Background and Purpose: Special nursing is considered an expertise in nursing profession and requires a special competency. Empathy is complementary to the skills and knowledge needed to effectively treat a patient. Clinical competency and empathy are followed by effective health cares. The aim of this study was to assess the correlation between clinical competency and empathy of nurses employed in Intensive Care Units (ICUs). Methodology: This descriptive, correlational study was carried out on 231 nurses employed in the ICUs of the educational hospitals of Kerman University of Medical Sciences that were selected through a census. The data collection tools included an intensive care nursing competency scale and a nursing empathy assessment questionnaire. Data were analyzed using the SPSS version 20 software and the independent t-test, ANOVA, Pearson’s correlation coefficient and regression. Results: The study results indicated that the mean score of nurses’ clinical competency was 574.08 ± 86.51, and the mean score of empathy was 150.12 ± 17.04. The highest level of clinical competency belonged to the field of knowledge, and the lowest level belonged to the field of skill. The highest level of empathy was related to the behavioral area, and lowest level was related to the emotional area. There was a correlation between the two variables of clinical competency and empathy and all of their areas (the overall correlation coefficient r = 0.7 and P < 0.001). Conclusion: Given the relationship between clinical competency and empathy, it can be concluded that a higher clinical competency in nurses makes them more likely to establish an empathetic relationship with patients. According to the findings of this research, nursing managers and nursing education planners can provide appropriate conditions to enhance the clinical competency of nurses and improve their chance of establishing empathetic relations.
Keywords: Clinical competency, empathy, intensive cares, nurse
|How to cite this article:
Jahanshahi Z, Sarabi AG, Borhani F, Nasiri M, Anboohi SZ. The correlation between the clinical competency and empathy of nurses: Case study, Intensive Care Units of the educational hospitals of Kerman Medical Sciences University, Iran. Ann Trop Med Public Health 2017;10:694-701
|How to cite this URL:
Jahanshahi Z, Sarabi AG, Borhani F, Nasiri M, Anboohi SZ. The correlation between the clinical competency and empathy of nurses: Case study, Intensive Care Units of the educational hospitals of Kerman Medical Sciences University, Iran. Ann Trop Med Public Health [serial online] 2017 [cited 2021 Mar 1];10:694-701. Available from: https://www.atmph.org/text.asp?2017/10/3/694/213146
One of the controversial topics in the field of health is clinical competency. Competency is introduced as a special adjective for judgment of the quality or capability of individuals and is a reflection of the knowledge, critical thinking, individual, and technical skills that lead professional individuals to a clinical and professional position. According to the opinion of the International Council of Nurses, the knowledge, skills, and competency of nurses are vital to ensure the quality of patient care. Assessment of clinical competency has a very important role in the management of the process of providing care, ensuring the appropriate provision of cares, achievement of care provision goals, identification of fields requiring promotion, determination of the educational needs of nurses, and safety of care.
Clinical competency in nursing has a high relationship with increased safe performance, quality of care, patient satisfaction, decreased medical errors, hospital infections, mortality, postoperative complications, and accidental dislocation of endotracheal tube, particularly in Intensive Care Units (ICUs)., A competent person improves and guarantees the quality of care and patient satisfaction. Since patients in ICUs are responsible for the provision of specialized cares to patients with severe conditions with potential and active complications in their vital organs and are subject to a high risk of complications threatening their health, it is significantly important to have clinical competency for the provision of care to these patients in the complicated environments of the ICU.
Conceptually, clinical competency and empathy are followed by more effective medical cares. A relationship between a medical team and a patient based on empathy compliments the skills and knowledge required for the effective treatment of the patient. Researchers believe that although there have been many developments in the field of physical cares in the ICU, but in general, care of all the human aspects that include the mental and spiritual care of patients is neglected. Therefore, nurses of ICUs should not only provide for the physiological needs of patients but also provide the mental needs of the patients by establishing a correct relationship. In ICUs, the relationship with a patient is of special importance and priority because nurses in the ICU are responsible to provide care for patients who may die at any moment. An appropriate relationship with a patient in these units, decrease their anxiety and worries and improves the treatment process of the patients. One way of establishing a relationship with a patient is to create empathy with him. Empathy is a fundamental component in the relationship between a nurse and a patient, and nurses are expected to use this ability in providing medical care. Empathy includes the ability to understand the experiences, worries, and opinions of others and the capability to establish a relationship based on this understanding, and in a general, it is the ability to place oneself in the position of others to better understand the experiences and feelings in a mutual interaction. Empathy has a fundamental role in interpersonal commitments, social interactions, friendship and maintenance of it, improved health, increased possibility of receiving or giving assistance, altruism, social cohesion, and creation and maintenance of interpersonal relations. When an empathetic nurse cares for a patient, outcomes such as relief from tension, a high level of physical and mental well-being, reception of emotional responses to conditions, increased conformity and increased cooperation with the medical team will be provided to patients. An empathetic relationship between a nurse and a patient not only improves the experience of the patient as the receiver of the care but will also lead to positive medical outcomes. Empathy can increase patient satisfaction, lead to a more correct diagnosis and treatment  and it particularly influences adherence to care recommendations and decreases care errors  and has a direct relationship with the positive clinical outcome of patients, decreased exhaustion, and dissatisfaction., A lack of empathy in the relationship between the medical personnel and a patient can disrupt the processes of diagnosis, treatment, and care. Given the necessity of the empathetic relationship of nurses with patients to access medical goals and promote the quality of care and also the importance of the relationship between a patient and a nurse in ICUs, it is necessary to investigate the empathy of nurses with these patients. Nurses’ empathetic attitude has a special place for the adhesion of patients to treatment and prediction and rating of clinical competency and correct diagnosis by nurses.
Currently, despite the importance of the subject, there is little awareness about the status of nurses’ competency and empathy in ICUs, and few studies have been performed in this area in Iran, and even in these few studies, nurses’ clinical competency has not been measured with specialized tools for clinical competency. However, the results of studies performed about the relationship between clinical competency and empathy area contradicting. Casas et al. (2016) indicate the existence of a relationship between empathy and clinical competency, while in Maleki, no significant relationship was seen between empathy and clinical competency. Ogle et al. concluded in their study that there is a strong relationship between clinical competency and empathy assessed by a supervisor, but there is no relationship between self-assessed empathy and clinical competency. Given the issues mentioned about clinical competency, empathy and the importance of evaluating them and also limited studies about the investigation of the correlation between clinical competency and empathy, existence of contradicting results in previous studies, it seems necessary to perform this study and by performing this study, it is possible to assess the relationship between various areas of clinical competency and empathy, and investigate the synergic or decreasing effect of the desired areas.
This is a descriptive, correlational study. The study population consists of nurses employed in ICUs and cardiac care units (CCUs) of the educational hospitals of Kerman University of Medial Sciences who at least had a bachelor’s degree in nursing.
In this study, sampling was performed through a census. Such that the questionnaires were given to all the nurses employed in ICU and CCU, with a total number of 260 nurses, out of this number, 231 nurses completed the questionnaire. The attrition rate was 11% which is statistically acceptable.
For data collection, three questionnaires were used: (1) Demographic data questionnaire consisting of 14 questions about age, gender, marital status, employment status, level of education, overall years of service, work background in ICU, work shift, average weekly work hours, overtime, history of illness and history of drug use, history of the stay of a family member, or friend in an ICU. (2) Farsi scale of ICU nursing competency used to assess the clinical competency of nurses. This scale was designed by Lakanema et al. in 2012 and underwent psychometry and introduced as a valid and reliable scale for the assessment of ICU nursing competency. This scale has the four areas of knowledge base, skill base, attitude and value base, and experience base and 144 items with each area including 36 items. Each item is investigated in a 5-point Likert Scale with the scores ranging from 1 = very poor to 5 = very good. The tools’ scores are categorized as poor competency (144–288), average competency (289–432), good competency (433–576), and excellent competency (577–720). These tools were translated by Shouryabi in 2014 in Iran and underwent psychometry. (3) The questionnaire of nurses’ empathy was prepared by Rahmatizadeh in 2015 under the supervision of Hojjat by adopting his tools. This questionnaire consists of 38 questions, out of which twenty questions were taken from the standard 20-item questionnaire of Jefferson which was created by Hojat et al. to investigate the level of physiologists’ empathy, and 18 questions were added to it after consultation with nursing and psychology professors. The advantage of this questionnaire over the standard 20-item questionnaire of Jefferson is that the questions of this questionnaire are categorized in the four areas of cognitive, emotional, behavioral, and ethical. The scores obtained are based on a Likert scale (5 = very much, 4 = much, 3 = almost, 2 = little, and 1 = very little) which are given to the areas of cognitive, emotional, behavioral, and ethical empathy of nurses with patients. The total score of the individuals is at the range of 38–190 and a higher score means a higher sympathy with an individual patient.
In this research, to determine the validity of the tool of empathy, a content validity index (CVI), and content validity ratio (CVR) were used. For this purpose, the empathy assessment questionnaire was given to ten professors of this field who were of the professors of Shahid Beheshti University of Medical Sciences. Next, they were asked to determine the necessity level of each term based on the CVI (level of clarity, relevance, and simplicity based on a 4-part score criterion) and CVR. The CVI of each question was determined which for all the questions amounted to a value higher than 0.8, and the overall value of it for all the tools was 0.89. The CVR of each question was determined which ranged from 0.8 to 1 and the overall value of it for all the tools was 0.94.
To determine the reliability of the questionnaire, internal consistency, and re-testing were used. To measure the internal consistency, the questionnaire was given to twenty nurses working in an ICU, and its Cronbach’s alpha was calculated. The overall Cronbach’s alpha coefficient of the empathy assessment questionnaire was 0.94, and the Cronbach’s alpha coefficient of the ICU nursing competency scale was 0.97. Also to measure external consistency using retest, the questionnaire was given 20 nurses working in an ICU, and 2 weeks later, the questionnaire was given to the same individuals again, and then, its reliability was calculated through an intraclass correlation coefficient. The intraclass correlation coefficient in the cognitive, emotional, behavioral, and ethical fields of the empathy assessment questionnaire were 0.90, 0.85, 0.78, and 0.92, respectively, and in the dimensions of knowledge, skill, attitude, and value and competency scale experience this value was 0.90, 0.88, 0.83, and 0.92, respectively.
In this research, after receiving the approval of the Ethics Committee in Shahid Beheshti School of Nursing and Midwifery and also receiving permissions from the study hospitals, to collect the data, the researcher visited the ICU and CCU of the educational hospitals of Kerman in the three work shifts of morning, evening, and night while carrying the questionnaire and after going through the stages of self-introduction, statement of research goals, ensuring the participants of the confidentiality of the information and receiving a written permission from the nurses participating in the research, and attempted to collect the data. The participants were asked to complete the questionnaires (utmost within 3 days) any time that they consider appropriate and return them.
The SPSS version 20 statistical software developed by IBM Corporation was used for data analysis. First descriptive indices such as mean and standard deviation were reported and to determine the correlation between clinical competency and empathy; the Pearson’s correlation coefficient was used. Mutual relations between clinical competency, empathy, and effective variables were investigated using ANOVA, t-test, and linear regression. In the tests performed, a confidence coefficient of 95% and degree of significance of (α = 0.05) were considered. The Kolmogorov–Smirnov test was used to investigate the normality of the data and all the variables were normal (P > 0.05).
The results showed that out of the 231 participating nurses, 67.96% (157 individuals) worked in an ICU and 32.04% (74 individuals) worked in a CCU. Most of the nurses were in the age range of 31–38. The overall service years of most of the nurses ranged from 6% to 10. 90.5% of the nurses (209 individuals) were female, 74.9% (173 individuals) were married, 95.2% (220 individuals) had a bachelor’s degree, 32.5% (75 individuals) had contract employment, 91.3% (211 individuals) had rotational shiftwork, 66.2% (153 individuals) had compulsory overtime, 92.2% (213 individuals) had no history of illness. 90.9% (210 individuals) had no history of drug use. 58% (134 individuals) had no history of the stay of a family member or friend in an ICU. The weekly work hours of the majority of the nurses ranged from 41 to 60.
The overall minimum and maximum mean clinical competency of the nurses were 144 and 720, respectively, 574.08 ± 86.51, which is good. The score of the clinical competency of the majority of the nurses (56.7%) was excellent [Table 1]. The highest competency score belonged to the field of knowledge, and the lowest competency score belongs to the field of skill [Table 2].
|Table 1: Frequency distribution of nurses employed in the Intensive Care Units of the educational hospitals of Kerman University of Medical Sciences in 2016 based on the scores obtained in clinical competency
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|Table 2: The correlation between the categories of clinical competency and the categories of empathy of nurses employed in the Intensive Care Units of the educational hospitals of Kerman University of Medical Sciences in 2016
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The overall empathy mean of the nurses ranged from 38 at the minimum to 190 at the maximum 150.12 ± 17.04. Since the number of the questions of the four fields are not equal, therefore in order for it to be clear that, in which field the lowest or highest empathy levels are, the mean of empathy with the number of the questions must be considered. The highest mean of empathy belonged to the behavioral category, and the lowest mean of empathy belonged to the emotional category [Table 3].
|Table 3: Clinical competency, empathy, and their categories in nurses employed in the Intensive Care Units of the educational hospitals of Kerman University of Medical Sciences in 2016
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The result of the Pearson’s correlation coefficient test showed that since r = 0.7 and P < 0.001, therefore, there is a direct relationship between the amount of nurses’ clinical competency and their empathy level, which was statistically significant. This means that a higher clinical competency of nurses indicates that they are more likely to establish an empathetic relationship with patients. There is a direct relationship between all the fields of clinical competency (knowledge, skill, attitude and value, and experience) and all the categories of empathy (cognitive, ethical, emotional, and behavioral). The highest level of correlation was between the field of attitude and value and the behavioral category, and the lowest amount of correlation was between the field of attitude and value and the emotional category [Table 2].
In investigating the demographic components related to clinical competency, findings suggested that there was a relationship between clinical competency and variables such as marital status, compulsory overtime, history of drug use, history of the stay of a family member or friend in an ICU, the type of ICU that nurses are employed in, employment status, work shift, work background in ICUs, overall years of service in an ICU, age and number of weekly work hours, and factors such as gender, different levels of education, and history of illness had no effect on the amount of the clinical competency of nurses.
Factors such as the type of employment of nurses, overall years of service in an ICU, number of weekly work hours, age, marital status, compulsory overtime, the type of ICU that the nurses are employed in, history of the stay of a family member or friend in an ICU and work shift affected the level of empathy in nurses but a history of the presence of illness, history of drug use, different levels of education, and gender did not affect the level of the empathy of nurses.
In the present study, regression analysis of the study variables showed that clinical competency affects the level of empathy in nurses such that for each 1 score increase of clinical competency, the score of empathy increases by a value of 0.11 [Table 4].
|Table 4: Investigating the linear regression of empathy with relevant factors in nurses employed in the Intensive Care Units of the educational hospitals of Kerman University of Medical Sciences in 2016
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There is a direct relationship between the mean of the overall clinical competency of nurses and the mean of their overall empathy. This means that a higher clinical competency in nurses makes them more likely to establish an empathetic relationship with patients. The results of this research are in alignment with the results of the studies of Hojat et al. in 2002 and Ogle et al. and contradict the results of Maleki. The results of the study of Maleki showed that there is no relationship between the amount of empathy and clinical competency of nurses employed in the cancer wards of the selected hospitals of University of Tehran, Iran. Hojat et al. in 2002 in their study (with the title: investigating the empathy of medical students and its relation to gender, academic performance, and clinical competency) concluded that samples with a higher empathy enjoyed a higher clinical competency. However, it cannot be certainly said that a person with a high empathy will doubtlessly have the best performance and a high level of clinical competency. Ogle et al. in 2013 in Australian Medical School in their study (empathy is relate to clinical competency in medical cares) showed that the observed behavioral criteria of empathy measured by the supervisor, are greatly related to clinical competency, and a strong relationship was seen between empathetic behaviors and clinical competency in medical positions. However, a self-assessed empathy is not related to clinical competency.
The overall mean of clinical competency of nurses employed in the ICUs of the educational hospitals of Kerman University of Medical Sciences in 2016 was 574.08 ± 86.51 which was at a good level. The clinical competency score of the majority of nurses (56.7%) was excellent. Since the present study is the first study performed to investigate the clinical competency of nurses employed in ICUs using these tools; therefore, it was not possible to compare the results of this study with other studies for different categories. In the study of Maleki performed to assess the clinical competency of nurses employed in the cancer wards of the selected hospitals of Tehran University of Medical Sciences, Iran, the value of clinical competency in 72.3% of the nurses was assessed as being good. The study by Bahreini et al. in 2010 performed on the self-assessment of clinical competency of nurses employed in various wards of Shiraz Hospital Iran, indicated a good level of clinical competency where the greatest clinical competency belonged to the nurses of CCU. The research findings of the study of Shatery performed to investigate the clinical competency of nurses in the ICUs of Tehran University of Medical Sciences, showed that the level of clinical competency of 22.8% of ICU nurses was poor, 67% was average, and 9.8% was strong. Ghalgeh et al. in their study performed to investigate the correlation between the clinical competency of nurses and patients’ satisfaction of nurses’ services, reported the clinical competency of 82.9% of the nurses of the clinical wards participating in their study as being at the expected level. The study of Karimi Moneghy et al. showed that the clinical competency of nurses employed in general, special, specialized, and emergency wards as begin good. In this study, there is a relationship between the clinical competency and number of overall service years of nurses and their number of service years in ICUs, given that the mean overall work years and overall work years in ICUs of the nurses participating in the study are 9.62 and 7.51, respectively, their enjoyment of clinical competency is at a good and reasonable level because nurses with a longer work experience can better adapt themselves with different circumstances and feel more competent due to their use of past experiences.
In this study, in addition to the overall mean of clinical competency, the scores in each category were calculated individually. The greatest mean score of competency is related to the field of knowledge, and the lowest score of competency is related to the field of skill. ICU nurses must have sufficient theoretical and clinical knowledge because they deal with patients with bad health conditions and ethical challenges. Advanced and complete knowledge about equipment and subjects related to special cares are the necessary and strong conditions for supporting nursing care which results in the provision of quality care. One of the important and key elements in the development of nurses’ competency is education which leads to the provision of high-quality care. In regards with professional skills, nurses as a part of the human resources in the health system play an important role in improving the health of the individuals in society. Education of nurses must take place in coordination with the new knowledge and findings related to the method of the provision of health services, so nurses can fully exhibit their job abilities, skills, and competency. In 2011 in his study, Khodayarian called experience as the most important factor affecting the acquisition of competency through feeling realities and called direct experiences as a valuable factor in improving clinical competencies which places individuals in a real test with all the associated challenges and difficulties, and considered the continuous repetition of care, especially in technical areas as an effective method in the acquisition of skills in this area. According to some nurses, the role of practice and repetition in improving competency is not only limited to technical measures but also includes fields such as establishing a relationship with a patient or making a decision. An experience is in fact the process of refining past opinions and knowledge of an individual through encountering several real-life cases. The understanding obtained from each experience is accumulated with past experiences, and at the end, they collectively lead to the understanding of details.
The mean of overall empathy of nurses employed in ICUs is 150.12 ± 17.04. The greatest mean of empathy was related to the behavioral category, and the lowest mean of empathy was related to the emotional category. The results of the study of Ouzouni and Nakakis on nursing students in Greece performed with the 20-item questionnaire of Jefferson showed that the empathy of students was 20 at the minimum and 140 at the maximum, 88.63 ± 8.93. The results of the study of Rahmatizadeh, 2015 performed to investigate the empathy of nurses employed in an oncology ward using the empathy assessment tool of the present study showed that the empathy score of nurses was 38 at the minimum and 190 at the maximum 149.24 ± 16.63. The greatest amount of the empathy of nurses of the oncology ward was related to the ethical category, and the lowest amount of empathy was related to the emotional category. The cognitive and behavioral empathy of nurses were equal. O’Connell and Landers (2008) in their study state that the emotional aspect of care is more important than all the other aspects. Maybe the reason for the low level of emotional care in Iran is due to cultural factors or nurses’ little opportunity to express their emotions for patients. A nurse will establish a relationship with a patient by the amount that she understands the feelings of the patient. Such that in the opinion of Jabbarifard et al. (2011), identification of the internal experiences and opinions of patients and their interactional ability, in addition to increasing clinical skills, is effective in creating a correct relationship and strengthening it and improving the effectiveness of the services and duties of patients. In the study of Negarandeh et al., out of the caring behavioral subscales of patients, the subscale of nursing ethics acquired an average score. Nurses consider that observing professional ethics is more important and sensitive than general matters. Any job which involves a direct communication with clientele requires ethics. Although ethics is necessary in all jobs, nurses require nursing ethics because they directly deal with patients. Because the spiritual behaviour of nurses and their responsibility in relation to the patients has an effective impact on improving and recovering the patients health. Therefore, the profession of nursing is based on ethics.
It seems that if nurses enjoy a good level of clinical competency, they will have a more positive view toward empathy with patients. During the study, the researcher obtained results that she hopes will be considered by the managers and authorities of the nursing community and will be useful for progressing the goals of nursing and facilitating nursing activities and lead to increased competency and empathy in nurses and improve caring quality and satisfaction level of nurses and patients. Based on the results of the study about the existence of a relationship between clinical competency and empathy, it can be stated that if ICU nurses, enjoy an appropriate empathy in addition to having sufficient knowledge, experience and skills, they can realize an organization’s goals with lower costs and a higher quality.
This research is adopted from a master’s thesis in intensive care nursing with the ethical code of IR.SBMU.PHNM.1395.394 in Shahid Beheshti School of Nursing and Midwifery. The researchers thank the authorities of Shahid Beheshti School of Nursing and Midwifery, managers, and nurses employed in the ICUs of the educational hospitals of Kerman University of Medical Sciences and all the colleagues who participated in this project.
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Conflicts of interest
There are no conflicts of interest.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]