Construct Validity of Clinical Nurse Specialist Core Competency Scale: An Exploratory Factor Analysis

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DSpace https://erepo.uef.fi

Rinnakkaistallenteet Terveystieteiden tiedekunta

2020

Construct Validity of Clinical Nurse

Specialist Core Competency Scale: An Exploratory Factor Analysis

Jokiniemi, Krista

Wiley

Tieteelliset aikakauslehtiartikkelit

© 2021 The Authors

CC BY-NC-ND https://creativecommons.org/licenses/by-nc-nd/4.0/

http://dx.doi.org/10.1111/jocn.15587

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J Clin Nurs. 2021;00:1–11. wileyonlinelibrary.com/journal/jocn

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1 DOI: 10.1111/jocn.15587

O R I G I N A L A R T I C L E

Construct validity of clinical nurse specialist core competency scale: An exploratory factor analysis

Krista Jokiniemi RN, PhD, Postdoctoral Fellow

¹

| Anna- Maija Pietilä RN, Professor (emer.)

¹

| Santtu Mikkonen PhD, Statistician

²

This is an open access article under the terms of the Creative Commons Attribution- NonCommercial- NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is noncommercial and no modifications or adaptations are made.

1Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland

2Department of Environmental and Biological Sciences and Department of Applied Physics, University of Eastern Finland, Kuopio, Finland

Correspondence

Krista Jokiniemi, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1, 70210 Kuopio, Finland.

Email: krista.jokiniemi@uef.fi Funding information

Suomen Akatemia, Grant/Award Number:

325022

Abstract

Aim: To conduct a construct validity test on a clinical nurse specialist core compe- tency scale.

Background: Clinical nurse specialists’ competency development dates back to the late 20th century; however, there is scarcity of competency descriptions from outside of North America. Furthermore, little knowledge is available on the previous research- driven efforts to develop and validate clinical nurse specialist core competencies.

Design: A descriptive study, using an online self- report questionnaire, was conducted from May to September 2019 in three Nordic countries.

Methods: An exploratory factor analysis using principal axis factoring and rotation method oblimin with Kaiser normalisation was undertaken to examine factors in the 50- item scale. Parallel analysis with eigenvalue Monte Carlo simulation and scree plot was used to determine the number of factors to extract. Psychometric properties of the scale were evaluated, and subjective interpretation was used to modify the tool in line with the statistical analysis. The STROBE checklist was used as the reporting guideline for this study.

Results: One hundred and eighty- four responses were obtained (Finland n = 52, Denmark n = 95, Iceland n = 37) with an overall response rate of 45%. The results provided construct validity evidence of the underlying theoretical structures of the four competency spheres of patient, nursing, organisation and scholarship. Cronbach's alpha coefficient for the original overall scale was 0.94, thus indicating adequate reliability of the scale.

Conclusions: Based on the analysis and subjective interpretation, we suggest a 47- item clinical nurse specialist core competency scale. Further study should be conducted to validate the core competency content and construct in other contexts beyond the present study.

Relevance to clinical practice: The scale may be used to guide clinical nurse special- ist practice and identify areas for professional development, develop graduate- level programme curricula and inform future competency research.

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1 | INTRODUCTION

The need to improve population health and health systems outcomes through the expanded and improved utilisation of nurses, including those in specialised and advanced roles, is a global priority according to the World Health Organization (World Health Organization [WHO], 2019). To optimally utilise resources, healthcare organisations and managers need to have high performing nurses who can implement the full range and scope of practice. Clinical nurse specialists (CNSs) add significant value by improving population health, providing better quality care and lowering healthcare costs.

(International Council of Nurses [ICN], 2014; WHO, 2019). It is noted that CNS role effects could be radically increased by optimising their competence; however, CNS competency development is rather novel, with lack of CNS competency descriptions from outside of North America. In this study, we will test the recently developed CNS core competency scale within Nordic countries to provide research evidence on CNS competency development and validation.

1.1 | Background

Clinical nurse specialists (CNSs) are experienced master's- or doctoral- prepared registered nurses (RNs) who manage the care of complex populations, offer expert clinical leadership to nurses at the bedside, support the learning of nurses and interdisciplinary team, and facilitate innovation and health system outcomes (Fulton et al., 2019; Jokiniemi et al., 2020; Lewandowski & Adamle, 2009).

To achieve the goals of the role, CNSs integrate direct clinical and non- clinical role activities that require advanced competencies (Jokiniemi, 2014; Lewandowski & Adamle, 2009). Competence refers to an individual's knowledge, skills and attitude underlining sets of behaviours that are instrumental in the delivery of desired outcomes (Fraser & Greenhalgh, 2001; Kurz & Bartram, 2002). Furthermore, competency standards have been used as benchmarks for entry to practice and thus form a base for safe nursing practices and role

standardisation (Sastre- Fullana et al., 2014). However, in many countries outside of North America, CNS competency development is in its early stages, and a lack of legislative and regulatory mechanisms or protected titles for CNS roles is evident (Jokiniemi et al., 2018;

Maier et al., 2017). Among the examined countries, in Finland and Denmark there is no title protection for the CNS, although general guidelines do exist (Jokiniemi et al., 2019; Sundhedsstyrelsen, 2009).

Iceland, in turn, has certified CNSs since 1993 (The Directorate of Health, 2019).

Although CNS roles were first developed more than 60 years ago in the United States, CNS competency development dates back to the late 20th century and has predominantly occurred in the United States and Canada (Baldwin et al., 2007; CNA, 2014; Jokiniemi et al., 2018). In the United States, the first core competencies of CNS practice were developed in 1998 (Fulton, 2014). In 2020, the fourth edition of these competencies was released with 44 distinct competencies descriptions. In addition to core CNS competencies, specialty- related competency descriptions, such as adult- gero, wom- en's and emergency care, have been developed in the United States.

(NACNS, 2020) Within Canada, CNS competencies were introduced for the first time in 2014 (CNA, 2019). The foundational document, outlining 59 core competencies of the CNSs (CNA, 2014), was developed by the Canadian Nurses Association (CNA). In addition to North American CNS core competencies, the European Specialist Nurses Organisations (ESNO) have published CNS competencies (ESNO, 2015); however, little is known about the extent to which these are used in practice by different European Union countries.

Considerable time and effort have been spent on developing these above- mentioned competencies. However, CNS competency development is still not a common practice, and the scarcity of CNS competency descriptions outside of North America is evident.

Overall, little knowledge is available reporting research- driven attempts to develop and validate CNS competencies within or across countries. As an increasing number of countries are implementing CNS roles, it is imperative to focus on competency development and role standardisation in order to increase understanding and K E Y W O R D S

advanced practice nurse, clinical nurse specialist, competence, exploratory factor analysis, Nordic countries, nurse clinician, reliability, validity

What does this paper contribute to the wider global clinical community?

• Based on statistical analysis and subjective interpretation of the exploratory factor analysis, we recommend a 47- item clinical nurse specialist core competency scale measuring competence in the areas of patient, organisation, scholarship and clinical nursing leadership.

Cronbach's alpha coefficient for the overall scale of 0.94 indicates adequate reliability of the competency scale.

• Validated CNS core competency scale may be utilised to develop and standardise CNS roles within healthcare organisations and identify areas for professional development. Academic institutions may use this scale to develop new graduate- level programme curricula.

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cohesive role development. Validated competency criteria can be used in several ways to clarify role descriptions, strengthen performance and role evaluations, guide CNS education curricula and inform procedures for optimal health system utilisation (Jokiniemi et al., 2018).

To validate the content and construct of scales, such as core competency descriptions, scientific procedures are required. To cre- ate the content and test the validity of the CNS core competencies in Finland, a four- phase rigorous research- driven process was conducted between 2013 and 2018 (Jokiniemi et al., 2018), resulting in a set of 50 core competencies for CNS practice. Within this study, we will report further research to examine these competencies in a wider context. In addition to reporting a construct validity test on the CNS core competency scale, we will release a 47- item scale which may be applicable in a global context when developing CNS roles, education and role evaluations.

2 | METHODS

2.1 | Aim

The aim of this study was to conduct a construct validity test on the CNS core competency scale by conducting an exploratory factor analysis (EFA).

2.2 | Design

A fifty- item self- report CNS core competency scale (henceforth referred to as CNS- CoCoS) developed and validated in Finland (Jokiniemi et al., 2018) was trialed using EFA (Rencher & Christensen, 2012). The study was reported based on the Strengthening the Reporting of Observation studies in Epidemiology (STROBE) checklist. (Appendix S2).

2.3 | Participants

A census sample of Danish (n = 277), Icelandic (n = 77) and Finnish (n = 72) practicing CNSs was recruited through each country's nursing/CNS associations (N = 426). To be eligible for this study, the participants had to be working as a CNS and preferably have a master's degree education. A total of 192 nurses returned the self- report survey, yielding an overall response rate of 45%.

2.4 | Data collection

Participant recruitment and data collection were conducted from May to September 2019 in three Nordic countries: Finland, Denmark and Iceland. Data were collected using an online self- report questionnaire.

2.5 | Validity and reliability

2.5.1 | Tool development

The scale, designed to assess the level of competence use by practicing CNSs, was developed in a four- phase rigorous research process conducted between 2013 and 2018 (Jokiniemi et al., 2018).

First, a policy Delphi, involving expert panellists in the areas of advanced practice nursing, healthcare management and advanced practice nurse education, was utilised to tease out CNS competency criteria. During three iterative policy Delphi rounds (n = 25, n = 22, n = 19), 75 preliminary CNS competency criteria were de- veloped and 88% of these criteria were supported with a high level of consensus. (Jokiniemi et al., 2015) Secondly, the preliminary competency criteria were cross mapped against well- developed CNS competency sets from the US (Baldwin et al., 2007) and Canada (CNA, 2014) to detect any missing or overlapping items.

The resulting 60- item competency criteria were thereafter, in the third phase, evaluated again by an expert panel for their content and relevancy to CNS practice. During this process, three missing items were added, 12 overlapping items excluded, and two items deleted due to a low content validity index score (I- CVI) of 0.4, resulting in a 50- item CNS competency scale. In the final, fourth phase, the 50- item self- report competency scale was sent to 16 CNSs to examine the use of the developed competency descriptions in actual CNS practice. (Jokiniemi et al., 2018).

As a result of the described exploratory sequential mixed- method study (Jokiniemi et al., 2018), a 50- item CNS- CoCoS was created and its content validated. The scale was used to measure the use of CNS competence during a typical month on a 5- point, Likert- type scale (0- never, 1- rarely, 2- sometimes, 3- often and 4- always);

however, it may be used with other scales such as the visual ana- log scale (VAS), to measure the perceived level of CNS competence.

Four distinctive role spheres of patient, nursing, organisation and scholarship emerged as the organising framework for the CNS core competencies and formed the four subscales of the scale. During the sequential process, it was confirmed that the developed CNS- CoCoS was as follows: (a) aligned with the US and Canadian CNS core competency descriptions; (b) valid in terms of content; and (c) used by practicing CNSs within Finland. The developed CNS- CoCoS received a relatively high- scale CVI average of 0.94 in an expert content validity study; thus, the criterion may be regarded as valid in terms of content. (Jokiniemi et al., 2018).

2.5.2 | Tool translation

The Finnish content validated CNS- CoCoS was first translated from Finnish into English and then back- translated by two independent authorised translators from a professional translation service. The English translation and back- translation were first assessed by a research team member in terms of meaning, accuracy, wording and grammar and thereafter by a native English- speaking researcher

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from the research field of CNS roles. Next, the English CNS- CoCoS was translated and back- translated by the same method from English to Danish and Icelandic and assessed by native Danish and Icelandic research experts in the field of CNS roles (Squires et al., 2013).

Furthermore, the surveys were tested within each country with participants (n = 8) who met the inclusion criterion of the upcoming research. Feedback was requested on clarity and understanding of the language, survey functionality and time burden, as well as appro- priateness of the length of the survey. As a result of their feedback, minor revisions were made to clarify problematic items.

2.6 | Data analysis

Statistical Package for the Social Sciences (IBM Corp., 2017) version 25 was employed to calculate descriptive statistics, to conduct the EFA and to calculate α coefficients. EFA was performed initially for Finland and Denmark separately in order to see whether they had a similar structure. The number of observations in Iceland was too low for a full EFA. As the factorisation proved to be similar between the countries, the data were combined for higher statistical power and to also include the data from Iceland.

The sample size just below 200 in our study was slightly below the commonly used rule of thumb of five observations per item.

However, the recommended sample size for EFA is dependent on the number of factors formed, the ratio of variables to factors and the level of communality (Mundfrom et al., 2005). With these criteria, the sample size for a four- factor solution can be considered excellent for the combined data, good for the subsamples from Finland and Denmark, and inadequate for the subsample from Iceland. This highlights the importance of combining the subsets.

The Kaiser– Meyer– Olkin (KMO) and Bartlett's test of sphericity (BTS) (Kaiser & Rice, 1974) were examined to ensure the assumptions associated with EFA. Parallel analysis with eigenvalue Monte Carlo simulation was used and confirmed by more conventional methods (i.e. scree plot) to determine the number of factors to extract for analysis (Cattell, 1966; Hayton et al., 2004; Horn, 1965). To determine the optimal number and nature of common factors needed to account for the patterns of these associations separately, an EFA was utilised (Pearson et al., 2013). As the factors cannot be assumed to be independent in these types of data, oblique oblimin rotation was used to rotate the EFA factors. Factor loadings ≥ 0.3 were considered significant and representative of the underlying construct (Costello & Osborne, 2005). Psychometric properties were evaluated by examining item statistics and asso- ciations among items (i.e. Cronbach's alpha).

2.7 | Data purification

Little's missing completely at random (MCAR) test revealed that data, evaluated by each country and each factor, were missing

completely at random (p > .05) in most cases and could therefore be imputed with the expectation– maximisation method (a numeri- cal algorithm that can be used to maximise the likelihood under a wide variety of missing data models) (Allison, 2001). Items were imputed if 90% or more of the answers were endorsed. Without imputation, there would have been 137 full data rows out of 184, and only 3 out of 50 items had no missing data. The Icelandic

‘scholarship subscale’ (=0.014) and the Danish ‘nursing subscale’

(=0.014) were non- MCAR, and to assure accuracy of imputation, the values given by the expectation– maximisation method were also checked against the mean score. If the participant had not answered a survey subscale at all (nursing subscale: n = 6, organisation subscale: n = 1 and scholarship subscale: n = 1), it was not imputed.

2.8 | Ethical considerations

This research follows the principles that are endorsed by the research community, that is, integrity, meticulousness and accuracy in conducting research and presenting the research results (Finnish Advisory Board on Research Integrity, 2012). The University of Eastern Finland Committee on Research Ethics evaluated the ethical aspects of the research and gave a supporting statement to the research (statement number 13/2018). Study permission from participating countries was gained in accordance with their instructions. Prior to their participation in the study, prospective participants were sent an information sheet about the study with a link to the survey. Completion of the e- survey was regarded as implied consent, and the participants were informed of this. Participation in the study was voluntary and could be ceased at any time (WHO, 2013).

3 | RESULTS

Of the 192 surveys returned, eight were excluded from the analysis:

six based on incomplete item responses (i.e. no responses for three or more subscales) and two due to duplicate saving. Therefore, 184 surveys were included in the final data analysis.

3.1 | Demographic background of the participants

Just over half of the responses came from Denmark (n = 95, 51.6%), 28% were from Finland (n = 52) and 20% from Iceland (n = 37). The respondents’ average age was 48.9 years (SD = 9.08), and most were female (94.6%). Respondents reported that they had worked as an RN for an average of 15.2 years (SD = 9.29), and as a CNS for 6.03 years (SD = 5.03). Most participants were master's- (84%) or doctoral- prepared (9%) and most worked in hospital settings (91%).

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3.2 | Exploratory factor analysis

The KMO value of 0.883 and BTS χ² = 5553.647, p < .000, indicate that the assumptions associated with EFA were met. According to the Shapiro– Wilk test, patient (sig 0.019) and organisation (sig 0.000) subscales were not normally distributed; therefore, principal axis factoring was employed instead of maximum likelihood (Fabrigar et al., 1999). Parallel analysis suggests that a four- factor solution is optimal, as the first four real eigenvalues (13.422– 2.079) were greater than the average random eigenvalues (2.337– 1.978).

Furthermore, a moderate decrease between the fourth and fifth scree plot was observed (Figure 1). The correlations among four common factors ranged from 0.039 to 0.438. Two factor loadings were below 0.3 and four below 0.4, with the rest of the 45 items loading over 0.428. Four factors accounted for 52.064% of the total variation. Factor loadings were generally high with small cross- loadings.

Factor loading of four factors can be seen in Table 1. Nineteen items loaded to the organisational competence factor, with factor loadings ranging from 0.250 to 0.779. One item, ‘Strengthens the cooperation between the various social and healthcare service providers with the aim of producing high- quality patient care’, loaded below the cut- off point ≥0.3. From the expected organisational factor items, two items loaded to another factor: ‘Supports the assessment of the resources required to provide safe patient care within the organisation’ and ‘Evaluates care development needs together with patients’ loaded both to the patient competence factor.

Overall, five additional items (discussed below) loaded to the organisational competence factor, instead of their expected factor.

Twelve items loaded to the patient competence factor, with factor loadings ranging from 0.395 to 0.834. From the expected patient competence factor, three items (‘Promotes the use of evidence- informed care practices within the specific area of expertise’,

‘Evaluates clinical practice development needs using reflective practice within the specific area of expertise’ and ‘Evaluates the effectiveness of his/her expert practice based on defined objectives’) loaded to the organisational competence factor.

Nine items loaded to the nursing competence factor, with factor loadings ranging from 0.289 to 0.818. One item, ‘Systematically strengthens his/her competence within the specific area of

expertise’, loaded below the cut- off point. Three nursing competence items loaded to different factors than those expected. Items

‘Evaluates practice development needs together with the staff’ and

‘Intervenes responsibly with any observed gaps within the care environment’ loaded to the organisational competence factor and item

‘Evaluates care development needs together with patients’ loaded to patient competence factor.

Ten items loaded to scholarship competencies, with factor loadings ranging from 0.505 to 0.832. All expected items loaded to this factor with no additional items loading to it.

3.3 | Psychometric properties of the scale

Overall, CNSs who participated in the survey utilised organisational competencies (mean 2.67), most frequently followed by the patient (mean 2.40), nursing (mean 2.40) and scholarship (mean 2.19) competencies. There was little variation within the use of competencies between observed countries except for the utilisation of patient competencies, which was the only competence area with significant differences between all countries (p = .000).

Cronbach's alpha coefficients for the original 50- item scale were high, being from the lowest to the highest subscale: 0.86 for nursing competence, 0.89 for patient competence, 0.90 for organisational competence and 0.92 for scholarship competence. Cronbach's alpha coefficient for the overall scale was 0.94.

3.4 | Recommendations

Based on the EFA, the research team recommends a 47- item CNS- CoCoS, with four factors (Tables S1 and S2). Based on EFA, eight items were relocated from their original factors. Three items are recommended to be left out of the scale. Two items to be removed received an item loading below 0.3: ‘Strengthens the cooperation between the various social and healthcare service providers with the aim of producing high- quality patient care’ (loading 0.250) and

‘Systematically strengthens his/her competence within the specific area of expertise’ (loading 0.289). The third item, ‘Evaluates practice development needs together with the staff’, is recommended for removal due to an overlap with other items. This item's expected factor was clinical leadership, yet due to loading to the organisational factor, subsequent overlap appears between the other items.

Six items, loading to factors different than those expected (mentioned above), are considered fitting well into the new factor.

However, due to the factor change, four minor wording edits are suggested by the research team to tie the items better to the new factor. The factor nursing competence is renamed clinical nursing lead- ership to better illustrate the items in the factor. The recommended CNS- CoCoS consisting of patient competencies (12 items), clinical nursing leadership competencies (8 items), organisational competencies (17 items) and scholarship competencies (10 items) may be F I G U R E 1 Scree plot confirming 4- factor solution

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TA B L E 1 Loadings of the exploratory factor analysis via rotation method Oblimin with Kaiser Normalisation (n = 184)

Variable 1 2 3 4

Cronbach's alpha if item deleted Organisational competence (19 items)

Acts to promote the implementation of best practices and policy guidelines

within the organisation 0.779 0.061 −0.075 −0.028 0.936

Promotes the standardisation of best practices and policy guidelines within

the organisation 0.775 −0.089 −0.074 0.018 0.936

Promotes interunit cooperation in the development of patient care 0.716 0.081 0.155 −0.114 0.936 Acts to support reaching the strategic objectives of the organisation 0.681 −0.198 0.066 0.007 0.937 Evaluates the development needs of the best practices and policy

guidelines within the organisation

0.662 −0.028 0.056 0.034 0.936

Acts to support the implementation of changes within the organisation 0.642 −0.043 0.128 0.043 0.936 Promotes innovation activities related to the development of care quality 0.633 0.100 0.117 −0.112 0.936 Promotes the use of evaluation and statistical information compiled within

the organisation for the development of patient care

0.616 −0.109 0.289 −0.131 0.937

Evaluates clinical practice development needs using reflective practice within the specific area of expertise

0.592 0.083 −0.059 0.041 0.937

Supports the management and immediate supervisors within the organisation in the development of nursing and the service system

0.583 −0.104 0.109 0.161 0.936

Evaluates the effects of the organisational culture on outcomes of care 0.580 −0.028 0.055 0.219 0.936 Anticipates the effects of changes in the healthcare operating environment

on patient care

0.509 0.106 0.193 0.065 0.936

Evaluates practice development needs together with the staff 0.503 0.040 0.000 0.303 0.936 Evaluates the effectiveness of his/her expert practice, based on defined

objectives 0.467 0.160 0.037 −0.043 0.937

Strengthens the positive work environment and cooperation of the care

community 0.435 0.259 −0.123 0.173 0.936

Intervenes responsibly with any observed gaps within the care environment

0.435 0.146 −0.087 0.293 0.936

Uses information on critical incidents for improving the safety of the staff and patients.

0.362 0.100 −0.147 0.270 0.937

Promotes the use of evidence- informed care practices within the specific area of expertise

0.317 0.198 0.054 0.147 0.937

Strengthens the cooperation between the various social and healthcare service providers with the aim of producing high- quality patient care

0.250 0.237 0.066 0.072 0.937

Patient competence (12 items)

Strengthens patients’ abilities for self- care and promotion of health

through his/her actions −0.044 0.834 0.032 −0.071 0.937

Utilises advanced competence in patient care within the specific area of expertise

−0.148 0.773 0.079 −0.021 0.938

Applies evidence- informed methods for treating patient illnesses and promoting their health

−0.090 0.770 0.163 −0.054 0.937

Carries out independent reception operations within the specific area of expertise

−0.085 0.747 −0.004 −0.058 0.938

Acts as a patient advocate 0.109 0.745 −0.055 −0.064 0.937

Supports the management of patients with complex care needs within the specific area of expertise

0.084 0.730 −0.110 0.055 0.937

Coordinates the overall care of patients with complex care needs −0.146 0.709 −0.088 0.186 0.938 Carries out healthcare needs assessments informed by evidence for

patients within the specific area of expertise

0.079 0.669 0.114 0.001 0.936

(Continues)

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seen in Appendix S1. These four factors account for 53.62% of the total variation.

Cronbach's alpha coefficients for the 47- item scale were slightly higher than those for the 50- item scale, thereby justifying the changes proposed. Cronbach's alpha coefficient for the 47- item scale was overall 0.94 and ranged from 0.83 for clinical nursing leadership competence, 0.91 for patient competence, 0.92 for organisation

competence to 0.92 for scholarship competence. The correlations among four common factors ranged from 0.031 to 0.418. Table 1 shows the alpha value if an item is removed. Removal of any item de- creases/increases alpha values slightly; however, the change is not so great that it would provide the basis for the removal of individual items. The removal of three items was done on the premises, as discussed above.

Variable 1 2 3 4

Cronbach's alpha if item deleted Acts to strengthen the person- centred approach to care planning and the

implementation of care

0.309 0.524 −0.001 0.076 0.936

Evaluates care development needs together with patients 0.183 0.507 −0.004 0.166 0.936

Promotes the implementation of ethical principles in patient care 0.240 0.437 0.028 0.129 0.936 Offers consultations with staff for questions related to the area of

expertise

0.175 0.395 −0.092 0.240 0.937

Scholarship competence (10 items)

Evaluates the outcomes and effectiveness of patient care within the

organisation, together with the scientific community −0.085 0.143 0.832 0.070 0.937

Participates in national and international multidisciplinary research and

development projects −0.131 0.097 0.821 0.007 0.938

Promotes the national and international publication of development and research projects

−0.010 −0.027 0.774 −0.053 0.938

Supports research within the specific area of expertise −0.039 0.128 0.773 −0.117 0.938

Promotes cooperation between the organisation and scientific communities

0.045 0.077 0.761 0.035 0.937

Analyses the significance of evaluation information from the perspectives of patient care, management, teaching and research

0.145 −0.022 0.718 0.144 0.936

Strengthens the staff's abilities to read and apply research 0.059 −0.172 0.610 0.129 0.938 Coordinates evidence- informed practice and quality improvement projects

within the specific area of expertise

0.344 −0.086 0.573 −0.127 0.937

Promotes the reporting of the effectiveness of nursing and advanced

practice nursing within the organisation 0.320 −0.011 0.505 0.021 0.936

Disseminates research evidence and acts to promote the use of research within the organisation

0.332 −0.099 0.505 0.018 0.937

Nursing competence (9 items)

Evaluates the competence of the staff, together with the unit supervisor 0.003 −0.091 −0.096 0.818 0.937 Drafts learning plans for the nurses, together with the unit supervisor −0.043 0.084 0.032 0.648 0.937 Promotes the professional development of the nursing staff by acting as a

mentor

−0.227 0.185 0.135 0.640 0.937

Supports the development of staff orientation 0.086 −0.016 −0.118 0.576 0.937

Promotes the competence of staff in the assessment of the processes and quality of care

0.370 −0.085 0.043 0.464 0.936

Supports staff in the critical evaluation of their clinical practice within the work community

0.373 0.045 0.092 0.455 0.936

Instructs staff in the development of evidence- informed practices 0.306 −0.182 0.239 0.428 0.936 Supports the assessment of the resources required to provide safe patient

care within the organisation

0.263 0.207 −0.102 0.307 0.937

Systematically strengthens his/her competence within the specific area of expertise

0.022 0.032 0.154 0.289 0.938

Note: Extraction method: Principal axis factoring. Rotation method: Oblimin with Kaiser normalisation.

TA B L E 1 (Continued)

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4 | DISCUSSION

Within this article, we have reported on a research validating the construct of the core competencies of CNS practice within Nordic countries. An initial content validity study (Jokiniemi et al., 2018) provided preliminary support for the CNS- CoCoS’s validity and factor structure. In the current study, factor analysis using parallel analysis revealed four- factor solutions with a sample of 184 Nordic CNSs and evidence regarding the internal consistency of the instrument revealed the adequacy of this solution. As a result of the EFA, the four- factor solution was confirmed, three items were removed, and six items were relocated to a different factor than the one expected.

Overall, the finding of a four- competency- factor solution reflects similarities in the US and Canadian CNS competencies. The US CNS competencies are grouped under three spheres of patient, nursing and organisation (Baldwin et al., 2007), whereas the Canadian CNS competencies include clinical care, systems leadership, advancement of nursing practice, and evaluation and research competencies (CNA, 2019). Cross- mapping of the US and Canadian CNS competency sets with the CNS- CoCoS in Jokiniemi et al.’s study (2018), revealed consistency regarding these three CNS competency criteria. Based on this examination, overlapping competency indicators as well as gaps in criteria were identified, and the logical consistency and relevance of all competencies to CNS practice were evaluated while developing the CNS- CoCoS (Jokiniemi et al., 2018). In comparison with the above- mentioned CNS competencies, CNS competency criteria published by ESNO (2015) appear to be constructed according to a different theoretical structure than the other examined competency criteria. According to ESNO (2015), the CNS competencies are displayed through 10 generic competencies (i.e. clinical role, patient relationship, mentoring and public health), which each consist of one to seven competency descriptions and correspond to the levels 7 and 8 in the European Qualifications Framework. Furthermore, there is little information on how these competencies were developed, whether they have been validated or are used by the European Union countries. We may conclude that the developed CNS- CoCoS is timely, evidence- based and has undergone rigorous content and construct validity testing.

Within the CNS- CoCoS, organisational competence (Factor 1) relates to the promotion of best practices, innovation and cooperation within the organisation. These competencies reflect the CNSs’ ability to support the organisation in its attempts to reach goals, anticipate and implement change, and ensure a positive work environment.

Furthermore, CNSs’ organisational competencies involve the CNS utilisation of evaluation information produced by the organisation and evaluation of several aspects of the care environment such as development needs, effects of culture and nursing practice, as well as safety of care. The CNS competence related to organisation is perhaps the most descriptive and distinguishing part of the CNSs’

practice differentiating them from other advanced practice nurses such as nurse practitioners, who do not primarily work within this sphere of practice (see, e.g., Canadian Nurses Association (2010);

ICN (2014); Mohr and Coke (2018); Thomas et al. (2017)). While

other specialty practitioners such as nurse administrators work in this sphere (Hanson & Hamric, 2003), the CNS practice within the organisation is supported by the other complimentary competence areas of patient, clinical nursing leadership and scholarship, which enable them to influence the organisational outcomes in the micro- , meso- and macrosystem (Mayo et al., 2017; Mohr & Coke, 2018).

The common thread in patient competence (Factor 2) relates to the CNS use of advanced competence and evidence- informed methods to assess care needs and care for their patients. These competencies help to promote person- centredness and ethical principles of care. CNSs coordinate and support the care of patients with complex needs and strengthen patient self- care abilities. Independent practice is reflective of this competence. The importance of patient domain, a cornerstone of CNS practice, has been voiced in the APN literature (i.e. Fulton et al., 2016, 2019; Hanson & Hamric, 2003; Jokiniemi et al., 2012). However, on a regular basis, the con- cern of diminishing CNS involvement in direct patient care is being raised (Jokiniemi et al., 2012; Kilpatrick et al., 2013; Lewandowski &

Adamle, 2009). It is notable that there does not seem to be a consis- tent definition of the concept of direct patient care in the context of CNS practice. Therefore, the developed CNS patient competencies offer a benchmark for the aspects of CNS direct patient care.

Scholarship competence (Factor 3) reflects CNS competence in evaluating care and in the analysis of evaluation information. CNSs participate in and support evidence- based practice, research and quality improvement activities within the organisation. Overall, CNSs promote knowledge translation and scientific cooperation within and across organisations. Although previous research has revealed that CNS involvement in research remains low (Jokiniemi et al., 2012; Kilpatrick et al., 2013; Oddsdóttir & Sveinsdóttir, 2011), research activity is viewed as an important aspect of CNS practice (Fulton et al., 2016; Kilpatrick et al., 2013; Mohr & Coke, 2018).

Moreover, the scope of scholarship competence goes far beyond research to include the promotion and assurance of other aspects of scholarly activities, such as evidence- based practice, quality improvement and knowledge translation.

Nursing competence, renamed clinical nursing leadership compe- tence (Factor 4), relates to CNS competence in promoting abilities and the professional development of nursing staff and supporting the critical evaluation of clinical practice within the work community. Furthermore, these competencies reflect CNSs’ ability to in- struct staff in the evidence- informed practices. CNS collaboration with the unit supervisor is essential in the actualisation of these competencies and assessment of the resources required to provide safe patient care. The competence construct is in line with the US CNS nurses/nursing practice sphere in addressing CNS practice in leading, mentoring and educating nurses in the development of in- novative, cost- effective, evidence- based nursing practice (Baldwin et al., 2007; NACNS, 2019). The increased need for CNS expert leadership at the bedside is highlighted by increased patient acu- ity, decreased hospital stays and expanded scientific knowledge (Cronenwett, 2012; Fulton et al., 2019; Lewandowski & Adamle, 2009). Moreover, with the nurse supervisors moving further away

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from the clinical practice (McWhirter & Scholes, 2009; Stanley &

Stanley, 2018), CNS involvement in working directly with nursing staff to improve care standards performed by the bedside nursing staff becomes therefore a high priority (see, e.g., Mohr & Coke, 2018).

The items within the four factors of the CNS- CoCoS fall into three domains (cognitive, affective and psychomotor) of cognitive taxonomy developed by Bloom and colleagues (Bloom et al., 1956;

Krathwohl, 2002). Although the items may meld more than one cognitive domain, according to the main emphasis, over 60% fall into the cognitive domain, a third into the affective domain and 10% into the psychomotor domain (Krathwohl, 2002). In addition to melding into more than one domain, each competence may illustrate different levels of the taxonomy (Kennedy, 2017). Based on mapping the competence items against the taxonomy, 64% of the items imply practitioner activity in the two highest levels of the different domains (synthesis/evaluation in cognitive domain; organisation/char- acterisation in affective domain; and articulation/naturalisation in psychomotor domain). It is inevitable that the CNS level of competence will evolve as the individual CNS becomes more experienced and moves from being a novice to an expert in their role (Benner, 1984; Kennedy, 2017).

It is notable that competency descriptions for the first developed APN role, CNS, are scarce (Mayo et al., 2017) and little tested by rigorous research methods. The United States and Canada have developed CNS core competencies (Baldwin et al., 2007; CNA, 2014), and the US competencies have undergone a rigorous content validation study (Baldwin et al., 2009). However, to our knowledge, no EFAs have been conducted on the existing CNS competencies. Furthermore, no rigorous research has been conducted before to study CNS competency descriptions in an international context. The reported research is therefore important in strengthening the international evidence base for CNS practice core competencies and may open up new directions in the con- ceptualisation and standardisation of the role. Moreover, the existing literature suggests that CNS role effects could be radically increased by optimising their competence (Fulton, 2014; Gardner et al., 2014).

The CNS- CoCoS may be used to reflect the diversity of CNS practice and promote role clarity, support role evolutions and advancement of CNS practice, and guide the development of educational curricula (Jokiniemi et al., 2018). We invite nurse leaders and educators, CNSs and politicians to utilise the CNS- CoCoS when developing, initiating and evaluating CNS practice. Conjoint efforts to develop and strengthen CNS practice and policy are required to enforce the efforts to strengthen the evidence base for this role. In addition, we invite researchers to further test the CNS- CoCoS, as research to validate the competencies in wider context with new samples is needed. We note that the competence related to CNS prescribing was removed from the scale during the content validity study (Jokiniemi et al., 2018), as CNSs have great variability in terms of prescriptive authority in many countries (Maier et al., 2017). This competence may be included in

the scale if the country in question has a CNS prescriptive authority. Finally, the next logical step will be to test with an independent sample how well the four- factor model would fit the data by confirmatory factor analysis.

4.1 | Limitations

The participants of this study came from three Nordic countries with similar healthcare systems (Olsen et al., 2016), where CNS roles have existed around two decades. This was the first study to inves- tigate the construct validity of the CNS- CoCoS with an adequate sample size; however, in the future further validation testing of the scale is needed to examine the scale in other contexts and with larger samples. Thus, results with a more representative, culturally diverse sample may differ from the current sample. Furthermore, psychometric testing to establish, for example, test– retest reliability and sensitivity to change, as well as to conduct confirmatory factor analysis will furthermore strengthen the validity of the scale.

Therefore, examination of the scale properties in new samples is important.

5 | CONCLUSION

The results of this study provided construct validity evidence of the underlying theoretical structures of the four competency spheres of patient, clinical nursing leadership, organisation and scholarship within the CNS- CoCoS. Furthermore, underlying dimensions between measured variables and latent constructs were examined and established. A 47- item CNS- CoCoS is recommended to be used in further studies and to be utilised to develop and implement CNS roles. The developed CNS- CoCoS has undergone a rigorous validation process in two phases (content validation study and construct validation study) to not only validate it in Finnish but also in a Nordic context. Therefore, the results are regarded as relevant to the international APN community in informing the clarification and standardisation of CNS core competencies, the development of educational programme curricula and identification of areas for professional development in an international context. In the future, it is important to test the CNS- CoCoS in other contexts to further validate its content and construct beyond the present study. The long- term goal is for the competency descriptions to enhance the role clarity and ultimately the effective development and implementation of CNS roles and their education.

ACKNOWLEDGEMENTS

We want to thank Dansk Sygeplejeråd, the Icelandic Nurses Association Clinical Nurse Specialists subchapter, and the Finnish Nurses Association CNS Network for their assistance with the participant recruitment. We also thank Dr. Kelley Kilpatric, Dr. Gísli Kort Kristófersson, Dr. Bibi Hølge- Hazelton and Dr. Kirsten Frederiksen for providing language help with the scale translations. Furthermore,

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we express our appreciation to the CNSs who participated in the study.

CONFLIC T OF INTEREST

No conflict of interest has been declared by the author(s).

AUTHOR CONTRIBUTIONS

KJ, A- MP, SM: Have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; KJ, A- MP, SM: Been involved in drafting the manuscript or re- vising it critically for important intellectual content; KJ, A- MP, SM:

Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public re- sponsibility for appropriate portions of the content; and KJ, A- MP, SM: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

FUNDING INFORMATION

This study received no specific external funding. During the study period, SM was supported by The Academy of Finland competitive funding to strengthen university research profiles (PROFI) for the University of Eastern Finland (grant no. 325022).

DATA AVAIL ABILIT Y STATEMENT Research data are not shared.

ORCID

Krista Jokiniemi https://orcid.org/0000-0002-6272-8203 Anna- Maija Pietilä https://orcid.org/0000-0003-0595-0657

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SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section.

How to cite this article: Jokiniemi K, Pietilä A-M, Mikkonen S. Construct validity of clinical nurse specialist core

competency scale: An exploratory factor analysis. J Clin Nurs.

2021;00:1–11. https://doi.org/10.1111/jocn.15587