Competency in Nursing Students : A Systematic Review

Introduction: Nursing students require highly specialized competencies to accurately determine patients' states and to predict and cope with problems that may occur during nursing care. This study explores the definition, domains, and levels of nursing students' competency. Methods: This study was a systematic review of nursing students’ competencies in English (ISI, SCOPUS, Ovid, Proquest, Iranmedex, Google scholar, PubMed) and Persian (Scientific Information Database) databases (1985–2015), according to the University of York Center for Reviewers and Dissemination Guidance approach, 2008. Results: From a total of 13,115 articles, 20 were retrieved in the final step. The individual experiences, dynamic process, and positive interactive social and beneficial changes in the equality of one’s professional life that cause meta-cognitive abilities, touch reality, motivation, decision making, job involvement, professional authority, self-confidence, knowledge and professional skills formulated the definition of nursing students' competency. Educational, cultural, individual, professional and inter-professional, research, clinical and practical domains were defined as belonging to nursing students' competency. Seven nursing student competency levels were identified. Conclusion: Although the definitions of competency, its domains, and its levels vary by profession and country, this systematic review demonstrated the comprehensive ones in three scopes. However, more research is needed to examine the three scopes in the nursing student competency concept.


Introduction
Healthcare institutions and organizations face numerous challenges, such as increasing amounts of information, the introduction of new technologies, decreased funding, and demands for accountability [1][2][3]; the practice of nursing requires a complex combination of various attributes [4][5][6][7], and nursing students require highly specialized competencies to accurately determine patients' states and predict and cope with the problems that may occur during nursing care [1,8].The urgency of adequate nursing competencies in changing and improving care is evident.Most employers expect new nursing graduates to be prepared to perform a wide range of functions and have the skills to provide safe care [1].Nurses at the undergraduate level should play an important role in developing the competency of new routines in quality improvement programs for patients [1].The requirement reflected in one of the first definitions of nursing competency given by Short et al. describes a competency as a quality possessed by someone without exact specifications of what one can do in specific circumstances [5]; however, many employers are concerned that recent graduates cannot competently perform basic clinical tasks or that their education and work competencies are disconnected [1].The assessment of clinical competency has always been a key component of clinical education for health professionals [9].
Clinical placement experiences are an integral aspect of practice development for undergraduate nursing students undertaking a Bachelor of Nursing degree to acquire competencies and abilities to learn independently, make decisions, and express ethical commitments [8,10,11].Development of nursing practice requires the synchronicity of both knowledge application and clinical skills, and students must demonstrate the ability to integrate these professional requirements of the qualified nurse for which they are being prepared [4].Otherwise, the situation results in disappointed employers, frustrated new graduates, and dissatisfied patients [12,13].
According to many authors, the most effective way to ensure students acquire competencies is to integrate the teaching of those skills into course curricula in a holistic approach to teach disciplinary knowledge and generic skills [10].A consensus was reached regarding strategies for assessing the competence of nursing students as they progress through their program of study based on the views of experienced clinicians and academics [14].Furthermore, in health care settings, it is important to assess the competencies that are essential for the professional role of nursing students to prepare them for future professional duties [15].
However, extensive review of the literature showed that the definition of nursing student's competency, its dimensions, levels, and scopes were obscure.The purpose of this systematic review was to explore the definition, domains, and levels of nursing student's competency; it sought to answer the following questions: 1. What is a comprehensive definition of nursing students' competency? 2. What are the domains of nursing students' competency? 3. What are the levels of nursing students' competency?

Methods
For this systematic review of the competency of nursing students, the University of York Center for Reviewers and Dissemination Guidance approach was used as the research framework [16,17].This approach has seven steps as follows:

Research Question Formulation
The study questions were three: 1. What is the comprehensive definition of nursing students' competency? 2. What are the domains of nursing students' competency? 3. What are the nursing students' competency levels?

Defining Search Strategy
An extensive review was made of the available literature in English and Persian databases , including ISI, SCOPUS, Ovid, Proquest, Iranmedex, Google Scholar, Pub Med, and Scientific Information Database (SID).The keywords searched included "nursing student competency," "nursing student ability," "undergraduate nurses competency," "nursing student professional," "nursing student skill," "clinical and educational nursing competency," "clinical qualification in nursing student," and different combinations of the aforesaid words.To find more related articles, the references of the searched articles were comprehensively investigated.Furthermore, the generalization of the retrieved final data, information, and knowledge was increased through a general and specific search on http://www.searchenginelist.blogfa.com.The mentioned site has several engine and super-engine search motors on different topics and scopes.In this section, oceans and oceans of data and information were retrieved.Some of the retrieved materials were repetitious and similar to previously searched documents, but some novel materials were detected and used in responding to Question 2. Keywords in the selected databases were utilized in the title, abstract, and keyword domains.It should be noted that some databases have overlap as some articles were cited in several databases.A reference manager software (Endnote version 7) was used to prevent re-entry of any retrieved articles.

Setting the Inclusion and Exclusion Criteria
The inclusion criteria for articles were publication from 1985 to August 2015; written in either the English or the Persian language; electronic publication with a formal peerreview process; congruency between the topic of the article and the study questions and purpose; application of different aspects of competency in nursing students; and originality of the paper.A total of 13,115 articles were found, including 7,730 articles in Pub Med, 3,590 in Google Scholar, 75 articles in Ovid, 14 articles in Proquest, 23 articles in Iranmedex, and 1,683 articles in SID.Searches were conducted by three members (AVA, AE, and BN).

Designing Quality Investigation Checklist
A checklist was designed based on the inclusion criteria, and all articles were assessed accordingly.

Deriving the Question's Responses
Based on the research questions, the responses were extracted from the retrieved articles in the review process.

Combination of Information Derived from Retrieved Articles
Information derived from the retrieved articles regarding the study questions and purpose were combined in this step.Figure 1 demonstrates the flow diagram of the article selection.

Results
From 13,115 articles selected in the first step, only 20 articles remained in the last step.The core concepts in the nursing students' competency scope were related to the definition, domains, and levels of nursing student's competency.In the following, the responses of the questions are explained.

First Question: Comprehensive Definition of Nursing Students' Competency
The common usage domain of the word "competency" existed in nursing and midwifery education from 1983 until the present; however, authorities have expressed concern over the lack of knowledge and skills of graduating nursing students, saying that they are not necessarily equipped to work [24].Defining and measuring competency in nursing students is difficult [35].Retrieved papers were included in the final review process according to the inclusion and exclusion criteria and relevancy to the review questions by the critical appraisal checklist (n = 20)  (8)   Hypothesis orientation; high specific competence, and high specific experience.
For assessing the clinical reasoning process and clinical decision making, virtual patient's model is suitable but how to score and grade such exams is the challenge.
For making clinical decisions, high specific competence and experience was so important.  (10  Teamwork and group processes; Reflection and documentation; Communication; Shared knowledge or general common knowledge, and Ethics.
The IP learning situations for IPE educators and developing professional practitioners is more helpful than one profession's perspective.
A meta cognitive model for interprofessional education and practice has been developed as a tool for analyzing professional competence on three levels: individual, team and organization with seven basic components of professional competence and the way they are related and interact.  (18  Attitudes to competencies; being a preceptor, and competencies in practice.
The importance of a regional and national review of competency assessment systems to find a common language for student assessment as well as promoting greater student skill development within competency frameworks is recommended.
Attitudes to competencies; being a preceptor, and competencies in practice were categorized.

Safety and teamwork collaboration
The concepts of quality and safety, although familiar to faculty, are not identifiable nor taught at the complexity level.
Education related to the safety, teamwork, and collaboration competencies occurs more frequently in the clinical setting than in the classroom.

Questionnaire
Master's degree female with teaching responsibilities in both the classroom and clinical settings

Competencies of Quality and Safety Education
Cabaniss (2014) (20)     In the literature review, competency in general has been defined as "the ability to perform the task with desirable outcomes under the varied circumstances of the real world" [24], and as "the overlap of knowledge with the performance components of psychomotor skills and clinical problem solving within the realm of affective responses" [36].Competency has general attributes that refers to having ability to successfully perform something [37].Moreover, the concept in nursing practice has multi factorial natures including empirical evidence, behavioristic, generic, holistic role [38] and responsibility [39].Competency has also been defined as the skill and ability to practice safely and effectively without the need for direct supervision, and as a level of performance demonstrating an effective application of knowledge, skill and judgment [40].Moreover, competency reflects knowledge, understanding and judgment, a range of skills, and a range of personal attitudes and attributes [41].
Based on the extensive literature review in this study (Table 1), researchers believe that nursing students' competency is the individual experiences, dynamic process, and positive interactive social and beneficial changes in the equality of one's professional life which causes metacognitive abilities, touch reality, motivation, decision making, job involvement, professional authority, selfconfidence, knowledge and professional skills, in which are included the five factors of "nursing process," "caring," "professionalism," "communities," and "diversity."The basic factors of nursing students' competency (Figure 12) were provider of care, manager of care, and professional identity, all three of which are very important in the progress of nursing students.Basically, they are basically the infrastructure of nursing students' competency levels.

Second Question: Domains of Nursing Students' Competency
According to the review of the literature (Table1), competency in nursing students has 6 domains and 12 subdomains.Educational-based competency, Cultural-based competency, individualized-based competency, researchbased competency, professional and inter-professionalbased competency, and clinical and practical-based competency were defined as nursing students' competency domains (Figure 12).

Third Question: Levels of Nursing Students' Competency
The literature review (Table 1) indicated that experiences of researchers in the nursing students' competency scope [18], the three basic factors of nursing student's competency (provider of care, manager of care, and professional identity), and the combination of the matters define seven levels as follows: 1. Nursing students do not have sufficient acceptable levels of educational and clinical abilities.2. Nursing students have sufficient and acceptable levels of educational abilities but his/her abiliities still need to be checked and supervised; they do nothave sufficient and acceptable levels of clinical abilities.

Nursing students have competency in educational
abilities, but still need occasional checking and supervision in his/her abilities; they do not have sufficient and acceptable levels of clinical abilities, but do have minimal abilities in the clinical settings.4. Nursing students are proficient in educational abilities, but still need periodic checking and supervision of his/her abilities; they are competent and have sufficient and acceptable levels of clinical abilities, but may also need occasional checking and supervision in his/her abilities.5. Nursing students are expert in educational abilities, are proficient, and have sufficient and acceptable levels of clinical abilities; they may need periodic checking and supervision in his/her abilities.6. Nursing students are expert in educational and clinical abilities, but may need to be reminded by their supervisors of some special points in educational and clinical settings .7. Nursing students are expert in educational and clinical abilities and are teachers and supervisors of educational and clinical skills and proficiencies.

Discussion
In this study, the researchers sought to define and describe the definition, domains, and levels of nursing students' competency in light of previous studies using the systematic review approach.Definitions of competence vary by profession and country [42,43], and many of the studies reviewed offered no clear or coherent definition or description of the mentioned concepts (Table 1).In the English language, the terms competence and competency are often used interchangeably.The term 'competency' should strictly be used for a "skill" itself, while competence is "the ability to perform that skill and the attribute of the performer" [42,43].In this study, nursing students' competency was clearly defined, and 6 domains with 12 subdomains of nursing student's competency were identified (Figure 2).Moreover, seven steps of nursing students' competency were introduced for the first time in competency-related literature.
The main purpose of the different domains of nursing students' competency is proper, correct, and exact use of knowledge and skills and the ability to apply the three basic factors of care management, care providing, and achieving and demonstrating a professional identity in different academic and clinical settings (Figure 12).This is congruent with the declaration that competency represents the integration of knowledge, skills, values, and attitudes [42,43].
In other words, the definition, domains, and levels of competency should separate the novice student from the expert student in the progress of different working, academic, and clinical settings.However, there are some problematic areas in the application of the mentioned concepts, including assessment and measurement of clinical competency, general versus specific competency, and divergent values among stakeholders.
In the assessment and measurement area, it is necessary to note that competency is difficult, perhaps impossible, to measure [44].It is also problematic to determine at what level of performance a student should be deemed competent [42,43].In this study, however, seven levels were identified for overcoming the problems in different clinical and academic settings.Moreover, the holistic nature of competency which "identifies broad clusters of general attributes which are considered essential for effective performance" means that competency is "more than the sum of individual competencies" [45].This definition resists the breaking down of competency into more manageable and measurable pieces, and objective assessment of competence suffers as a result.However, the study definition of nursing students' competency is congruent with the breaking down of competency into more manageable and measurable pieces and defined the concept as "the individual experiences, dynamic process, and positive interactive social and beneficial changes in the equality of one's professional life that causes meta-cognitive abilities, touch reality, motivation, decision making, job involvement, professional authority, self-confidence, knowledge and professional skills, which includes the five factors of "nursing process," "caring," "professionalism," "communities," and "diversity."Moreover, one very important point to overcoming the unclear nursing students' competency is that the determination of competency is often influenced by a student's level of comfort, confidence, and self-efficacy in a variety of contexts and considers more than one perspective Communication [5], Values and beliefs [3], Social determinants (cultural prerequirement) [23], Minority recruitment [16], Socio-cultural differences [3] Feedback [2], Lifelong learning [1], Coaching [3], Service learning [5], Critically evaluating [3] Competency Domains

Cultural-based Competency
Racial/ethnic disparities in healthcare [11], Ineffective or lower quality care culturally/linguistically inappropriate [17], Cultural innovations in healthcare system and structure design [7], Interactions between patients and healthcare staff [14], Lack of diversity in healthcare leadership and workforce [9], Cross-cultural communication between healthcare providers and patients [17] [46].Next, the study defined seven steps of nursing students' competency in different academic and clinical settings.
Regarding general versus specific competencies, it seems that clinical nursing skills have taken a back seat to other priorities [47][48][49].The set of general competencies tends to be so vague that it fails to demarcate nursing from other professions while also failing to define nursing practices [50]; while general competencies are often used to assess students, it may be of greater benefit (and challenge) for students to attain specific nursing competencies.If students lack exposure to basic nursing skills, they may gain insufficient experience for even minimal competency [47,49].Furthermore, tooverpower the problem, the researcher suggested seven steps for first-year nursing students to senior nursing students.
In connection with the diverse values among stakeholders, there is often a lack of shared assumptions between educational institutions, employers, patients, and regulatory bodies about what to expect from new nursing graduates [47,49,51].The researchers strongly believe that nursing stakeholders must be accompanied by the seven nursing students' competencies for different academic and clinical settings to overcome the problems.
Moreover, it is of paramount importance that the nursing students' stakeholders manage different academic and clinical settings to achieve flexibility, personalization, selfpacing, a supportive environment, a skill-based, respected, and finally affordable points in the mentioned settings [37,52] in teaching different educational and practical skills and abilities in different academic and clinical settings.

Conclusion
The current study gives more comprehensively described definition, domains, and levels of nursing students' competency in different academic and clinical settings than previous studies, but it is more obvious that more systematic reviews, concept analyses, and even meta-analysis are needed to scrutinize specifically nursing students' competency in academic and clinical settings.The current study was the first review study in the nursing competency scope to introduce seven new competency levels in nursing students.However, the concept strictly depends on the profession and country.

Figure 1 .
Figure 1.Flow diagram of articles selection

*
The number in parenthesess is the frequency of repetition of an item in the whole literature review.

Table 1 .
Final retrieved articles in the review process Touching the realities, decision making, learning, opportunities, precious experience, job involvement, motivated agent, and theoretical knowledge.