International Emergency Nursing (2010) 18, 3–7

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Research plan for developing traumacore competencies for nurses in Thailand

Krongdai Unhasuta RN, EdD (Assistant Professor) a,1,Marylou V. Robinson PhD, FNP (Assistant Professor) b,*,Kathy Magilvy PhD, FAAN (Professor, Associate Dean for Academic Programs,PhD Program Director) b

a Surgical Nursing Department, Faculty of Nursing, Mahidol University, Bangkok 10700, Thailandb College of Nursing, University of Colorado Denver, Aurora, CO, USA

Received 26 May 2009; received in revised form 30 July 2009; accepted 11 August 2009

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KEYWORDSTrauma nurse;Core competency;Emergency department;Thailand

55-599X/$ - see front matti:10.1016/j.ienj.2009.08.00

Corresponding author. Addlorado, 13120 E. 19th Ave045, USA. Tel.: +1 303 724E-mail addresses: nskuh@m

binson@ucdenver.edu (M.V.Tel.: +66 2 4197466 80x17

er ª 2001

ress: Unnue, Ma8564; faxahidol.aRobinso55 6; fax

Abstract The aim of this research plan was identification and development of core competen-cies for emergency trauma nurses in Thailand. The research plan was undertaken in threephases. Phase I: a national survey of the critical dimensions of care; Phase II: developmentof a 64 item tool; and Phase III: efficiency study with emergency nurses representing Level-1, Regional, Community and Rural facilities. Six dimensions of competency were identified:cooperation, decision-making, leadership, problem-solving, teamwork, and technical knowl-edge with a content validity index (CVI) of 1.00 and internal consistency (Cronbach’s a) of0.98 (N = 485 RNs in 29 hospitals). Analysis of the first year pilot study data using a 5 point likertscale (N = 285 RNs in 16 hospitals), nurses rated themselves as 4.18 (SD = 0.69) and their peersat 4.00 (SD = 0.68). Head nurse evaluations averaged 3.98 (SD = 0.55). ANOVA demonstrated nostatistical significance (p = 0.09) between groups. The results of the preliminary studies dem-onstrated appropriateness of the core competency items, but refinement is required prior tonational distribution.ª 2009 Elsevier Ltd. All rights reserved.

9 Elsevier Ltd. All rights reserved

iversity of Colorado Denver,il Stop C288-19, Aurora, CO: +1 303 724 8559.c.th (K. Unhasuta), marylou.n).: +66 2 4128415.

Introduction

The goals of current trauma treatment systems in Thailandare the same as they are worldwide: (1) develop an inclusivesystem to provide definitive care to the critically injuredpatient (American College of Surgeons, 2006); (2) identifyand promote ways of reinforcing excellence in trauma

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4 K. Unhasuta et al.

treatment; and (3) prevent or lessen the burden of deathand disability from injury. A qualified emergency traumateam, including surgical physicians, nurses, specialist physi-cians, anesthesiologists and technicians, is needed for thissystem to function optimally. Such a team, for example,recognizes hypoxemia and inadequate tissue perfusion ofthe critically injured patient as significant causes of death.Skills in accurate assessment and judgment enable the teamto avoid delays in treatment (Tien et al., 2004; Gruen et al.,2006; Spahn et al., 2007).

Studies in the United States, Canada and Europe indicatedelays in care result in unnecessary trauma deaths fromrespiratory problems, uncontrolled blood loss, and thoracictrauma (Tien et al., 2004; Gruen et al., 2006; Spahn et al.,2007). Comparative studies in Thailand reveal the delaysthat cause preventable deaths stem from several factors:incomplete initial assessments, lack of standards to guidepractice, delayed interventions, improper treatment, lackof resuscitation skills, and incomplete history-taking (Sakol-sattayatorn, 1999; Summavaj and Chantorn, 2002).

Trauma deaths in Thailand from motor vehicle crashesalone averaged 13,260 deaths per year from 2002 to 2006.Added to that figure, approximately 5 million people wereinjured, and several hundreds of thousands became perma-nently disabled during that same period (Mahaisavariya,2008). Advanced Trauma Life Support (ATLS�) was insti-tuted in 2003 as a solution for deficits in Thai physicians’and surgeons’ knowledge and skills (Wora-ulai, 2006); how-ever, no unified efforts have been made to improve nursingskill levels (Unhasuta, 2005). There are no programs to pre-pare Thai trauma nurses who work in the emergency room(ER). Such educational programs are critical because inmany 400 bed hospitals there are only two to three ATLS�

trained surgical physicians. Nurses must help stabilize pa-tients before the physician arrives, and then be preparedto function as effective team members. In some hospitals,there are no ATLS physicians, so the critically injured pa-tient receives initial trauma care from nurses who typicallyhave no specialty education. Any trauma training availablefrequently is not standardized. In many areas training isnot available at all.

No standards exist to evaluate Thai emergency nurses.These nurses are evaluated against the same criteria usedin other areas of the hospital, although their workload andrequired skill sets are very different. The experience, skilland knowledge required to ensure success in trauma careis not acknowledged in any formal way (Unhasuta et al.,2008). Together, the lack of specialty training, knowledgelevel and inability to provide an effective team approachto trauma care likely contribute to many preventable deathsin Thailand.

To address these issues, the projects described in this pa-per were undertaken to develop a way to assess Thai ERnurses’ core competency. This research is significant be-cause if core competencies can be established for staffnurses, nurse managers will be able to develop specialtytraining programs and establish objective evaluative criteriathat specifically reflect ER nursing practice. Better ER nurs-ing care will result. Through this research, the authors hopeto establish the groundwork to create a unified network ofThai ER nurses; and influence the standards for the prepara-tion of emergency trauma nurses nationwide.

Methods: a three phase design

A developmental study design was used to improve and testemergency trauma nurses’ core competencies in Thailand.The study consisted of three phases: (1) a survey and assess-ment of trauma nurses’ core competency; (2) developmentand construction of a dictionary denoting the dimensions ofeach identified area of competency, to include leveling ofexpectations from novice to expert; and (3) an efficiencystudy to test the identified competencies in actual practice.Each phase of the study consisted of several steps. The workwas carried out by the primary author over a period of twoyears. For clarity, results are reported as the phases aredescribed.

Phase I: survey and testing for validity andreliability

Brainstorming

The first step was to generate a vision of what emergencytrauma care could become in Thailand. The researcher led62 emergency head nurses from every level of trauma cen-ter in several brainstorming sessions that led to agreementof a vision for the country’s ER nurses. They then identified123 items that varied from skills to leadership attributesthey believed accurately described the core of theirspecialty practice. The items were grouped under six behav-ioral dimensions: cooperation, decision-making, leadership,problem-solving, teamwork, and technical knowledge(Unhasuta et al., 2008).

Refinement

The items were sent to three experts to evaluate how rele-vant each item was to the six behavioral dimensions. Oneexpert came from a quality improvement background, andtwo were experts in staff development. Relevance wasjudged on a 3-point rating scale (1 = not relevant, 2 = rele-vant, 3 = very relevant). Items were deleted if all three ex-perts gave ratings of 1 or 2. Only 64 items were retainedwithin the six dimensions. Content validity was endorsedby five emergency care experts with each dimension at1.00 exceeding the minimal required 0.80 Content ValidityIndex (CVI) (Polit and Beck, 2008).

To ensure the bedside nurse agreed with these experts,485 emergency nurses from 29 hospitals across Thailand,(7 Level-I, 10 regional, 6 community, and 6 rural), com-pleted a self-evaluation indicating how often they used eachitem in the scale during one month of use. A strong internalconsistency (Cronbach’s a = 0.98) (Polit and Beck, 2008) re-sulted with the scale mean (l) and standard deviation (SD)for frequency of item use of 4.09 and 0.91, respectivelyon a 5 point scale: 1 = ‘‘never uses’’, to 5 = ‘‘always uses’’in clinical practice. The lowest score was decision-making(l = 3.39; SD = 0.89) and the highest was teamwork(l = 4.21; SD = 0.90). Every item was identified as reflectinga part of their practice in treating trauma patients. Thismeans the items focused on what emergency nurses actuallydo in trauma care and reflect the Emergency Nurses

Research plan for developing traumacore competencies for nurses in Thailand 5

Association’s description that ‘‘The dimensions of emer-gency nursing include the roles, responsibilities, functions,and skills that involve a specific body of knowledge.’’(Emergency Nurses Association, 1999, P.4).

Phase II: dictionary development

Dictionary construction

With confidence that both experts and staff nurses were inagreement that the 64 items did reflect ER practice, the pri-mary author constructed a dictionary to define each itemand dimension. This document would provide clarity if usersneeded to have the items differentiated when using them inpractice. Using Benner’s work as a framework (Benner,1984), each item was leveled by expectations of actionsfrom novice to expert nurses (See Table 1). The dictionarywas sent to five experts to determine whether associateddefinition and proposed leveling expertise were congruent.Consensus agreement was reached that these items wouldprovide a pathway to meet the original group vision for bet-ter trauma care.

Nineteen nurses in a Level-I hospital were asked toperform a self-assessment by using these competencies.An alpha of 0.98 was achieved using 1 = ‘‘poor’’ to5 = ‘‘excellent’’ to rate their personal competency for eachitem. These nurses all rated themselves as 4–5 for all thecompetencies. The lowest averages were on ‘‘Coopera-tion’’, ‘‘Teamwork’’, and ‘‘Decision-making’’, yet they stillrated self as very high on ‘‘Leadership’’. Technical skillswere also rated very high. The items demonstrated stronginternal consistency (Polit and Beck, 2008).

Table 1 Example of leveling from the technical knowledge dime

Novice Beginner Competent0–1 year >1–3 years >3–5 years

Follows specificorders

Follows standardprotocols

Applies protocols and considpatient’s status

Benner, P. From novice to expert: excellence and power in clinical nu

Table 2 Self-evaluation of trauma competencies across levels o

Dimension Level of hospital

University N = 28 Regional N = 17

Mean SD Mean

Total 4.66 0.18 4.12Cooperation 4.70 0.38 4.18Decision-making 4.55 0.42 3.98Leadership 4.65 0.44 4.09Problem-solving 4.60 0.52 4.14Teamwork 4.72 0.38 4.25Technical knowledge 4.69 0.39 4.14* p = <.05.

Input from ER nurses

Because the previous scores were obtained from a Level 1trauma center, it was unknown whether the nurses in thesespecialty centers would rate themselves differently thanstaff nurses employed in smaller facilities. Hence, an addi-tional 65 emergency nurses employed across all levels ofhospitals were asked to do a self-evaluation of competence.The sample included 28 nurses in a university hospital, 17 ina regional hospital, 11 in a community hospital, and 9 fromrural settings. Securing agreement from nurses outside thehighest level trauma hospitals was crucial, because the in-tent is to use the list of competencies nationally, not justin major urban centers. Additional open-ended questionfeedback was sought on the ease of use and whether nursesagreed their performance could be objectively ranked usingthese criteria. The results in Table 2 showed divergence be-tween sites. Self-assessments from regional hospital nurseshad the lowest mean scores on every behavioral dimensionacross levels of hospitals. Decision-making was the onlydimension to demonstrate significant differences amonghospitals. The items, ‘‘Analyze the consequences of deci-sion-making’’ and ‘‘Follow up on results of decisionsmade’’ showed the lowest item averages with regional hos-pital nurses ranking themselves lowest across all facilities(3.76). The average of all nurses was not below 4.00. Be-cause 17 regional nurses are only a small sample, inferencescan not be reliably drawn that distinguish the cause of thisvariance. The standard deviation for the community groupwas very small, suggesting consistency in response, unlikethe larger standard deviation in the regional and universitygroups, suggesting that these nurses may have had a greater

nsion.

Proficient Expert>5–10 years >10 years

ers Integrates protocols withevidence-based guidelines

Generates scientific-basedapproaches appropriate topatient’s status

rsing Practice; 1984.

f hospitals (n = 65).

Community N = 11 Rural N = 9 p value

SD Mean SD Mean SD

0.11 4.91 0.09 4.99 0.07 0.890.38 4.89 0.20 4.98 0.05 0.380.54 4.83 0.17 4.96 0.07 0.00*

0.46 4.93 0.08 4.99 0.03 0.450.78 4.89 0.14 4.99 0.04 0.340.48 4.91 0.08 5.00 0.00 0.760.42 4.95 0.05 5.00 0.00 0.24

6 K. Unhasuta et al.

mix of levels of competence. No difference was identified inyears of experience to explain this finding.

Phase III: efficiency study

Three trauma center nurse directors and 16 head nursesacross all levels of hospitals were sampled to participatein a focus group to discuss ease and appropriateness of usingthe items as a measure of core competency. The wording offour items was changed to help clarify meaning. The groupdiscussed the particulars of fielding the tool across thenation.

Sixteen hospitals agreed to perform the first field tests ofthe competencies for a 3 year period (2008–2010). A totalof 302 emergency nurses will use the items: 16 head nurses,153 staff nurses from seven level-I hospitals, 81 work in 5 re-gional hospitals, 29 staff 2 community hospitals, and 23practice in 2 rural hospitals. Head nurses will evaluate theirstaff periodically, with staff nurses evaluating themselvesand their peers. A comparison is planned to see if staffnurses and head nurses have similar perceptions of compe-tency levels. Planned data analysis include within and be-tween group means across different levels of hospitals.

Ethical considerations

The staff nurses in every step of this project agreed to par-ticipate by signing a consent form that was approved by theCommittee on Human Rights for Research on Human Beings,Mahidol University. The participants had the right to cancelparticipation in the studies at any time. None refused and asof this date, none have dropped out. The de-identified datawill be kept confidential and to be used only for research.Nurse managers will not have access to the peer or self-evaluations of any participating nurse.

Preliminary results

Six month preliminary data from 2008 became available asthe primary author entered post-doctoral study at the Uni-versity of Colorado Denver. Following the pattern of theearlier studies, it became quickly evident that a ceiling ef-fect was present. No one evaluated self below ‘‘good’’ onany item. Plans are underway to re-tool the method of scor-ing assessment to enable collection of more useful data inthe remaining years of the study. A factor analysis is also re-quired to ascertain if the number of items in the currenttool can be reduced.

Discussion

Many steps were used in this research plan for establishingappropriate core competencies for emergency nurses inThailand. The content validity index (CVI) and internal con-sistency (Cronbach’s a > 0.80) results plus the rating of ex-pert opinion were used to guide the process. Congruenceexists between the objectives for a unified national care ini-tiative and acceptance about using a framework for deter-mining competency amongst the emergency trauma nursesthemselves.

Similar steps were used in the development of compe-tency inventories for registered nurses in the People’sRepublic of China (Liu et al., 2006). Unique to the Thai re-search plan is incorporation of levels of clinical competenceas per Benner’s model (Benner, 1984). Benner’s frameworkcan be linked to the development of professional knowledgeand competence throughout a practitioner’s learning career(Munro, 2008). Benner’s work has been previously used fornurses in a heart failure specialty setting (Goodlin et al.,2007).

Use of self-assessment. Self-assessment is best used tohelp individuals analyze their work practices and to promotereflection on performance (Stewart et al., 2000). Individualsusing self-assessment should be able to provide summativeevaluation of themselves (Kerby et al., 2005) as well as de-tailed analysis of items that support that summary state-ment (Eva and Regehr, 2005). Self-assessment canconstitute the basis for professional development to furtheron-the-job learning in collaboration with their nursing peers(Vuorinen et al., 2000). Competency assessment should beevaluated from multiple raters: self, peers and administra-tors (Weigelt et al., 2004). Self-assessment and peer evalu-ation have been shown to be important methods forascertaining the changes and successes in the developmentof nursing practice. Self-assessment and peer evaluation areseen as being complementary, supporting one another; but,nurses were found to be more critical in their self-assess-ment than in peer evaluation (Lofman et al., 2007).

Self-assessment was a foundational part of this programto influence quality in care provision in the Thai ERs. The re-sults from all the preceding work demonstrates a high aver-age score for teamwork as would be expected for nurseswho routinely work together. They assessed themselvesgreater in leadership capability than their peers and headnurses did. Staff nurses expressed great confidence in taskperformance; however, they identified themselves as havinglimited competence in decision-making abilities. On the sur-face it appeared they were able to discriminate betweentheir weaknesses and strengths.

In these Thai studies, no significant differences werefound in assessment between groups within and across manylevels of hospitals (p > .05). No statistically significant dif-ferences were observed within or between rater groups. Un-like Lofman’s study (Lofman et al., 2007), self-assessmentwas higher than that given by peers and head nurses. A largeceiling effect was found in repeated use within several co-horts of nurses. This effect is a recognized as a potentialweakness. If everyone assesses themselves as ‘‘good or bet-ter’’, the usefulness for measuring improvement of posteducational endeavors or quality improvement programs isplaced in jeopardy. Future research plans to fix the scaleto limit this ceiling effect. Information sessions with everygroup enrolled in the efficiency study to introduce thisnew scale is also hoped to bring more reliable observations.

Conclusions

These studies found that there is strong support for themeasurement of competency in Thai emergency nurses’clinical practice. The items and dictionary core competencyin this research plan demonstrated internal consistency,

Research plan for developing traumacore competencies for nurses in Thailand 7

reliability and validity, and were accepted by nurses acrossmultiple centers of care. The items and dictionary can beintegrated into a strategic plan for development of betterquality trauma care across Thailand, and would establishlevels of consistency in training and practice for emergencynurses nationally.

Funding source

Sixteen hospitals facilitated ER head nurses to cooperatewith the research process and provided office supportthroughout the project. Faculty of Nursing, Mahidol Univer-sity funded a post-doctoral fellowship for the first author atthe College of Nursing, University of Colorado Denver fromOctober 1, 2008 to May 31, 2009.

Conflict of interest

None declared.

Acknowledgements

The researchers wish to thank the experts, the directors of allthe hospitals, and the emergency nurses who participated.

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