Core competencies of different-level clinical nurse specialists: A comparative study between two years

Core competencies of different-level clinical nurse specialists: A comparative study between two years | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Core competencies of different-level clinical nurse specialists: A comparative study between two years Yafang Zhao, Xiaoxing Lai, Danping Zheng, Xinyue Zhang, Hongmei Zhang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4390373/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: To promote the collaborative development of CNSs at different levels, it is necessary to have a targeted understanding of the current core capabilities of CNSs at different levels. The study aims to describe and compare the core competencies of clinical nurse specialist (CNS) between two years in China and investigate the differences among three levels of expertise of CNSs: primary, intermediate, and advanced. Methods: This is a cross-sectional study. An online survey was conducted in 5 November, 2021 and 7 November, 2023. The study was conducted in a grade 3A hospital in China. A population sample of clinical nurse specialists from China was recruited. Core competency was assessed through a self-evaluation strategy, and the assessment instrument included five first-level domains and 35 items. The data were analysed based on their level and survey year. Results: A total of 483 clinical nurse specialists, classified into primary, intermediate, and advanced levels of expertise, participated in the study. The average CNS competency scores increased after two years ( P =.002). Among the primary-level CNSs, the scores for all five core competencies significantly differed from 2021 to 2023 ( P = .032, .009, .031, .006, .047). The competency of intermediate-level CNSs improved throughout the two years, and their scores for ‘consulting and teaching’ and ‘management and leadership’ were significantly different ( P < .001). For advanced-level CNSs, self-assessment scores all increased but were not significantly different. Conclusion: After two years of working at the clinic and receiving further education, the overall core abilities of specialized nurses improved. The performance improvement of intermediate specialized nurses is particularly outstanding, and they are the most popular among colleagues in clinical practice and can provide effective care for patients. The core abilities of primary and intermediate clinical nurse specialists need to be further improved to meet the more urgent needs of hospitals and patients in difficult clinical problems, team management, and professional development. advance practice clinical nurse specialist competency evaluation system management nurse professional development Figures Figure 1 Figure 2 Figure 3 Introduction Clinical nurse specialists (CNSs) focus on promoting professional nursing practices and enhancing patient care through the implementation and evaluation of quality initiatives and patient demands ( 1 ). The extension and expansion of nursing practices at an advanced level usually emerge as a result of service demand. The recent 13th Five-Year Plan issued by the Ministry of Health of the People's Republic of China included an assertion of the need to educate a critical mass of clinical specialists to enhance the standards of the general nursing team and accelerate nursing professional development( 2 ). Defining and assessing mastery in nursing competencies is the foundation for developing CNS roles and improving nursing care quality( 3 ). Although there have been research reports on China's CNS core capabilities, these evaluation frameworks have not been applied to CNSs with different levels of capabilities. CNS development started relatively late in China, and some Chinese hospitals have CNSs with an important hierarchical level of business capabilities. To promote the collaborative development of CNSs at different levels, it is necessary to have a targeted understanding of the current core capabilities of CNSs at different levels. Many studies have aimed to define core competencies for CNSs so that nursing practices may be developed for specialty areas ( 4 , 5 ). The CNS is a core member of the critical care multidisciplinary team( 6 ) whose competency is crucial for providing safe and effective critical care nursing practices and interventions for patients. With the increasing complexity and integrality of critical care delivery( 7 ), CNSs are required to possess a unique combination of professional skills, knowledge, attitudes, values, and technical abilities( 8 ). Developed countries have constructed competency frameworks that match the specific needs of their specialist critical care nurses. In 2013, the European Federation of Critical Care Nursing associations identified four domains and 14 subdomains of competencies to facilitate the assessment, development, and progression of critical care nurses( 9 ). The United States published “The AACN Synergy Model for Patient Care”, the framework included 8 domains that aim to improve nurses’ competence to provide optimal outcomes for patients( 10 ). These competency frameworks are intended to promote the effective provision of safe, high-quality health care services by CNSs thus adapting to today's complex, ever-changing health care environment( 11 ). Chinese scholars have established a competency framework tailored to the Chinese context, as working conditions and educational preparation in mainland China are different from those in developed countries( 12 , 13 ). However, the current status of China's CNS core capabilities has not been reported internationally, and surveys on CNS core capabilities in Western countries are rare. Jokiniemi et al.( 14 ) conducted a comparison survey among CNSs in Finland, Denmark, and Iceland, and the results illustrated that CNSs utilized the organizational competency most frequently, followed by patient, clinical nursing leadership and scholarship competencies. Li et al.( 15 ) conducted a cross-sectional survey on the core competencies and their implementation with 1875 specialized nurses in Anhui Province, China; they found that the CNSs had the highest score in the clinical practice dimension and the lowest score in the research and consulting dimension. By the end of March 2015, there were 84 clinical nursing master’s programs in China, and the Chinese Nurses Association currently has 26 specialized committees( 16 ) that form numerous specialty groups, which may reflect the foci of various nursing interests. There are more than 50000 CNSs in China, but few studies have reported on the use and assessment of CNS competencies in clinical practice. On the other hand, as the number of CNSs continues to grow and their fields continue to expand, the stratification of nursing staff by ability level is gradually becoming evident, but the current evaluation system for CNSs always uses the same standards and does not reflect the differentiating abilities and responsibilities of the CNS at diverse levels( 17 ). Drawing on the core idea of Benner's theory( 18 ) that nurses advance from beginners to experts, we further formulated standards for the graded management and clinical practice of CNSs, where CNSs are considered primary, intermediate, or advanced-level CNSs based on their years of clinical work, professional titles, and educational qualifications. The graded distribution of CNSs in our hospital reflected their different responsibilities in the clinical practice and improved plans for continuing their education. In 2021, we developed a graded competency framework for CNSs based on the International Council of Nurses (ICN) core competency requirement standards. The evaluation system included 5 dimensions and 35 subitems. Competencies are the essential foundation for effective practice, education and evaluation of the CNS role; therefore, benchmarking CNS core competencies within and across countries will benefit role development, integration and standardization and thus strengthen the CNS role in various contexts( 19 ). In this study, we compared the data from specialized nurses surveyed in 2021 and 2023 and compared the changes in core competencies of specialized nurses at different levels of expertise over the past two years to understand the clinical practice status and development needs of specialized nurses at different expertise levels. We also sought to elucidate whether the clinical application of hierarchical management of specialized nurses meets the medical and development needs of the nurses themselves. The study aims to describe and compare CNS core competencies throughout two years and compare it between CNS subgroups. Design This was a descriptive correlational study using a self-reported online questionnaire conducted in and 7 November, 2023. The study also utilized data collected from the same participants in 5 November, 2021 for comparison. Materials& Methods Participants Convenience sampling was used to recruit participants who had completed the CNS training course at the Beijing Nursing Association or Chinese Nursing Association and still worked at the hospital; these participants should have joined the survey in 2021. Participants were informed that completion of the e-survey was regarded as implied consent to participate in the study. Participants could withdraw from the study at any time, finally 498 CNSs completed the questionnaire in 2021. A total of 483 CNSs joined the survey in 2023, and the remaining participants were not included in the 2023 survey due to having been transferred to other positions or not agreeing to participate. Finally, 483 valid questionnaires were collected. Data collection In this study, the core competencies of CNSs were evaluated through a self-report survey. The evaluation questionnaires for the specialized nurses who participated in the survey were completely consistent over the two years. Data were collected using an online self-report questionnaire and wjx.cn ( https://www.wjx.cn/ ) website between October and November 2023. Instrument A validated 35-item CNS core competency questionnaire was used to compare CNS competency use between the two years. The CNS core competency scale was self-developed through a rigorous research process conducted in 2021 and included five competence spheres. i.e., those of clinical practice, consulting guidance and teaching, research and innovation, management and leadership, and discipline development. The scale used a 5-point response scale for the CNS to indicate the extent to which they agreed or disagreed with each core competency item. The response options were preferably, relatively good, average, not very well, not good (Supplementary-file-1 ). Data analysis For sociodemographic data, descriptive statistics were used to summarize the characteristics of the participants. The sum of each competency was calculated to illustrate the CNSs’ performance, and the mean scores for each subscale were calculated. Subgroups of CNS differences were compared using ANOVA with a p value of less than 0.05 to establish statistical significance. Univariate analysis or the Mann–Whitney U test was used to analyse the difference between the two years and to compare the difference between each competence. P < 0.05 was considered statistically significant. SPSS 25.0 (IBM Corp, 2017) was used for the data analysis. Ethical consideration This research was reviewed and approved by the ethics committee of the Peking Union Medical College Hospital on 8 October, 2022 (project: National High Level Hospital Clinical Research Funding, approval number: 2022-PUMCH-B-130). All participants provided a written consent inform before data collection (Supplementary-file-2). Results Participant characteristics Of the 498 surveys performed, 16 were excluded due to incomplete item responses. A total of 483 questionnaires were included in the final data analysis. Most participants were female, with an average age of 39.74 ± 5.76 years, an average of 18.9 (4.5) years of experience working as a registered nurse, and an average of 8.97 (4.6) years working as a CNS. Twenty-five (5%) of them achieved a master’s degree, while the others held a bachelor’s degree. Participants’ experience as a CNS was grouped into three levels: primary (n = 283), intermediate (n = 180), and advanced (n = 20). A total of 35 different specialized nursing fields were involved. (Table 1 ) Table 1 Characteristics of Clinical nurse specialists (n = 483) Item Number Percentage Female 474 98.1 Male 9 1.9 Highest level of Education Bachelor 458 94.8 Graduated 25 5.2 Mean SD Age 39.74 5.76 Year worked as RN 18.9 6.5 Year worked as CNS 7.6 2.7 The average core competency scores from both self-reported and peer evaluations in 2021 and 2023 Overall, the average competency scores of CNSs all increased after two years, reaching 163.96 and 162.89 in 2023 and 2021, respectively, and univariate analysis of variance revealed a significant difference between these scores ( P = .002). All five aspects of competence improved significantly after two years ( P < .001). Comparison of competency use between the two years (primary, intermediate, advanced) Among primary-level CNSs, the self-reported average scores for all five competencies in 2023 were greater than their counterparts in 2021, and all five aspects were significantly different from the rest ( P = .032, .009, .031, .006, .047). All competencies of the intermediate-level CNSs improved in two years, and the statistical analysis revealed significant differences in the self-assessment scores for the ‘consulting guidance and teaching’ and ‘management and leadership’ competencies ( P < .001). For advanced-level CNSs, all self-assessment scores increased, but without a significant difference (Table 2 ). Table 2 Score of specialized nurses at different levels in years of 2023 and 2021 (n = 483) Primary CNS Intermediate CNS Advanced CNS P value for comparison among subgroups (2023) a 2023 2021 2023 2021 2023 2021 Clinical practice 33.65 ± 2.88 33.4± 2.49 33.98± 2.24 32.64± 3.78 34.15± 2.18 32.80± 2.89 .044 a P value .032 .521 .390 Consulting guidance & teaching 32.48± 3.77 32.38± 3.82 32.64± 3.78 32.14± 4.85 32.58± 2.61 31.84± 5.33 .032 a P value .009 < .001 .997 Scientific research innovation 31.54± 4.55 30.98± 4.63 31.41± 4.51 31.43± 4.77 32.95± 3.32 31.80± 4.36 .251 a P value .031 .089 .914 Management & leadership 32.31± 4.13 32.36± 4.32 32.66± 3.85 32.39± 4.71 33.80± 2.67 31.50± 2.82 .097 a P value .006 < .001 .562 Discipline development 33.54± 2.26 32.97± 2.21 34.27± 1.62 33.89± 2.25 33.72± 2.71 33.47± 2.43 .129 a P value .047 .357 .908 All CNS 2023 2021 P value Total score 2023 2021 33.62± 2.67 33.59 ± 3.66 < .001 163.96 ± 3.62 162.89 ± 3.77 32.58± 3.66 32.29 ± 3.61 < .001 P value .002 31.55± 3.74 31.16 ± 4.99 < .001 32.48± 3.61 32.37 ± 3.2 < .001 34.04 ± 2.22 33.93 ± 2.22 < .001 P value for comparison among domains (2023) b < .001 b Comparison of competency scores at different CNS levels in 2023 (self-reported, peer evaluated, comparison) The scores of specialized nurses in different subgroups increased sequentially from the primary to the intermediate to the advanced level, and the results were consistent over the two years (Fig. 1, Fig. 2 ). In addition, there was a significant difference in scores between the different expertise levels in 2023. According to the results from the 2023survey, the ‘discipline development’ competency showed the highest scores, followed by ‘clinical practice’, ‘consulting guidance and teaching’, ‘management’, and ‘scientific research innovation’. ANOVA also revealed significant differences within each dimension ( P < .001). When comparing within CNS subgroups (Fig. 3), the self-reported results for the core competencies ‘clinical practice’, ‘consulting guidance and teaching’, and ‘scientific research innovation’ had the highest scores in advanced CNSs; in particular, the intermediate CNSs showed the highest ‘management and discipline development’ scores. The ANOVA showed that ‘clinical practice’ ( P = .044) and ‘consulting guidance and teaching’ scores were significantly different between primary-level and intermediate-level CNSs ( P = .032), but the other three competency scores were not significantly different among the three CNS subgroups (). Discussion This is the first study to compare CNS competency levels over two years in China. Furthermore, few studies have evaluated CNS competency in a graded fashion. The current study identified differences among the three levels of expertise, indirectly reflecting the effectiveness of implementing a graded clinical competency and evaluation system. The survey results showed that the competency of all nurses improved, with the improvements of primary and intermediate specialized nurses being more significant and showing greater room for further development. Significant changes in education consulting, professional development, and scientific innovation have also been identified. The results of this study can provide a clinical basis and reference for the long-term sustainable development of specialized nurses and the optimization of human resource allocation based on their level of competence. Although the changes in competence among individuals with different CNS levels over two years varied, their clinical practice competence levels all improved according to self-evaluation, with advanced-level CNSs improving the most. Clinical practice or direct clinical care was the most consolidated dimension of CNSs( 20 ); a possible explanation is that direct care is the most traditional nursing role and essence of nursing practice. These findings are consistent with those of other international and domestic studies investigating advanced practice nursing performance, which revealed that CNSs were most frequently involved in providing direct nursing services because of their expertise in specific domains( 21 , 22 ). As the main force in specialized nursing care practice, primary CNSs need to improve their professional and technical abilities as quickly as possible in clinical work to lay a solid foundation for the improvement in professional abilities and level advancement. Higher-level nurses, especially advanced CNSs, should undertake professional care for difficult and critically ill patients in specialized fields in clinical practice, coordinate with other levels of nurses, and take on leadership roles if necessary( 23 ). This finding is consistent with the progress training ideas of Shui et al.( 24 ) for setting training goals for neonatal PICC-specialized nurses. Abilities and responsibilities that match ability levels can not only improve patient satisfaction and clinical outcomes but also play a practical role in the development of CNSs in clinical practice. A US consensus study revealed that the prevalence of CNS involvement in direct patient care decreased from 25% in 2014 to less than 10% in 2018( 14 ). The decrease in the time spent in direct patient care is concerning and reinforces the perception that CNS roles are virtually invisible( 25 ). When comparing the results of two years of scoring, intermediate specialist nurses showed a significant improvement in their scores in consulting and teaching and professional development, indicating that more intermediate specialist nurses improved in these areas during the two years and were recognized by colleagues and patients. Notably, professional development is the primary competency dimension in higher-level CNSs, standing out above all other roles. Competency in this respect seems to be essential for the proper development and implementation of other roles( 25 ). Implicit in professional development capacity is the notion of competence in clinical practice, both of intermediate and advanced CNSs and of their coworkers( 26 ). Being at the mid-level of the process, the intermediate CNS obtains the potential power to improve to a higher level and at the same time has the responsibility to carry out educational activities in a downwards and parallel manner. Furthermore, our finding of CNS education parallels the results of the most recent CNS census study in the U.S., in which CNSs reported the highest amount of time (up to 32.5%) precepting nursing students. Teaching nurses/staff and patients/families were also among the top six activities for CNSs( 27 ). The modern health system has faced many challenges, especially the transition from an acute care-driven model to the management of chronic diseases and the provision of specific nursing. Shifting from a biomedical to a patient-centred model has been difficult but is required to increase the productivity of health professionals to optimize care services and manage patient expectations( 28 ). To deliver high-quality care, nurses are expected to continually update their knowledge and skills to maintain their competency in practice. CNSs are found to focus on educating, precepting, mentoring, and facilitating the professional development of nurses and nursing students( 29 , 30 ). The differences in the average competency scores obtained are reflected by differences in the competency gradient between primary, intermediate, and advanced CNSs, with advanced CNSs showing the highest level of competency in research and innovation and leadership and management. These results are in line with previous research carried out in other countries( 26 , 31 , 32 ). In addition, an undeveloped competency of research and innovation and leadership and management with relatively low scores in the current study was also suggested by some authors( 26 , 33 ). Although nursing research and innovation in China have advanced in the last decade, the development of nursing research is still necessary and has been related to the development of the CNS role( 34 , 35 ). CNSs may participate in medical studies and, mainly, in clinical trials led by medical teams; however, they may have more difficulties playing a leading role in their own research projects, especially in leading the innovation and achieving a transformation in nursing care. The reasons may involve multiple aspects, such as a lack of support from managers of healthcare organizations, from other healthcare professionals and even from nurses themselves. Moreover, the limitation of the scope of the research dimension and ability performance of CNSs could be explained by the lack of knowledge and acceptance of the new competencies of CNSs in the modern healthcare system in China( 36 , 37 ). The leadership and management dimensions in the current study differ from those of previous research, which has mainly reflected the ability to monitor quality improvement and team management. This dimension included two aspects: communicating and cooperating effectively with colleagues. Previous studies in China have shown that communication is a time-consuming activity during the nursing process and is directly related to most conflicts and medical errors in the clinical environment( 38 ). On the other hand, it is noteworthy that leadership is the primary competency dimension among intermediate-level CNSs, standing out above all other roles. Leadership is essential for clinical practice, especially for teamwork collaboration, and multidisciplinary collaboration can further provide better clinical care to suit patients’ needs and contribute to clinical research promotion( 39 ). Only through effective management can the full value of resources be realized, ultimately leading to the greatest professional development and clinical outcome. Our study has limitations. We surveyed CNSs from only one comprehensive hospital, and those working or training at other institutions were not included in this study. It was valuable and reliable to interpret changes in CNSs’ core competencies over two years within the same population, but these changes should be carefully interpreted when the results are applied to different healthcare system conditions and environments. Additionally, the self-assessment scores of the participants were not contrasted with the available documentation evidence. Future studies should further consider the influence of different working environments on CNSs, especially concerning the development of advanced competencies. Conclusion This study focused on comparing changes in core competency among CNSs over a two-year period and revealed that CNSs performed exceptionally well and improved remarkably in discipline development, consulting guidance and teaching, and clinical practice. These findings indicate that the CNSs in our hospital not only focus on the basic role of nursing practice but also reinforce the importance and hands-on practice of discipline development and the spread of knowledge to other areas. Additionally, the lack of scientific research and management ability was significant because of the need to promote evidence-based nursing scientific transformation and enhance multidisciplinary collaboration to achieve better healthcare outcomes, which is one of the hallmarks of leadership. We also interpreted from the survey data that primary CNSs were potentially the main force of specialist nursing development and that intermediate CNSs played a joint role in helping primary partner promotion and shouldering the mission of upwards promotion. Furthermore, research that describes the work of nurse practitioners in other areas with different healthcare environment backgrounds and diverse patient requirements will aid in understanding the advanced and specialist nature of the CNS role in China. Declarations Ethics approval and consent to participate: The study was reviewed by the Institutional Review Board of the Peking Union Medical College Hospital, which granted permission to conduct the study. The study followed the ethical guidelines, protocol, and regulations stated in the Declaration of Helsinki. Informed consent was obtained from all participants. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare no competing interests. Funding: Project: National High Level Hospital Clinical Research Funding Peking Union Medical College Hospital. Approval number: 2022-PUMCH-B-130) Author’s contributions ZYF: conceptualisation, formal analysis, investigation, writing–original draft, writing–review and editing, visualisation. LXX: conceptualisation, investigation, writing–review and editing, visualisation. ZDP: conceptualisation, methodology, writing–review and editing. ZXY: investigation, conceptualisation, methodology. ZHM: writing–review and editing. HXP: conceptualisation, methodology, writing–review and editing. Acknowledgements: Not applicable. Authors’ information: Yafang Zhao. Department of Ophthalmology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China. Xiaoxing Lai. Department of neurology, Chinese Academy of Medical Sciences &Peking Union Medical College Hospital, Beijing, China. Danping Zheng. International Medical Services, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China. Xinyue Zhang. Department of Medical intensive care unit, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China. Hongmei Zhang. Department of Nursing, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China. Xiaopeng Huo. Department of Nursing, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China. Contributors: ZYF: conceptualisation, formal analysis, investigation, writing–original draft, writing–review and editing, visualisation. 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Journal of nursing management. 2022;30(4):1002-10. Xue W, Heffernan C. Therapeutic communication within the nurse-patient relationship: A concept analysis. Int J Nurs Pract. 2021;27(6):e12938. Wan J, Xia H. How Advanced Practice Nurses Can Be Better Managed in Hospitals: A Multi-Case Study. Healthcare (Basel). 2023;11(6). Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1CNStwoyearquestionnaire.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4390373","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":307740179,"identity":"4e16c99a-6320-4ab2-a39a-c0231d164365","order_by":0,"name":"Yafang Zhao","email":"","orcid":"","institution":"Department of Ophthalmology, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Yafang","middleName":"","lastName":"Zhao","suffix":""},{"id":307740180,"identity":"4dd7cb5e-fff1-4ca6-b0a0-0f482b3568ee","order_by":1,"name":"Xiaoxing Lai","email":"","orcid":"","institution":"Department of neurology, Chinese Academy of Medical Sciences \u0026Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxing","middleName":"","lastName":"Lai","suffix":""},{"id":307740181,"identity":"644d30ea-645e-4808-896a-5f227b0749d9","order_by":2,"name":"Danping Zheng","email":"","orcid":"","institution":"International Medical Services, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Danping","middleName":"","lastName":"Zheng","suffix":""},{"id":307740182,"identity":"63b18f1d-94fb-4590-b9c2-4dc081b47884","order_by":3,"name":"Xinyue Zhang","email":"","orcid":"","institution":"Department of Medical intensive care unit, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Xinyue","middleName":"","lastName":"Zhang","suffix":""},{"id":307740186,"identity":"c46c5f91-34bc-4cda-98b8-d21932ecf31c","order_by":4,"name":"Hongmei Zhang","email":"","orcid":"","institution":"Department of Nursing, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":false,"prefix":"","firstName":"Hongmei","middleName":"","lastName":"Zhang","suffix":""},{"id":307740187,"identity":"4e979b44-826e-4a1c-8313-f9ec632e101e","order_by":5,"name":"Xiaopeng Huo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDklEQVRIie3RMUvEMBTA8VcC75bXq+CSwnG3OfconAiH9aO0BO4WUcTFMRA5Fz9Ai34IJ3FMCZxL0fXglhNXh3ZzUuMspKtD/mOSHyR5AD7fvyzYmc8rHGeK1bvua07RQPYRNjXQDNNkgGJa4mIU3+pekprgelwkER3sE5p5sjlxg0kpwFzIWX7ICBnRK8EGgrY7dbzkl1RPi7MjFa7f7vmWgjvJ4urRcS1+rnXYrC/BDJfJR7IlNtLIQgdBLkCHq+9CGppxyl8Iee4mZIkJV1g8WBKT1kR9hNM71GWDaazsJ1dSEKdaOd8yuRGsbe0oo8jYUcrjLHtWdds5COzlf5YC6Thvi7R73+fz+XzwA++CU/twy7oiAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Nursing, Chinese Academy of Medical Sciences \u0026 Peking Union Medical College Hospital, Beijing","correspondingAuthor":true,"prefix":"","firstName":"Xiaopeng","middleName":"","lastName":"Huo","suffix":""}],"badges":[],"createdAt":"2024-05-08 15:42:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4390373/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4390373/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57801342,"identity":"77a42f24-4d62-4e6a-bb1c-0e8065033471","added_by":"auto","created_at":"2024-06-05 22:16:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":880143,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure1CNSBMC.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4390373/v1/c431732720a4e1e5d5d1ee5c.jpg"},{"id":57801340,"identity":"0234db95-21a3-45bc-b6aa-f826d6a35956","added_by":"auto","created_at":"2024-06-05 22:16:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":940226,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure2CNSsbmc.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4390373/v1/14e6a72616ab52c7bf684dd6.jpg"},{"id":57801837,"identity":"3ce8cd17-a4cd-4416-8de7-ea52e79c0217","added_by":"auto","created_at":"2024-06-05 22:24:50","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":873269,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure3CNSBMC.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4390373/v1/ea4e1c3807d167864858c668.jpg"},{"id":81626929,"identity":"14a90643-79af-432f-b74f-6934bc4d7c84","added_by":"auto","created_at":"2025-04-29 10:32:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4129551,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4390373/v1/4a6afbeb-7a35-4706-b04a-f4b9b122db91.pdf"},{"id":57801338,"identity":"d57b4ac2-c116-496c-8346-3515b91f8d15","added_by":"auto","created_at":"2024-06-05 22:16:50","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22344,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1CNStwoyearquestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-4390373/v1/05c3f46d43273fc337d9a1de.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Core competencies of different-level clinical nurse specialists: A comparative study between two years","fulltext":[{"header":"Introduction","content":"\u003cp\u003eClinical nurse specialists (CNSs) focus on promoting professional nursing practices and enhancing patient care through the implementation and evaluation of quality initiatives and patient demands (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The extension and expansion of nursing practices at an advanced level usually emerge as a result of service demand. The recent 13th Five-Year Plan issued by the Ministry of Health of the People's Republic of China included an assertion of the need to educate a critical mass of clinical specialists to enhance the standards of the general nursing team and accelerate nursing professional development(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Defining and assessing mastery in nursing competencies is the foundation for developing CNS roles and improving nursing care quality(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Although there have been research reports on China's CNS core capabilities, these evaluation frameworks have not been applied to CNSs with different levels of capabilities. CNS development started relatively late in China, and some Chinese hospitals have CNSs with an important hierarchical level of business capabilities. To promote the collaborative development of CNSs at different levels, it is necessary to have a targeted understanding of the current core capabilities of CNSs at different levels.\u003c/p\u003e \u003cp\u003eMany studies have aimed to define core competencies for CNSs so that nursing practices may be developed for specialty areas (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The CNS is a core member of the critical care multidisciplinary team(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) whose competency is crucial for providing safe and effective critical care nursing practices and interventions for patients. With the increasing complexity and integrality of critical care delivery(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), CNSs are required to possess a unique combination of professional skills, knowledge, attitudes, values, and technical abilities(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Developed countries have constructed competency frameworks that match the specific needs of their specialist critical care nurses. In 2013, the European Federation of Critical Care Nursing associations identified four domains and 14 subdomains of competencies to facilitate the assessment, development, and progression of critical care nurses(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The United States published \u0026ldquo;The AACN Synergy Model for Patient Care\u0026rdquo;, the framework included 8 domains that aim to improve nurses\u0026rsquo; competence to provide optimal outcomes for patients(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These competency frameworks are intended to promote the effective provision of safe, high-quality health care services by CNSs thus adapting to today's complex, ever-changing health care environment(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChinese scholars have established a competency framework tailored to the Chinese context, as working conditions and educational preparation in mainland China are different from those in developed countries(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, the current status of China's CNS core capabilities has not been reported internationally, and surveys on CNS core capabilities in Western countries are rare. Jokiniemi et al.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) conducted a comparison survey among CNSs in Finland, Denmark, and Iceland, and the results illustrated that CNSs utilized the organizational competency most frequently, followed by patient, clinical nursing leadership and scholarship competencies. Li et al.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) conducted a cross-sectional survey on the core competencies and their implementation with 1875 specialized nurses in Anhui Province, China; they found that the CNSs had the highest score in the clinical practice dimension and the lowest score in the research and consulting dimension.\u003c/p\u003e \u003cp\u003eBy the end of March 2015, there were 84 clinical nursing master\u0026rsquo;s programs in China, and the Chinese Nurses Association currently has 26 specialized committees(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) that form numerous specialty groups, which may reflect the foci of various nursing interests. There are more than 50000 CNSs in China, but few studies have reported on the use and assessment of CNS competencies in clinical practice. On the other hand, as the number of CNSs continues to grow and their fields continue to expand, the stratification of nursing staff by ability level is gradually becoming evident, but the current evaluation system for CNSs always uses the same standards and does not reflect the differentiating abilities and responsibilities of the CNS at diverse levels(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Drawing on the core idea of Benner's theory(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) that nurses advance from beginners to experts, we further formulated standards for the graded management and clinical practice of CNSs, where CNSs are considered primary, intermediate, or advanced-level CNSs based on their years of clinical work, professional titles, and educational qualifications. The graded distribution of CNSs in our hospital reflected their different responsibilities in the clinical practice and improved plans for continuing their education. In 2021, we developed a graded competency framework for CNSs based on the International Council of Nurses (ICN) core competency requirement standards. The evaluation system included 5 dimensions and 35 subitems.\u003c/p\u003e \u003cp\u003eCompetencies are the essential foundation for effective practice, education and evaluation of the CNS role; therefore, benchmarking CNS core competencies within and across countries will benefit role development, integration and standardization and thus strengthen the CNS role in various contexts(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In this study, we compared the data from specialized nurses surveyed in 2021 and 2023 and compared the changes in core competencies of specialized nurses at different levels of expertise over the past two years to understand the clinical practice status and development needs of specialized nurses at different expertise levels. We also sought to elucidate whether the clinical application of hierarchical management of specialized nurses meets the medical and development needs of the nurses themselves. The study aims to describe and compare CNS core competencies throughout two years and compare it between CNS subgroups.\u003c/p\u003e\n\u003ch3\u003eDesign\u003c/h3\u003e\n\u003cp\u003eThis was a descriptive correlational study using a self-reported online questionnaire conducted in and 7 November, 2023. The study also utilized data collected from the same participants in 5 November, 2021 for comparison.\u003c/p\u003e"},{"header":"Materials\u0026 Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eConvenience sampling was used to recruit participants who had completed the CNS training course at the Beijing Nursing Association or Chinese Nursing Association and still worked at the hospital; these participants should have joined the survey in 2021. Participants were informed that completion of the e-survey was regarded as implied consent to participate in the study. Participants could withdraw from the study at any time, finally 498 CNSs completed the questionnaire in 2021. A total of 483 CNSs joined the survey in 2023, and the remaining participants were not included in the 2023 survey due to having been transferred to other positions or not agreeing to participate. Finally, 483 valid questionnaires were collected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eIn this study, the core competencies of CNSs were evaluated through a self-report survey. The evaluation questionnaires for the specialized nurses who participated in the survey were completely consistent over the two years. Data were collected using an online self-report questionnaire and wjx.cn (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wjx.cn/\u003c/span\u003e\u003cspan address=\"https://www.wjx.cn/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) website between October and November 2023.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eInstrument\u003c/h2\u003e \u003cp\u003eA validated 35-item CNS core competency questionnaire was used to compare CNS competency use between the two years. The CNS core competency scale was self-developed through a rigorous research process conducted in 2021 and included five competence spheres. i.e., those of clinical practice, consulting guidance and teaching, research and innovation, management and leadership, and discipline development. The scale used a 5-point response scale for the CNS to indicate the extent to which they agreed or disagreed with each core competency item. The response options were preferably, relatively good, average, not very well, not good \u003cb\u003e(Supplementary-file-1\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eFor sociodemographic data, descriptive statistics were used to summarize the characteristics of the participants. The sum of each competency was calculated to illustrate the CNSs\u0026rsquo; performance, and the mean scores for each subscale were calculated. Subgroups of CNS differences were compared using ANOVA with a p value of less than 0.05 to establish statistical significance. Univariate analysis or the Mann\u0026ndash;Whitney U test was used to analyse the difference between the two years and to compare the difference between each competence. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. SPSS 25.0 (IBM Corp, 2017) was used for the data analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical consideration\u003c/h2\u003e \u003cp\u003e This research was reviewed and approved by the ethics committee of the Peking Union Medical College Hospital on 8 October, 2022 (project: National High Level Hospital Clinical Research Funding, approval number: 2022-PUMCH-B-130). All participants provided a written consent inform before data collection \u003cb\u003e(Supplementary-file-2).\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eOf the 498 surveys performed, 16 were excluded due to incomplete item responses. A total of 483 questionnaires were included in the final data analysis. Most participants were female, with an average age of 39.74\u0026thinsp;\u0026plusmn;\u0026thinsp;5.76 years, an average of 18.9 (4.5) years of experience working as a registered nurse, and an average of 8.97 (4.6) years working as a CNS. Twenty-five (5%) of them achieved a master\u0026rsquo;s degree, while the others held a bachelor\u0026rsquo;s degree. Participants\u0026rsquo; experience as a CNS was grouped into three levels: primary (n\u0026thinsp;=\u0026thinsp;283), intermediate (n\u0026thinsp;=\u0026thinsp;180), and advanced (n\u0026thinsp;=\u0026thinsp;20). A total of 35 different specialized nursing fields were involved. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Clinical nurse specialists (n\u0026thinsp;=\u0026thinsp;483)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e474\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest level of Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e458\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear worked as RN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear worked as CNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThe average core competency scores from both self-reported and peer evaluations in 2021 and 2023\u003c/h2\u003e \u003cp\u003eOverall, the average competency scores of CNSs all increased after two years, reaching 163.96 and 162.89 in 2023 and 2021, respectively, and univariate analysis of variance revealed a significant difference between these scores (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002). All five aspects of competence improved significantly after two years (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eComparison of competency use between the two years (primary, intermediate, advanced)\u003c/h2\u003e \u003cp\u003eAmong primary-level CNSs, the self-reported average scores for all five competencies in 2023 were greater than their counterparts in 2021, and all five aspects were significantly different from the rest (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.032, .009, .031, .006, .047). All competencies of the intermediate-level CNSs improved in two years, and the statistical analysis revealed significant differences in the self-assessment scores for the \u0026lsquo;consulting guidance and teaching\u0026rsquo; and \u0026lsquo;management and leadership\u0026rsquo; competencies (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). For advanced-level CNSs, all self-assessment scores increased, but without a significant difference (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScore of specialized nurses at different levels in years of 2023 and 2021 (n\u0026thinsp;=\u0026thinsp;483)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePrimary CNS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eIntermediate CNS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eAdvanced CNS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value for comparison among subgroups (2023)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.4\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.98\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.64\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.15\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e32.80\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.044\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConsulting guidance \u0026amp; teaching\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.48\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.38\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.64\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.14\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.58\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.84\u0026plusmn;\u003c/p\u003e \u003cp\u003e5.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.032\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eScientific research innovation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.54\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.98\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.41\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.43\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.95\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.80\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.251\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.914\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eManagement \u0026amp; leadership\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.31\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.36\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.66\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32.39\u0026plusmn;\u003c/p\u003e \u003cp\u003e4.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.80\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.50\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.097\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.562\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiscipline development\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.54\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.97\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.27\u0026plusmn;\u003c/p\u003e \u003cp\u003e1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.89\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e33.72\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e33.47\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.129\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.908\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAll CNS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eTotal score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.62\u0026plusmn;\u003c/p\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.59\u0026thinsp;\u0026plusmn;\u0026thinsp;3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e163.96\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e162.89\u0026thinsp;\u0026plusmn;\u0026thinsp;3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.58\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.29\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.55\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.16\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.48\u0026plusmn;\u003c/p\u003e \u003cp\u003e3.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.04\u0026thinsp;\u0026plusmn;\u0026thinsp;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e \u003cb\u003evalue for comparison among domains (2023)\u003c/b\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComparison of competency scores at different CNS levels in 2023 (self-reported, peer evaluated, comparison)\u003c/h2\u003e \u003cp\u003eThe scores of specialized nurses in different subgroups increased sequentially from the primary to the intermediate to the advanced level, and the results were consistent over the two years (Fig.\u0026nbsp;1, \u003cb\u003eFig.\u0026nbsp;2\u003c/b\u003e). In addition, there was a significant difference in scores between the different expertise levels in 2023. According to the results from the 2023survey, the \u0026lsquo;discipline development\u0026rsquo; competency showed the highest scores, followed by \u0026lsquo;clinical practice\u0026rsquo;, \u0026lsquo;consulting guidance and teaching\u0026rsquo;, \u0026lsquo;management\u0026rsquo;, and \u0026lsquo;scientific research innovation\u0026rsquo;. ANOVA also revealed significant differences within each dimension (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eWhen comparing within CNS subgroups (Fig.\u0026nbsp;3), the self-reported results for the core competencies \u0026lsquo;clinical practice\u0026rsquo;, \u0026lsquo;consulting guidance and teaching\u0026rsquo;, and \u0026lsquo;scientific research innovation\u0026rsquo; had the highest scores in advanced CNSs; in particular, the intermediate CNSs showed the highest \u0026lsquo;management and discipline development\u0026rsquo; scores. The ANOVA showed that \u0026lsquo;clinical practice\u0026rsquo; (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.044) and \u0026lsquo;consulting guidance and teaching\u0026rsquo; scores were significantly different between primary-level and intermediate-level CNSs (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.032), but the other three competency scores were not significantly different among the three CNS subgroups ().\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study to compare CNS competency levels over two years in China. Furthermore, few studies have evaluated CNS competency in a graded fashion. The current study identified differences among the three levels of expertise, indirectly reflecting the effectiveness of implementing a graded clinical competency and evaluation system. The survey results showed that the competency of all nurses improved, with the improvements of primary and intermediate specialized nurses being more significant and showing greater room for further development. Significant changes in education consulting, professional development, and scientific innovation have also been identified. The results of this study can provide a clinical basis and reference for the long-term sustainable development of specialized nurses and the optimization of human resource allocation based on their level of competence.\u003c/p\u003e \u003cp\u003eAlthough the changes in competence among individuals with different CNS levels over two years varied, their clinical practice competence levels all improved according to self-evaluation, with advanced-level CNSs improving the most. Clinical practice or direct clinical care was the most consolidated dimension of CNSs(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e); a possible explanation is that direct care is the most traditional nursing role and essence of nursing practice. These findings are consistent with those of other international and domestic studies investigating advanced practice nursing performance, which revealed that CNSs were most frequently involved in providing direct nursing services because of their expertise in specific domains(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). As the main force in specialized nursing care practice, primary CNSs need to improve their professional and technical abilities as quickly as possible in clinical work to lay a solid foundation for the improvement in professional abilities and level advancement. Higher-level nurses, especially advanced CNSs, should undertake professional care for difficult and critically ill patients in specialized fields in clinical practice, coordinate with other levels of nurses, and take on leadership roles if necessary(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This finding is consistent with the progress training ideas of Shui et al.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) for setting training goals for neonatal PICC-specialized nurses. Abilities and responsibilities that match ability levels can not only improve patient satisfaction and clinical outcomes but also play a practical role in the development of CNSs in clinical practice.\u003c/p\u003e \u003cp\u003eA US consensus study revealed that the prevalence of CNS involvement in direct patient care decreased from 25% in 2014 to less than 10% in 2018(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The decrease in the time spent in direct patient care is concerning and reinforces the perception that CNS roles are virtually invisible(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). When comparing the results of two years of scoring, intermediate specialist nurses showed a significant improvement in their scores in consulting and teaching and professional development, indicating that more intermediate specialist nurses improved in these areas during the two years and were recognized by colleagues and patients.\u003c/p\u003e \u003cp\u003eNotably, professional development is the primary competency dimension in higher-level CNSs, standing out above all other roles. Competency in this respect seems to be essential for the proper development and implementation of other roles(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Implicit in professional development capacity is the notion of competence in clinical practice, both of intermediate and advanced CNSs and of their coworkers(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Being at the mid-level of the process, the intermediate CNS obtains the potential power to improve to a higher level and at the same time has the responsibility to carry out educational activities in a downwards and parallel manner. Furthermore, our finding of CNS education parallels the results of the most recent CNS census study in the U.S., in which CNSs reported the highest amount of time (up to 32.5%) precepting nursing students. Teaching nurses/staff and patients/families were also among the top six activities for CNSs(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The modern health system has faced many challenges, especially the transition from an acute care-driven model to the management of chronic diseases and the provision of specific nursing. Shifting from a biomedical to a patient-centred model has been difficult but is required to increase the productivity of health professionals to optimize care services and manage patient expectations(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). To deliver high-quality care, nurses are expected to continually update their knowledge and skills to maintain their competency in practice. CNSs are found to focus on educating, precepting, mentoring, and facilitating the professional development of nurses and nursing students(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe differences in the average competency scores obtained are reflected by differences in the competency gradient between primary, intermediate, and advanced CNSs, with advanced CNSs showing the highest level of competency in research and innovation and leadership and management. These results are in line with previous research carried out in other countries(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In addition, an undeveloped competency of research and innovation and leadership and management with relatively low scores in the current study was also suggested by some authors(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Although nursing research and innovation in China have advanced in the last decade, the development of nursing research is still necessary and has been related to the development of the CNS role(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). CNSs may participate in medical studies and, mainly, in clinical trials led by medical teams; however, they may have more difficulties playing a leading role in their own research projects, especially in leading the innovation and achieving a transformation in nursing care. The reasons may involve multiple aspects, such as a lack of support from managers of healthcare organizations, from other healthcare professionals and even from nurses themselves. Moreover, the limitation of the scope of the research dimension and ability performance of CNSs could be explained by the lack of knowledge and acceptance of the new competencies of CNSs in the modern healthcare system in China(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe leadership and management dimensions in the current study differ from those of previous research, which has mainly reflected the ability to monitor quality improvement and team management. This dimension included two aspects: communicating and cooperating effectively with colleagues. Previous studies in China have shown that communication is a time-consuming activity during the nursing process and is directly related to most conflicts and medical errors in the clinical environment(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). On the other hand, it is noteworthy that leadership is the primary competency dimension among intermediate-level CNSs, standing out above all other roles. Leadership is essential for clinical practice, especially for teamwork collaboration, and multidisciplinary collaboration can further provide better clinical care to suit patients\u0026rsquo; needs and contribute to clinical research promotion(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Only through effective management can the full value of resources be realized, ultimately leading to the greatest professional development and clinical outcome.\u003c/p\u003e \u003cp\u003eOur study has limitations. We surveyed CNSs from only one comprehensive hospital, and those working or training at other institutions were not included in this study. It was valuable and reliable to interpret changes in CNSs\u0026rsquo; core competencies over two years within the same population, but these changes should be carefully interpreted when the results are applied to different healthcare system conditions and environments. Additionally, the self-assessment scores of the participants were not contrasted with the available documentation evidence. Future studies should further consider the influence of different working environments on CNSs, especially concerning the development of advanced competencies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study focused on comparing changes in core competency among CNSs over a two-year period and revealed that CNSs performed exceptionally well and improved remarkably in discipline development, consulting guidance and teaching, and clinical practice. These findings indicate that the CNSs in our hospital not only focus on the basic role of nursing practice but also reinforce the importance and hands-on practice of discipline development and the spread of knowledge to other areas. Additionally, the lack of scientific research and management ability was significant because of the need to promote evidence-based nursing scientific transformation and enhance multidisciplinary collaboration to achieve better healthcare outcomes, which is one of the hallmarks of leadership. We also interpreted from the survey data that primary CNSs were potentially the main force of specialist nursing development and that intermediate CNSs played a joint role in helping primary partner promotion and shouldering the mission of upwards promotion. Furthermore, research that describes the work of nurse practitioners in other areas with different healthcare environment backgrounds and diverse patient requirements will aid in understanding the advanced and specialist nature of the CNS role in China.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was reviewed by the Institutional Review Board of the Peking Union Medical College Hospital, which granted permission to conduct the study. The study followed the ethical guidelines, protocol, and regulations stated in the Declaration of Helsinki. Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProject: National High Level Hospital Clinical Research Funding Peking Union Medical College Hospital. Approval number: 2022-PUMCH-B-130)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZYF: conceptualisation, formal analysis, investigation, writing–original draft, writing–review and editing, visualisation. LXX: conceptualisation, investigation, writing–review and editing, visualisation. ZDP: conceptualisation, methodology, writing–review and editing. ZXY: investigation, conceptualisation, methodology. ZHM: writing–review and editing. HXP: conceptualisation, methodology, writing–review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNot applicable.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ information:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYafang Zhao. Department of Ophthalmology, Chinese Academy of Medical Sciences \u0026amp; Peking Union Medical College Hospital, Beijing, China.\u003c/p\u003e\n\u003cp\u003eXiaoxing Lai. Department of neurology, Chinese Academy of Medical Sciences \u0026amp;Peking Union Medical College Hospital, Beijing, China.\u003c/p\u003e\n\u003cp\u003eDanping Zheng. International Medical Services, Chinese Academy of Medical Sciences \u0026amp; Peking Union Medical College Hospital, Beijing, China.\u003c/p\u003e\n\u003cp\u003eXinyue Zhang. Department of Medical intensive care unit, Chinese Academy of Medical Sciences \u0026amp; Peking Union Medical College Hospital, Beijing, China.\u003c/p\u003e\n\u003cp\u003eHongmei Zhang. Department of Nursing, Chinese Academy of Medical Sciences \u0026amp; Peking Union Medical College Hospital, Beijing, China.\u003c/p\u003e\n\u003cp\u003eXiaopeng Huo. Department of Nursing, Chinese Academy of Medical Sciences \u0026amp; Peking Union Medical College Hospital, Beijing, China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors:\u003c/strong\u003e ZYF: conceptualisation, formal analysis, investigation, writing–original draft, writing–review and editing, visualisation. LXX: conceptualisation, investigation, writing–review and editing, visualisation. ZDP: conceptualisation, methodology, writing–review and editing. ZXY: investigation, conceptualisation, methodology. ZHM: writing–review and editing. HXP: conceptualisation, methodology, writing–review and editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHarne-Britner S, Schafer DJ. Clinical nurse specialists driving research and practice through Research Roundtables. Clinical nurse specialist CNS. 2009;23(6):305-8.\u003c/li\u003e\n \u003cli\u003ePRC NHCot. 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Healthcare (Basel). 2023;11(6).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"advance practice, clinical nurse specialist, competency, evaluation system, management, nurse, professional development","lastPublishedDoi":"10.21203/rs.3.rs-4390373/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4390373/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTo promote the collaborative development of CNSs at different levels, it is necessary to have a targeted understanding of the current core capabilities of CNSs at different levels. The study aims to describe and compare the core competencies of clinical nurse specialist (CNS) between two years in China and investigate the differences among three levels of expertise of CNSs: primary, intermediate, and advanced.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This is a cross-sectional study. An online survey was conducted in 5 November, 2021 and 7 November, 2023. The study was conducted in a grade 3A hospital in China. A population sample of clinical nurse specialists from China was recruited. Core competency was assessed through a self-evaluation strategy, and the assessment instrument included five first-level domains and 35 items. The data were analysed based on their level and survey year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 483 clinical nurse specialists, classified into primary, intermediate, and advanced levels of expertise, participated in the study. The average CNS competency scores increased after two years (\u003cem\u003eP\u003c/em\u003e=.002). Among the primary-level CNSs, the scores for all five core competencies significantly differed from 2021 to 2023 (\u003cem\u003eP\u003c/em\u003e= .032, .009, .031, .006, .047). The competency of intermediate-level CNSs improved throughout the two years, and their scores for ‘consulting and teaching’ and ‘management and leadership’ were significantly different (\u003cem\u003eP\u003c/em\u003e\u0026lt; .001). For advanced-level CNSs, self-assessment scores all increased but were not significantly different.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAfter two years of working at the clinic and receiving further education, the overall core abilities of specialized nurses improved. The performance improvement of intermediate specialized nurses is particularly outstanding, and they are the most popular among colleagues in clinical practice and can provide effective care for patients. The core abilities of primary and intermediate clinical nurse specialists need to be further improved to meet the more urgent needs of hospitals and patients in difficult clinical problems, team management, and professional development.\u003c/p\u003e","manuscriptTitle":"Core competencies of different-level clinical nurse specialists: A comparative study between two years","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-05 22:16:45","doi":"10.21203/rs.3.rs-4390373/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"711d1261-ea5a-40cd-9a78-d788c64d70eb","owner":[],"postedDate":"June 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-29T10:23:43+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-05 22:16:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4390373","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4390373","identity":"rs-4390373","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}