Nursing Students’ Competency about Writing Nursing Care Plan: An Exploratory Study in Iran

Background . By utilizing the nursing care process, healthcare professionals can implement nursing knowledge efectively and efciently, ultimately leading to a signifcant improvement in the quality of care provided. Objective . Tis study aimed to assess writing nursing care plan competence among Ardabil nursing students in northwestern Iran. Methods . Te study involved 248 nursing students from the second to eighth semesters in three nursing and midwifery schools located in the Ardabil province of northern Iran. Te data were collected using a simple random sampling method and included a demographic questionnaire along with a survey questionnaire on nursing care plan writing skills. Tis was conducted between May and June 2023. Descriptive statistics, Pearson correlation, t -test, ANOVA, and multiple linear regression analyses were conducted for data analysis. Results . Te mean score (SD) for writing a nursing care plan in a student survey was 3.35 (0.57) on a scale of 1 to 5. Te survey’s weighted mean score for each dimension is as follows: data gathering ( D ) � 3.40 (0.73), identifcation of client’s problems ( P ) � 3.40 (0.73), sustainable goals ( G ) � 3.31 (0.77), appropriateness of intervention ( I ) � 3.30 (0.67), and recognizing outcomes ( O ) � 3.37 (0.69). Tis indicates that the students performed well overall. However, the lowest score was in the appropriateness of interventions dimension. Multiple linear regression analysis revealed that four variables, mean score of grade point average (GPA), age, academic term, and time spent studying (hours per day), were signifcant predictors of the student survey’s scores on writing nursing care plans. Tese variables could predict 61% of the total variance. Implication for Nursing Management . Nursing school administrators can establish programs to improve education and practice in nursing care plan development based on this study. Tey can use these fndings to enhance nursing education and practice for students, which will ultimately lead to better nursing care plans. Administrators should ensure that students have the necessary skills for writing efcient care plans and provide training courses to improve their writing and critical thinking skills. Policies can be implemented to encourage students to increase their study hours and maintain quality care programs. Conclusion . Nursing students are skilled in creating well-written nursing care plans that follow the nursing process. Te quality of these plans improves with higher GPAs and longer study hours. To enhance nursing care plans, nursing education should focus on developing skills and allocating sufcient time for studying and practicing. Collaborating with faculty and administrators, as well as using reliable resources, can also help improve the quality of care plans.


Introduction
Nursing care is a critical aspect of nursing practice that involves efciently managing care for patients [1].Te nursing process is a scientifc approach that is widely accepted and involves fve stages: assessment, nursing diagnosis, planning, implementation, and evaluation [2,3].Te nursing process is a problem-solving method that uses scientifc reasoning, critical thinking, and problem-solving skills to guide nurses in providing individualized patient care according to their unique needs [1,2].Te primary objective of nursing care is to provide high-quality care that enhances patient outcomes [4,5].Te nursing process is a fundamental policy and principle for nursing care and it promotes analytical reasoning and standardizes performance among nurses [3].Its efective implementation in patient care enhances nursing efciency, facilitates care documentation, and provides a unifed language for the nursing profession [6].Nursing is a globally accepted approach in clinical practice to deliver quality, individualized patient care [2].Nursing students are expected to demonstrate high competency levels in clinical settings [7].
Healthcare providers must possess practical knowledge, skills, and attitudes to carry out care tasks efectively [8].Maintaining high standards of nursing performance is a challenge for the healthcare sector of any country [9].Weak nursing competencies can result in low-quality healthcare and increased mortality rates [2].According to a study by Seçer and Karaca, 93.4% of nurses believed the nursing process should be used for care [1].Another survey by Zeleke et al. reported that 74.7% of nurses followed the process [3].Assessing the skills of nursing students can provide accurate information for better planning and management at educational and practical levels [10].Precise educational strategies are necessary to improve future nursing competencies [11].
Nursing education management is crucial for bridging the gap between theory and practice in the nursing process.Assessing the skills and efectiveness of nursing students is essential for their development and improvement in the nursing process [10].Evaluating the quality of nursing process development by students helps enhance their competencies in patient care management [5].Nursing instructors need a clear understanding of critical competencies in nursing to efectively support their students and seize opportunities to assist them [11].Nursing students must be well prepared and qualifed to plan care and emphasize accurate documentation for patient safety.Mastering the art and science of writing a nursing process is crucial for every student [5].At the undergraduate level, nursing students require varying support, supervision, and regulatory guidance to learn skills such as physical examination and nursing processes while gaining practical experience [12].
Implementing the nursing process in hospitals is challenging due to factors such as lack of time, inadequate training, insufcient managerial support, low motivation, shortage of specialized individuals, unclear job descriptions, and low salaries [2,6].One solution is to involve nursing mentors who can provide courses and active learning strategies to improve nursing students' competency.National policy frameworks and interventions are necessary to enhance education and the implementation of the nursing process in clinical settings [2,3,6].Adequate stafng levels and reduced workloads for individual nurses are crucial for efectively using the nursing process and improving patient care quality [6].Standardizing nursing process documents across all hospitals can streamline the process and enhance problem-solving skills [3].Positive attitudes and nursing students' ability to develop and implement the nursing process can improve the quality of patient care [2,[13][14][15].
Optimizing the nursing process is essential for providing quality patient care, reducing expenses, and minimizing medical errors.Focusing on research in this area can lead to better patient outcomes, lower healthcare costs, and improved community health.Nursing students have a unique opportunity to develop their nursing process development skills, contribute to enhancing healthcare outcomes, and improve the quality of patient care.Tis study aims to evaluate the competency of Ardabil nursing students in writing nursing care plans in Northwestern Iran.

Setting, Sample, and Data Collection.
A cross-sectional, descriptive study was conducted to investigate the competencies of nursing students in writing nursing care plans.Te study included nursing students from the second to eighth semesters, studying at nursing schools in Ardabil province, located in northern Iran.Te Ardabil province has three nursing and midwifery schools: Ardabil, Meshgin, and Germi.Nursing students in Iran learn the nursing process in theoretical courses such as principles and skills of nursing and nursing concepts in the frst semester, which they use during their internships.First-semester students were excluded from the study as they had yet to pass the nursing process unit.Te total number of nursing students in these schools was 667.Using Epi Info StatCalc version 7 software, a sample size of 244 was estimated at a 95% confdence level and a 0.05 margin of error.Considering a nonresponse rate of 10%, the fnal sample size was determined to be 268 individuals.Te sample attrition rate in this study was 8%, with 22 incomplete questionnaires removed due to missing data.Te required number of samples from each center was distributed among second-, third-and fourth-year students based on their population size.Terefore, students from each year were randomly selected for the study (152 from Ardabil nursing and midwifery school, 51 from Germi nursing school, and 45 from Meshgin nursing school).Data from 248 samples were analyzed and collected face-to-face based on the student's educational program from May to June 2023.Only those who provided written informed consent and willingly agreed to participate were given the questionnaire.Te confdentiality of their responses was ensured, and there would be no adverse consequences resulting from their refusal to participate.All researchers involved in the study were responsible for distributing and collecting the questionnaires, and they took full responsibility for ensuring that the participant's privacy and confdentiality were maintained.Te questionnaire was self-reported, and it took 5 to 15 minutes to complete.Te frst page of the questionnaire included details of the study objectives, confdentiality, anonymity, and privacy of the respondents.Te participants' responses were kept confdential, and the researchers involved were responsible for distributing and collecting the questionnaires.

Data Analysis.
To describe the demographic characteristics and research variables, descriptive statistics such as percentages, frequencies, mean, and standard deviation were used.Te questionnaire items were analyzed using mean, standard deviation, and a 95% confdence interval.T test, ANOVA, and Pearson correlation were used to examine the diference and relationship between the main study variable and demographic factors of nursing students.To evaluate the predictors of student surveys on writing nursing care plans, multiple linear regression analysis was employed, using demographic factors as independent variables.A signifcance level of 0.05 was set for this study.

Results
A total of 248 nursing students participated in this study, comprising 134 females (54%) and 114 males (46%).Tey had a mean GPA of 16.37 (1.29) on a scale of 0-20.Out of the total participants, 231 (85.9%) were single.Te study included 152 students (61.3%) from the midwifery nursing department in Ardabil.Among them, 207 (83.5%) had not completed the nursing process in their education, while 199 (80.2%) showed a keen interest in nursing.In addition, 96 students (38.7%) studied for one to two hours daily.You can check Table 1 for more information on the demographic characteristics of the participants.Te scores of Table 2 from the survey questionnaire for student survey on writing nursing care plans were organized into domains.In the data gathering subgroup, the item that received the highest rank mean score 3.45 (standard deviation (SD) � 0.98) was "I utilize a systematic way in collecting my objective data like Gordon's Assessment or any other pertinent assessment tool," while the lowest level among nursing students 3.33 (0.83) was for the item "I utilize therapeutic communication throughout patient assessment."In the identifying clients' problem subgroup, the highest-ranked phrase 3.43 (0.95) was "I am aware of the various ways on how to formulate good nursing diagnoses," while the lowest-ranked item 3.34 (1.02) was "I use and refer to NANDA resources every time I formulate my client's nursing diagnosis."In addition, in the formulating sustainable goals subgroup, the item that obtained the highest rank 3.34 (1.07) was "I specify in my planning the recipient and reason for formulating the nursing care plan," while the lowest-ranked item 3.28 (0.99) was "I put a time frame whenever I formulate my nursing care plan for evaluation."In the providing appropriate interventions subgroup, the item that received the highest score 3.35 (1.01) was "I base my independent interventions on the identifed needs of my patient," while the lowest score 3.20 (0.96) was received by the item "I incorporate interdependent collaborations with various healthcare departments whenever I plan care for my client."Finally, in the recognizing Client's outcomes subgroup, the item that received the highest score 3.45 (0.95) was "I seek back to my planning's goals and objectives if I have achieved my SMART plan."while the lowest score 3.29 (1.09) was received by the item "I review my nursing care plan and decide whether to terminate, continue and change it after a series of evaluation."Te overall mean score of the student survey on writing nursing care plans was 3.35 (0.57) on a scale of 1 to 5.
Table 2 presents the weighted mean score and interpretation for each dimension.Te scores we obtained are as follows: (a) data gathering (D) � 3.40 (0.73), which is considered good; (b) identifcation of client's problems (P) � 3.40 (0.73), which is also good; (c) sustainable goals (G) � 3.31 (0.77), again, good; (d) appropriateness of intervention (I) � 3.30 (0.67), good; and (e) recognizing outcomes (O) � 3.37 (0.69), which is, again, good.Te overall weighted mean score is 3.35 (0.57), indicating that the students' nursing care plan (NCP) writing skills are of good quality.Te dimension with the lowest score was the appropriateness of intervention.

Journal of Nursing Management
Table 3 summarizes the relationship between the student survey on writing a nursing care plan and the demographic factors of nursing students.It shows the study's overall mean scores and range based on the participants' demographic characteristics.Te results indicate a signifcant positive correlation between the overall mean score of the student survey on writing a nursing care plan and the mean score of grade point average (GPA), academic term, interest in nursing commitment, interest in the nursing feld, and time spent studying.On the other hand, there is a signifcant inverse correlation between the overall mean score of the student survey on writing a nursing care plan and age.
Te results of multiple regression analysis, indicating the predictors of the student survey on writing a nursing care plan, are shown in Table 4.A considerable variable regression analysis was conducted using the student survey on writing a nursing care plan as the dependent variable and demographic characteristics as the independent variable.Of these ten variables, 4 were signifcant predictors of the student survey on writing a nursing care plan.Te regression model's coefcient of determination (R 2 ) indicates that 61% of the total score of the student survey on writing a nursing care plan can be explained by the input variables in the model.Among the input variables in the model using the ENTER method, as reported in the table, there was a statistically signifcant relationship between mean GPA, age, academic term, and time spent studying (hours per day).

Discussion
Nursing students play a crucial role in providing continuous care and improving the healthcare system in the future.Te nursing process serves as a framework for nursing care, an essential tool for implementing nursing knowledge that enhances the quality of care.Writing nursing care plans is a skill and competency identifed in the nursing profession.Tis study was conducted to investigate nursing students' competence in writing nursing care plans.
Although students showed a good score in writing NCP, previous studies have indicated that nursing students require appropriate training to improve their implementation of the nursing process [6,16].Tere are several barriers to implementing the nursing process, such as high patient-tonurse ratios, inadequate and improper training, lack of continuous supervision and control, insufcient time allocated for training, and lack of retraining opportunities [17].Nursing students must be familiar with real-life conditions and appropriate tools to efectively implement the process.Addressing these obstacles can lead to better outcomes.Improper implementation of the nursing process is often due to insufcient education, inadequate attitudes, and a lack of training in nursing schools [18].Nurses who are more familiar with the nursing process and use it in their care have a more positive attitude towards it [3].Te nursing process enhances the quality of nursing care by ensuring individualized and high-quality care [6,19].To ensure  [6].Patient care skills and the nursing process should be assessed and monitored through evaluation courses [17].Te results showed nursing students have good writing skills for creating nursing care plans (NCPs).Tey are profcient in data collection during the evaluation phase, with an average score of 3.40.In a study by Salvador et al., nursing students performed excellently [5].Assessing patients is the frst step in nursing and guiding interventions [20].Nurses' initial patient assessment translates theory into practice and demonstrates the value of knowledge, skills, and attitudes in Journal of Nursing Management providing individualized care to complex healthcare needs.It is crucial for nursing diagnosis and the nursing process [3].In Namibia, nursing students may miss out on physical examination aspects due to not completing all stages of nursing.Tis can lead to incorrect diagnoses as each stage of nursing is interrelated and a failure in one stage can afect other stages [21].Te diference in mean data collection between the two communities is due to cultural diferences [5].Among the data collection items, the lowest score was related to "I use therapeutic communications throughout the patient assessment."Good communication and collaboration are important competencies in patientcentered care and nursing practice.Students' perception highlights that nursing is infuenced by various aspects of patient care, including patient preferences and efective communication.Language barriers and patients' preferences for professional nurses may hinder nursing students' ability to apply the nursing process [11,21].Based on our results, in the second component of the survey, students had a good quality level in writing NCP, meaning that nursing students have good foundations during problem identifcation or nursing diagnoses  [22].Nurses and nursing students should apply the nursing process to enhance patient care quality and safety [23].Nursing students learn education topics and use the nursing process to understand patient health problems and study evidence [24].A nursing diagnosis refects the student's ability to identify patient problems during the initial assessment.A correct diagnosis leads to proper intervention and evaluation, while an incorrect diagnosis can have the opposite efect.Identifying patient problems is critical for quality care [25].
Te study results indicated that in the third dimension, nursing students also had good quality in developing nursing processes, meaning they had reasonable primary goals (G) or planning for patient nursing diagnoses.In Salvador et al. study, most nursing students felt the management course provided enough knowledge to set patient goals.Nursing mentors should teach SMART goal-setting principles [5].A review in Iran found that the nursing process is not commonly used in low-income countries like Iran, Ethiopia, Kenya, and Taiwan.Reasons include a lack of awareness among nursing faculty about the process, inadequate hospital infrastructure, and insufcient support from nursing organizations [26].It is imperative to adopt and implement appropriate policies that ensure nursing students can confdently execute the nursing process in the clinical environments of low-income countries on a widespread and continuous basis.
Te lowest score among the items was related to "I set a time frame when scheduling my nursing care plan for evaluation."Te nursing process is challenging, timeconsuming, and difcult to perform.Taking care of multiple patients simultaneously can disrupt decision-making.Software can help manage time and streamline the process [26].Nurses cite workload and staf shortages as obstacles to using the nursing process efectively in patient care, as per Bassah et al. and colleagues [6].It is essential that managers take prompt action to overcome any obstacles hindering nurses from implementing the nursing process efectively.By doing so, nurses will have adequate time to provide individualized care to patients, leading to better health outcomes.
According to the study results, nursing students had good-quality writing NCP in the fourth dimension.Nursing students could use appropriate interventions (I) based on sound planning.In the Salvador et al.'s study, students achieved a perfect score.In the Sendir et al.'s study, nursing students faced difculty determining nursing interventions [27].Te appropriate diagnosis of intervention depends on the nurse's knowledge and awareness of the disease and the patient's status.According to Zeleke et al., nurse awareness is the most predictive factor for the nursing process [3].Students had the lowest score in the fourth-dimension item, "Whenever I intend to take care of my patient, I consider the collaborative eforts with various healthcare departments."One of the issues surrounding nursing profession development includes physician dominance in healthcare systems.When nurses demonstrate sufcient ability to improve the quality of care they provide, other health teams can identify the nursing profession [11].
Te study results indicated students exhibited highquality nursing writing skills in the ffth dimension.Tis fnding meant that nursing students had good foundations in evaluating outcomes (O) or evaluating interventions performed.However, in the Salvador et al.'s study, students had achieved excellent grades.Nursing students must master the art of writing a care plan using all available resources to ensure optimal patient health [5].Among the items related to the ffth dimension, the lowest score was related to the item "I review my nursing process and decide whether to terminate it after a series of evaluations, continue it, or make changes."Trough the nursing process, nursing students and nurses play a signifcant role in evaluating nursing care results [9].Te evaluation stage assesses nursing care programs for efciency, completeness, and adequacy while identifying defciencies in previous programs [28].Nursing education is crucial in preparing students with the knowledge and skills needed for efective nursing practice [10].Nursing instructors shape the future of nursing.Tey must equip students with the skills to deliver quality care.Te nursing process and fnal evaluation are critical components of patient care.Prioritizing them empowers nurses to deliver the best care and improve patient health outcomes.Let us support the full implementation of the nursing process and fnal evaluation.
Te fndings suggest that as students' GPAs increase, their scores in writing nursing care plans rise, which is consistent with prior research [29].According to a study by Vasli et al., GPA is a signifcant predictor of clinical competency scores among nursing students [29].It is possible that academic skills have an impact on clinical skills, which could explain the results.Students who excel in their academic studies and have high GPAs may have a better understanding of nursing concepts, which can have a positive impact on their clinical skills.On the other hand, students with lower GPAs may need to have a deeper understanding and application of the nursing process.Terefore, it is crucial for students who did not receive satisfactory GPAs during their academic years to enhance their competence in writing nursing process formulations through more practice and study.However, further research is required to comprehend and confrm this relationship fully.
According to the results of the present study, as students' progress through their academic terms, their competency scores in nursing process formulation increase, which is consistent with the fndings of Huang et al.According to Huang et al. study, frst-and second-year nursing students had lower nursing competency scores than third-and fourth-year students [11].Te use of the nursing process depends on many factors, including knowledge and skills that ideally should be developed in nursing students throughout their education [21].In addition, as students' age, their competency scores in nursing process formulation also increase.Tis fnding contradicts the results of Bassah et al.'s study [6].Tese fndings may be due to improved Journal of Nursing Management clinical experience and practice in formulating the nursing process with age and longer academic terms.
Te fndings of this study suggest that an increase in nursing students' time spent studying (hours per day) can lead to an improvement in their ability to develop nursing processes.Tis may be due to the higher level of knowledge that nursing students possess due to increased studying and staying up-to-date with the latest information.Terefore, nursing instructors and managers should promote programs that enhance students' academic motivation [30].Nursing is a dynamic and demanding profession requiring high knowledge and experience [31].As such, nursing students should continuously study to become familiar with the latest advancements in the feld and provide the best possible care to patients.In addition, increased studying helps students perform better in nursing and cope with this profession's complex and risky conditions.4.1.Limitations.Te study's small sample size of nursing students presents a signifcant limitation, which may compromise the generalizability of the results.To ensure more accurate and reliable outcomes, it is imperative for future studies to consider evaluating nursing care programs with larger sample sizes.It is important to note that this study solely focused on undergraduate nursing students at Ardebil University of Medical Sciences; thus, caution should be exercised when applying these fndings to the entire population of Iran.In order to enhance the generalizability of the fndings, it is highly recommended to conduct multicenter studies involving students from various universities in Iran as well as diferent regions of the world.Lastly, it is crucial to address the limitations of this study by conducting further research in the future, which will contribute to a more comprehensive understanding of the topic.

Implications for Nursing Management.
Nursing schools must prioritize the development of practical care plan writing skills among their students.Teachers should use efective teaching methods and implement comprehensive training programs to facilitate learning [32].Students should also be encouraged to aim for greater efciency and create high-quality care programs.Tese initiatives will help to advance research methodologies and improve nursing studies.Investing in these eforts will ensure that nursing education meets the needs of society and empower students to promote community health.

Conclusions
According to the study, nursing students can create highquality writing nursing care plans.Nurses are essential as caregivers, coordinators, educators, and information sources [33].Te study found that nursing students with higher GPAs and more time studying produced better nursing care plans.Terefore, it is recommended that students focus on improving their skills in various courses during their training period.Tey should strive to have a deep and accurate understanding of nursing concepts and principles and devote sufcient time to studying and practicing nursing care plans.Using reliable and up-to-date resources in nursing care planning and collaborating with faculty members and school administrators can also help improve the quality of nursing care programs.Based on these fndings, school nursing administrators can develop programs to enhance the quality of education and training in nursing care planning for students.However, further studies are needed to conduct additional qualitative research to analyze the ability of nursing students to write care plans.

Table 2 :
Te status of Iranian nursing student survey on writing nursing care plan (N � 248).

Table 3 :
Relationship between nurses' sociodemographic characteristics and student survey on writing nursing care plan (N � 248).

Table 4 :
Multiple regression analysis predicting student survey on writing nursing care plan according to sociodemographic characteristics (N � 248).� 3.31).As per Salvador et al., the lowest score was related to "I use NANDA nursing diagnosis resources every time I formulate a nursing diagnosis."Nursing diagnosis should be based on assessment results and used as a reference for interventions