The main finding in this study was a significant improvement in nurses’ self-reported confidence in their professional skills from 2007 to 2011. This corresponds well with the findings in previous studies in health care, showing the positive effect of systematic and scrutinized education. Groups under Källestedt and Preusch reported an increase in resuscitation skills among health care professionals after training [8, 9], and Lam and associates an improvement in doctors’ confidence to diagnose and manage common dermatology problems after a Certificate Course in Clinical Dermatology designed for primary care doctors . In our study in question the skills were divided into 15 categories. Improvements were revealed in 13 categories, of which eight were significant.
It was encouraging to note here an improvement in professional skills in widely different areas. There was notable progress with cannulations (+22%), cardiac patients (+15%), equipment (+22%), psychiatric patients (+14%) and infection risk (+11%). These improvements can be attributed to systematic and scrutinized training. For example in cardiac care there was abundant training because patients with acute cardiac problems are very common in the clinic. Since these patients are treated by all nurses, personnel gain extensive experience in this area. On the other hand, even though we found evident improvement in practical skills in cannulations, work evidently remained to be done, since the overall confidence in this area was only 70 per cent. This can be explained in terms of the number of operations, involved, for example preparing the patient for kidney transplantation, of which are very few in our clinic.
The rareness of certain operations in the emergency clinic would also appear to explain lack of confidence in some other categories. Minor ear, nose and throat (ENT) and eye operations in our hospital are usually performed in the outpatient clinic for elective patients, while in the emergency clinic they do not occur every day. These operations are also assigned to nurses who have more experience of them. By reason of the unusualness of more demanding ENT and eye operations within these categories the overall confidence remained low. Confidence was lowest in traumatology and in the recognition of instruments. The category involving measures in the field of the immobilization of trauma patients was fairly wide and included tasks which in Finland are undertaken by senior emergency trauma technicians. Hence the nurses participating in this study would not usually carry out those operations in our clinic. Among all participants, recognition of instruments was the only category where the confidence had an evident, albeit non-significant tendency to decrease. Our finding is in line with those in a study carried out among physicians working in emergency medical service . It can be explained by the considerable turnover in the personnel in our emergency clinic and thereby the lack of practical experience.
Confidence was particularly high (almost 100 per cent) in the fields of urinary catheterization, observation of the patient and infection risk. Patient observation was the only category, in which “new” nurses seemed to feel non-significantly more confident than more experienced staff. Nurses in “new” group had less practical experience. It might in some cases lead to the self-deception described by Baxter and Norman, who found a lack of association between self-assessment and actual performance among nursing students . In 2007 the mean number of years after graduation was 11.3, and in 2011 it was 10.5. Although the mean difference was not conspicuous, it is noteworthy that in 2011 there were a considerable number nurses just graduated. This can be seen in the medians of experience in 2007 and 2011, 8.85 and 7.35 years, respectively.
Nurses who worked in both 2007 and 2011 felt their professional confidence increased in all categories, in 13 of them significantly. These improvements also included significant changes in six categories which were not significant among the nurses of the whole clinic. In infection risk the confidence was in 2011 almost 100%, but the change did not reach statistical significance.
As there was a notable turnover in personnel we also compared the confidence of the nurses who worked in both 2007 and 2011 to those who only worked in 2011. This revealed that experienced nurses had a tendency to be more confident in all categories but one, although the difference was significant in only five categories. These categories were punctures, ENT and eye procedures as well as equipment and triage. Experience seemed to have an influence on nurses’ confidence. This observation is supported by earlier findings by George and colleagues, who studied doctors’ confidence levels in diagnosing diabetes . They reported that those doctors who had had post graduate training in diabetes obtained a higher score in confidence.
The basic idea was to assess nurses’ self-reported confidence in their professional skills as a matter of the organization, not of the individual nurses. Some of the nurses in the “new” group had experience of years in working in our ED or in other EDs. It could be possible, that non-confident nurses had left the ED in order to work elsewhere and were replaced by more confident nurses. However, during the study period many experienced nurses reached their retiring age and were obliged to leave the department. Therefore, the turnover in personnel caused a potential risk of decreasing competence of the staff.
The strength of this study is that the questionnaire was devised by collaboration among multiple professionals. Nurses, physicians, emergency trauma technicians and ED secretaries all participated in the preparation of the questions. In this way we were able to cover as many skills as possible. Since the individual questions were explicit, the possibility of misunderstandings was minimal.
The focus of this study is quite new in the field of emergency medicine, and we had no established and validated questionnaire. The confidence scale we used involved only three choices, which made it easy and quick to answer. We also sought to avoid e.g. a Likert-type scale, as this would have made it difficult to assess results. Using a scale differing from those used in schools prevented nurses from answering according to their previous grades.
In the questionnaire nurses’ clinical responsibility was emphasized and related to the confidence scale. When nurses assessed their confidence in handling certain operations they also had to consider whether they could be the nurse in charge in that operation during the shift.
We were concerned in this inquiry to avoid feelings of guilt or shame if a participant could not carry out certain measure or lacked some practical skill. Answer C “cannot manage the specific measure” was related to the responsibility of employer to provide education and practical training. We believe this written principle contributed to the truthfulness of the answers.
To our knowledge there have been no previous studies dealing with improvements in the confidence of nurses in one whole ED. We examined the confidence of all the nurses working in the department and were able to establish the overall level of confidence in our clinic.
The use of self-reported confidence instead of an objective measure is a limitation to this study. Previous studies have brought out concerns regarding evaluating professional skills and competence by self-assessment. Some studies carried out among medical and nursing students have questioned the correlation between self-assessments and actual performances [12, 14]. Davis and associates have compared 17 studies to determine how accurate physicians’ self-assessments are compared to external observations of their competence . Thirteen comparisons out of 20 (three studies used two external comparisons) showed little or no connection between self-assessments and external observations. In seven studies a positive association was noted. To avoid such previously noted shortcomings, we tied the questions to practical responsibility by asking whether respondents felt confident to be the nurse in charge during each operation.
Meretoja and Koponen have made a study designed to develop a model to compare nurses’ optimal and actual competence . A multiprofessional expert group defined what was the optimal competence needed in a perioperative care setting. This was compared to nurses’ and nursing managers’ assessments of nurses’ actual competence. A significant difference was found between nurses’ optimal and actual competence. Also nurses’ self-assessed competence was lower than their competence as assessed by nursing managers.
The goals for learning were defined before the clinical reform of the ED in spring 2007. We were thus obliged to guess what skills nurses would need in the new department. The items included in the questionnaire might therefore not fully correspond to the skills needed in real life. However, according to our experience they covered surprisingly well the skills and measures needed in the ED today. Since the reform we have encountered new machines, knowledge and experience which would help us to devise more extensive questions. In the present questionnaire there were also some operations which for nurses are good to know about but which come up only rarely. For example assisting in the insertion of a pacemaker or emergency cricothyroidotomy are not common in the clinic. Such operations have probably lowered the overall confidence.
Our questionnaire comprised 15 different categories. The number of questions per category varied from 4 to 35. This might have had an influence on the statistical significance of the findings in different categories. Nevertheless, such influence would not appear to have been particularly marked, since we found significant improvements in categories with both few and numerous questions.
Even though the improvements in nurses’ professional skills might not be as good as they assume, we believe they are real. Such a conception is supported by the fact that the improvements were extensive and systematic. There was improvement especially in areas the nurses working frequently.