hand, 78.7% of participants were competent enough in applying critical thinking to patient care.

Download:

• PNG
  larger image
• TIFF
  original image

Table 2. Distribution of the participants according to their levels of clinical competence.

https://doi.org/10.1371/journal.pone.0314206.t002

In the domain of general performance, over half of the participants, 52% were competent enough to educate patients or families on disease care. Additionally, 8.9% of them were highly competent in handwashing and daily routine care. However, only 3.3% were slightly competent in conducting nutrition and fluid balance assessments.

In terms of the participants’ competence in core nursing skills, it was discovered that 70% were competent enough to provide emotional and psychological support to patients, while 66.7% were skilled enough to administer blood transfusions. However, only 32% showed slight competence in carrying out sterilization techniques and procedures.

When it comes to advanced nursing skills, the study found that 51.3% of participants were somewhat competent in providing preoperative and postoperative care. Additionally, 73.3% of them were deemed competent in wound dressing care. However, only 1.8% of participants were considered slightly competent in performing chest tube care procedures.

The average score for clinical competence among the participants is presented in Fig 1. In terms of professional behaviors and general performance, the average score for clinical competence was 48.4±3.6 and 40.7±4.1 respectively. Additionally, the average score for clinical competence regarding core and advanced nursing skills was 43.4±3.0 and 22.8±1.5 respectively. Overall, it was found that the nurses displayed a moderate level of clinical competence (155.3±7.2 out of 230).

Download:

• PNG
  larger image
• TIFF
  original image

Fig 1. Distribution of the participants according to their mean score of clinical competence domains.

https://doi.org/10.1371/journal.pone.0314206.g001

The relationship between the mean clinical competence score of participants and their occupational and demographic variables is presented in Table 3. The mean clinical competence score of nurses was found to be highly significant (P<0.001) concerning their age, with the nursing professional behaviors domain scoring the highest. Furthermore, a significant correlation was observed between the nurses’ level of nursing education and their mean clinical competence score (P<0.001), with the nursing professional behaviors category scoring the highest. It was also evident that the average clinical competency score was strongly correlated with the number of years of clinical work experience the nurses had (P<0.001), with the nursing professional behaviors domain receiving the highest score.

Download:

• PNG
  larger image
• TIFF
  original image

Table 3. Relation between the participants’ demographic and occupational characteristics and their mean score of clinical competence domains.

https://doi.org/10.1371/journal.pone.0314206.t003

Discussion

Global healthcare systems aim to provide high-quality care at a reasonable cost with universal access for all populations [35]. Given the local nursing shortage, it is crucial to ensure that hired nurses are qualified to deliver quality nursing care, especially concerning patient safety and treatment [36]. Competency assessment is a critical issue for all involved in healthcare, including managers, educators, policymakers, and nursing professionals [37].

The current study’s findings revealed that nurses had a moderate overall level of clinical competence according to their average score, as perceived by nurses themselves. This moderate level of competence may be due to organizational issues, resource limitations in outpatient clinics, or training deficiencies. They demonstrated proficiency in the core competence areas of nursing skills, general performance, and professional behaviors as they form the backbone of nursing practice and are considered the set of ethical standards and codes of conduct that are expected to be adhered to in a professional setting but scored poorly in advanced nursing competence. Nurses may prioritize areas closest to direct patient care, leading to differences in competency scores.

When assessing their performance, individuals often rate themselves higher, and the nurses in this study displayed a strong sense of confidence in their abilities. Similar conclusions were drawn in studies from Jordan [38], China [39], and Ethiopia [40], where nurses believed their competence level to be average or slightly above average. Contrary to the findings of the current study, a study conducted in Italy by [41] revealed that the degree of clinical competencies and the extent to which nursing skills are employed by nurses were high. These outcomes contradict the research findings of studies conducted in Iran [42], and Europe [43], which indicated that nurses assigned a very high rating to their competence. Furthermore, a Swedish study conducted by [44] found that nurses’ assessments of their clinical competency were lowest in areas of professional development and direct clinical practice and highest in areas related to team collaboration and ethics. Additionally, a study by [45] revealed that nurses who rated their competence as the lowest had high workloads, unsatisfactory jobs, and experiences with both financial and professional insecurity.

The level of competency varies across different domains of competence. For example, in a study using a different scale, nurses rated their level of competency highest in organizing and implementing nursing care and in following ethical and legal standards of nursing practice [46]. The study found a strong correlation between nurses’ clinical competence and various occupational and demographic factors, such as age, gender, workplace setting, level of nursing education, and years of clinical experience. Nurses who are older, female, work in government hospitals, have a bachelor’s degree in nursing, and have more than ten years of clinical experience tend to have higher levels of clinical competence. One plausible explanation for this could be that nurses’ ages, educational backgrounds, and work experiences are all on the rise, which could lead to an improvement in their clinical competence. Due to curriculum-required competencies, nurses with a bachelor’s degree in nursing were anticipated to possess superior abilities and knowledge, and they are also more likely to have received additional training. The findings of the present study corroborated those of the studies conducted by [37, 47], which discovered a substantial correlation between age and clinical competence. However, the findings of this study are at odds with those of studies conducted in Ethiopia [48], and Iran [49], which reported that there was no statistically significant correlation between gender variable and mean clinical competence. Moreover, these findings contradict those of [50, 51], who found no connection between clinical competence and the sex variable.

Higher self-assessed competence among registered nurses in post-graduate programs has been linked to higher academic degrees [52]. However, this conflicts with the findings of the current study, which showed that nurses with bachelor’s degrees believed they had a higher clinical competence score. This result is understandable, as many of the nurses in the study held bachelor’s degrees in nursing. This result makes sense. Additionally, these results contradict those of a previous Iranian study [49], which found that nurses with MSc degrees had a higher mean clinical competence than nurses with BSc. Degrees, despite the lack of a statistically significant difference.

Previous Ethiopian studies have shown that a nurse’s competency varies according to the duration and frequency of their work experience [40, 48]. The current study discovered a statistically significant relationship between years of clinical work experience and the degree of clinical competence. In actuality, the nurses’ work experience increases with their employment history. Therefore, it is anticipated that as work experience increases, clinical competence will also rise. This may be because they have had more exposure to different patients and situations, and they have also had the opportunity to learn from their mistakes. A similar conclusion was reached by another study [41]. On the other hand, the study by [53] disagrees with the findings of this study because it suggests that factors such as a high workload, job satisfaction, and salary contribute to nurses’ impairment in their line of work. As a result, they are not satisfied with their jobs, and this situation worsens as the age and work experience thresholds increase. However, a systematic review conducted by [54] found that environmental-organizational factors, identification of patients’ culture, provision of care based on their culture, job satisfaction, and consultation with colleagues were effective in improving nurses’ clinical competencies. Additionally, in nursing practice, developing trust, using adaptive care techniques, and fostering interdisciplinary teamwork are essential. Healthcare organizations should provide conditions that help nurses advance their careers and deliver effective, person-centered care [54].

We acknowledge that cultural issues significantly influence nurses’ judgments of clinical competence in the Egyptian healthcare system. The way Egyptian culture views hierarchy, deference to authority, and gender conventions may affect how nurses view themselves and are viewed by other members of healthcare teams. Furthermore, cultural perspectives on lifelong learning, career advancement, and the role of nursing in the healthcare system might influence an individual’s perception of their abilities as well as assessments from other sources.

Conclusion

Based on the self-reported results of the nurses, our study found that their level of clinical competency was moderate based on average scores. There is a strong correlation between nurses’ clinical competency levels and occupational and demographic characteristics, such as age, sex, type of work environment, degree of nursing education, and years of clinical experience. These findings highlight the importance of implementing targeted training programs, potentially utilizing effective modalities like e-learning, role-playing, or simulations, known to enhance clinical competence. Policymakers, nurse educators, and healthcare providers can use this knowledge to promote nurses’ clinical competencies through intervention measures and foster a culture of continuous learning. Advanced nursing skills can be improved through knowledge enhancement, skill acquisition, ongoing training, emotional intelligence, and constructive feedback. Our findings support the notion that competence grows and improves with experience in real-world settings. To optimize nurses’ clinical competencies, future studies and interventions should focus on exploring the impact of specific training interventions, such as, role play, and problem-based learning, on nurses’ clinical competence, or conduct comparative studies across various healthcare settings.

Recommendations

The study recommends that healthcare organizations create educational interventions to improve nurses’ clinical competence. These interventions should include organized and systematic feedback mechanisms, comprehensive training programs, mentorship programs, and continuous opportunities for professional development. By implementing these measures, nurses will be able to stay up-to-date on the latest procedures and technological advancements, cultivate a positive learning environment, and address the specific challenges faced by nurses of different genders. Moreover, to assist stakeholders such as healthcare industry managers, legislators, nurse educators, and nursing faculties in meeting the expectations and demands for competence, it is essential to engage in practicing advanced nursing skills and conducting ongoing evaluations of clinical competence. Effective management improvement and educational planning are necessary for nurses to enhance their clinical competence.

Strengths and limitations of the study

The study is the first of its kind in Egypt, aiming to measure the level of clinical competence and its relationship with demographic and occupational parameters among registered nurses. Since measurement instruments for assessing nursing clinical competence are limited, the research findings may be of great interest to the professional community.

Despite this valuable contribution, the study has several limitations that need to be considered when interpreting the findings. Firstly, the non-probability purposive sample used in the study raises the possibility of bias. Secondly, there is a potential selection bias as those who did not participate in the questionnaire may have different responses compared to those who did. Thirdly, assessing clinical competence based on self-reported responses from participants may lead to over-reporting or information bias, which reduces confidence in the findings. Additionally, the participants’ employment situations were not sufficiently large or evenly dispersed to allow for generalization of the results.

However, by identifying areas of strength and potential growth through self-assessment, nurses can enhance their practice. Therefore, it would have been beneficial to incorporate information obtained through objective methods alongside self-assessment. To address these limitations, the authors of this study attempted to minimize bias by having a non-biased scorer consistently score the questionnaire. Future research should consider other study designs, such as longitudinal and intervention studies, to further explore this topic.

Supporting information

Acknowledgments

The authors are thankful to the Deanship of Graduate Studies and Scientific Research at the University of Bisha for supporting this work through the Fast-Track Research Support Program.