Elisa Fabbri,Alfonso Sollami,Luca Bertolaccini
The expert vascular access nurse: a pilot study of competencies
Nursing skills,Vascular Access Devices,Competency Assessment,Conceptual Framework,Professional Competence
Background and aim: In health care, competencies evolving with clinical and professional practice increasingly need to be defined. Identifying professional competencies in a general sense is no longer enough; it is necessary to define what competencies the professional must possess to ensure the appropriateness and effectiveness of their work. This pilot study aims to outline an initial competency framework specifically for vascular access nurses. Methods: A transversal observational study was conducted through the administration of an ad hoc questionnaire, which after a review of the literature aimed to identify the necessary skills for nurses involved in placing vascular accesses in situ. The questionnaire thus constructed identified 108 competencies, which were subjected to content validation by expert nurses through the calculation of a critical content validity ratio (CVR). Results: The research involved 14 expert professionals who reported no significant language barriers or comprehensibility difficulties. The expert review showed that the content was valid for all proposed items in a critical Content Validity Ratio (CVR .571 to 1.0). This implies that the proposed competencies can be considered a starting structure for further and necessary analyzes of the same. Conclusions: The findings of our study are encouraging, for a more robust assessment of identified competence, futher in-depht studies and evaluation need to be conducted (e.g. qualitative studies). ( www.actabiomedica.it )
The expert vascular access nurse: a pilot study of competencies

In health care, competencies evolving with clinical and professional practice increasingly need to be defined. Identifying professional competencies in a general sense is no longer enough; it is necessary to define what competencies the professional must possess to ensure the appropriateness and effectiveness of their work. This pilot study aims to outline an initial competency framework specifically for vascular access nurses.

A transversal observational study was conducted through the administration of an ad hoc questionnaire, which after a review of the literature aimed to identify the necessary skills for nurses involved in placing vascular accesses in situ. The questionnaire thus constructed identified 108 competencies, which were subjected to content validation by expert nurses through the calculation of a critical content validity ratio (CVR).

The research involved 14 expert professionals who reported no significant language barriers or comprehensibility difficulties. The expert review showed that the content was valid for all proposed items in a critical Content Validity Ratio (CVR .571 to 1.0). This implies that the proposed competencies can be considered a starting structure for further and necessary analyzes of the same.

The findings of our study are encouraging, for a more robust assessment of identified competence, futher in-depht studies and evaluation need to be conducted (e.g. qualitative studies). (www.actabiomedica.it)

The development of the nursing profession is an essential process that aims to provide activities to meet the care needs of citizens. Nurses, who numerically are a large group of professionals, have a significant impact on human health, so much so that the care provided must meet the requirements for high-quality care (1). The increased complexity of today’s health care environment and patient care means that nurses must acquire essential skills to provide high-quality care (2). Today, nursing is seen as a true science and a profession that prescribes and practices activities aimed at acquiring well-being based on acquired and established scientific skills and knowledge (3). What has been assumed defines that the assessment of competencies possessed by nurses should be a continuous process, to be carried out at recruitment and repeated, more or less regularly, throughout professional life. Similarly, Italian health authorities, which must provide an immediate response to the needs of citizens in terms of improving the quality of services, ensure the recognition of professionalism through the identification, description and promotion of the knowledge and skills in an organization. Competency management, at the various organizational levels, obliges the structure to consider knowledge as the true asset of the organization itself: this asset must therefore be known, promoted, disseminated, developed and protected(3). According to Tilley(4) , the roles and responsibilities expected of nurses change along with the changing health care system; therefore, the definition of competence is constantly being questioned (5). Today, nursing is considered a complex profession that requires a variety of competencies. As a result, nurses are expected to expand further their ability to adapt to new technologies, new roles, new workplaces, and new health challenges (6). Last but not least, it is the responsibility of all practising nurses to maintain their competence in practice. For this to be ensured by regulators, well-developed and comprehensive continuing competence frameworks are necessary (7). With this in mind, both undergraduate and professional education plays a crucial role in implementing the competencies that are necessary for effective and appropriate care, from theoretical preparation to practice, critical components of nursing curricula and, most importantly, necessary for nurses and nursing students to achieve a professional level of nursing competence (8). Indeed, with advances in medicine and diversifying patient needs, modular and complex nursing care is also required, capable of evolving dynamically by changing skills and competencies. Among the various definitions of competence found in the literature, we recall the one initially proposed by Klemp (9), later reformulated by multiple scholars(10) (11) and, finally, used by Levati and Saraò(12) in their most famous text: “by competence we mean an intrinsic individual characteristic, causally related to effective and/or superior performance in a task or situation and assessable based on an established criterion.” The authors conceive of competence as the product of the interaction of several components, three of which are “core”: skills, knowledge, and purposeful experience. The concepts of knowledge and purposeful experience do not require particular specifications, while the concept of ability is to be distinguished from the concept of skill. Skill translates the English term skill and is often misused to define competence. The social and economic changes that have taken place in recent years have profoundly altered the business environment: creating a global market, international competition, and changing demographics have created a new habitat to which organizations must adapt, or else they will disappear. For companies in general, and for healthcare companies in particular, uncertainty, unpredictability, competition and innovation have become constants, to which it is essential to respond through the transformation of the organizational structure into different forms that are flexible and ready for change. All this is possible only by investing in people, their continuous learning and their competencies since these represent the true and, in some cases, unique assets of the company. The concept of “competence” has stimulated rich reflection in various educational, psychological and organizational sciences fields. The Anglo-American literature has two terms. Competence is used in colloquial language, and competency with a more technical connotation (13). Wright (14) defines “competence” as the application of knowledge, skills and behaviours necessary to fulfil organizational duties in specific contexts. In more detail, Di Leonardi and colleagues (15) describe “competency” as what a nurse can do in terms of skills and manifest in measurable actions and behaviours. Ultimately “competence” refers to being able to do things in a given context, which becomes “competency” when measured by a standard. These definitions, in our view, represent a crucial node so that in operational contexts, the competencies acted upon for that specific function can be defined according to a shared framework.

The study aims to validate the content of a framework of skills that the expert nurse working in a vascular access center must possess.

A pilot observational study was conducted between April and October 2021 by developing an instrument (questionnaire) administered to a pool of experienced vascular access management professionals recruited from different companies (Sardinia, Tuscany, Emilia-Romagna), with a total of fourteen (14) professional nurses. The pool of professionals was a convenience sample selected for their knowledge of the topic. A criteria for recruited professionals were at least 1 year of experience in a vascular access implant center and they have performed at least 4 implants in the last 6 months. Professionals rated 108 questions using a Likert rating scale from 1 (not relevant) to 4 (very relevant) which allowed us to carry out the evaluation of the content through the Lawshe method (see data analysis).

The tool used was built ad hoc. Starting from the literature search by consulting the major databases (PubMed, Scopus, Cinhal, Medline, and Cochrane Library) and some of the reference sites for vascular accesses, we aimed to identify a likely competency framework for experienced nurses implanting venous accesses. The purpose-built instrument, derived from the analysis of the available literature and the recent guidelines published by the Emilia-Romagna Region (16), involved the proposal of 108 items, which therefore identify what skills a nurse expert in the creation of venous accesses must possess (see instrument). The questionnaire/framework defines four macro areas of relevance: Collaboration area (22 items) Organizational area (34 items) Training area/guidelines (30 items) Care/anamnestic area (22 items) For each item, respondents gave their assessment using a rating scale from 1 (not relevant) to 4 (very relevant). To complement the questionnaire and assess the experience of the professionals surveyed, professional experience in vascular access implantation (e.g., PICCs. Medline...) and the number of vascular accesses performed in the past six months were asked.

Data analysis was conducted using the method developed initially by Lawshe and recently revived by Ayre, and Scally (17), which starts from the paradigm that content validity is different from face validity, the latter referring not to the test measures but to what it superficially appears to measure. Conversely, content validation refers to a process that aims to assure that an instrument (checklist, questionnaire or scale) measures the content area it is supposed to measure (17). To assess content validity, the procedure involves a panel of subject matter experts who consider the ‘importance of individual items within the instrument. Lawshe’s method has been widely used to establish and quantify content validity in several fields, including health care, education, organizational development, personnel psychology, and market research (18). The method requires that the panel of experts indicate which of the items that make up the instrument are defined as “essential” and which as “nonessential/not necessary,” and only those that reach the critical content validity ratio (CVR) can be included in the final instrument. Ayre & Scally’s (17) recent revision of the method, echoing the original methodology proposed by Lawshe, indicates that this coefficient is valid only if a significant proportion of experts judging that particular item as essential is reached relative to the total number of experts (17). When that proportion is reached, the CVR can be calculated according to the following formula: C V R = (n e - N /2) / (N / 2), where: ne= number of experts who rated the item as essential (in our study, we considered those who responded with “fairly relevant” and “very relevant.” N= number of experts responding. Comer indicated by Ayre and Scally (17), in the specifics of our study, the minimum proportion to be achieved is .786 or 78.6% (in our study, this proportion meets the ratio of 11/14) of the responding experts will have to indicate the item as essential. At the same time, the corresponding critical CVR value is .571.

After reading the informed consent and expressing their agreement, the participants filled out the questionnaire. Because we did not collect personal information, the participants were adults, and voluntary participation, Ethics Committee approval was not required following national laws.

Fourteen experts from the Health Boards of Tuscany, Sardegna, and Emilia-Romagna responded to the questionnaire, of whom 64.3% (n=9) stated that they had professional experience in the field of venous access implants (PICCs, Medline...) of more than five years, 14.3% (n=2) between two and five years, and 21.4% (n=3) of less than two years. Similarly, 64.3% (n=9) of the respondents report having performed more than ten implants in the past six months, 7.1% (n=1) between five and ten implants, and 28.6% (n=4) less than five.

As indicated by Ayre & Scally (17), the number of experts who rated each item as essential was counted for each item. All proposed items were judged essential. Only three items (2.8%) had a minimum consensus of 11 experts, six items (5.6%) had a consensus of 12, and 21 items (19.4%) had a consensus of 13 experts. As many as 78 items (72.2%) were judged essential by all experts. Therefore, the critical CVR was calculated for each proposed item according to the formula. Again, all proposed items reached the critical level of .571. Only items 1, 9, and 51 reached the minimum level of .571, while items 2, 5, 10, and 19 recorded a medium/low CVR of .714. In contrast, the remaining 99 items recorded a medium/high CVR of .857 (16 items) or a maximum of 1.0 (83 items) (see table 1).

The limits of the study can be referred to the heterogeneity of the origin of the experts, which could lead to a bias, determined by the non-contextualization of the skills and/or in their subjective interpretation in the declension used.

The results seem to show good content validity for most of the proposed items/competencies, except for the three items with a minimal content validity ratio. One hypothesis could be due to the unclear identification/description of the items and a non-technical transposition of clinical needs and responsiveness to daily actions. The hypotheses described and these results indicate the need for further study through qualitative studies, for example, through the analysis of the results within Focus Groups (FGs), in order to broaden and focus the analysis of the questions in the context of the confrontation between professionals, the criticalities that emerged, hypothesize actions for improvement of the adopted instrument, analyzing in addition to specific technical competencies also the whole field of soft skills, also described in this paper, now an integral part of all professional activities and increasingly tools/skills/attitudes that can convey/facilitate the information/training/educational transition both between professionals and users and between professionals themselves and, last but not least, between professionals and the directorates of competence. Once the competency framework has been discussed and defined, further studies will need to be conducted to assess the psychometric qualities of the framework, including, for example, the internal consistency of the proposed instrument. In this regard, the one proposed in the appendix represents a hypothesis of item classification, dividing the items into areas defined as care/anamnestic area, training/guidelines area, organizational area, a collaboration area.