SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA ASSESSING NURSES’ COMPETENCIES IN MANAGING CRITICALLY ILL PATIENTS IN THE INTENSIVE CARE UNIT. A STUDY AT THE KORLE- BU TEACHING HOSPITAL BY ESTHER OWUSU-TAKYI (10754090) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF AMPHIL IN NURSING DEGREE DECEMBER, 2023 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh i DECLARATION This is to certify that this thesis is the outcome of a study undertaken by Esther Owusu- Takyi under supervision towards the award of a Master of Philosophy Degree in Nursing at the School of Nursing and Midwifery by the University of Ghana. All materials used in this study have been duly acknowledged in both the text and the list of references. 21/12/2023 ……………………………… ……………………… Esther Owusu-Takyi Date (STUDENT) 21/12/2023 ………………………..……. …………………….. Dr. Samuel Adjorlolo Date (SUPERVISOR) 21/12/2023 ……………………………….. ……………………… Ms. Patricia Avadu Date (CO-SUPERVISOR University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh i ABSTRACT Critically ill patients have life-threatening health problems that leave them in a vulnerable state and thus need urgent medical attention. The critical care nurse (CCN) forms an integral part of the expert team of medical professionals who provide the needed care for such patients and spend the most time with the patient. The CCN possesses the requisite set of competencies to decide care strategies for patient management for optimum recuperation, and comfort for the patient. Lack of these competencies as a result of the shortage of CCNs could have dire consequences for the patient in the ICU. Critical care nurses form approximately one-third of the nursing workforce in the ICUs of Korle-Bu Teaching Hospital (KBTH). Thus, evaluation of nurse competencies in the ICUs of KBTH was found to be necessary. A quantitative and cross-sectional study employing a 66-item questionnaire was used to assess demographic characteristics, critical thinking, professional development and practice, and communication and coordination competencies of 133 nurses from all the ICUs at the Korle-Bu Teaching Hospital (KBTH). Benner’s scale was used to guide the grading of the level of competence of all consenting participants. The study revealed that more than 80% of nurses in the ICUs were competent although critical care nurses formed less than one-third of participants. The areas of competencies assessed were also found to correlate strongly with each other (p<0.001). Competence was found to be significantly associated with age, status in the ICU, level of education, specialty, and years of experience (p<0.001). Additionally, logistic regression analysis showed that the years of experience, as well as Senior and Principal officer ranks significantly (R2 = 0.407, F(4, 128) = 21.98, p < .001) predicted the overall competence of the ICU nurse. Steps would have to be taken to train and mentor younger and less experienced staff of the ICU even if they are trained as critical care nurses to achieve an acceptable level of competence in their duties towards the critically ill. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh i DEDICATION This work is dedicated to my family for their understanding, support, and patience throughout this journey. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh ii ACKNOWLEDGEMENT My heartfelt appreciation goes to my family for their continuous prayer and support during my MPhil programme. My sincere thanks go to my first supervisor Madam Patricia Avadu for her continuous support and steady commitment to the completion of this project. To Dr. Samuel Adjorlolo for his constructive criticisms, guidance, and immense contribution to the success of this work. I wish to thank all the nurses and midwives at the intensive care units of the National cardiothoracic Centre, Department of Surgery, Department of Child Health, National Reconstructive Plastic Surgery and Burns Centre, Department of Obstetrics and Gynaecology, and Department of Medicine of the Korle-Bu Teaching Hospital who took time off their busy schedule to participate in this study. I also wish to thank the two sisters and friends I found on this journey: Yvonne and Erica. Your support and encouragement cannot be described by mere words. God richly bless you. Lastly, I want to appreciate all faculty members of the School of Nursing and Midwifery for their guidance, support, and training that empowered me to finish the course work and this thesis. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh iii TABLE OF CONTENTS DECLARATION ............................................................................................................ i ABSTRACT .................................................................................................................... i DEDICATION ................................................................................................................ i ACKNOWLEDGEMENT ............................................................................................. ii LIST OF TABLES ....................................................................................................... vii LIST OF FIGURES ...................................................................................................... ix LIST OF ABBREVATIONS ......................................................................................... x CHAPTER ONE ............................................................................................................ 1 1.1 Background .................................................................................................................... 1 1.2 Problem Statement ........................................................................................................ 8 1.3 Purpose of the Study..................................................................................................... 9 1.4 Objectives of the Study ................................................................................................ 9 1.5 Research Questions ...................................................................................................... 9 1.6 Significance of the Study ........................................................................................... 10 1.7 Operational Definition of Terms .............................................................................. 11 CHAPTER TWO ......................................................................................................... 11 LITERATURE REVIEW ............................................................................................ 11 2.1 Conceptual Framework applied in the study ........................................................... 12 2.1.1 The Competency Outcomes Performance Assessment (COPA) Model .......... 13 2.1.2 The Quality and Safety Education for nurses (QSEN) model ........................... 14 2.1.3 Core Competence Framework Model for Emergency nurse Specialist (CCFMENS) ...................................................................................................................... 14 2.2 Literature review ......................................................................................................... 19 2.2.1 Critical thinking, Professional practice and development, and communication and coordination competencies in the care of the critically ill patient ................................................................................................................... 19 2.2.2 Relationship between nurses’ critical thinking, professional development and practice, and communication and coordination competencies. ..................... 25 2.2.3 Demographic Predictors of competence of the ICU nurse .......................... 27 2.4 Summary of literature review .................................................................................... 30 CHAPTER THREE ..................................................................................................... 31 METHODOLOGY ...................................................................................................... 31 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh iv 3.1 Study Design ............................................................................................................... 31 3.2 Research Setting.......................................................................................................... 32 3.3 Study Population ......................................................................................................... 34 3.3.1 Inclusion Criteria ......................................................................................... 34 3.3.2 Exclusion Criteria ........................................................................................ 34 3.5 Sample size .................................................................................................................. 35 3.6 Data Collection Tool .................................................................................................. 36 3.7 Data Collection Procedure ......................................................................................... 36 3.8 Validity and Reliability of Research Instrument .................................................... 37 3.9 Data Management ....................................................................................................... 38 3.10 Data Analysis ............................................................................................................ 39 3.11 Ethical Considerations ............................................................................................. 40 CHAPTER FOUR ........................................................................................................ 41 RESULTS .................................................................................................................... 41 4.1 Socio-demographic characteristics of study participants ...................................... 42 4.1.1 Comparison of competence scores for demographic factors associated with critical thinking, professional development and practice, and communication and coordination competencies ................................................................................... 43 4.2 Critical thinking competencies in the care of the critically ill in the ICU........... 47 4.3 Professional development and practice competencies in the ICU ....................... 50 4.4 Communication and coordination competencies in the ICU ................................ 52 4.5 Overall competency on critical thinking, professional development and practice, and communication and coordination competencies .................................................... 55 4.6 Correlation between critical thinking, professional practice and coordination competencies ...................................................................................................................... 56 4.8 Predictive analysis of demographic factors determining competence in the ICU ............................................................................................................................................. 56 4.8.1 Demographic predictors of Critical thinking competence of the ICU nurses . 58 4.8.2 Demographic predictors of Professional development and practice competencies of the ICU nurse........................................................................................ 59 4.8.3 Demographic predictors of Communication and coordination competencies of the ICU nurse ..................................................................................................................... 60 4.8.4 Demographic predictors of overall competency in the ICU nurse .................... 61 CHAPTER FIVE ......................................................................................................... 63 DISCUSSION OF FINDINGS .................................................................................... 63 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh v 5.1 Socio-demographic characteristics of participants ................................................. 64 5.2 General competence of nurses in the ICU ............................................................... 64 5.3 Critical thinking competence .................................................................................... 65 5.4 Professional development and practice competencies of nurses in the ICU....... 67 5.5 Communication and coordination competence of nurses in the ICU .................. 70 5.6 Relationship between the categories of competence .............................................. 74 5.6.1 Correlation between critical thinking, professional practice competence and communication and coordination competence. .................................................... 74 5.6.2Demographic Factors associated with critical thinking, professional development and practice, and communication and coordination competencies. 76 5.7 Demopraphic predictors of competence of nurses in the ICU .............................. 77 CHAPTER SIX ............................................................................................................ 81 SUMMARY, IMPLICATIONS, LIMITATIONS, CONCLUSIONS AND RECOMMENDATIONS ............................................................................................. 81 6.1 Summary of The Study .............................................................................................. 81 6.1.1 General competence in the ICU................................................................... 84 6.1.2 Critical thinking competence ....................................................................... 84 6.1.3 Professional development and practice competencies ................................. 85 6.1.4 Communication and coordination competence ........................................... 86 6.1.5 Demographic predictors of competence in the ICU .................................... 86 6.2 The Implication Of The Study .................................................................................. 87 6.2.1 For nursing practice ..................................................................................... 87 6.2.2 For nursing education .................................................................................. 89 6.2.3 For nursing research .................................................................................... 90 6.3 Limitations of the study ............................................................................................. 90 6.4 Conclusion ................................................................................................................... 91 6.5 Recommendations....................................................................................................... 92 6.5a To the Ministry of Health ............................................................................. 92 6.5b To the management of KBTH ...................................................................... 92 6.5c To the intensive care facility management ................................................... 93 REFERENCES ............................................................................................................ 94 APPENDIX A: INTRODUCTORY LETTER .......................................................... 119 APPENDIX B: LETTER OF SUPPORT FROM SUPERVISORS .......................... 120 APPENDIX C: STUDY APPROVAL BY THE KBTH STC ................................... 122 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh vi APPENDIX D: IRB APPROVAL FROM KBTH ..................................................... 123 APPENDIX E: LETTER OF AFFIRMATION OF RECEIPT OF KBTH-IRB ....... 124 APPENDIX F: LETTER OF INTRODUCTION TO ALL ICUs .............................. 125 APPENDIX G: PARTICIPANT CONSENT FORM ................................................ 126 APPENDIX H: RESEARCH QUESTIONNAIRE .................................................... 128 APPENDIX I: KOREAN NURSES’ CORE COMPETENCY SCALE.................... 134 APPENDIX J: COMPETENCY INVENTORY FOR REGISTERED NURSES ..... 137 APPENDIX K: ICN FRAMEWORK OF COMPETENCIES FOR THE NURSE SPECIALIST ............................................................................................................. 139 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh vii LIST OF TABLES Table 1. Competent versus Less Competent ICU nurse .............................................. 40 Table 2. Socio-demographic characteristics of participants ........................................ 42 Table 2a. Comparison of competence scores for demographic factors (nominal variables) associated with critical thinking, professional development and practice, and communication and coordination competencies of nurses in the ICU .................. 44 Table 2b. Comparison of competence scores for demographic factors (ordinal variables) associated with critical thinking, and professional development and practice competencies of nurses in the ICU .............................................................................. 45 Table 2c. Comparison of competence scores for demographic factors (ordinal variables) associated with communication and coordination competencies of nurses in the ICU ......................................................................................................................... 46 Table 3. Descriptive statistics of critical thinking competence variables .................... 48 Table 4. Descriptive statistics of critical thinking competencies in the care of the critically ill in the ICU ................................................................................................. 49 Table 5. Descriptive Statistics of professional development and practice competencies in the care of the critically ill in the ICU ..................................................................... 51 Table 6. Descriptive statistics of communication and coordination competencies in the care of the critically ill in the ICU ............................................................................... 53 Table 7. Descriptive statistics of communication and coordination competencies in the care of the critically ill in the ICU ............................................................................... 54 Table 8. Overall competency based on critical thinking, professional development and practice, and communication and coordination competencies .................................... 55 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh viii Table 9. Correlation between critical thinking, professional practice and development, and communication and coordination competencies ................................................... 56 Table 13. Dummy codes for categorical variables ....................................................... 57 Table 14. Logistic regression analysis of demographic predictors of critical thinking competencies of the ICU nurse .................................................................................... 58 Table 15. Logistic regression analysis of demographic predictors of Professional development and practice competencies of the ICU nurse .......................................... 59 Table 16. Logistic regression analysis of demographic predictors of communication and coordination competencies of the ICU nurse ........................................................ 60 Table 17. Logistic regression analysis of demographic predictors of the overall competence of the ICU nurse ....................................................................................... 61 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh ix LIST OF FIGURES Figure 1. Conceptual framework from the Core competence framework model for ENS (Fan, Gui, Xi & Qiao, 2016) ............................................................................... 16 Figure 2. Conceptual framework on Competencies for ICU nurses adapted from the Core competence framework model for Emergency nurse Specialist (Fan, Gui, Xi & Qiao, 2016) .................................................................................................................. 19 University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh x LIST OF ABBREVIATIONS ABCDE: Airway, Breathing, Circulation, Disability, and Exposure ABGs: Arterial Blood Gases BIPAP: Bilevel Positive Pressure CCFMENS: Core Competence Framework Model for Emergency Nurse Specialist CCN: Critical Care Nurse/Nursing CCNC: Core Clinical Nursing Competence CIRN: Competency Inventory for Registered Nurses COPD: Chronic Obstructive Pulmonary Disease COVID-19: Coronavirus Disease 2019 CPAP: Continuous positive pressure CPD: Continuing professional development ECG: Electrocardiogram GCS: Glasgow Coma Scale HICs: High-Income Countries IBM: International Business Machines Corporation ICN: International Council of Nurses ICP: Intracranial pressure ICU: Intensive care unit IRB: Institutional Review Board University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh xi IT: Information Technology KBTH: Korle-Bu Teaching Hospital KNCCS: Korean nurses ‘Core Competency Scale LICs: Low-Income Countries LMICs: Lower Middle-Income Countries NMC: Nursing and Midwifery Council PCC: Patient-centered care SPSS: Statistical Package for Social Sciences STC: Scientific and Technical Review Committee VBGs: Venous Blood Gases University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.1 Background Critical illness or acute illness denotes any life-threatening, reversible condition of a severe stage, that could lead to a poor outcome or death if left untreated (Baker, 2015; Schell et al., 2018). Critical illness rarely strikes without warning, but it is often preceded by a sequence of unrecognized changes (in some cases) in important clinical signs over several hours (Vincent, 2019). Patients with conditions such as Pneumonia, Eclampsia, Sepsis, Peritonitis, Haemorrhage, Asthma, Trauma, Stroke (Schell et al., 2018), acute-on-chronic liver disease, haematological malignancy, et cetera become critically ill (Khan & Ridley, 2014). Several millions of deaths have been crudely estimated to result from critical illness across the globe each year (Schell et al., 2018). The process of caring for patients who have or are in danger of acquiring life- threatening diseases is known as critical care (Jackson & Cairns, 2021). Patients with critical illnesses are often managed in the intensive care unit (Vincent, 2019). The intensive care unit (ICU) is a geographically distinct location where high staffing ratios, improved monitoring, and organ support can be provided to reduce patient morbidity and mortality (Jackson & Cairns, 2021). The ICU provides an organized system for the provision of care by a specialized medical and nursing team. It also provides an enhanced capacity for the monitoring of multiple modalities of physiologic organ insufficiency and supports sustaining life (Vincent, 2019). Medical care involves care provided by surgeons, intensivists, and pulmonologists. The surgeon provides advice and guidance for specific management of the surgical condition, wound care, nutrition, and anticoagulation therapy during the postoperative period (Jackson & Cairns, 2021). Nursing care or roles on the other hand include handling referrals and admissions to the ICU, managing and monitoring airway and respiratory support, cardiovascular support, renal support, gastrointestinal support and nutrition, infection prevention and control, University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 2 communication with patients, and patient’s family and control among others. (Scholtz et al., 2016). Furthermore, the ICU requires the use of preventative measures, early warning and response systems, and a multidisciplinary approach both before and during the stay in the ICU (Jackson & Cairns, 2021). Reportedly, mortality and morbidity rates are greater for patients admitted to the ICU compared to those admitted to standard wards (Akkoç et al., 2017; Elhadi et al., 2021; Khan & Ridley, 2014). The high morbidity and mortality have been associated with the age of the patient, level of hospital care, annual patient volume, the number of comorbidities, the acuteness or severity of the patient’s condition on admission, competence of ICU team members et cetera (Akkoç et al., 2017; Weigl, Adamski, Goryński, et al., 2018). Geographical location and income categories have been reported to influence mortality rates in the ICU. Mortality rates in the ICU in some high-income European countries were 6.7 to 17.8%. Similar mortality rates have been reported for other high-income countries such as the USA (11.3%) as well as Australia and New Zealand (7%) (Weigl, Adamski, Goryn´ski, et al., 2018). Relatively higher ICU mortality rates (26% and 23.2% respectively) have been reported in other high- income countries such as Italy (Elhadi et al., 2021) and Spain (Borobia et al., 2020). A study in China, an upper-middle-income country, reported that among 344 ICU patients, the mortality is estimated to be about 38.7% within 28 days after ICU admission (Wang et al., 2020). In a meta-analysis of 24 studies outside of Africa and in this case low to lower-middle-income countries, ICU mortality was 41.6% (34.0– 49.7%). However, the only study from the African region will be that of Biccard et al., 2018, which found a 48.2% mortality rate among patients in several African countries (Biccard et al., 2018). The survival and fatality rates of ICU admissions in African nations are, however, little documented. (Siaw-Frimpong et al., 2021). Researchers in University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 3 Africa would have to pay attention to this gap and would need to look into this area as this can help determine the trajectory and impact of ICU care in African countries. Intensive care unit (ICU) bed capacity among 19 Asian countries revealed that there were 3.6 critical care beds per 100,000 population. Lower (2.3 critical care beds per 100,000 population) values were reported in low- and lower-middle–income economies compared to the upper-middle–income economies (4.6 critical care beds per 100,000 population) and high-income economies (12.3 critical care beds per 100,000 population) (Phua et al., 2020). Larger variations in ICU bed capacities were realized across countries and regions of the same World Bank income classification (Phua et al., 2020). For every 100,000 people in Germany, Canada, and the United Kingdom, there were 24.6, 13.5, and 3.5 ICU beds respectively (Phua et al., 2020). In developing countries, large urban areas mostly and exclusively hosted the available ICUs (Siaw- Frimpong et al., 2021). Africa is estimated to have 0.8 critical care beds per 100,000 population (Ayebale & Kassebaum, 2020). For every 100,000 population, South Africa (High income) has 8.9 ICU beds, and Uganda (low income) has 0.1 ICU beds. West Africa has an estimated critical care bed capacity of 0.6 per 100,000 population while Ghana has 0.9 critical care beds per 100,000 population (Ayebale & Kassebaum, 2020). In Ghana, there are a total of 113 adults and 36 pediatric ICU beds for up to thirty (30) million people. In Ghana, there is a significant shortage of ICU beds. Compounding this challenge is the inequitable distribution of these beds across the country and the low intensivists to nursing staff ratio in the ICUs (Siaw-Frimpong et al., 2021). Patients who are critically ill usually have poor respiration, circulation, or awareness, and they require immediate intervention and therapy to be stabilized (Engebretsen et al., 2021). Clinical management of the critically ill comprises many activities but essentially includes airway management (oxygen administration, suctioning, and chest physiotherapy), haemodynamics monitoring (Arterial Blood Gases, ABGs, Venous University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 4 Blood Gases, VBGs, Central Venous Pressure, CVP, and vital signs), cardiac management (Electrocardiogram “ECG” monitoring, pacemaker and defibrillation), drug administration (inotropes), neurologic management (monitoring Intracranial pressure, ICP and Glasgow Coma Scale, GCS) and physiologic alteration management (CII) (Brown & Cadogan, 2015). To aid the work of ICU personnel equipment such as pulse oximeters, cardiac monitors, blood gas analyzers, ventilators (Continuous positive pressure (CPAP) and bilevel positive pressure (BIPAP), defibrillators, spirometers, systems as well as other essential equipment are provided within the ICU space (Baker, 2015). Robertson and Al-Haddad (2013) suggested that management of the critically ill patient requires health care expert evaluation using the airway (monitoring patency), breathing (respiratory rate), circulation (pallor, haemorrhage), disability (physical or mental impairment that prevents a person from moving, sensing, or carrying out specific actions), and exposure (unseen haemorrhage, wound leakage) (ABCDE) approach to improve health outcomes of these patients (Robertson & Al- Haddad, 2013). This implies that critically patients require specially trained healthcare providers especially nurses to care for them. This is because it is universally known that the nurse spends the most time with patients on admission and this is most true for the critical care unit nurse (Scholtz et al., 2016). This makes the nurse best suited to recognize subtle changes in a patient and take action either independently or with other members of the critical care team (Vincent, 2019). Detecting critical illness early, before it progresses to the point of being life-threatening, is difficult and time- consuming and thus requires specialized training, as well as experience (Feliciano et al., 2021). Nursing in the ICU focuses on all areas of fundamental nursing care and life support. The nurse in the ICU further combines the essence of nursing with observation, in- depth and even intuitive interpretation, and response to the slightest imbalance or University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 5 deviation in a patient's state to provide optimum care for the critically-ill patient (Jackson & Cairns, 2021). Critical care nurses (CCN) working in the ICU must function within their own culture to adapt to a fast-paced and stressful setting (Scholtz et al., 2016). Owing to the fast-paced and stressful ICU setting, nurses’ competencies particularly in critical thinking, professional development and practice as well as communication and coordination are deemed indispensable in the ICU setting (Fan et al., 2016). These make up the critical thinking competence the nurse must possess to work efficiently in the ICU (Fan et al., 2016; Fukada, 2018; Khanmoradi et al., 2021). Care in the ICU also requires that the nurse understands the legal and ethical principles of the profession and recognizes the importance of quality improvement and performing actions relating to it (Bahreini et al., 2011). This role will require active participation in professional learning activities and training, constantly improving professionally, and gradually honing the nurse to become a specialist (Fan et al., 2016). This is very important to allow patients to derive the best, relevant and expedient care from the ICU nurse (Fan et al., 2016). Communication is an integral nursing role that is meant not only for purposes of therapy but also for information sharing between the nurse and the patient, other healthcare staff at the ICU, and patient relations. Most patients in the ICU are not able to communicate well owing to the nature of the illness, level of consciousness, and therapeutic intervention (e.g on a mechanical ventilator) among others (Dithole et al., 2016). The nurse would have to initiate communication most of the time and also be able to communicate with the patient’s family (Dithole et al., 2016; Slatore et al., 2014). To summarize the points raised thus far, nurses working in the ICU must possess specific knowledge, technical proficiency, and interpersonal abilities to meet the needs of patients who are seriously ill, (Bloomer & Bench, 2020). In a high-income country (HIC) like the United States of America (USA), the American Association of critical care nurses (AACN) agrees that nurses in facilities that take care University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 6 of severely ill patients have to be competent. They however noted that staffing in the ICUs has neglected the proper match between nurse competencies and patient needs. Only 39% of ICU nurses were said to have the knowledge and abilities necessary to care for seriously ill patients. From 2013 to 2018, scores for effective decision-making, communication, and teamwork increased across the board. They also reported that support for continuing education also improved from 74% to 79%. Although there has been much improvement in the critical care nurse working environment in the USA, 54% of nurses working in critical care settings intend to quit their current role within the next year or the next 3 years (Ulrich et al., 2019) The burden of critical illness in low-income (LICs) and lower-middle-income (LMICs) countries is substantial and its outcome has been reported to be poorer compared to high-income countries (HICs). In the HICs, resources to manage the critically ill, high- cost technologies, and highly trained and specialized teams of healthcare staff are readily available (Vukoja et al., 2014). However, this cannot be said for the LICs and LMICs concerning the care of the critically ill (Macey et al., 2022; Vukoja et al., 2014). Intensive care unit (ICU) development in low-income nations has been hampered by the high cost of training healthcare staff, infrastructure, and supplies (Murthy et al., 2015; Papali et al., 2019). There is a dearth of information on nurses working in the ICU with regards to competence, work settings, capacity, communication and coordination, conditions of service, and job satisfaction among others in low-income countries (Murthy et al., 2015). This information is crucial to building strong and resilient nursing care in ICUs in these low-resource environments. Macey et al., 2022 also reported that human and physical resources for ICUs varied greatly by location, but were frequently cited as insufficient to satisfy demand in Low-income and Lower middle-income country health systems (Macey et al., 2022). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 7 To provide the patient with safe and effective treatment, the nurse tending to them needs to be qualified, have a full awareness of the subject, and possess specialized knowledge. (Nobahar, 2016). Local and international authors agree that this specialized knowledge enhances competence and would most probably be acquired from the nurse undertaking a post basic Diploma/Master’s degree in critical care nursing (Briggs et al., 2006; Macey et al., 2022; Schmollgruber, 2007). A survey in the United States among 50 states and a few island states that fall in the LMIC category indicated that a little over 60% of ICU nursing staff had specialty qualifications in critical care nursing and about 24% had graduate qualifications (Ulrich et al., 2019). In Ghana, most nurses who work in ICUs do not qualify for critical care nursing (Osei-Ampofo et al., 2018). By their education, nurses who are not certified in intensive care nursing are assumed not to have been exposed to the specialized knowledge necessary to practice in the ICU environment. This disqualifies them from caring for critically ill patients as they are deemed incompetent (Scholtz et al., 2016). The shortage of nursing staff in Ghana is mostly to blame for the high proportion of "non-qualified" nurses seen in ICUs. Due to this circumstance, the ICUs are now lacking ICU-qualified nurses, who have had to be replaced by non-ICU-qualified nurses (Siaw-Frimpong et al., 2021). According to Morrison, as cited by Scribante & Bhagwangee (2007), providing nursing care without the proper training could be seen as an intrusion that could be harmful to the patient. When inexperience is combined with staff shortages, inadequate supervision, and a lack of support staff, patients may be exposed to adverse outcomes and mistakes are more likely to occur. (Madede, et al., 2017; Morrison, et al., 2001; Scribante & Bhagwanjee, 2007). Variations in education or training, as well as experience, may compromise consistency in the competence of the nurses in the ICU, and this further would compromise patients’ health and safety (Vaismoradi,, et al., 2020). The consequences of having a nurse who might not be competent due to not having received the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 8 specialized knowledge necessary to care for the critically sick patient could be dire and result in the patient getting worse, the patient's treatment failing, and at worst, higher mortality and morbidity (Feliciano, et al., 2021; Kushemererwa, et al., 2020). The above exposition makes it important to assess nurses’ level of competence in managing critically ill patients in the ICU in the Ghanaian Hospital setting given the peculiarity of available resources. 1.2 Problem Statement About 85% of patients admitted to ICUs are managed as critically ill patients; however, the competence of critical care nurses as core staff of the ICU in managing such patients has been reported to be average in developed countries (Botha, 2012; Osei-Ampofo et al., 2013). Nurses' knowledge of the critically ill in countries with improved staffing and relatively advanced medical resources has also not been impressive. Such scenarios in developing African countries are a recipe for disaster when coupled with the ongoing rise in ICU admissions due to the COVID-19 pandemic and other pathologies affecting the respiratory system directly or indirectly(Botha, 2012). In overwhelming circumstances, patients on mechanical ventilation who are deemed to be critically ill are likely to be cared for by general nurses who have limited competencies in management protocols, and monitoring of severely ill patients in the ICU (Wells et al., 2021). Within the African context, studies conducted in South Africa and Rwanda have reported that even where the nursing education is of good standards, the level of competence in the ICU is far from ideal (Botha, 2012). In Ghana, there are inadequate skilled critical care nursing experts and those that exist are over-burdened with high volumes of work. At the point when patients show up at the emergency unit, they are seriously ill, as they have postponed looking for medical services until critically ill (Japiong et al., 2016; Osei-Ampofo et al., 2013). These difficulties become dire if there University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 9 is a mismatch between the competence of the nurse in the ICU and the skill required to care for such patients. Evidence suggests that a great proportion of nurses working in ICUs in Ghana lack the requisite critical care competencies expected for nursing the critically ill. This challenge may result in the critically ill patient suffering complications, prolonged stays at the ICU, and increased costs of care (Siaw-Frimpong et al., 2021). It appears that no study has assessed the competencies of nurses working in the ICU as well as factors that influence their competence level. Neither are there reports on the competencies of nurses in managing critically ill patients in the ICUs of hospitals in Ghana. 1.3 Purpose of the Study The purpose of the study was to assess nurses’ competencies in the management of critically ill patients in the intensive care units of the Korle-Bu Teaching Hospital in Ghana. 1.4 Objectives of the Study The objectives of the study are to: i. Describe nurses’ critical thinking, professional development and practice, and communication and coordination competencies in the care of critically ill patients in the ICU. ii. Investigate the relationship between nurses’ critical thinking, professional development and practice, and communication and coordination competencies. iii. Elucidate the demographic predictors of nurses’ critical thinking, professional development and practice, and communication and coordination competencies in the ICU. 1.5 Research Questions University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 10 To ensure that the research objective is achieved, the study will be guided by the following questions: i. What are nurses’ critical thinking competencies, professional development and practice competencies, and communication and coordination competencies in managing critically ill patients in the ICU? ii. What is the relationship between nurses’ critical thinking competencies, professional development and practice competencies, and communication and coordination competencies? iii. What are the demographic predictors of critical thinking, professional development and practice, and communication and coordination competencies of nurses in the ICU? 1.6 Significance of the Study Little is known or documented about the nurses’ competencies in the management of critically-ill patients in the intensive care units in Ghana. This study is important because intensive care unit admissions are increasing globally largely owing to the rise in non-communicable diseases with accompanying pulmonary pathologies. The COVID-19 disease pandemic and other complicated illnesses with its associated increase of admissions into the intensive care units have equally placed a high demand for advanced skills in the ICU. This situation has placed more weight on the need to improve competencies among nurses. Core competencies would therefore be required to improve patient outcomes. The study will provide information on the perceived competence level of staff working in the intensive care units in the premier teaching hospital in Ghana. The study will unearth the kind of training needed by the staff in the ICU to enable them to work effectively and efficiently. Furthermore, the findings would guide the management of University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 11 the hospital and leadership of the ICUs on nursing staff recruitment for the ICU. The relationship between nursing education level and the competencies required for nursing the critically ill in the ICU would be established and this would provide evidence for recruitment and training needs for the nursing team in the ICU. Last but not the least, the findings of the research will add to the existing knowledge on critical care nursing and will guide and encourage the conduct of future studies in critical care nursing. 1.7 Operational Definition of Terms Nurse: A well-trained and licensed medical professional who provides nursing care for the sick. Competent: Having sufficient skill, knowledge, ability, or qualification to do something well enough to achieve a basic standard. Competence: Knowledge, skills, talents, and behaviors that contribute to individual and organizational success. Critically ill patient: A patient with severe or life-threatening illness or injury Intensive Care Unit (ICU): A specialized unit in a hospital or health care facility that provides care for patients who are acutely unwell and require critical medical care. CHAPTER TWO LITERATURE REVIEW This chapter highlights the literature reviewed concerning assessing the competence of nurses in managing patients in the ICU. This is to help relate the present study to other studies bordering on the same or similar theme. It will as well identify gaps in other studies and help disseminate the findings of other research works. The first part of the review will elaborate on the three (3) conceptual frameworks that were considered for University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 12 this study, out of which one was selected as a model for the study. The focus of this study was to assess nurses’ competencies in managing patients in the ICU. Hence a search for models on nursing competencies was carried out. Three (3) models of nursing competencies were found namely the Competency Outcomes Performance Assessment (COPA) Model (Lenburg et al., 2008), Quality and Safety Education for Nurses (QSEN) model (DiCenso et al., 2005), and the Core Competence Framework Model for Emergency Nurse Specialist (CCFMENS) by Fan et al., 2016. The limitations of the models that were set aside and the justification for the use of the Core Competence Framework Model for Emergency Nurse Specialists (CCFMENS) by Fan et al., 2016 will be discussed. The next session will focus on the adaption and adaption of the constructs of the Core Competence Framework Model for Emergency Nurse Specialists (CCFMENS) with study objectives. The last section of this chapter will review information about the competence of the nurse in the ICU. This will be broken down into sub-sections namely; critical thinking, professional development and practice, communication and coordination, and finally, predictors of competence of the nurse in the ICU. Online databases that were accessed to review literature included PubMed, Google Scholar, CINAHL, Cochrane Medical Library, Science Direct, Sage journal online, and Health Source. Keywords such as “Nursing competence”, “Intensive care unit (ICU)”, “critical thinking”, “Professional development and practice”, “communication and coordination in the ICU”, and “Roles and responsibilities of nurses in the ICU”, “factors that predict competence in the ICU” were employed to search for relevant literature. Other related literature to the above search terms was also used to supplement the literature on the competence of nurses in the ICU. 2.1 Conceptual Framework applied in the study University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 13 The conceptual framework explains the path of research. It is arranged in a logical structure that gives direction and meaning to the theoretical constructs in the research (Imenda, 2014). The conceptual frameworks that were read concerning the research were, the Competency Outcomes Performance Assessment (COPA) Model (Lenburg et al., 2008), Quality and Safety Education for Nurses (QSEN) model (DiCenso et al., 2005), and the Core Competence Framework Model for Emergency Nurse Specialist (CCFMENS) by Fan et al., 2016. 2.1.1 The Competency Outcomes Performance Assessment (COPA) Model The Competency Outcomes Performance Assessment (COPA) Model was designed in the early 1990s by Lenburg based on 17 years of experience directing and consulting with the clinical assessment-based Regents College. The model was created and organized as a theoretical educational framework to support nursing practice competency. This model is double-edged in that it applies to both the learning (training) as well as the practice (work) environments to determine levels of competence for a student to graduate or for the practicing nurse to be endorsed by the employer or her supervisor. This paradigm is organized around four crucial conceptual pillars and is founded on the ideas of competency-based, practice-oriented procedures and outcomes. namely “ a) the specification of essential core practice competencies, b) end-result competency outcomes, c) practice-driven, interactive learning strategies, and d) objective competency performance examinations in all courses” (Lenburg et al., 2008). This model aims to promote quality care and safety for patients. Eight (8) core practice competency categories that are derived from the COPA model include Skills in evaluation and intervention, communication, critical thinking, human care and relationship building, teaching, management, leadership, and knowledge integration University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 14 (Lenburg et al., 2008). However, the model does not provide a guide to measuring competence based on patient characteristics-driven intervention by the nurse. 2.1.2 The Quality and Safety Education for Nurses (QSEN) model The goal of the Quality and Safety Education for Nurses (QSEN) model is to equip nurses with the knowledge and skills they need to enhance the standard of care and safety in the healthcare facilities where they work. The developers of this model adapted the Institute of Medicine (IOM) competencies for nurses comprising: “Patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, and informatics” (Cronenwett et al., 2007). The purpose of this model was to enable the definition or description of what is meant by being a competent nurse and earning the respect thereof. Additionally, they wanted to outline the skills that all registered nurses should possess. These abilities are listed under what the nurse is required to know: her attitude, as well as the set of skills he or she needs to possess to be respected as a competent professional. Although the core competencies by the IOM are five (5), safety was considered in the QSEN model making a total of six (6) core competencies for nurses (Cronenwett et al., 2009). The advantage of this model is that it combines patient preferences and values with the clinical knowledge required to recognize when clinicians (nurses) should stray from evidence-based recommendations to provide high-quality, patient-centered care. (Ciliska, 2005; DiCenso et al., 2005). It however appears that this model is focused more on nursing education and training than being an assessment model for measuring the competence of practicing nurses. 2.1.3 Core Competence Framework Model for Emergency Nurse Specialists (CCFMENS) University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 15 The conceptual model by Fan et al, 2016 on Core Competence Framework Model for Emergency Nurse Specialists (CCFMENS) was adapted and modified to suit the objectives of the study. This model was developed as an assessment tool for nurse emergency specialists as well as critical care nurses in 2016 by Fan, et al. This model's main goal was to support and direct Chinese nursing administrators in creating core competency requirements for emergency nurse specialists. The CCFMENS is presented in the form of concentric circles (figure 1). The essential elements of the emergency nurse's core competence, based on the nurse's clinical practice, are contained in the second layer of the concentric circle. These components include knowledge, skills, and abilities. The outer ring identifies five distinct competency modules that are in line with the fundamental demands on the knowledge, skills, and abilities of the nurse. The first circle's five modules have the following connotations: Professional practice and development as demonstrated by nursing conduct that complies with the law and professional ethics. To safeguard the rights of both people and communities, this behavior required knowledge and experience. To tackle nursing problems in a complicated clinical setting and find answers, critical thinkers must be able to self- regulate their judgment and reflection processes in a meaningful and purposeful way. Analysis, judgment, assessment (evaluation), reasoning, and prediction are some of the most important critical thinking skills. Important aspects of management include planning, organizing, controlling, and coordinating nursing procedures to raise the standard of care and maintain patient safety. Communication and coordination denote the capacity to interact and work together with patients, their families, and other healthcare professionals. Professional development entailed actively engaging in learning opportunities and training, continuously raising professional standards, and progressively becoming a nurse specialist. (Fan et al., 2016). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 16 Figure 1. Conceptual framework for the Core competence framework model for ENS (Fan, Gui, Xi & Qiao, 2016) From the above diagram (Fig. 1), the conceptual model by Fan et al, 2016 on Core Competence Framework Model for Emergency Nurse Specialists (CCFMENS) is broad and all the concepts in this model were not used in this study. The concepts of the model used in this study included critical thinking, professional practice, professional development, and communication and coordination. The CCFMENS offers nurse administrators resources and instructions for teaching and assessing clinical emergency nurses' essential competencies which in this case applies to the nurses working in the ICU. Additionally, ICU nurses can use the CCFMENS for self-evaluation based on predetermined goals to improve and appropriately modify their compassionate behavior and support the advancement of high-quality comprehensive care. The CCFMENS' drawback is that its creators neglected to look into the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 17 relationships between nurse core competency, nursing education, and quality of care. Hence, no objective in this regard was set for the current study. This model was selected because the competence constructs were chosen after a thorough review of the literature, as well as from approved sources from the International Council of Nursing, the United States, the United Kingdom, Australia, Hong Kong, and Taiwan, as well as China’s requirements for professional nurse registration. (Affara, 2009; Fan et al., 2016; O’Connell & Gardner, 2012). Furthermore, this model was found to be most suitable for this investigation among others that the researcher came across from the literature. The purpose of the study is to assess nurses’ competence in the management of critically ill patients in the intensive care unit. The study will focus on nurses working in the intensive care unit and describe their critical thinking competencies, professional development and practice competencies, and communication and coordination competencies in the care of critically ill patients in the ICU. The study will further investigate the relationship between nurses’ critical thinking competencies, professional development and practice competencies, and communication and coordination competencies and elucidate the predictors of nurses’ critical thinking, professional development and practice, and communication and coordination competencies in the management of critically ill patients in the ICU. Also due to time and financial constraints, all the aspects not relevant to this study were excluded. Only aspects of the model that falls under the research objectives were assessed. Hence a modified conceptual framework based on the original model was developed for this study (Fig. 2). In this modified model (Fig 2) adapted from the Core competence framework model for Emergency Nurse Specialists (Fan et al., 2016), three constructs namely critical University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 18 thinking, professional development and practice and communication, and coordination competencies were used to describe the ICU nurses competencies concerning clinical practice needed for the management of critically ill patients in the ICU. Professional development, communication and critical thinking all sum up nurses' competencies. But for this study, the researcher examined the individual competencies to unearth their representation among nurses in Ghana. 2.1.4 Justification for the use of the Core competence framework model for Emergency Nurse Specialist The model provides references and guides for nurse managers to train and evaluate the core competencies of clinical emergency nurses (Fan et al., 2016) which applies to nurses working in the ICU. The model can also be used for objective self-evaluation to foster the development of caring behaviors and the enhancement of overall care quality. (Vujanić et al., 2020). Furthermore, the scale from this framework could be used to discover factors that influence nursing care competency in the ICU and aid research in competency-based education programs (Yoon, 2021). Finally, this model was chosen because the constructs are applicable and can be adapted to the objectives of this study University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 19 Figure 2. Modified Conceptual framework on Competencies for ICU nurses adapted from the Core competence framework model for Emergency nurse Specialist (Fan, Gui, Xi & Qiao, 2016) 2.2 Literature review The section presents the studies reviewed on the objectives of the study 2.2.1 Critical thinking, Professional practice and development, and communication and coordination competencies in the care of the critically ill patient Competence is a familiar term in nursing, which implies that the nurse can work efficiently and exhibit a comprehensive understanding of a situation. Benner defined competence as, “the ability to perform an assigned task with desirable outcomes under varied circumstances of the real world” (Benner, 1984). When a person performs a certain activity, they are said to be competent if they possess a combination of knowledge, abilities, and attitudes that take into account the work's wider practice implications as well as its impact on the patient. (Schmollgruber, 2015). Pijl-Zieber et University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 20 al., 2014 also defined competence as the ability to undertake tasks correctly and skillfully (Pijl-zieber et al., 2014). Nurses must ensure safe and high-quality patient care. To effectively perform this role, their competency to perform both clinical and non-clinical tasks is essential to providing patients with safe and effective care (Hassankhani et al., 2018). To accomplish this, they must increase their nursing expertise and apply it to their daily work. Although nurses are required to have competency in technical skills, they also need skills in decision-making, prioritization, and collaboration (Harding et al., 2013). In understanding and evaluating the concept of competence, nursing competency is described under three theories including behaviorism, trait theory, and holism. Behaviorism refers to competency with the capacity to perform individual key activities and is assessed by demonstration of those skills. The Trait theory considers individual characteristics required for properly completing duties such as knowledge and critical thinking among other traits referred to as competency. Holism experts define competence as a collection of attributes—knowledge, skills, attitudes, ability to think, and values—that are required in specific situations. (Fukada, 2018). These theories also guided the formulation of the objectives for this study. Studies on critical thinking as a measure of competence will be discussed according to the researcher's understanding of previous works of other researchers and how they fit into the context of the current work. According to the chosen model for this study, critical thinking is vital to the role of the nurse and especially so for the nurse taking care of a critically ill patient in the ICU. In this context, critical thinking may be defined as the active reasoning skills that permit the appropriate assessment and prediction of patient conditions, dealing with adjustments, comprehension and analysis, judging and making choices, and evaluating the clinical situation (Fan, et al., 2016; Fukada, 2018; University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 21 Khanmoradi, et al., 2021). Additionally, critical thinking entails making decisions based on scientific knowledge principles, identifying priority risks in clinical settings, and making judgment calls that are informed by both factual knowledge and excellent judgment. Furthermore, critical thinking entails selecting multiple approaches to address clinical problems, planning clinical research data collection, integrating pertinent data from various sources, as well as using a variety of information-finding techniques, and incorporating pertinent research findings into nursing practice. (DeGrande, et al., 2018). Additionally, critical thinking was defined by Papathanasiou and his associates as the mental process of actively and skillfully observing, experiencing, synthesizing, and evaluating gathered information through observation, experience, and communication that results in a decision for action. (Papathanasiou, et al., 2014). According to Ignatavicius (2001), critical thinking nurses should possess the following cognitive skills: interpretation, analysis, evaluation, inference, explanation, and self-regulation. These traits are in sync with the core competencies as proposed by Fan et al., (2016). Assessment and prediction as functions of critical thinking include the evaluation of laboratory results, vital signs, physical assessment data, etc. to determine their significance. It also includes understanding the meaning of a patient's behavior, especially in the case of critically ill patients who may not be able to express themselves verbally (Ignatavicius, 2001). The nature and scope of ICU nursing expose the nurse to a diverse patient population (socio-cultural disparities), rapidly changing and clinically unclear situations, as well as sophisticated logistics and procedures. ICU nurses must therefore be prepared to competently handle a variety of clinical issues and provide care to patients in a timely and efficient manner. (Bam et al., 2020; Jastremski, 2000). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 22 Ignatavicus summarized a critical thinking nurse as one who is outcome-driven, open to new ideas, adaptable, willing to change, innovative, creative, analytical, communicative, assertive, persistent, caring, energetic, risk-taking, knowledgeable, resourceful, observant, intuitive, and able to think "beyond the box" (Ignatavicius, 2001). According to the CCFMENS Model, professional practice for nurses involves the application of nursing knowledge and professional skills. Additionally, it shows nursing conduct that adheres to the moral and ethical standards of the industry. To defend the rights of individuals and groups calls for knowledge and expertise. It involves the ability of the nurse to comprehend the function of professional organizations and actively participate in them, to show initiative in one's own personal development, to take advantage of learning opportunities for ongoing professional and personal growth, and to be aware of one's learning requirements (Fowler, 2015). The nurse's professional practice also entails demonstrating self-awareness of one's weaknesses and strengths, understanding pertinent and current information about the health care system, being aware of the legal and ethical principles that apply to the profession, and applying knowledge and professional skills. (Liu, et al., 2009). Professional development places a strong emphasis on participating actively in professional learning opportunities and training, continuously raising professional standards, and advancing toward nurse specialist status over time. (Fan et al., 2016). It also reflects the ability of the nurse to learn about the patient, patient conditions, clinical points for monitoring progress et cetera. Additionally, the nurse’s ability to carry out research in the work environment and make inferences to impart patient care, impart clinical skills to other nurses, educate patient’s relations about their condition and allay their anxieties, and many others are good markers of professional development (Fan et al., 2016; Fukada, 2018). Nursing professional development in simple terms keeps the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 23 nurses up to date on the latest techniques, technology, and evidence so that they can provide quality care to patients. Additionally, professional development among nurses helps them cope with an ever-changing healthcare environment by preparing them for current and future roles. (Brunt & Morris, 2021). Nurses' lifetime learning is centered on continuing professional development (CPD) programs, which are essential for maintaining the relevance and adequacy of nurses' knowledge and abilities. Continuing professional development for nurses can be mandatory or optional depending on the country or the setting within the health facility (Pool et al., 2016). For example, participation in CPD programs is not obligatory in countries such as Ireland, Netherland, and Sweden (Ross et al., 2013). However, participating in CPD programs is compulsory in countries such as Australia, the United Kingdom, Spain, and Belgium (Brekelmans et al., 2013) just to mention but a few. It must be noted also that in jurisdictions where CPD is required by nursing regulatory authorities, nurses are required to participate in CPD programs that are relevant to their areas of practice (Brekelmans et al., 2013). In Ghana, participating in CPDs is mandatory for all registered nurses and midwives and this is regulated by the Nursing and midwifery council (NMC), which has instituted a system to ensure the professional development of its members (NMC, 2022). In summary professional development and practice among nurses are not separate entities or activities. They complement each other and are needed to ensure that nurses at any point in time provide safe, timely, and well-informed care to clients. In meeting essential patient-centered care, the nurse at the ICU should be able to provide holistic treatment that respects the patient as a complete participant in the care that is empathetic, well-coordinated, age- and culture-appropriate, secure, and efficient. The preferences, values, and needs of the individual are respected through holistic care (NOF Nursing Core Competencies, 2016). Communication is an integral nursing role University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 24 that is meant not only for purposes of therapy but also for information sharing between the nurse and the patient, the nurse and other healthcare staff at the ICU, and the nurse and patient relations (Dithole et al., 2016). This very crucial nursing role is very important to providing effective and efficient patient-centered care (Tembo et al., 2015). It requires the nurses to be able to adapt their actions to those of others, work cooperatively with other healthcare professionals to solve problems to meet patient needs, verbally communicate facts, ideas, and feelings to other members of the health team, build trust by keeping promises and commitments, recognize the differences in the cultural practices and worldviews of individuals and groups, demonstrate a willingness to share the workload when necessary, and express facts and thoughts in writing concisely and clearly. (Lui et al, 2009). Lack of communication between the nurse and the critically ill patient may compromise the continuity of care in the ICU. Studies on nurse-patient interactions have revealed that nurses only marginally assess the communication needs of ICU patients and communicate with them ineffectively. (Pullen, 2005). Tembo et al. (2015) indicated that more efforts would be required to assist nurses to communicate more effectively with ICU patients (Tembo et al., 2015). According to a report by Hofhuis et al. from 2008, patients have favourable opinions of nurses when they are forthcoming with information and take the time to explain nursing procedures and treatments. The ICU patients' levels of stress and anxiety decreased as a result of the nurses' actions. Patients in turn have expressed appreciation for nurses including them and their family members in the decision-making processes (Terragni et al., 2010). ICUs are employing multidisciplinary approaches to provide optimum care for the critically ill. For this reason, the management of an ICU patient is provided for by a multidisciplinary team of health workers usually led by an intensivist (Alsharari et al., 2020). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 25 According to Shultz and McDonald, 2014, care coordination is the purposeful arrangement of patient care tasks among two or more parties (including the patient) involved in patient management to hasten the efficient provision of healthcare services. (Schultz & McDonald, 2014). This role involves coordinating activities of personnel and other resources contributing to appropriate patient care activities, and it is organized by the exchange of information by individuals responsible for different aspects of care (Schultz, E. M. & McDonald, 2014). It is common knowledge that nurses stay longer at the bedside to see to the steady but sometimes unpredictable progress of the patient and so Alsharari et al., 2020 suggested that the nurse takes the centre stage in coordinating the care of such patients (Alsharari et al., 2020). Nursing care coordination is therefore a critical competency to be upheld in the management of the patient who is critically ill. Hence, Alsharari and his colleagues suggested four (4) domains for the assessment of competence for nurses: Promotion of team cohesion, comprehension of care coordination requirements, gathering and sharing of information, and creation and concise expression of the care vision (Alsharari et al., 2020). 2.2.2 Relationship between nurses’ critical thinking, professional development and practice, and communication and coordination competencies. The competence of the ICU nurse is a multidimensional concept. The competence of the ICU nurse contains four bases: knowledge base, skill base, attitude base, and value base (Lakanmaa et al., 2015). The multidimensionality of competence here means that there is a link or relationship between these dimensions of competence and that incompetence in any one may lead to dire consequences for the patient (O’Leary, 2012; Zheng et al., 2017). Following admission of a patient to the ICU, he or she receives multiple interventions to prevent worsening of the initial condition, and hopefully, lead to moving the patient from the ”danger” zone (Vincent, 2019). At the end of the day, University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 26 the nurse in the ICU would be assessed by his or her ability or contribution to a successful recovery of the patient (Khan & Ridley, 2014; Scholtz et al., 2016). As a result, care for the critically ill must be viewed as a continuum, a continuous series of interconnected events that begins right from diagnosis of disease and continues through the ICU stay, recovery, and rehabilitation (Vincent, 2019). Better collaboration, communication, and teamwork between the primary care team members are thus crucial to patient survival and quality care in the ICU (Reader et al., 2007; Vincent, 2019). In a study by Happ et al. 20ll, they observed that nurses initiated most communication (86.2%) exchanges with the patient (Happ, M. B., Garrett, K., Thomas, D. D., Tate, J., George, E., Houze, M., Radtke, J., & Sereika, 2011). This has been necessitated by most patients’ inability to speak while on admission mainly owing to their state of consciousness, being on mechanical ventilators, and intubation (Happ, 2021). It was suggested by Wei et al. (2019) that the core abilities of intensive care unit (ICU) nurses comprised the critical capacity to affect patient safety and interdisciplinary collaboration. The capacity to integrate a broad range of professional thought and technical skills can be characterized as one of the primary characteristics of ICU nurses. These competencies however need to be constantly refined and developed to make the ICU efficient and effective (Wei et al., 2019). This need calls for professional development programs christened continuous professional development to consolidate and secure positive outcomes for patient care in the ICU (Brunt & Morris, 2021; Mlambo et al., 2021; Pool et al., 2016). The chosen model (CCFMENS) clearly demonstrates that there is a relationship of interdependence between the constructs on competence all feeding into the holistic competence of the ICU nurse (Fan et al., 2016). Although most literature on competence of nurses in the ICU do not state categorically that there is a relationship between critical thinking, professional development and University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 27 practice as well as communication and coordination, the discussion so far seem to suggest that there is. 2.2.3 Demographic Predictors of competence of the ICU nurse The competency of nurses and their socio-demographic variables are strongly linked (Feliciano et al., 2021). From Fig. 2 (Conceptual framework on Competencies for ICU nurses adapted from the Core competence framework model for Emergency Nurse Specialists) above, some demographic factors are highlighted as associated with the competence of the emergency nurse which invariably applies also to the ICU nurse. The demographics included age, gender, rank, specialty, qualification or level of education, and the job title or status at the ICU. Literature on some of these variables and their association with the competence of the nurse were reviewed. From the perspective of Numminen, et al. (2013), age and employment experience substantially influence nursing professionals' competence. It is common knowledge that newly recruited nurses are usually younger and have little to no experience in the hospital setting except for the exposure they had during their training at some health facilities. Findings from the study by Numminen, et al. (2013) concluded that the competence level of experienced nurses was good. Nurse managers compared to their subordinates are equipped with wide knowledge and skill and most times have the most experience in the unit. As much as it is not always the case that nurses playing a leadership role in the unit are the oldest or most experienced, they are usually competent and ensure that their colleagues meet the requirements to ensure the quality of care and maintenance of best practices to ensure better patient outcomes (Numminen, et al., 2014). Age was also found to be a predictor of critical thinking competence among nurse managers compared to general nurses in a study by Zuriguel-Pérez, et al. (2018). The results of their study suggested that the global critical thinking level of nurse University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 28 managers superseded that of general nurses. They were however quick to point out that age played a significant role in this level of competence among nurse managers. This was further corroborated by studies that point out that nurse managers were significantly older than general nurses on a unit-by-unit basis (Zuriguel-Pérez et al., 2018). According to Feng et al. (2010), clinical nurses' critical thinking abilities and attitudes are influenced by their age. Song et al., 2020 bemoaned the high attrition rate in the newly recruited nursing staff of most hospitals. He pointed out that over 20% of these nurses quit as a result of their perceived low levels of competence. It is also quite evident that most of these nurses are young and have little to no experience (Song & McCreary, 2020). Age remains a critical factor when the competence of the nurse is in discussion (Feng et al., 2010; Salonen et al., 2007). The status of a nurse in the ICU plays a critical role in determining the level of competence. Status here defines the role of the nurse either as a leader (manager, shift leader, unit head, or clinical facilitator) or having a general role in the ICU (Numminen, et al., 2014). Numminen, et al. (2014) again noted that the nurse manager has an essential influence on the competence of the general role nurse. Comparison of competence levels between nurse managers and general role nurses went in the favour of nurse managers (Mirlashari, et al., 2016; Numminen, et al., 2014). An assessment of the critical thinking competence revealed higher scores for nurse managers than in general role nurses. Age, shift work pattern, and educational degree were all connected with nurse supervisors having higher levels of critical thinking proficiency. The same factors were also found to be predictors of critical thinking competence among nurses (Zuriguel-Pérez, et al., 2018). The length of clinical experience or to put it simply, work experience has also been noted among some studies as being a significant predictor of the competence of nurses generally and not just in the ICU. Takase (2012), highlighted that the length of clinical University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 29 experience does not only influence their competence in general but also their professional development (Takase, 2013). She further noted that competence development in nurses was marked by two distinctive curves: a rapid rise in the early stages of the nursing carrier and a slower increase subsequently. The length of clinical experience has also been established to influence the critical thinking competence of the nurse. This is because, the nurse from the early carrier stages experiences various situations in the clinical setting that help to develop their critical thinking competencies (Feliciano, et al., 2021; Feng, et al., 2010; Fero, et al., 2009; Lakanmaa, et al., 2015; Lee & Oh, 2020; Salonen, et al., 2007; Murshid, 2021). Yoo et al., 2020, also noted that compared to nurses in wards, communication skills among ICU nurses are relatively underdeveloped. When compared to their older and more experienced counterparts, younger and less experienced nurses showed the same characteristics (Song & McCreary, 2020; Yoo, et al., 2020). This has called for an assessment of communication competence among ICU nurses in this country. Level of education has usually been a common demographic factor associated with many measurable outcomes among many professional groups. It has been established to impact both theory and practice in many fields of endeavor (Glaesser, 2019). Nursing as a profession and particularly the intensive care nurse has not been left out of the discussion about competency and its relationship with the level of education. Zuriguel- Pérez, et al. (2018), in their study that sought to compare the level of critical thinking as an aspect of competence of the ICU nurse between nurse managers and general role nurses indicated that educational level was associated with a higher critical thinking prowess in nurse managers. The study further established educational level to be a predictor of critical thinking among nurse managers. In Saudi Arabia, Feliciano, et al. (2021), also established that the level of education significantly impacted the competency of nurses. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 30 In the acute clinical setting, it is important to be able to take critical decisions in many unusual situations. High critical thinking ability is therefore a must in the ICU. The earlier submitted research seems to agree that the level of education impacts positively competence in the ICU (Feliciano, et al., 2021; Zuriguel-Pérez, et al., 2018). Nibbelink & Brewer, 2018 however, seem to hold a different opinion on the impact of the level of education on critical thinking. Accordingly, they stated that, is uncertain whether education has an impact on clinical decision-making and think that education alone may not be the best indicator of clinical decision-making effectiveness (Nibbelink & Brewer, 2018). These discussions above make it crucial to determine the competence level of ICU nurses as well as determine predictors of competence among this critical group at the Korle-Bu Teaching Hospital. 2.4 Summary critique of the literature review Literature was reviewed on the competence of nurses generally as it may apply to nurses working in the ICU. The literature first of all had to consider theoretical frameworks or models that could be applied to guide the study. These included literature on the Competency Outcomes Performance Assessment (COPA) Model (Lenburg, et al., 2008), Quality and Safety Education for Nurses (QSEN) model (DiCenso, et al., 2005), and the Core Competence Framework Model for Emergency Nurse Specialist (CCFMENS) by Fan, et al. (2016). Among these, the latter was chosen to guide this research. Subsequently, competence among nurses working in the ICU was reviewed: critical thinking, professional development and practice as well as communication and coordination competencies. Additionally, literature on demographic factors that could predict the competence of nurses in the ICU was reviewed. The review unearthed the fact that very little research has been conducted concerning the competence of nurses University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 31 in the ICU worldwide as compared to other nurse categories such as nurses in emergency settings. The literature reviewed comprised approximately 30 studies from across the world with a breakdown as follows: 8 studies from the Western world, 3 studies from Sub-Saharan Africa (Nigeria and Ghana), 15 studies from Asia and the Middle East, and 2 from Ghana. The review shows there is limited research from sub-Saharan Africa, especially Ghana, on the competence of nurses working in intensive care units. More studies have been conducted on this topic in Western and Asian countries. The review calls for more research in Ghana and other African countries to address this gap. CHAPTER THREE METHODOLOGY 3.1 Study Design A quantitative research approach and a cross-sectional correlational design were employed for this study. This cross-sectional correlational design enabled the assessment of the competencies of nurses working in the ICU concerning some factors University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 32 that could predict the level of competence. This design allowed the researcher to look at two or more variables at the same time and was effective for describing the relationship between the measured variables (Breakwell, 1995). The cross-sectional correlational design can provide the researcher with the opportunity of having a one- time measure of the study variables. According to Levin (2006), a cross-sectional design is an observational study in which data is collected and analyzed at a certain period. It is also cost-effective and less time-consuming. The demerit of this type of design is that findings from the analysis do not give a strong basis to establish a cause- and-effect relationship between the variables. 3.2 Research Setting The study was conducted at the Korle- Bu teaching hospital (KBTH) in the Accra Metropolis of the Greater Accra Region of Ghana. Korle-Bu Teaching Hospital (KBTH). The hospital was built during the governorship of Sir Gordon Guggisberg the then Gold Coast, in 1923. The hospital is situated at Korle-Gonno, a suburb of Accra, in the Ablekuma South constituency. The boundaries of the hospital are Korle-Gonno in the South, Accra Central to the East, Laterbiokorshie to the North, and Mamprobi to the West. It was built initially as a general hospital to attend to the health care needs of the indigenous people. Korle-Bu in the literal sense means, “Valley of the lagoon”. The Hospital attained teaching hospital status in 1962. It is the foremost tertiary health care facility to be built in Ghana and happens to be the third largest referral facility in Africa. It currently has 21 clinical and diagnostic departments and three Centers of Excellence. The clinical and diagnostic departments include Obstetrics and Gynaecology, Family Medicine/Polyclinic, Reconstructive Plastic Surgery and Burns Centre, and Accident and Orthopaedics. Internal Medicine and Therapeutics, Surgery, Child Health, Anaesthesia, Accident & Emergency, and Psychiatry. The rest are Radiology, Pathology, Pharmacy, and Laboratory. There are also non-clinical departments such as University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 33 Engineering, Finance, and General Administration. Additionally, the KBTH provides urbane scientific treatment procedures in various sub-specialties such as Reconstructive Plastic Surgery, Paediatric surgery, Neurosurgery, Cardiothoracic Surgery, Radiotherapy, Nuclear Medicine, Dental/Oral maxillofacial, Renal, Oncology, Ophthalmology, Ear, Nose & Throat (ENT), Orthopaedics, and Dermatology. The hospital also has three National Centers of Excellence namely, the National Cardiothoracic Centre, the National Reconstructive Plastic Surgery and Burns Centre, and the National Centre for Radiotherapy and Nuclear Medicine. These Centers host a large number of clients within the country and from some West African countries and include countries such as Burkina Faso, Nigeria, Togo, and Benin among others (KBTH, 2022). Having grown from a bed capacity of 200 to 2000, KBTH has over 4000 medical and paramedical staff: Doctors, nurses, laboratory scientists, pharmacists, health informaticians, dieticians and nutritionists, radiographers, and many more. The hospital currently hosts an average out-patient attendance of 1,500 with approximately 250 in- patient admissions. Korle-Bu Teaching Hospital has presently engaged approximately 3,000 nurses with a total of 182 working in the ICU. The ICUs where the study was conducted has one hundred and forty-nine (149) beds with a staff strength of 182 of all category of nurses (Critical care nurses, Registered general nurses, Registered midwives, health care assistants, and enrolled nurses). Of the 149 beds, 36 are in the pediatric units and 113 are within the adult care units (Osei-Ampofo et al., 2018; Siaw-Frimpong et al., 2021). The hospital currently has 7 ICUs found in the following departments/units: Maternity, Paediatrics, Surgical, Obstetrics & Gynaecology, National Cardiothoracic, and internal University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 34 medicine (KBTH Annual Report, 2016). The KBTH was chosen for this study mainly because it hosts the majority of ICUs and critical care nurses in the country. 3.3 Study Population The study population for this study is the entire nursing staff of all ICUs at the KBTH. However, for this study, the target population was all the available nurses working in the ICUs within the KBTH. The population of ICU nurses in the hospital was 182. 3.3.1 Inclusion Criteria The study included 1. Registered nurses (RGN) working in the intensive care unit 2. Registered critical care nurses who were working in the ICU These nurses should have at least one year post qualification experience. This was to assess whether nurses attained satisfactory competence in the ICU within a year post- recruitment 3.3.2 Exclusion Criteria 1. Nurses who are working in the ICU but are on clinical rotations 2. Auxiliary nurses working in the ICU 3. Nurses who are on leave (sick, annual, study, or maternity leave) were also excluded from the study. 4. General nurses or critical care nurses working in the ICU but are not willing to participate 3.4 Sampling Method A sample is a subset of the population elements being studied. An element is the most fundamental unit for or about which data is collected. Study participants were selected as an initial step in conducting the research. This process is referred to as sampling. Etikan, Musa, & Alkassim (2016) defined sampling as selecting a subset of the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 35 population under study. Taherdoost (2016) further characterized sampling as the strategy used in examining a destined number of participants taken from a target population. In this study, the non-probability convenience sampling technique was employed since subjects were chosen based on their availability at the time of the study. 3.5 Sample size The sample size was calculated using Yamane’s (Yamane, 1967) formula as cited by Adam (2020). This is shown below: 𝑛 = N 1+𝑁(𝑒)2 Where: n = required sample size, N = study population size (i.e. the total number of professional nurses in ICUs, 182), and e = desired margin of error (0.05)’ or significance level. Substituting the values for the factors in the formula: N= 182 and e= 0.05, the minimum sample size required for the study will be; n= 182 1+182(0.05)2 n= 125 The minimum sample size calculated is 125 however, 10% of the calculated sample size was added to the 125 to accommodate for participants who may not answer all the questions on the questionnaire. Thus 10% of “n” = 125 x 0.10, n =12.05 ⸫ n = 138 Consequently, 138 people were needed to reach the study's desired sample size. As a result, generalization of the results was possible, sampling errors were reduced, and the sample size was representative of the target population. (Ary et al., 2013; Polit & Beck, 2013). University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 36 3.6 Data Collection Tool The study employed a structured questionnaire (Appendix H) consisting of validated competency items from three (3) competency assessment tools/frameworks: the Korean Nurses ‘Core Competency Scale (KNCCS) (Lee et al., 2017) (Appendix I), the Competency Inventory for Registered Nurses (Liu et al., 2009) (Appendix J) and the International Council of Nurses (ICN) Framework of Competencies for the nurse Specialist (Affara, 2009) (Appendix K). Items selected were chosen because they could address the objectives of the study. No single competency assessment tool from among the three selected tools could fulfill achieving all the objectives alone. This made it necessary to select items from the three assessment tools to prepare the questionnaire (final tool) used for the study. The final questionnaire comprised 66 items and divided into two sections (A and B). Section A covered Demographic data such as age, gender, marital status, profession, professional qualification position, work experience and leadership role, among others (16 items in total). Section B starts with an explanation of the Benner Scale and how it is to be used to score the level of competence “(Novice=1, Advanced Beginner=2, Competent=3, Proficient=4, Expert=5)”. This is followed by 50 items and divided into three (3) sub-sections as follows: (1) critical thinking (8 items), (2) professional development and practice (16 items), and 34) communication and coordination (26 items) competencies in the management of the critically ill patient. The overall reliability coefficient score for the items was 0.99. 3.7 Data Collection Procedure The researcher visited the ICU, presented herself to the head of the unit, and explained the purpose of her visit. Letters of introduction from the School of Nursing and Midwifery, University of Ghana, and the KBTH Administration as well as approval for the study from the STC and ethical clearance letter from the KBTH-IRB were also presented to the unit head. The Head of the ICU then introduced the researcher to the University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 37 nurses in the unit. Following the introduction and purpose of the visit to the nurses in the unit, the researcher then went ahead to talk to each nurse on a one-on-one basis. Concerns on risks, benefits, confidentiality, and other ethical issues about the research were provided to the prospective participant, and they were allowed to ask questions to throw more light on aspects of the study they did not understand. Following this, the prospective participant was asked if they wanted to participate in the research. When the nurse agrees to be part of the study, a consent form (Appendix G) was provided for their signature. Each consent form was witnessed by colleague nurses on duty. The researcher then introduced and explained the content of the questionnaire to the participant and guided them on how to respond to the questions following the Benner Scale. The questionnaire was then left momentarily for the participant to respond to or complete. The researcher stayed close by to explain any question that the participant needed further explanation. An average of 20-30 minutes was used by participants to complete the questionnaire. Questionnaires were given out and collected the following day to participants who were busy at the time of visit to the ICU. Coded IDs were assigned to each questionnaire to maintain the anonymity of the participants. Documentation and storage of data were keyed into a Microsoft Excel spreadsheet to ease data handling and analysis. The researcher ensured that the facility’s regulations on data collection as directed by the KBTH-IRB as well as the safety protocols for COVID-19 prevention were strictly adhered to. These safety protocols included the wearing of face masks, social distancing, regular handwashing, or use of hand sanitizers among others. 3.8 Validity and Reliability of Research Instrument The degree to which a concept is precisely quantified in a quantitative investigation is known as validity. (Heale & Twycross, 2015). Content validity was achieved by carrying out an extensive and rigorous review of the most recent and relevant literature. University of Ghana http://ugspace.ug.edu.ghUniversity of Ghana http://ugspace.ug.edu.gh 38 The content of the questionnaire was assessed by the supervisors to ensure that it validly targets the objectives of the study. Reliability determines the accuracy of a research instrument (Heale & Twycross, 2015). To assess reliability, the questionnaire was piloted at the ICU and other units of the Ho Teaching Hospital where critically ill patients are found. This activity helped to modify and correct questions which were ambiguous or not clearly understood. The researcher ensured that the face validity and content validity of the questionnaire together with its sub-subscales were met. The instrument was adapted from the revised International Council of Nurses (ICN) Framework of competencies for the Nurse Specialist, the Korean Nurses ‘Core Competency Scale (KNCCS, Cronbachs alpha coefficient, 0.97), and the Competency Inventory for Registered Nurses (CIRN, Cronbach’s alpha coefficient, 0.89). These competency frameworks have been used