Clinical Competence of Nurses and the Associated Factors in Public Hospitals of Gamo Zone, Southern Ethiopia: A Cross-Sectional Study

Introduction Nursing competency is an essential component for improving the quality of care in the healthcare system. However, assessing competency solely on the dimensions of skills and knowledge does not provide complete picture of a nurse ability to provide quality patient care. This is because it lacks focus on the nurse's attitudes and values, which are also important determinants of clinical competence. Therefore, this study aimed to assess the comprehensive clinical competence of nurses and its associated factors in public hospitals of Gamo Zone, Southern Ethiopia. Materials and Methods A cross-sectional study was conducted using a census method to collect information from nurses through self-administered questionnaires. The data were entered into EpiData version 3.1 and exported to Stata version 15 for analysis. A linear regression model was used to identify factors associated with clinical competence. Results In this study, the average clinical competence of nurses was 177.32, with a standard deviation of 19.19, and 31.2% of the respondents had a high level of clinical competence. Associated factors identified with clinical competence include gender, age, marital status, qualification, position, work experience, unit, interest in their profession, critical thinking disposition, clinical self-efficacy, and emotional intelligence. Conclusions The overall level of clinical competence among nurses in this study was moderate. As such, nurses improve their clinical competence by receiving training and development opportunities that focus on critical thinking, clinical self-efficacy, and emotional intelligence; working in a supportive work environment that encourages them to take risks and learn from their mistakes; and being monitored and coached on a regular basis.


Introduction
Clinical competence in nursing refers to the knowledge, skills, attitudes, and values that nurses need to provide safe and efective care to patients [1,2].It is essential for improving the quality of care, increasing patient satisfaction, and promoting nursing as a profession [1,3].
Nurses play a vital role in achieving the Sustainable Development Goal (SDG) 3 of reducing maternal and neonatal mortality by 2030.Tey are part of an integrated team of professionals in maternal and newborn health (MNH), and their unique skills and knowledge are essential for providing high-quality care to mothers and newborns [4,5].Te United Nations International Children's Emergency Fund (UNICEF) and the World Health Organization (WHO) recognize the importance of nurses in MNH.Tey have stated that nurses are "instrumental in infuencing patient outcomes" [5].Tis is because nurses have a deep understanding of the needs of mothers and newborns, and they are able to provide individualized care that is tailored to each patient's specifc situation [4].In addition to their technical skills, nurses also bring a set of core values to their work.Tese values include compassion, respect, and commitment to quality care [6].Nurses are dedicated to providing the best possible care to their patients, and they are always striving to improve their skills and knowledge [4].By working together with other healthcare professionals, nurses can make a real diference in the lives of mothers and newborns.Tey can help to reduce maternal and neonatal mortality, and they can ensure that all mothers and newborns have access to the care they need [4,5].
Continuing competency is essential for nurses to maintain their professional growth, confdence in the workplace, and ability to provide safe and positive care to patients.Nurses with higher clinical competency are more likely to establish empathetic relationships with patients and utilize their skills efectively in clinical settings [7][8][9].On the other hand, burnout is negatively associated with clinical competency, meaning that nurses who are more burned out are less likely to be clinically competent [10].
Studies have shown that nurses' clinical competence varies depending on the setting and the specifc components of competence being assessed.For example, a study in Iran found that nurses had the highest level of clinical competency in knowledge and the lowest level in skills [11].However, a study in China found that nurses had the highest level of clinical competency in attitudes and the lowest level in practice [12].Te mean score of nurses' clinical competence has also been shown to vary depending on the setting.For example, a study of nurses in critical care settings found that the mean score was 174.4,while a study of nurses in primary care settings found that the mean score was 2.7 [13,14].In pocket studies, which are small-scale studies that are conducted in a clinical setting, the mean scores of nurses' clinical competence have been shown to be above average [15][16][17].For example, a pocket study of nurses in emergency departments found that the mean score was 104.2 [18].Te components of clinical competence that have been studied most often include knowledge, skills, attitudes, and practice.However, other components of clinical competence have also been studied, such as quality assurance [19], job responsibility [20], caring ability [21], and research ability [22].Other components of clinical competence include managing situations and work [15], critical thinking, and research attitude [23].
Nurses' clinical competence is infuenced by a variety of factors, including their background, training, and experience [24,25].Other factors that have been associated with nurses' clinical competence include attitudes, personality, evaluation of the quality of nursing care [26], emotional intelligence, self-efcacy [27], critical thinking [28], job satisfaction [29], the autonomy of nurses [25], and prudence [28].Studies conducted in Korea and Iran have also found that nurses with high compassion satisfaction (CS) and low compassion fatigue (CF) (burnout (BO) and secondary traumatic stress) tend to have higher clinical competence [24,30].Raising nurses' professional quality of life (Pro-QOL) levels can also help improve their clinical competence [24].
Assessing clinical competence solely on the basis of skills and knowledge does not provide a comprehensive picture of a nurse's ability to deliver quality patient care [24].Nurses' clinical competence is a key component of patient care that requires regular and thorough evaluation to ensure the best possible outcomes for patients.However, this area is often overlooked, and nurses' competence does not receive the recognition it deserves in the healthcare system.Terefore, this study aimed to assess the comprehensive clinical competence of nurses and its associated factors in public hospitals of Gamo Zone, Southern Ethiopia.

Study Design and Period of the Study.
Te study adopted a cross-sectional study design and was conducted in public hospitals in Gamo Zone, Southern Ethiopia, from January 1 to 20, 2022.

Study
Setting.Gamo Zone is an administrative zone in the Southern Ethiopia.Gamo Zone has one general hospital and fve primary hospitals which include Arba Minch General Hospital, Dilfana Primary Hospital, Chencha Primary Hospital, Kamba Primary Hospital, Gerese Primary Hospital, and Selamber Primary Hospital.

Study Population.
Nurses working in a neonatal intensive care unit, operating room, pediatric, surgical, and medical wards, and emergency units were chosen for the study.

Eligibility.
All nurses who completed the probation period in each hospital were recruited in this study, and those on annual leave at the time of data collection were excluded.

Sample Size Determination and Sampling Procedure.
Cochran's formula was used to determine the sample size.Te assumptions were mean score and standard deviation (2.82 ± 0.53) of nurses' clinical competence from the study conducted in Iran among 230 nurses [25], a 95% level of confdence, and a 15% nonresponse rate.Based on the stated assumptions, the calculated sample size for this study was 359.Nevertheless, to increase the power and precision of the study, all the nurses who worked in the respective wards in each hospital were involved.Census method was used to involve study participants in this study.It was measured by using a 4-point Likert scale and the higher score represented that the nursing practice environment tends to be autonomous, supportive, and collaborative [32][33][34][35].(iv) Critical thinking disposition was measured using a 35-item tool with eight dimensions.It was measured by using a 5-point Likert scale and the higher score represented a higher critical thinking disposition [32,36].(v) Professional quality of life was measured using a 30-item tool with three dimensions.Each dimension was measured by using a 5-point Likert scale and the higher score represented a higher professional quality of life [37].(vi) Clinical self-efcacy was measured using the Self-Efcacy in Clinical Performance (SECP) questionnaire.Te SECP is a 37-item tool with fve dimensions.It was measured by using a 4-point Likert scale and the higher score represented good clinical self-efcacy [38][39][40].(vii) Personality traits were measured using the 10-item version of the Big Five-Factor Inventory.It was measured by using a 5-point Likert scale and the higher score represented good personality traits [41][42][43][44].(viii) Emotional intelligence was measured using the Schutte Self Report Emotional Intelligence Test (SSEIT-33).Te SSEIT-33 is a 33-item tool with three dimensions and additional uncategorized groups.It was measured by using a 5-point Likert scale and the higher score represented good emotional intelligence [44][45][46].

Data Collection
Te data were collected by twelve data collectors who had bachelor's degree in nursing and were supervised by four supervisors who had a master's degree in nursing.Both the data collectors and supervisors were trained before starting data collection.Te data collectors were given information about the study's aim before providing the selfadministered questionnaire to the study participants.Te questionnaire was ofered to the nurses when they were not busy with patient management and comfortable in a private room to fll it out freely.

Study Variables.
Te dependent variable was the nurses' clinical competence.Background and professional-related characteristics, practice environment, critical thinking, professional quality of life, personality and emotional intelligence, and clinical self-efcacy were the independent variables for this study.

Data Quality Control.
To ensure the consistency and standardization of data collection techniques, the data collection tool was pretested and the data collectors received extensive training.Te content, face, and construct validity of the tool were checked, and the interclass correlation coefcients (ICC) of all the tools were greater than 0.7 to ensure the reliability.
2.9.Data Processing and Analysis.Te data were coded, cleaned, edited, and entered into EpiData version 3.1.Tey were then exported to Stata version 15 for analysis.Univariate analysis was performed to calculate proportions, percentages, and summary statistics.Te normality distribution was examined using a scatter plot, kurtosis, and skewness.A multiple linear regression model was used to identify factors associated with clinical competence.All variables with a P value less than 0.25 in the simple linear regression and variables that were signifcant in previous studies were included in the fnal model to control for all possible confounders.Te goodness of ft was tested using the R-squared (R 2 ) value.A multicollinearity test was performed to check for correlation between the independent variables.A variance infation factor (VIF) of greater than 10 and a tolerance value of less than 0.1 were considered to be indicative of multicollinearity.A crude and adjusted beta (β) coefcient with a 95% confdence interval (CI) was estimated to identify the factors afecting nurses' clinical competence.In this study, a P value less than 0.05 was considered to be statistically signifcant.Te results were presented using simple frequencies, summary measures, tables, and fgures.

Clinical Self-Efcacy.
Findings from this study indicated the mean and standard deviation of the overall clinical selfefcacy was 100.62 ± 11.37.Of the dimensions, the assessment had a mean and standard deviation of 33.76 ± 3.44 (Figure 2).

Personality Traits and Emotional
Intelligence.Te mean and standard deviations of personal traits and emotional intelligence were 34.94 ± 5.2 and 131.89 ± 8.59.

Discussion
Quality nursing care is essential to improve patient outcomes, develop the profession, and increase satisfaction for patients, families, and nurses.However, nurses are often undervalued and seen as subordinates to physicians.Evaluating nurses' clinical competence is a key component of assessing the quality of nursing care.However, there is a lack of recent and updated studies on this topic in Ethiopia.Te mean score of nurses' clinical competence was above average, which is consistent with studies conducted in Ethiopia [47], Iran [48], Taiwan [49], Finland [50], and Korea [24].Nurses scored the highest mean in the clinical care, leadership, and interpersonal relations dimensions.Tey scored moderately in the legal/ethical practice and research aptitude/critical thinking dimensions and lowest in the professional development and teaching-coaching dimensions.Tis is also consistent with studies conducted elsewhere [44,51].A study from Ethiopia found that participants had higher competence scores on the legal/ethical dimension and lower competence scores on the teachingcoaching dimension [47].However, a study from Iran found that 92.3% had good critical thinking and research attitude, 65.8% had moderate clinical care, and 73.5% had moderate leadershipþ [52].Another study found that clinical competence was highest in areas relating to team collaboration and ethics and lowest in areas relating to professional development and direct clinical practice [53].Te discrepancy between these studies may be due to diferences in the measurement of the constructs, study setting, health care system, and the nature of the clinical service delivery.
Tis study found that male nurse was signifcantly associated with higher clinical competence.Tis fnding is inconsistent with studies conducted in Ethiopia [47] and Iran [54][55][56], which found no association between gender and clinical competence.Te reason for this discrepancy may be that male nurses are more likely to perform clinical examinations and procedures than female nurses [57,58], and they are also more confdent in their abilities [59].Additionally, the proportion of male nurses with more work experience was higher in this study.
Age was also found to be signifcantly associated with clinical competence in this study.However, the relationship Nursing Research and Practice was inverse meaning a unit increase in age decreases the clinical competence.Tis may be because older nurses are more resistant to change, they may be more fatigued, and they may not be as up-to-date on the latest clinical practices [60,61].Te study found that marital status was a signifcant predictor of clinical competence.Single nurses had lower clinical competence than widowed nurses.Tis may be because widowed nurses have more experience and are more likely to have had to take on additional responsibilities after the death of their spouse.Additionally, widowed nurses may have more social support, which can help them to cope with the demands of the job.A bachelor degree in nursing was signifcantly associated with the clinical competence.Tis was consistent with studies conducted in Ethiopia [47], Finland [62][63][64], Korea [65], and Taiwan [66].Nurses with a bachelor's degree in nursing were expected to have better skills and knowledge because of the required competencies in the curriculum.Tis fnding supports the current thinking that a degree adds value to competence [67].Current position was also  6 Nursing Research and Practice  Nursing Research and Practice signifcantly associated with the clinical competence of the nurses.Tis was consistent with studies conducted in Korea [65], Taiwan [66], China [68], Iran [55], and Ethiopia [47].
Nurses in more senior positions, such as head nurses and clinical instructors, were more likely to have higher clinical competence.Tis may be because they have more experience and responsibility, and they are also more likely to have received additional training.Work experience showed a signifcant association with clinical competence.Tis was consistent with studies conducted in Ethiopia [47], Taiwan [66], Iran [31,54], and Finland [62,63].Nurses with more work experience were more likely to have higher clinical competence.Tis may be because they have had more exposure to diferent patients and situations, and they have also had the opportunity to learn from their mistakes [47].
Studies from China [68] and Iran [55] found that working unit was a signifcant predictor of nurses' competence in practice.Tis study also supported this fnding.However, nurses working in the medical and emergency unit had lower clinical competence than nurses working in other units.Tis may be because the proportion of diploma nurses in the medical and emergency unit was higher than in other units.Diploma nurses have lower levels of education and training than bachelor's degree nurses, and they are therefore less likely to have the skills and knowledge necessary for providing high-quality care in the medical and emergency units.Tis study also found that interest in the nursing profession was signifcantly associated with nurses' clinical competence.Nurses who were interested in the nursing profession were more likely to have higher clinical competence.Tis may be because they were more motivated to learn and develop their skills, and they were also more likely to be confdent in their abilities.
Critical thinking disposition was found to be a predictor of clinical competence in studies conducted in Korea [24], Iran [25], and Taiwan [49].Tis means that nurses who have a strong critical thinking disposition are more likely to have higher clinical competence.Critical thinking is the ability to think clearly and rationally, and it is an essential skill for nurses.Nurses who are able to think critically are better able to assess patients, make decisions, and provide safe and efective care.Tis study also reported that nurses who had higher levels of critical thinking disposition, such as intellectual integrity, creativity, challenge, open-mindedness, prudence, objectivity, truth-seeking, and inquisitiveness, also had higher levels of clinical competence.Tis suggests that critical thinking disposition is an important factor in clinical competence.Terefore, it is essential to develop nurses' critical thinking disposition through in-service education and short-and long-term training.
Tis study found that clinical self-efcacy had a signifcant efect on nurses' clinical competence.Tis is consistent with fndings from studies conducted in Iran [69] and Taiwan [70].Clinical competence and self-efcacy (another name for the nursing process) are highly correlated.Terefore, nurses who are competent in applying the nursing process to their patients in the clinical setting will also have high clinical competence, as these two concepts are two sides of the same coin.Te study found that emotional intelligence is signifcantly associated with nurses' clinical competence.Tis is consistent with fndings from studies conducted in Iran [71,72].Emotional intelligence is the ability to understand and manage one's own emotions as well as the emotions of others.It is essential for nurses, as they need to be able to build relationships with patients and colleagues and to manage stressful situations [73].

Implication of the Study.
Te importance of this study is paramount, as nurses' clinical competence is essential to maintaining the nursing profession as a profession that provides quality nursing care and improves patient outcomes.Te fndings of this study provide recent evidence of the status of nurses' clinical competence and the factors that infuence it.Tis information is valuable for policymakers, program planners, and other scholars who are interested in conducting interventional studies to improve nurses' clinical competence.Additionally, the fndings of this study can be used by scholars, nursing associations, and other concerned bodies who are working to improve the quality of nursing care.

Strength and Limitation of the Study.
Te main strengths of this study were its use of a multidimensional approach to measuring factors that afect clinical competence and its use of updated and validated tools to measure the outcome and its constructs.However, there were also some limitations to the study.Te fndings were subject to recall bias and social desirability bias, as the responses only included self-reported data.Additionally, it was difcult to show the temporal relationship between the factors that were studied and clinical competence.Tese limitations should be kept in mind when interpreting the fndings of the study.

Conclusions
Te overall level of clinical competence among nurses in this study was moderate.However, there was a signifcant variation among nurses.Te following factors were signifcantly associated with clinical competence: gender, age, marital status, educational status, position, work experience, ward, interest in the nursing profession, critical thinking disposition, clinical self-efcacy, and emotional intelligence.Te fndings of this study add to the existing knowledge about clinical competence by providing new insights into the factors that contribute to it.Te fndings can also be used to reconcile the disparities between diferent clinical competence studies because they were assessed using a validated and reliable tool.Tis makes the fndings more convincing and credible.Based on the fndings of this study, there are a number of ways to improve the clinical competence of nurses.Tese include providing training and development opportunities that focus on critical thinking, clinical selfefcacy, and emotional intelligence; creating a supportive work environment that encourages nurses to take risks and learn from their mistakes; and monitoring the clinical competence of nurses on a regular basis and providing feedback and coaching as needed.Nursing Research and Practice

Figure 3 :
Figure 3: Level of clinical competence of the nurses in hospitals of Gamo Zone, Southern Ethiopia, 2022 (n � 404).

Figure 4 :
Figure 4: Mean scores for the dimensions of clinical competence of the nurses in hospitals of Gamo Zone, Southern Ethiopia, 2022 (n � 404).
Characteristics.In this study, 404 nurses were involved, and the mean and standard deviation of the age were 33.39 ± 6.34.Tis study reported the mean and standard deviation of the critical thinking disposition was 130.71 ± 14.25.Of the dimensions, intellectual integrity had a mean and standard deviation of 23.45 ± 3.71 (Figure1).Professional Quality of Life.Te mean and standard deviation of professional quality of life was 111.09 ± 15.82.Out of the dimensions, compassion satisfaction had a mean and standard deviation of 42.10 ± 5.34, burnout had 36.49± 7.43, and secondary traumatic stress had 32.51 ± 8.99.
Clinical Competence of Nurses 3.8.1.Simple Linear Regression.In the bivariate model, gender, age, qualifcation, position/title, ward/unit, training in nursing care, interest in the nursing profession, practice environment, critical thinking disposition, professional quality of life, clinical self-efcacy, personal traits, and emotional intelligence were signifcantly associated with clinical competence of nurses.Fifteen variables were inputted in the bivariate model and candidates for the fnal model (Table 2).3.8.2.Multiple Linear Regression.In this study, gender, age, marital status, educational status, position, work experience, ward, interest in the nursing profession, critical thinking disposition, clinical self-efcacy, and emotional intelligence were signifcantly associated with the clinical competence of the nurses in the fnal model.

Table 1 :
Background and professional characteristics of the nurses in hospitals of Gamo Zone, Southern Ethiopia, 2022 (n � 404).
Mean scores for the dimensions of the critical thinking disposition in hospitals of Gamo Zone, Southern Ethiopia, 2022 (n � 404).
Figure 2: Mean scores for the dimensions of clinical self-efcacy in hospitals of Gamo Zone, Southern Ethiopia, 2022 (n � 404).

Table 2 :
Simple linear regression for the factors associated with the clinical competence of nurses in hospitals of Gamo Zone, Southern Ethiopia, 2022 (n � 404).

Table 3 :
Multiple linear regression for the factors associated with the clinical competence of nurses in hospitals of Gamo Zone, Southern Ethiopia, 2022 (n � 404).