Kisut et al.

BMC Nursing (2022) 21:134

https://doi.org/10.1186/s12912-022-00898-y

RESEARCH Open Access

Competency assessment for community

health nurses: a focus group expert panel
discussion
Ramlah Kisut1†, Hajah Dayang Jamilah Haji Awang Sulaiman1, Hanif Abdul Rahman2,3* and
Khadizah H. Abdul‑Mumin2,4†

Abstract
Background: General Practice setting in the Primary Health Care Services are the utmost visited by the public. It is
important that the nurses’ competencies in this area be assessed to ensure provision of safe and quality services.
Aim/objective: To explore perceptions and experiences of competencies assessment tool for community health
nurses working at the General Practice setting in the Primary Health Care Services.
Methods: An exploratory qualitative study utilizing focus group discussions were conducted on purposive sample of
12 officers with expertise in competency assessment and community health nursing from higher nursing education
institutions, the Nursing Training and Development Centre, the Nursing Board and the Community Health Nursing
Services in Brunei Darussalam. The existing competencies assessment tool was revised, the participants were divided
into two groups of expert panel review team and two focus group discussions were held with each team. The focus
group discussions encompassed components and methods of assessment; methods of grading; and overall organiza‑
tion and structure of the revised competency assessment tool.
Findings: Four themes emerged: 1) International equivalent core competencies components; 2) Multi-methods
approach to assessment; 3) Definitive guidelines as framework for assessment; and 4) Understanding and acceptabil‑
ity of the competency assessment tool.
Conclusions/implications to practice: The expert panel reviews provide practical input that were inculcated in the
preliminary developed competencies assessment tool. Identification of eligible assessors were recommended based
on standardized criteria, and socialization and training held to set direction and guidance for implementing the utili‑
zation of the competencies assessment tool. Further studies are deemed important to critically evaluate and validate
the preliminary competencies assessment tool for development of a more robust assessment instrument.
Keywords: Competency, Assessment, Tool, Instrument, Community health nurses, Primary health care, General
practice setting

Introduction
Healthcare systems across the globe are equally and pri-
†
Ramlah Kisut and Khadizah H. Abdul-Mumin contributed equally to this
marily aiming at providing quality and safe health care to
work. the public. It is important for the front-facing healthcare
*Correspondence: hanif.rahman@ubd.edu.bn providers, for example such as nurses [1], midwives, and
3 social workers to have the appropriate competencies at
Research Scholar, School of Nursing, University of Michigan, Ann Arbor, USA
Full list of author information is available at the end of the article

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Kisut et al. BMC Nursing (2022) 21:134 Page 2 of 14

least at a minimum standard to enhance healthcare pro- rank of nurses working at various clinical sites in the
vision which is of quality and safe care. three level of healthcare system of Brunei – Primary, Sec-
The worldwide perspectives of professional nursing ondary and Tertiary. The first level of health care system
competencies are focused on providing safe and quality provision in Brunei is the Primary Health Care that com-
service. It is the responsibility of each professional nurse prised of 14 primary health centers and 16 maternal and
to be competent in delivering the skills sets required to child clinics. There are about 300 CHNs working in 14
improve and sustain the quality of patient care, hence PHC across Brunei. To work as CHNs, they are required
increasing patient satisfaction [2]. Substantial evidence to have at least an education background of general nurs-
also pinpointed the importance for health care organiza- ing. Whereas, those who work in maternal and child clin-
tions to give attention to professional competencies for ics are required to have midwifery or community health
nurses to maintain safety and quality service [3]. Medi- nursing qualifications. Maternal and child health (MCH)
cal errors, negligence, or malpractice built from incom- nursing, or midwifery, or Community Health Nurs-
petence can risk patients’ lives [4]. For all these reasons, ing qualifications are additional advantage. Some CHNs
there is a need for valid and reliable instruments to assess work at the General Practice (GP) setting in the PHC
the competencies of nurses in the practice setting. Many providing care in the outpatients’ departments (OPDs),
attempts to define competence and competencies have Chronic Diseases Clinics (CDCs), and nurse-led clinics.
been published in the literature but there are still con- Other CHNs work at the MCH setting providing mater-
fusion and lack of clarity surrounding the concept [5]. nal and child health care, and Women’s Clinics. Both GP
Competencies can be described as a combination of and MCH settings are integrated in the PHC. This paper
observable and measurable knowledge, skills, abilities, specifically focuses on the CHNs in the GP setting.
and personal attributes that constitute an employee’s
performance. Whatever the agreeable definition is, the Core competency standards in Brunei
ultimate goal is that the employee can demonstrate the Similar to other countries, in Brunei Darussalam (hence-
required attributes to deliver safe and quality care [6]. forth: Brunei), there also exists core competency stand-
ards for Registered Nurses developed by the Brunei
Background of the study Nursing Board (BNB) [16], the national regulatory body
The importance of competencies standard that governed nursing practice. However, the core com-
In the healthcare system, core competency standards are petency standards are more generic but not specific to
the standards and requirements usually set by the rel- nurses working in a specific setting. One of the aims doc-
evant healthcare profession regulatory body to inform umented in the core competency standards is:
standards of practice of the specific profession intended
“to assess clinical performance competency and
for the provision of safe and quality care to the public
measure the professions’ fitness to continue practice
as consumers of the healthcare system. Such healthcare
in Brunei Darussalam”.
professions extend beyond nursing and include for exam-
ple midwifery, social workers, physicians, optometrists [16].
[7], and other medical professions [8]. Core competency Aligned with the core competency standards for Reg-
standards are important for these healthcare professions istered Nurses, a generic competency assessment tool
for monitoring of safe practice and provision of quality (GCAT) was also developed by the Brunei Nursing Train-
patients’ care. ing and Development Centre (Pusat Latihan Perkem-
In the nursing profession, nursing regulatory body is bangan Kejururawatan [PLPK]). However, the GCAT is
responsible for nurses’ competencies in providing safe generic and only purposely designed for assessing newly
and quality care to patients. Having competent nurses in employed nurse, for a one time use when they were first
the healthcare services increase trust and confidence of employed. CAT for continuous assessment of core com-
the public [9–11]. Being competent in providing patients’ petency standards for Registered Nurses are not available
care also uphold the high reputation of nursing profes- yet. Nurses in Brunei are assessed based on evaluation of
sion [12]. Poor and unsafe patient care may occur if nurs- the Key Performance Indicators (KPIs) assigned by the
ing practices do not met expectations laid in the core Department of Nursing Services via the Head of Nurs-
competency Standards [13, 14]. ing in each department across the primary, secondary
and tertiary level of healthcare. This KPIs are integrated
Context of the study feature in the yearly performance appraisal tool (PAT)
Nursing profession in Brunei Darussalam (henceforth: designed by the Department of Public Services which
Brunei) is the largest that contributed to at least 70% of are generic for all civil servants’ regardless of their pro-
the total healthcare workforce [15]. There are different fessions. The PAT may only be suitable for assessing and
Kisut et al. BMC Nursing (2022) 21:134 Page 3 of 14

evaluating generic skills, which pose challenges to the as reflective accounts, critical incidence analysis, peer
nursing profession as it is not specific to nurses’ skills and review, evidence-based practice and acknowledgement
competencies. from patients and colleagues at work.
Another CAT was developed in 2016 by a Primary
Health Centre (PHC) [17], which is specific and initially Needs and significance of the CHNs CAT development
used biennially for assessing core competency standards In view of the limitations of the CHNs CAT that assessed
of the community health nurses (CHNs) working at Gen- only generic, basic and practical nursing skills, being
eral Practice in the PHC. It is identified that this CHNs the Head of the Community Health Nursing Services
CAT was developed in response to the PHC accredita- in Brunei, the primary author takes the lead for evalua-
tion assessment by the Joint Commission International. tion, development, implementation and validation of the
Since then, there is no further evidence of regular and CHNs CAT as a pilot or trial. The similar process may
continuous use of this CHNs CAT. further be adapted in the development of CAT in other
nursing clinical areas. This paper presents the first two of
Limitations of the existing CHNs CAT​ the four-part tasks which are the instrument evaluation
The development of the CHNs CAT were not based on and development.
a systematic process of instrument development and It should be noted that the role of nurses in GP setting
validation, and the core competencies assessed may has expanded over the years [6]. With the evolving and
risk the bias views of the former developer(s). The tool expansion scopes of nurses working in the GP setting
has never been reviewed and evaluated, hence, reliabil- of the PHC, CHNs CAT need to be developed in align-
ity and validity of the CATs have yet to be established. ment with the expanded scope of practices (SoP) and
Assessment of core competency standards should not consistent with the actual regulated practices. Reviewed
be a one off, but a regular and continuous process so of literature evident that nurses practices either below
that standards are consistently maintained throughout or beyond their SoP that cause either loss of or inad-
nursing practices. This concurs with the international equate skills that eventually will compromise nursing
health care accrediting agencies such as Joint Commis- practices in the General Practice setting of the PHC
sion International [6] which highlighted the require- [18]. Hence, this study is significant in various ways: 1)
ment for periodic performance evaluation to assure consideration of development of a credible and reliable
ongoing competencies of nurses. CHNs CAT that is appropriate and able to accurately
In terms of the feature and contents of the CHNs CAT, assess competencies of CHNs working at the GP setting
analysis uncovered that the instrument only predomi- in the PHC; 2) in a longer term, this study can inform
nantly contains a set of basic nursing procedural skills to development of similar standardized CAT for assessing
be assessed by checking the ‘DONE’ or ‘NOT DONE’ col- core competency standards of nurses in many different
umn (See Table 1 for examples of skills assessed). Other clinical settings in Brunei.
higher level of core competencies such as that recorded
in the BNB [16] are not found. These include legal and
ethical framework of practice, professional practice, Aim/objective
leadership and management, continuous professional This study aimed to explore expert panel perceptions
and personal development, and education and research. and experiences of CHNs CAT for CHNs working at the
There is no scale that differentiate achievement of a CHN General Practice setting in the PHC Services in Brunei
to another. The method of assessing was only through Darussalam. The objectives were:
observation methods instead of diverse methods of evi-
dence, to name a few the CHNs CAT do not use such

Table 1 Examples of what were assessed in the existing CHNs CAT​

1. Wound dressing
2. Triaging outpatient cases
3. Infection prevention and control
4. Immunization
5. Collecting specimen for pap test
6. Computer information system
7. Electrocardiogram
Kisut et al. BMC Nursing (2022) 21:134 Page 4 of 14

1) To evaluate the competencies required for CHNs of others. Participants’ anonymities were also ensured
working at the GP setting in the PHC Services where participants were coded using a personal iden-
2) To determine how would the competencies be tification number (PIN code). They were requested
assessed to refer to this code and were not allowed to call real
3) To develop preliminary CHNs CAT​ names during the FGDs. The research and any publica-
tions will not report participants’ details that can easily
identified their affiliations.
Research design and methods
Design Preparation prior to data collection
This study was qualitative and exploratory underpinned Defining CHNs CAT​
by instrument evaluation and development process, uti- A working definition for CHNs CAT was formulated to
lizing focus group discussions to collect in-depth data on ensure all the study participants have the same idea on
expert panel’s perceptions and experiences of competen- the CHNs CAT, hence, guide them in the evaluation and
cies assessment tool for CHNs working at the General development. CHNs CAT is defined as an instrument
Practice setting in the Primary Health Care Services. or a tool for assessing and evaluating CHNs competen-
cies that encompassed their knowledge and skills which
should be performed at a minimum standard.
Ethical considerations
This study is conducted in line with the principles Identification of literature for instrument evaluation
underpinning the Declaration of Helsinki [19]. Ethical and development
clearance was provided by the joint committee of the The research team conduct literature search on evidence-
Pengiran Anak Puteri Rashidah, Institute of Health Sci- based core competencies standard where four interna-
ences Research Ethics Committee (IHSREC), Universiti tional regulatory documents were initially gathered to
Brunei Darussalam and Medical and Health Research facilitate expert panel review. Table 2 illustrated the key
and Ethics Committee (MHREC), Ministry of Health documents.
(ERN: UBD/PAPRSBIHSREC/2O19/18). Written per-
mission to evaluate and re-developed the existing CAT Data collection
was granted by the Director of Health Services and Expert panel review
Director of Nursing Services. Participants were assured Expert panel or working group was formed. Participation
that their participations were voluntary and they could and selection as expert panel were by invitation where
withdraw from the study without penalty at any time letters were sent to the Dean and Directors of the higher
throughout the study prior to completion of data anal- nursing education institutions, Head of Brunei Nursing
ysis. Written informed consent was obtained from all Board, Head of Nursing Administration of the Commu-
participants once their enquiries were answered and nity Health Nursing Services, and Head of the Nursing
they were fully satisfied with the information about the Training and Development Centre for nomination of at
study. Confidentiality was ensured where the study was least an expert in developing CAT for CHNs at the Gen-
done in private room free from distractions and access eral Practice setting in the Primary Health Care Services.

Table 2 International regulatory documents

1)General Practice Nurse Competencies from the United Kingdom (Royal College of General Practice Foundation and Royal College of Nursing [20])
2)Primary Health Care Competency Framework originated from Canada (Capital Health Nova Scotia [21])
3)National Practice Standards for Nurses in General Practice from Australia (Australian Nursing and Midwifery Federation [22])
4)World Health Organization, Competencies for nurses working in Primary Health Care [6].

Table 3 Inclusion criteria for the study

For participants to be eligible as expert panel in the study, they must have:
1)knowledge and/or experiences of either the domains, skills and job descriptions of community health nurses in General Practice settings of the
PHC; or competency assessment tool development;
2)been working clinically for at least 5 years in their field.
Kisut et al. BMC Nursing (2022) 21:134 Page 5 of 14

The mixture of different participants ensured a diverse team to determine if there were any further divergent
range of stakeholders within the specialization of either feedbacks which may be overlooked by the first team,
community health nursing or competency assessment. and the last one was to finalize all feedbacks from the
The participants were selected using purposive sampling second team for development of a preliminary revised
guided by coherent inclusion criteria (Table 3). Partici- CHNs CAT. The FGD encompassed components and
pants whom do not met these criteria were excluded. methods of assessment; methods of grading; and over-
Through FGDs the expert panel critically review, all organization and structure of the revised competency
analyse, compare, evaluate and synthesize the exist- assessment tool.
ing CHNs CAT with the current empirical evidences The revised CAT was emailed to the expert panel a
from the authoritative regulatory documents. The week before the FGDs to allow them preparation prior
components and/or domains on competencies stand- to the FGDs. The FGDs were also guided with a pre-
ard of CHNs in the existing CHNs CAT was compared designed open-ended question so that the FGDs would
with those in the international regulatory documents. not side track. All FGDs were audio recorded with con-
The expert panel further suggested appropriate recom- sent from the participants to ascertain accurate and con-
mendations for development of the preliminary revised sistent account of the FGDs for transcriptions.
CHNs CAT. The expert panel also added another three Table 4 presented summary of the critique of the exist-
international regulatory documents that further facili- ing CAT by the two expert panel group. The domains and
tate evaluation and development of the preliminary performance indicators were identified and refined which
revised CHNs CAT: resulted to construction of a revised version of the pre-
liminary CHNs CAT.
1) International Council of Nurses (ICN), Nursing Care
Continuum Framework and Competencies [9] Data analysis
2) The Nursing Council of Hong Kong, Core competen- All FGDs were transcribed verbatim. The transcriptions
cies for Registered Nurses (General) [23] were then checked for accuracy against the audio record-
3) Jordanian Nursing Council, National Standards and ings. Two members of the research team (first and last
Core Competencies for Registered Nurse [11] authors) systematically analyzed the transcripts to iden-
tify both deductive themes based on the focus group
It is expected that expert panel review tasks will be con- guide and inductive themes that emerged during coding.
ducted only by one expert panel group throughout the Transcripts were read and re-read to identify potential
instrument evaluation and development to ensure con- themes. Emerging themes were then coded by hand inde-
sistencies in the development of the preliminary revised pendently by each team members, then coding was com-
CHNs CAT. Six participants initially volunteered in the pared with discrepancies resolved through discussion to
expert panel review. However, due to other administra- enhance reliability of the findings.
tive commitments, it was not possible to get the same
expert panel to wholly complete the tasks, hence invita- Results
tion was extended, and another six participants further Participants’ characteristics
volunteered which formed the second group of expert Participants were six nurse managers from Community
panels. The change in the planning was observed as Health Nursing Services, two academics from the higher
opportunistic as it considers the diverse views [24] from nursing education institutions, two authorities from the
the two expert panel groups. They comprised of nursing Nursing Board and two senior nurses with capacities as
academics from the higher nursing education institu- competencies evaluators and trainers from the Nursing
tions, nursing managers of Community Health Nursing Training and Development Centre. Nine of the partici-
Services from the PHC Services, nursing authorities from pants were female (75%) and the rest were male (25%).
the Nursing Board and competencies evaluators and All of these individuals have expertise in both compe-
trainers from the Nursing Training and Development tency assessment and Community Health Nursing ser-
Centre. vices. Their details and main expert field is presented in
Four FGDs, two for each team were held with the Table 5. They have more than 10 years of clinical work
expert panel review team. The first FGD was to collect experiences in community health nursing setting of the
analysis, evaluation, perceptions and experiences related PHC and are well versed with the core competencies of a
to the revised competencies assessment tool from the CHN. For confidentiality purpose, gender, exact age and
first expert panel review team, and a second one was qualifications, and workplace are not reported.
conducted to finalize their collective agreement. The
third FGD was held with the second expert panel review
Kisut et al. BMC Nursing (2022) 21:134 Page 6 of 14

Table 4 Critique of the existing CHNs CAT​

Criteria Current CAT​ Suggested recommendation from the literature

Competency tool development process Methodology not reported in the document Comprehensive literature reviews are critically
important for gathering evidence-based practice
[24] on CHNs CAT. Methodology for instrument
development includes involvement of panel
experts through focus Group Discussion (FGD),
Delphi approach o Face-to-face interview which
should be done in a systematic process (see
Table 2). The instrument must be pretested [24].
Methods/approaches used for assessment of Limited to direct observation of skill demon‑ Adopt variety of assessment approaches. E.g. return
competencies strated by assessors demonstration, case presentations, case studies,
certification recognized by the nursing profession,
continuing education programmes related to the
nurses individual practice, documentation review,
examinations for skill assessment and/or clini‑
cal reasoning, nursing Research, skill assessment
inventories (via self, peers, supervisors, and clients),
observation of daily work, portfolio development
and review, presenting at local, state and national
meetings, publishing in a scholarly journal, quality
improvement indicators, self-directed learning
activities, Self-assessment tools, and simulations
[13, 25].
Performance indicators Tick boxes limited to two performance indicators Competency involves more than just technical and
(either DONE or NOT DONE) procedural skills [13]. Use findings from the litera‑
ture and international regulatory documents.
Level of competence Not acknowledge Adopt strong theoretical background [24] such as
Benner’s framework of a competent nurse – from
novice to expert to acknowledge level of compe‑
tence [26].
Competencies assessed Limited to procedural skill Other aspects of Based on criteria such as high risk, low volume,
competencies such as thought process (critical problem prone procedures or situations, unusual
thinking skill) and knowledge, communication incidents and regulatory requirements. Should also
and values are not assessed focus on new, changing, high-risk and problematic
area of practice [25].
Frequency of competency Not stated in the document On-going and assessed at regular interval as identi‑
fied by the organization [8, 27].
Who performed the competency assessment Not mentioned in the document Should be registered nurses skilled in the field of
competence assessment and methodologies to
ensure valid and reliable competency assessment
processes [8, 28].

Table 5 Expert Panel Characteristics

Participants’ Personal Identification Main Expert field Age range Qualification
Number

P01 Competency Assessment 26–35 years Degree

P02 Community Health Nursing 36–45 years Higher Degree
P04 Competency Assessment 46–55 years Higher Degree
P05 Community Health Nursing 26–35 years Degree
P06 Competency Assessment 36–45 years Diploma
P07 Community Health Nursing 46–55 years Degree
P08 Competency Assessment 26–35 years Degree
P09 Community Health Nursing 36–45 years Higher Degree
P10 Competency Assessment 46–55 years Higher Degree
P11 Community Health Nursing 36–45 years Degree
P12 Competency Assessment 46–55 years Degree
Kisut et al. BMC Nursing (2022) 21:134 Page 7 of 14

Table 6 Examples of deductive and inductive coding

Deductive coding Inductive coding Finalized Themes

Components of core Benchmark with international regulatory documents Theme 1: International equivalent core competencies com‑
competencies to be At par with international countries ponents
assessed
Ensure Brunei CHNs can function globally
Different CATS for different level of nurses
Target for Staff Nurse only
Contains generic competencies and also specific competen‑
cies for CHNs
Must not be procedural only – should contain more than
basic and procedural skills
Cover and demonstrate higher level of thinking
Leadership and management must be assessed because
CHNs working in GP setting are like nurse specialist or prac‑
titioners
Identify domains or components, put what are to be assessed Theme 3: Definitive guidelines as framework for assessment
under the components or domains
Describe performance indicators, what needs to be achieved,
how it needs to be achieved, how achievements are measure
Methods of assessment Must be varieties Theme 2: Multi-method approach to assessment
Do not use observation only
CAT should be assessor/assessors friendly
Use reflective diaries
Evidence of research/evidence-based practice
Objective structured clinical examination/ assessment
Case studies/case presentations
Methods of grading Scale must be not too wide and not too rigid Theme 3: Definitive guidelines as framework for assessment
Define the scale, give descriptions of the scale
From novice to expert
Four or seven scale
Audit
Viva defense/verbalization/discussion
Organization and struc‑ Readable Theme 4 – Understanding and acceptability of the compe‑
ture of the CAT​ Terms used must be understood by both assessors and tencies assessment tool
assesses – provide glossary of terms
Socialization of the CAT through workshops and seminars
Acceptable to be implement (not westernized) - culturally
acceptable
Feasible in Brunei healthcare system

Findings from the expert panel review Understanding and acceptability of the competencies
Table 6 showed some examples of the results derived assessment tool.
through the process of deductive and inductive coding
of the FGDs transcripts that eventually lead to the fina-
lization of themes. Quotes that exemplified the induc- Theme 1: international equivalent core competencies
tive coding are presented in the final themes. Four final components
themes emerged from the expert panel review process This theme described the expert panel affirmation for the
of refining and finalizing the preliminary CHNs CAT: core competencies components to be equivalent of the
1) International equivalent core competencies compo- international standards. All of the expert panel pointed
nents; 2) multi-methods approach to assessment; 3) out that the core competencies components should be
Definitive guidelines framework for assessment; and 4) benchmarked that equivalent to the international stand-
ards. The expert panel justified that this is to ensure that
the CHNs will achieve the minimal core competencies
Kisut et al. BMC Nursing (2022) 21:134 Page 8 of 14

standards which should be arranges into key compo- these core competency standards.” (P05, Expert
nents. The World Health Organization (WHO) is the Panel Group 1, FGD 1)
most commonly referred international organization as
the governing body for the CHNs core competencies.
“ … the competencies tool should follow competency Theme 2: multi‑method approach to assessment
framework from WHO. It should be at the interna- This theme explained the expert panel assertion that
tional standards so that performances of our com- the assessments grading system should not be rigid
munity health nurses should be at par with other to observations only but diverse encompassing other
countries … The core competencies should be divided methods such as audit, certificate of training and chart
into five clusters and under each cluster there should review. It was notified by some of expert panel that
be list of competencies to be achieved” (P04, Expert method of assessment in the revised CAT need more
Panel Group 1, FGD 1) clarification in terms of appropriate methods of assess-
ment that will accordingly assessed and measure spe-
Majority of the expert panel also pointed out that bench- cific competencies performance.
marking of the core competencies standards should be
comparable with the requirement of the International “How do we assessed a specific skill required by the
Council for Nurses competencies framework [9]. They specific core competencies components? We can-
also pinpointed that the core component of competencies not depend on 100% observations only. Assessing
also needs to reflect role of PHC nurses in General Prac- through discussion with others may be subjective
tice or also called Out-Patient Department (OPD) set- too. The main point is the appropriateness of the
ting, and should be consistent with the core competencies competencies assessment, it should assess what
standards set by the Nursing Board for Brunei. it should measure. For examples achievement of
skills require direct observations, demonstration
“ … the components of the competencies should mir- of knowledge require evidence of assignments, and
ror the ICN competencies framework but also must research may need evidence such as published
matched with NBB (Nursing Board for Brunei) manuscripts or evidences of changes in practices …
requirements. Comparing these both together, the ” (P10, Expert Panel Group 2, FGD 3
core competencies components should be put into
domain. For examples, ethical responsibilities, lead- The expert panel believed that evidences of compe-
ership or continuous professional development, and tencies should be included or submitted at the end
so on. Then it will be easy to arrange the competen- of assessment period to ensure validity of the assess-
cies either skills or knowledge under each domain” ment conducted. The expert panel provided examples
(P02, Expert Panel Group 1, FGD 1) of evidences such as certificate of attendance or par-
ticipation, audit result, chart review or other relevant
Arranging core components into key areas or domains documentation supporting the achievement of the
was agreeable by the expert panel to provide clarity of the core competencies. Quality improvement activity was
knowledge or skills set under the domains. Five core com- also suggested by half or the expert panel to diversify
petency standards (Legal and ethical framework for prac- methods of assessment. Other expert panel members
tice; professional practice, leadership and management; also recommended that Objective Structured Clinical
continuous professional and personal development, and Examination (OSCE) as on the best way to assess com-
education and research) established by Nursing Board for petency albeit time consuming.
Brunei [16] were commonly suggested by majority of the
expert panel. “ … I think OSCE is a good way to assess compe-
tency but we may not able to afford it … It need
“ … The ICN core competency standards are time and lots of resources in preparation for the
extended version. But core competency standards session” (P12, Expert Panel Group 2, FGD 2)
from NBB are succinct. We should use the five main
components and arranged list of competencies under Many participants favour the use of different methods
these five main components accordingly” (P01, of assessment over single method;
Expert Panel Group 1, FGD 1) “ … apart from the stated methods, can we add
quality improvement activity as one of the assess-
“ … It would be more appropriate if we adopt com- ment methods? . . . it can save much of our time
petency standards from local context … so it would to assess some of the components by just providing
be meaningful as we also teach our student using evidences of participation or contributions such as
Kisut et al. BMC Nursing (2022) 21:134 Page 9 of 14

certificates, letter of acknowledgment or participa- edge on how to rate the performance … again
tion, and so on. This should be submitted to sup- the different methods of assessment that can be
port the competencies assessment. This is to make employed … also because the scale is only 1, 2, 3, 4
sure that the community health nurses truthfully and 5. How would you rate based on this scale to an
achieved the performances which were assessed.” experienced nurse and how would you differently
(P6, Expert Panel Group 1, FGD 2) rate a new graduate nurse?”(P11, Expert Panel
Group 2, FGD 3)
Theme 3: definitive guidelines as framework The concern about the possibilities of inconsistencies
for assessment among assessors were also highlighted by a quarter of the
This theme represented the expert panel emphasis on expert panel as assessment can be subjective reliant on
the importance of a distinctive grading system that can the individual assessor.
differentiate the performance of newly employed nurses
“ … different nurse managers may have different way
from the experienced nurses. All of the expert panel were
of interpreting their competency assessment findings
on favor of a scoring or grading system for the competen-
so at the end of the day we may have discrepancy of
cies assessment.
the score given” (P08, Expert Panel Group 2, FGD 3)
“The grading system or scoring system for competen-
cies assessment is very good. It gives high marks to “ … some nurse managers may be very lenient, but
high performer nurses and low marks to low per- some may strictly adhere to their high level of expec-
former nurses. It is good because it differentiates tation … … this again all depend on their individual
how a nurse is more competent than the others, and interpretation of the performance standards.” (P05,
remedies can be planned to improve competencies.” Expert Panel Group 1, FGD1)
(P09, Expert Panel Group 2, FGD 3)
However, about three quarter of the expert panel rec-
ommended that in view of the multiple methods of Theme 4 – understanding and acceptability
assessment, explanations should accompany the grading of the competencies assessment tool
system as a framework that guide the grading or scor- This theme illustrated the expert panel concern about the
ing system. They commented that development of such users’ understanding of the CAT comprising the nurse
framework will be useful because the General Practice assessing and the nurse to be assessed in order to ensure
or OPD is usually a very busy setting, hence, if the CAT that expected performances are similarly perceived by
is unclear, the purpose of doing competency assessment both parties. Majority of the expert panel pointed out
will be defeated by time constraint, work overload, inad- that competency standards should be appropriately
equate staffing and lack of knowledge on how to use the assessed by an experienced or senior nurse. They further
CAT among assessors and the nurses to be assessed. highlighted that assessment needs to be done regularly as
an ongoing activity in order to monitor and maintained
“ … the use of different methods of assessments the standards of practice.
on the same competencies is very good. The direct
observations may be complemented by collections of “ … The competencies assessment should not be a
reflective diaries, which further can be strengthen by one-off activity … looking at the number of com-
providing certificate of attendance that sharpen the ponents, we must set interval period for the assess-
skills being assessed. However, how do we know the ment to be conducted … are we going to make it
assessor is choosing the right method of assessments annually or every 3 years … ” (P07, Expert Panel
for a particular performance in the core competen- Group 2, FGD 4)
cies component, while other assessor may also use More than half of the expert panel felt that the CAT
different method for that same performance?” (P12, acknowledged their understanding of the CAT address-
Expert Panel Group2, FGD 3) ing that it will be useful to assist nurse managers in
A few of the expert panel argued that due to the scale determining whether or not a community health nurse is
nature (1 to 5) of the grading system, there may be issues competent in a particular standard. Having said that, the
in segregating how the score be awarded to an experi- expert panel also proposed several recommendations to
enced nurse from the new nurses. be put in place before the implementation of the CAT. It
was perceived that the CAT can be utilize properly with
“ … I am not a 100% supportive of the grading sys- adequate information and guidance along with adequate
tem … an assessor may not have adequate knowl- training, particularly on what are the expectations on the
Kisut et al. BMC Nursing (2022) 21:134 Page 10 of 14

competency standards nurses have to achieve and how to It is important to highlight that competencies are
utilize the CAT. acquired and developed steadily and progressively over-
time, which should not be a ‘one off ’ or ‘once-only’ activ-
“ … I can see that this CAT can be useful to ensure
ity. Assessment should be continuous, on-going and
nurses are competent though it may be very tough
perform at regular interval [8]. This is particularly true
to conduct the assessment if nurse managers are
in a way that it allows time for assessors to adequately
not fully informed about the assessment. The CAT
observe, monitor and evaluate the performance rather
must be clear in every aspect so that the nurse
than jump into conclusion at 1 hour observation for
who assessed and the nurses to be assessed equally
instance. The issue of ‘once-only’ assessment and a ‘tick-
understand expectations laid on by the CAT. A
box’ approach in competency assessment should be
briefing and training on how to use the CAT would
given attention as there is empirical evidence to show
be a good start before using the CAT in practice … ”
that these strategies may not be able to adequately assess
(P03, Expert Panel Group 1, FGD 2)
competence [8, 24, 27, 29].
Three quarters of the expert panel expressed their accept- Review of the CATs internationally also suggested that
ability of the CAT and stated that the revised CAT would the core competencies standards should be expanded
be more applicable and useful than the existing generic to include higher level of knowledge and skills such as
annual performance appraisal for civil servant. They research, leadership and management [30]. Our study
raised the issue of time constraint and increase work- demonstrated that the seven-core competency generic
load, if the CAT would be additional to the performance nurses standards framework advocated by the ICN [9]
appraisal. appropriately aligned with the five-core competency
generic nurses standards domains established by the
“ … I can foresee the difficulty face by nurse manag-
Nursing Board for Brunei [16]. Comparison of the two
ers if the CAT is used in addition to annual perfor-
generic competencies standards with other international
mance appraisal establish for civil servant. It will be
countries showed that the contents are all similar and
extra work for nurse managers and some of us may
relevant [11, 23, 31, 32]. Likewise, the specific core com-
not have enough time to do them both at one time”
petencies standards for CHNs in the preliminary revised
(P08, Expert Panel Group 2, FGD 3)
CHNs CAT concurs with Brunei Nursing Board [16] and
the rest of the international regulatory documents.
The alignment of the preliminary revised CHNs CAT
Discussion with the local and international document coincide
This study was conducted to explore expert panel per- with the expert panel view that implied CAT should be
ceptions and experiences on the existing CHNs CAT developed based on benchmarking with international
including its components, methods of assessment, grad- regulatory bodies and other countries. It is viewed that
ing system and its overall structure and organization. benchmarking ensure that core competencies of the
This study evident that it is fundamental to identify a CHNs in Brunei are at least at the international stand-
comprehensive core competencies domain and the list ards. This is expressed by the expert panel in theme 1.
of core competencies for CHNs in the general practice This may possibly due to the fact that community health
setting of the PHC Services. This was pinpointed by the services worldwide are facing similar current global
expert panel in their critique of the existing CHNs CAT challenges. These include growing number of chronic
as shown in Table 6 and theme 1 of the study findings. diseases, ageing population and shortage of healthcare
As emphasized by the WHO [6], the role of nurses in professionals [33]. Aside from this, another possible rea-
GP setting has expanded over the years [6]. Identifica- son is due to the global mobility and migration of nurses
tion of a set of clear competencies domains ensure that that requires them to acquire competencies which are
CAT assessed the scope of practices (SoP) within the globally adaptable [34].
country they practice, hence, consistent with the actual The findings presented in this study delineated the pro-
regulated practices [18]. The findings are consistent with cess of instrument evaluation and development under-
qualitative research exploring the relevance of existing taken by the expert panel that include critical analyses
Australian Competency Standards for Registered Nurses and evaluations of the existing CHNs CAT, which were
that is capable of assessing the specific community health further revised, refined and finalized by the expert panel
nursing practices. CHNs must be better equipped with through the process of FGDs. This process was con-
knowledge, skill and ability to deal with these complexi- ducted systematically and is considered rigorous in terms
ties in order to provide safe and the best care possible. of face and contents validity [35]. Future studies should
consider quantitative design encompassing pilot testing
Kisut et al. BMC Nursing (2022) 21:134 Page 11 of 14

of the CAT and performing the psychometric properties existing generic civil servant’s performance appraisal
for determining reliability and validity of the preliminary may be viewed as task duplications by assessors, in par-
CHNs CAT. The systematic process in instrument devel- ticular, nurse managers which is highlighted in theme
opment which was first advocated by Benson and Clark 4. The use of multiple competency assessment tools to
[36] and evident in many of the developed instruments meet mandatory evaluation of performance and regula-
include the implementation and psychometric proper- tory requirements may put extra burden for the assessing
ties testing for determining instruments’ reliability and nurses and the nurses being assessed alike. This may at
validity. It is anticipated that the CHNs CAT for the gen- the end highly likely resulted to the ‘tick-box’ approach
eral practice setting of the PHC Services would set the which defeat the purpose to adequately assess nurses
basis for assessment to determine the competence level ongoing ability to competently undertake their daily
of CHNs from entry into practice and throughout their nursing duties [40]. In an equilibrium, being specifically
professional nursing careers instead of a one-off activity. competent of nursing practices denotes safety and quality
Concern over the inconsistencies of perceptions of the measures in nursing care whilst annual appraisal will only
CAT from the FGDs with the expert panel are also con- look at the general performance of aptitude and attitude
sistent with findings from the literature [29]. Traditional nursing staff.
approach of competency assessment is distorted with
ambiguity and inconsistency. Such concern may be jus- The preliminary CHNs CAT​
tified because competencies assessments are subjective The revised version of the preliminary CHNs CAT was
to individuals whom may either be lenient or have high refined and finalized as Draft 1 Preliminary CHNs CAT
expectations. In addition, interpretations of assessors are (see supplementary materials) after three major revisions
subject to clarity of the core competencies to be assessed. following the expert panel review from the FGD. Upon
The expected core competencies must be communicated suggestion from the expert panel review, the preliminary
to the CHNs and their assessors so that they have simi- CHNs CAT now contents glossary of the terms used in
lar understanding of the competencies, hence the com- the CAT, a concise introduction of the document, com-
petencies performance and assessment are conducted as ponents of the competencies, method of assessment,
expected [37, 38]. grading system and a step-by-step guide on how to use
In term of acceptability to use in practice settings, the document. The expert panel equally agreed for the
time constraint, work overload, inadequate staffing and importance of culturally specific and context specific
lack of knowledge on how to rate competence are the CHNs CAT, hence the inclusion of the additional three
identified obstacles that may lead to hesitancy to use documents.
the preliminary CAT. These findings are similar to a The expert panel also aligned the requisites identified
study conducted by Figueroa, et al. [39] in determining in the international regulatory bodies with the core com-
the compliance of nurses to national core competency petencies standards of the Brunei Nursing Board [16] in
standard. The use of multi-methods and multi-asses- the preliminary CHNs CAT. The whole process of devel-
sors approaches in conducting assessment may solve oping the CHNs CAT is not completed yet. Instrument
this issue. Holanda et al. [40] indicates that using these development should include pilot testing the CAT and
approaches may reduce inconsistencies among asses- analysis of the psychometric properties of the CHNs
sors as well as reduce time taken to do the assessment. CAT for its reliability and validity. The next tasks for the
Although evidences on the most effective method is primary author is to continue on implementation, valida-
limited, there is general agreement in the literature tion, and reevaluation and redevelopment of the CHNs
that competency assessment should use more than one CAT accordingly. It is planned that these will be done in
assessment methods that include such as self -assess- the near future.
ment, direct observation, Objective Structured Clini-
cal Examination (OSCE), and simulation [24, 29]. The Conclusion
multi-methods competencies assessment and multi- This study had provided two distinct inputs. First, the
assessors of core competencies acknowledged unique- valuable insight in the refinement of a preliminary
ness of individual nurses through diverse approaches. developed CAT and second, the identification of issues
Other widely used method is patient-centered com- that may affect the acceptability and the implementa-
petency model which addressed patient as an assessor tion process of the revised CAT. The expert panel had
to add greater reliability and validity to the assessment given substantial contributions in the revision process
process [29]. of the existing CAT leading to preliminary development
This study pinpointed that usability and acceptability of a new CAT. The study highlighted the significant of
of using the preliminary CHNs CAT additional to the using a multi-method and multi-assessors’ approach
Kisut et al. BMC Nursing (2022) 21:134 Page 12 of 14

in the assessment. These include direct observations Thus, this reflects that using ‘one size fits all’ approach
of the nurse’s practice, an interview to ascertain nurs- poses a significant limitation to competency-based assess-
ing care in different scenarios and evidences provided ment in the clinical setting which demonstrated that one
by the nurse (including self-assessments, exemplars or single method will not be able to adequately measure
examples of practice, documentation, and reports from competence. Future research should include this area to
other nurses and other health professionals). Adequate consistently improve the preliminary revised CHNs CAT.
information and training of using the preliminary new It is worth mentioning that the revised CAT is
CAT, and providing clear explanations of terms used in intended to assess and evaluate competency standard at
the preliminary new CAT are some recommended solu- staff nurse level. Knowing the importance of assessing
tions concerning the utilization and acceptability of the and evaluating competencies of other level of nurses, it
CAT. It is also suggested that competencies assessments is imperative to develop similar tool with different core
should be periodic, regular assessment instead of a ‘once- competencies standards in the future studies.
only’ assessment. It is found imperative to paid attention
to multiple competency assessment tools which may put
Abbreviations
extra burden to the nurses. AJCAHO: American Joint Commission on Accreditation of Healthcare Organi‑
zation; CATs: Competency Assessment Tools; CHNs: Community Health Nurses;
FGDs: Focus Group Discussions; IHSREC: Institute of Health Sciences Research
Strengths and limitations of the study Ethics Committee; ICN: International Council of Nurses; MHREC: Medical and
This study reviewed the existing CHNs CAT for nurses Health Research and Ethics; OPD: Outpatient Department; OSCE: Objective
working at the General Practice setting in PHC through Structured Clinical Examination; PHC: Primary Health Care; PLPK: The Brunei
Nursing Training and Development Centre; SoP: Scope of Practice; WHO:
the review of expert panel groups that have background World Health Organization.
in community health nursing. The FGDs with the expert
panel evident that challenges remain in establishing Supplementary Information
components or domains of competencies, list of compe- The online version contains supplementary material available at https://​doi.​
tencies and assessments approaches in terms of meth- org/​10.​1186/​s12912-​022-​00898-y.
ods and assessors. Further FGDs may deem required to
establish a more comprehensive list of assessment items. Additional file 1.
Further quantitative analysis is also required to assess the
psychometric properties of the preliminary new CAT to Acknowledgements
evaluate the tool critically, hence development of a more The authors would like to express sincere appreciation to all the participants
who have joined and supported the project.
robust assessment instrument.
Authors’ contributions
RK, JS and KHA contributed to the conception or design of the study. RK and
Implication to practice, policy and research KHA were involved in acquisition of data/or interpretation of data. All authors
The World Health Organization (2010) emphasize that participated in writing, drafting and revising the manuscript, and agreed to be
it is imperatively important to ensure nurses are compe- accountable for all aspects of the work and any issues related to the accuracy
or integrity of any part of the work. All the authors read and approved the final
tence to perform their jobs. The American Joint Com- manuscript.
mission on Accreditation of Healthcare Organization
(AJCAHO) (2010) claimed that in order to provide qual- Funding
No funding was received for this undertaken project.
ity patient care, the individuals delivering patient care
services must be competent enough to do so. AJCAHO Availability of data and materials
standards also require leaders to ensure the competence The datasets generated during and analyzed during the current study are not
publicly available due to institutional data sharing policy but are available
of staff members to be continually assessed, maintained, from the corresponding author on reasonable request.
demonstrated and improved [8]. Therefore, taking safety
and quality of care into consideration, it is vital to utilize Declarations
reliable and validated tool to assess competency. Policy
makers may enforce the preliminary revised CHNs CAT Ethics approval and consent to participate
The study protocol was designed and performed according to the Declara‑
for implementation. tion of Helsinki. Ethical clearance was provided by the joint committee of the
There is no single best method that can be used to Pengiran Anak Puteri Rashidah, Institute of Health Sciences Research Ethics
assess competence. The combination approach is recom- Committee (IHSREC), Universiti Brunei Darussalam and Medical and Health
Research and Ethics Committee (MHREC), Ministry of Health (ERN: UBD/
mended to ensure adequate assessment of competence. PAPRSBIHSREC/2O19/18). Written informed consent was obtained from all
Methods of assessment identified in the literature include participants.
return demonstration, skill assessment inventories (via
Consent for publication
self, peers, supervisors, and clients), portfolio develop- Not applicable.
ment and review and observation of daily work [25, 41].
Kisut et al. BMC Nursing (2022) 21:134 Page 13 of 14

Competing interests Health. 2016. [Internet]. Available from: https://​www.​moh.​gov.​bn/​Downl​

The authors do not have conflict of interest to declare. oadab​les/​Health%​20Inf​ormat​ion%​20Boo​klet%​202016%​20(21st%​20Rev​
ision%​202).​pdf. Accessed 30 Apr 2021.
Author details 18. Feringa MM, De Swardt HC, Havenga Y. Registered nurses’ knowledge,
1
Department of Nursing Services, Ministry of Health, BB3910, Bandar Seri attitude, practice and regulation regarding their scope of practice: a
Begawan, Brunei Darussalam. 2 Pengiran Anak Puteri Rashidah Sa’adatul literature review. Int J Africa Nurs Sci. 2018;8:87–97.
Bolkiah, Institute of Health Sciences, Universiti Brunei Darussalam, BE1410, 19. Association WM. World medical Association declaration of Helsinki:
Gadong, Brunei Darussalam. 3 Research Scholar, School of Nursing, University ethical principles for medical research involving human subjects. Jama.
of Michigan, Ann Arbor, USA. 4 Adjunct Senior Lecturer, School of Nursing 2013;310:2191–4.
and Midwifery, La Trobe University, VIC3086, Bundoora, Australia. 20. Royal College of General Practice Foundation and Royal College of
Nursing. General Practice Nurse competencies. 2015. [Internet]. Available
Received: 30 August 2021 Accepted: 9 May 2022 from: https://​www.​worce​ster.​ac.​uk/​docum​ents/​RCGP-​Gener​al-​Pract​ice-​
Nurse-​compe​tenci​es-​2015.​pdf.
21. Capital Health Nova Scotia. Primary Health Care Competency Framework.
2012. [Internet]. Available from: https://​www.​cdha.​nshea​lth.​ca/​system/​
files/​sites/​123/​docum​ents/​prima​r y-​health-​care-​compe​tency-​frame​work-​
References quick-​refer​ence-​guide.​pdf.
1. Honda K, Fujitani Y, Nakajima S, et al. On-site training program for public 22. Australian Nursing and Midwifery Federation. National practice standards
health nurses in Fukushima prefecture, Japan: effects on risk communica‑ for nurses in general practice. Australian Nursing and Midwifery Federa‑
tion competencies. Int J Disaster Risk Reduct. 2022;67:102694. tion Standards funded by the Australian Government Department of
2. Feliciano EE, Boshra AY, Mejia PCG, et al. Understanding Philippines Health. 2014. [Internet]. Available from: https://​www.​anmf.​org.​au/​docum​
nurses’ competency in the delivery of healthcare services. J Patient Care. ents/​Natio​nal_​Pract​ice_​Stand​ards_​for_​Nurses_​in_​Gener​al_​Pract​ice.​pdf.
2019;5:146. Accessed 30 Apr 2021.
3. Heydari A, Kareshki H, Armat MR. Is nurses’ professional competence 23. The Nursing Council of Hongkong. Core competencies for registered
related to their personality and emotional intelligence? A cross-sectional nurses (general) (February 2). HKNC; 2012. [Internet]. Available from:
study. J Caring Sci. 2016;5:121. https://​www.​nchk.​org.​hk/​filem​anager/​en/​pdf/​core_​comp_​engli​sh.​pdf.
4. World Health Organization. Framework for Action on Interprofessional 24. Flinkman M, Leino-kilpi H, Numminen O, et al. Nurse competence scale
Education & Collaborative Practice. Health Professions Networks Nursing : a systematic and psychometric review. J Adv Nurs. 2017;73:1035-1-5.
and Midwifery Office, the Department of Human Resources for Health. https://​doi.​org/​10.​1111/​jan.​13183.
2010. [Internet]. Available from: http://​www.​who.​int/​hrh/​nursi​ng_​midwi​ 25. Levine J, Johnson J. Competency toolkit: an organizational competency
fery/​en/. validation strategy for registered nurses. 2014;30(2):58–65. https://​doi.​
5. Ahmadi S, Yazdani S, Mohammad-Pour Y. Development of a nursing org/​10.​1097/​NND.​00000​00000​000041.
competency framework: thematic content analysis. Int J Sci Study. 26. MacKusick CI, Minick P. Why are nurses leaving? Findings from an initial
2017;5:827–31. qualitative study on nursing attrition. Medsurg Nurs. 2010;19:335–40.
6. Joint Commission International. Joint Commission Accreditation Stand‑ 27. Liu Y, Aungsuroch Y. Current literature review of registered nurses’ compe‑
ards for Primary Health Care. 2nd Ed. Joint Commission International; tency in the global community. J Nurs Scholarsh. 2018;50:191–9.
2017. 28. College of Registered Nurses of Manitoba. Standards for RN Clinical Com‑
7. Rodríguez-Zarzuelo G, Gómez-Niño Á, Martín-Herranz R. A Delphi study petence Assessment. 2013. [Internet]. Available from: https://​www.​crnm.​
to identify and assess professional competencies in the education of mb.​ca/​resou​rce/​stand​ards-​for-​clini​cal-​compe​tence-​asses​sment/.
optometrists. J Optom. 2022. 29. Franklin N, Melville P. Competency assessment tools: an exploration of
8. Stollenwerk MM, Gustafsson A, Edgren G, Gudmundsson P, Lindqvist M, the pedagogical issues facing competency assessment for nurses in the
Ericsson T. Core competencies for a biomedical laboratory scientist–a clinical environment. Collegian. 2015;22:25–31.
Delphi study. 2022. https://​doi.​org/​10.​21201/​rs.3.​rs-​12579​91/​v1. 30. Bagnasco A, Catania G, Zanini M, et al. Core competencies for family
9. International Council of Nurses. Nursing Care Continuum Framework and and community nurses: a European e-Delphi study. Nurse Educ Pract.
Competencies. ICN regulation series. 2008. https://​siga-​fsia.​ch/​files/​user_​ 2022;103296.
upload/​07_​ICN_​Nursi​ng_​Care_​Conti​nuum_​Frame​work_​and_​Compe​ 31. Singapore Nursing Board. Core competencies of registered nurse. 2012.
tenci​es.​pdf. Accessed 30 Apr 2021. [Internet]. Available from: https://​www.​healt​hprof​essio​nals.​gov.​sg/​docs/​
10. Casagrande J. Nursing and midwifery council revalidation. Nursing stand‑ libra​riesp​rovid​er4/​publi​catio​ns/​core-​compe​tenci​es-​gener​ic-​skills-​of-​rn_​
ard (Royal College of Nursing (Great Britain): 1987). 2016;30(49):64–5. snb_​april-​2018.​pdf.
11. Jordanian Nursing Council. National Standards and Core Competencies 32. Myanmar Nurse and Midwife Council. Core Competencies for MNMC
For Registered Nurse. 2016. [Internet]. Available from: http://​www.​jnc.​gov.​ registered Nurses and Midwives. 2015. [Internet]. Available from: https://​
jo/​Docum​ents/​‫ريياعم‬%​20‫تايافكو‬%​20‫ضرمملا‬%​20‫ماعلا‬%​202016.​ myanm​ar.​unfpa.​org/​sites/​defau​lt/​files/​pub-​pdf/​Natio​nalSt​andar​dsfor​
pdf. Midwi​ves_​previ​ew_0.​pdf.
12. Beogo I, Rojas BM, Gagnon M-P, Liu C-Y. Psychometric evaluation of the 33. Benziger CP, Roth GA, Moran AE. The global burden of disease study and
French version of the clinical nursing competence questionnaire (CNCQ- the preventable burden of NCD. Glob Heart. 2016;11:393–7.
22): a cross-sectional study in nursing education in Burkina Faso. Nurse 34. Rosa WE, de Campos AP, Abedini NC, et al. Optimizing the global nurs‑
Educ Today. 2016;45:173–8. ing workforce to ensure universal palliative care access and alleviate
13. Wilkinson CA. Competency assessment tools for registered nurses: an serious health-related suffering worldwide. J Pain Symptom Manag.
integrative review. J Contin Educ Nurs. 2013;44:31–7. 2022;63:e224–36.
14. Blažun H, Kokol P, Vošner J. Research literature production on nursing 35. Ladhani Z, Stevens FJ, Scherpbier AJ. Does community health care
competences from 1981 till 2012: a bibliometric snapshot. Nurse Educ require different competencies from physicians and nurses? BMC Med
Today. 2015;35:673–9. Educ. 2014;14:1–8.
15. Ministry of Health Brunei. Ministry of Health Brunei Darussalam. Depart‑ 36. Benson J, Clark F. A guide for instrument development and validation. Am
ment of Nursing Services. 2022. [Internet]. Available from: https://​www.​ J Occup Ther. 1982;36:789–800. https://​doi.​org/​10.​5014/​ajot.​36.​12.​789.
moh.​gov.​bn/​SiteP​ages/​Nursi​ng%​20Ser​vice.​aspx. 37. Fater KH, Weatherford B, Ready RW, et al. Expanding nurse of the future
16. Ministry of Health. CORE COMPETENCY STANDARDS FOR REGISTERED nursing core competencies across the academic–practice transition: a
NURSES AND MIDWIVES IN BRUNEI DARUSSALAM. 2013. [Internet]. Avail‑ pilot study. J Contin Educ Nurs. 2014;45:366–72.
able from: https://​www.​moh.​gov.​bn/​SiteC​ollec​tionD​ocume​nts/​Nursi​ng%​ 38. Mangubat NRC, Mangahas BT, Matias CJC, Mauleon AJA. Level of compe‑
20Boa​rd/​core-​compe​tency-​stand​ards.​pdf. tency of new registered nurses as perceived by their nursing supervisors.
17. Ministry of Health Brunei. Health Information Booklet 21st Edition (Revi‑ CAM Res J. 2014;2:136–69.
sion 2). Data Management Office of Policy and Foresight Ministry of
Kisut et al. BMC Nursing (2022) 21:134 Page 14 of 14

39. Figueroa S, Bowling J, Cummings JL, et al. Nurses’ perception of unit-

based competency assessment compared to traditional skills fair.
Medsurg Nurs. 2018;27:373.
40. de HFL, Marra CC, Cunha ICKO. Assessment of professional competence
of nurses in emergencies: created and validated instrument. Rev Bras
Enferm. 2018;71:1865–74.
41. Bezemek R. Assessing nurses’ competency to achieve highly reliable care.
Am Nurse Today. 2017;12:40–2.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub‑
lished maps and institutional affiliations.

Ready to submit your research ? Choose BMC and benefit from:

• fast, convenient online submission

• thorough peer review by experienced researchers in your field
• rapid publication on acceptance
• support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions