Development of emergency nursing care competency scale for school nurses

RESEARCH ARTICLE Open Access

Development of emergency nursing care competency scale for school nurses Jaehee Yoon

Abstract

Background: School nurses perform vital student emergency services at school, and assessing their emergency nursing care competency is critical to the safety and quality of care students receive. The purpose of the study was to develop a scale for measuring school nurses’ competency.

Methods: This was an instrument development and validation study. It was conducted according to the revised DeVellis scale development process coupled with the application of the International Council of Nurses’ Nursing Care Continuum Competencies Framework. Eight experts specializing in school health and emergency care evaluated the content validity, while 386 school nurses evaluated the scale. The validity evaluation comprised factor analysis, discriminative validity analysis according to differences in school nurse experience, and criterion validity analysis. Scale internal consistency was analyzed using Cronbach’s α value. Results: The final scale comprises a self-reported 5-point Likert scale with 30 items based on three factors and three sub-factors. Both the convergent validity of the items by factor and the discriminative validity were both confirmed. The criterion validity was also found to be positively correlated with the Triage Competency Scale.

Conclusion: The scale may be used to identify factors influencing school nurses’ competency in emergency nursing care and contribute to research in competency-based education programs.

Keywords: Emergency nursing care, School nursing, Competency, Scale, Instrument

Student medical emergencies at schools precipitated by accidents and health problems are common occurrences these days given the considerable amount of time stu- dents spend at school for educational activities [1, 2]. For example, the incidence of sudden cardiac arrest per 100,000 students ranged from 0.17 to 4.4 in the United States [3] and reached 0.4 in Japan [4]. In South Korea, the number of school accidents increased from 86,468 in 2011 to 122,570 in 2018 [5], while the number of stu- dents diagnosed with rare or chronic illnesses grew from 1626 in 2017 to 1758 in 2018 [6], making student med- ical emergencies at school more likely than ever [7–10].

School nurses represent the only medical professionals available to provide emergency care in schools [11, 12], making their Emergency Nursing Care Competency (ENCC) a vital component of the school emergency ser- vices. The ENCC is also a critical factor in school emer- gency response given the primary role they play in planning emergency care and training school staff [10, 13]. In particular, ENCC is essential for a safe and posi- tive student care outcome because school nurses make student care decisions largely on their own [14, 15]. Competency scales, which can be used to effectively

assess nursing competency, contribute to maintaining and improving competency [16]. In fact, Resha [17] con- tended that competency evaluation constitutes a critical aspect of maintaining competency and establishing im- provement methods. Competency assessment can also be used to improve the existing practices and promote

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Correspondence: rnyjh@snu.ac.kr Wolchon Elementary School, 132, Mokdongjungang-ro, Yangcheon-gu, Seoul 07980, South Korea

Yoon BMC Nursing (2021) 20:63 https://doi.org/10.1186/s12912-021-00580-9

continuing education [16, 18, 19]. Previous studies [20– 22] on the factors affecting nurse competency might help identify effective ways to improve competency, and com- petency scales have been used in such research. In addition, many studies [23, 24] have shown that compe- tency scales could be used to develop competency-based educational programs and test their effectiveness [18, 25]. To date, however, no scale capable of measuring

school nurses’ ENCC has been developed. There are pre- vious studies [26, 27] on the overall competencies of school nurses, but they invariably suffered from limita- tions regarding identifying the content and level of the ENCC. Given these challenges, the current study aimed to develop and validate a scale to measure school nurses’ ENCC.

Methods Procedures This was an instrument development and validation study. The study was conducted according to the revised

DeVellis scale development process [28]. Since this process was primarily theoretical, it needed to be modi- fied for data collection and analysis. The revised process was classified into five phases, with the scale being com- pleted by changing the number of items and factors dur- ing each phase (Fig. 1).

Scale development Phase 1: clarification of concept The concept was analyzed and developed in detail using the Nursing Care Continuum Competencies Framework (NCCCF), consisting of 3 factors, competencies, and be- havioral indicators [29]. Some of the processes used by Elo and Kyngas [30] for qualitative content analysis, such as preparation and organization, were applied. In the preparation phase of the content analysis, we

reviewed the dictionary of terms and conceptual analysis studies [31–33] for each competency listed in the NCCC F [29] to understand their meaning. We also added be- havioral indicators or competencies to the NCCCF [29]

Fig. 1 Scale development process and change based on the revised DeVellis scale development process [28]

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by reviewing previous studies [10, 26, 27, 34–36]. We se- lected previous studies were searched using the follow- ing search criteria:

1. Date: from 2007 to 2017 2. Search terms 3. [(emergenc* OR crisis OR critical OR Hotlines OR

nurs* OR service* OR responders OR care OR acute care OR patient care, prehospital OR trauma nursing OR emergency aid OR urgent medical aid OR first-aid) AND (competenc*): ti]

4. Databases: KISS, KISTI, Dbpia, and EMBAS 5. Exclusion criteria: No relevant to study subject, full

text, or not written in Korean or English 6. Hand search: The Journal of School Nursing, the

Journal of School Health, and the Journal of Korean Society of School Health, the references to the cited studies

The identified content from the preparation stage was coded in words or phrases after multiple readings in the organizational phase. The coded content was then col- lected and categorized into themes, which were written as school nurse’s competency and behavioral indicators with due consideration given to the characteristics of the school environment.

Phase 2: development of initial items Initial items were developed on the basis of the behav- ioral indicators derived during Phase 1. Data from the School Safety Insurance Federation from 2015 to 2016 [5] were analyzed to identify the type and frequency of school emergencies.

Phase 3: content validity of initial items (expert panel review) We formed an expert panel comprised of nine members: one emergency nurse, one emergency head nurse, one professor of nursing with school nurse experience, one professor of nursing with emergency nurse experience, one professor of community nursing, one supervisor for school health, and three school nurses enrolled in a doc- toral nursing program. A total of 18 competencies, 65 behavioral indicators,

and 165 items were assessed for their content validity. The nine modified items from the Triage Competency Scale (TCS) for emergency nurses that had not fit the school context were also reviewed [35]. The Content Validity Index for Item (CVI-I) was com-

puted using the number of the experts’ ratings of 3 or 4 on a 4-point scale (1 = not relevant, 2 = somewhat rele- vant, 3 = quite relevant, 4 = highly relevant) given to each item, divided by the total number of experts [37]. The criteria for acceptability were above .80.

Further deletions and modifications were made follow- ing additional comments from the panel regarding clar- ity, length, and duplication. The adjusted items were reviewed again by two professors of nursing.

Scale evaluation Phase 4: Main survey

Participants and settings The main survey participants were school nurses in Korea. They were divided into five groups on the basis of the length of experience as a school nurse for the discriminative validity test: Novice Beginner (< 1 Year), Advanced Beginner (1–3 Years), Competent (3–6 Years), Proficient 1 (6–16 years), and Proficient 2 (≥16 years) [10]. A sample size of 500 was determined using five times

the 92 items on the initial scale needed for the factor analysis [38] with an anticipated dropout rate of approxi- mately 10%. The minimum sample size per group was 40, considering a Cohen’s medium effect size of .25 [39]. A total of 387 participants took part in the study. Al-

though the total figure did not reach the targeted sample size, there were more than 300 cases for the factor ana- lysis and more than 40 school nurses for each group. One respondent was ultimately excluded for giving the identical answer to all items.

Data collection Data were collected from an online sur- vey from November 26 to December 31, 2018, and con- sisted of 92 initial items, 30 items from the TCS [35], and 10 items related to the participants’ demographic characteristics. We contacted the Korea School Nurses Association to recruit the participants and asked a local representative of the association to send e-mails and text messages regarding participant recruitment to school nurses who were local members.

Data analysis The data were analyzed using IBM SPSS 25.0 (Armonk, NY; IBM Corp.) and AMOS 25.0 (Chi- cago, IL; IBM SPSS Statistical Programs). Items with an absolute value of 2 or more for skewness and kurtosis were dropped [40]. Items-total correlations that were above .30 were regarded as acceptable. The Kaiser–Meyer–Olkin (KMO) sample fit scale and

Bartlett’s test of sphericity was performed with a KMO value ≥ .50 and a p-value for Bartlett’s test < .05 [38] to examine the appropriateness of the factor analysis. Exploratory Factor Analysis (EFA) was conducted

using principal axis factoring and oblique rotation using SPSS to select items that fit the factors in the research framework and to reduce the number of items. The cri- teria for deleting items were a cumulative value of .40 or less and a factor loading value of .30 or less [41]. Items were deleted until the number of extracted factors

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having eigenvalue =1 matched the factors of the hypoth- esized model based on the research framework. The convergent validity and model fit of the scale was

analyzed using Confirmatory Factor Analysis (CFA). The convergent validity of the items was verified through the following criteria: standardized factor loading (SFL ≥ 0.50), critical ratio (CR ≥ 1.96), p-value (p < .05), average variance extracted (AVE ≥ 0.50), construct reliability ≥ .70, and squared multiple correlation (SMC ≥ .40) [42, 43]. The criteria used for the fit indices included Normed χ2 (CMIN/df) ≤ 3, Comparative Fit Index (CFI) ≥ .90, Turker Lewis Index (TLI) ≥ .90, Root Mean Square Error of Approximation (RMSEA) ≤ .08, and Standardized Root Mean-square Residual (SRMR) ≤ .05 [43, 44]. The discriminative validity test was analyzed using the

school nurse experience groups as these groups have been shown to have different levels of competency in previous studies [45, 46]. An analysis of covariance (ANCOVA) was conducted by assigning covariates to the variables that have confirmed differences using a chi-square test or one-way ANOVA. The TCS [35] was modified for the school context and

was used to assess criterion validity. Triage is one emer- gency nursing’s main features and a major challenge for school nurses [10]. The TCS [35] has several similarities to the sub-attributes of the competencies derived in this study. The relationship between the developed scale and the TCS were analyzed using Pearson’s correlation coef- ficients, with rs .40–.80 being regarded as acceptable [47]. The reliability of the whole scale and each factor was

deemed to be acceptable if the Cronbach’s α > .65 [28].

Final scale Phase 5: final scale The scale was finalized with items derived from the scale evaluation process. Five professors of nursing reviewed the final items to improve the items’ readability and comprehensibility.

Results Scale development Clarification of concept and development of the initial items The school nurse’s emergency nursing care competen- cies and behavioral indicators were developed with 4 fac- tors, 18 competencies, and 65 behavioral indicators. In addition, 20 major school emergencies were identified (Table 1) on the basis of the analysis of 23,985 accidents from School Safety Insurance Federation and literature on school emergencies [10, 48], Overall, 31 items were developed for the major assessments and interventions at the school.

The initial scale included 165 items: 21 on the Profes- sional, Ethical, and Legal Practice factor, 94 on the Care Provision factor, 33 on the Leadership and Management factor, and 17 on the Professional, Personal, and Quality Development factor.

Content validity of initial items The content validity analysis showed that one compe- tency, nine behavioral indicators, and eight items had a CVI-I less than .80. All behavior indicators were dropped except for one that moved to another factor. Additional items were excluded or modified when they belonged to excluded competency and behavioral indica- tor, or demonstrated ambiguity or overlap (Fig. 1). Based on the similarity between factors, the Professional, Eth- ical, and Legal Practice factor was renamed as the Eth- ical and Legal Practice factor, and the Professional, Personal, and Quality Development factor was renamed as the Professionalism and Quality Development factor.

Scale evaluation Participant characteristics A total of 386 participants were included in this study. Of whom, 162 (42.2%) participants had experience in caring for severe emergency patients at school, while 88 (22.8%) participants held certifications related to emer- gency nursing care such as Basic Life Support Provider, Advanced Life Support Instructor, First Aid Rescue, and First Aid Instructor (Table 2).

Items analysis Four items on the Ethical and Legal Practice factor and one item on the Care Provision factor had an absolute value of skewness and kurtosis of more than 2. Further, three items showed lower item-total correlations than the criteria (r ≥ .30). Thus, eight items were dropped.

Validity analysis

Factor analysis The KMO value was high (.97, p < .001) as was Bartlett’s test of sphericity, demonstrating the ad- equacy of the data for producing a reliable factor solution. The number of items was reduced to 37 through se-

quential deletion, taking into consideration the factors of the research framework, the importance of the items, cu- mulative value, and the factor loading value. The total explanatory variance was 61.50%. Item 6 (Ethical Prac- tices) had a cumulative value of .39, and Item 66 (Dele- gation and Supervision) had a factor loading < .30, but they were not dropped to maintain the construct of the factors. The adjusted scale including 37 items was analyzed for

its convergent validity and model fit. The fit indices did

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not meet criteria for an acceptable fit, and the modifica- tion indices indicated a high correlation between the Care Provision factor and the Leadership and Manage- ment factor. The Care Provision and the Leadership and Management factors were integrated into a single fac- tor—Emergency Care Provision and Management. Sub- factors were created by separating Assessment, Diagnosis, and Planning and Intervention, Evaluation, Therapeutic Communication, and Relationships because they tended to load differently. Item 41, initially dropped for failing to meet the validity criteria, was added back to the final scale, as it was a characteristic intervention used in schools. Eight items (22, 24, 25, 37, 76, 78, 75, and 80) were dropped sequentially as the modification indices were high, and the items were considered less important. The final version of the School Nurse’s Emergency Nursing Care Competency Scale (ENCCS_SN) consisted of the 30 remaining items (Fig. 1). The fit indices of the final scale met criteria for accept-

able model fit (Table 3). The convergent validity analysis of each of the factors in the final scale had AVE values ranging from .57 to .95 and construct reliability values ranging from .79 to .98, meeting their criteria. The SFL

for item 41, the reverse item, was .34, and the SMC = .12, which did not meet the criteria. However, the SFL of the other items ranged from .62 to .86 and the SMC from .39 to .74. The convergent validity analysis of the sub-factors for the Emergency Care Provision and Man- agement factor showed an AVE of .95 and construct reli- ability of .98, meeting the criteria. In addition, the SFL of the sub-factors ranged from .88 to .99 and the SMC from .78 to .98, also meeting criteria (Supplementary Material 1).

Discriminative validity Having emergency experience (χ2 = 35.43, df = 4, p < .001) and hospital nurse experi- ence (F = 4.06, df = 3, p = .007) were assigned as covari- ates. Table 4 shows the results of the differences between the school nurse experience groups (F = 3.64, df = 4, p = .006). The competencies of the short- experience groups were lower than those of the long- experience groups.

Criterion validity Correlation analyses of the scores measured by the TCS (Moon & Park, 2018) showed the overall correlation coefficient was r = .86 (p < .001), with

Table 1 Classification of School Emergencies

Classification (n = 20) Note

Injury

Musculoskeletal Fracture, Sprain, Strain, Dislocation† Frequent Injury (1st)

Face Eye injury

Dental & Oral

Nose

Skin Skin wound requiring suture Frequent injury (2nd)

Burn

Head Skull Fracture, Concussion, Scalp Damage Serious Injury

Other Choking, Abdominal Injury, Bites, Toxic Exposure, Genital Injury, Rape, Suicide

Sudden Symptoms

Neurological Syncope, Unconsciousness† Serious Symptoms

Severe headache

Cardiovascular and Respiratory Dyspnea, Hyperventilation, Pneumothorax Serious Symptoms

Chest Pain, Arrhythmia, Tachycardia, Hypertension Serious Symptoms

Heart Arrest

Gastrointestinal Severe Abdominal Pain

Other Psychiatric Symptoms, Dehydration

Deterioration of Disease

Allergy Allergic Reaction, Anaphylaxis† Specified in Law

Cardiovascular and Respiratory Asthma

Endocrine Hypoglycemia & Hyperglycemia Specified in Law

Neurological Seizures Serious Symptoms

Other Hemophilia

Note: †Included in the final version scale

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r = .45 (p < .001) for the Ethical and Legal Practice fac- tor, r = .87 (p < .001) for the Emergency Care Provision and Management factor, and r = .55 (p < .001) for the Professionalism and Quality Development factor.

Reliability: internal consistency Analyses of the reliability of the final scale found no items increased the Cronbach’s α of a factor when delet- ing items. The Cronbach’s α for the whole scale was .96. For each factor, it ranged from .74 to .96.

The final scale The final scale consisted of 30 items loading on three factors: The Ethical and Legal Practice factor, the Emer- gency Care Provision and Management factor, and the Professionalism and Quality Development factor. The sub-factors under the Emergency Care Provision and Management factor were the Clinical Decision-Making sub-factor, the Care Provision sub-factor, and the Lead- ership and Management sub-factor. The final scale in- cluded 22 behavioral indicators of competency (Table 5). One reverse-scored item was changed to a positive item

Table 2 General Demographic Characteristics of Participants (N = 386)

Characteristics Total (N = 386)

Group A (n = 75)

Group B (n = 50)

Group C (n = 56)

Group D (n = 105)

Group E (n = 100)

n (%) or M (SD)

n (%) or M (SD)

n (%) or M (SD)

n (%) or M (SD)

n (%) or M (SD)

n (%) or M (SD)

Gender Male 2 (0.5) 0 (0.0) 1 (2.0) 1 (1.8) 0 (0.0) 0 (0.0)

Female 384 (99.5) 75 (100.0) 49 (98.0) 55 (98.2) 105 (100.0) 100 (100.0)

Age in years 41.09 (10.08) 31.65 (6.15) 32.94 (6.80) 36.54 (8.14) 43.49 (6.42) 52.22 (4.59)

Education Doctoral Degree 4 (1.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (4.0)

Master’s Degree 73 (18.9) 7 (9.3) 1 (2.0) 4 (7.1) 22 (21.0) 39 (39.0)

Bachelor’s Degree

292 (75.7) 65 (86.7) 42 (84.0) 48 (85.7) 81 (77.1) 56 (56.0)

Associate Degree

17 (4.4) 3 (4.0) 7 (14.0) 4 (7.1) 2 (1.9) 1 (1.0)

Workplace Elementary School

210 (54.4) 49 (65.3) 28 (56.0) 22 (39.3) 46 (43.8) 65 (65.0)

Middle School 105 (27.2) 20 (26.7) 14 (28.0) 21 (37.5) 33 (31.4) 17 (17.0)

High School 71 (18.4) 6 (8.0) 8 (16.0) 13 (23.2) 26 (24.8) 18 (18.0)

Length of School Nurse Experience in years 10.28 (9.80) 0.88 (0.35) 2.32 (0.56) 4.16 (0.94) 10.37 (3.31) 24.66 (5.74)

Length of Hospital Nurse Experience in years 4.83 (4.38) 5.48 (5.69) 5.18 (4.45) 5.13 (3.80) 5.36 (4.55) 3.41 (2.82)

Emergency Experience Yes 162 (42.2) 14 (18.7) 18 (36.0) 20 (35.7) 48 (45.7) 62 (62.0)

No 224 (58.0) 61 (81.3) 32 (64.0) 36 (64.3) 57 (54.3) 38 (38.0)

Certificate Related to Emergency Nursing Care

Yes 88 (22.8) 15 (20.0) 4 (8.0) 13 (23.2) 30 (28.6) 26 (26.0)

No 298 (77.2) 60 (80.0) 46 (92.0) 43 (76.8) 75 (71.4) 74 (74.0)

Note. M, mean; SD, standard deviation; Group A: Novice Group (< 1 year); Group B: Advanced Beginner Group (≥ 1 but < 3 years); Group C: Competent Group (≥ 3 but < 6 years); Group D: Proficient 1 Group (≤ 6 but < 16 years); Group E: Proficient 2 Group (≥ 16 years)

Table 3 Model Fit (N = 386)

Model (No. of items)

CMIN/df CFI TLI RMSEA SRMR

≤ 3 ≥ .90 ≥ .90 ≤ .08 ≤ .05

Initial (37)

3.88 .85 .84 .07 .06

Final (30)

2.67 .92 .91 .07 .05

Note. CMIN/df: Normed χ2; CFI: Comparative Fit Index; TLI: Tucker Lewis Index; RMSEA: Root Mean Square Error of Approximation; SRMR: Standardized Root Mean-square Residual

Table 4 Differences in the Emergency Nursing Care Competency by School Nurse Experience (N = 386)

Classification n M (SD) F p

Group A 75 84.28 (16.73) 3.64 .006 A, B, C < D, E

Group B 50 86.58 (18.23)

Group C 56 85.84 (19.93)

Group D 105 93.56 (17.21)

Group E 100 93.32 (18.94)

Note: Adjusted by emergency experience; hospital nurse experience. Post hoc analysis using LSD; M, mean; SD, standard deviation; Group A: Novice Group (< 1 year); Group B: Advanced Beginner Group (≥ 1 but < 3 years); Group C: Competent Group (≥ 3 but < 6 years); Group D: Proficient 1 Group (≤ 6 but < 16 years); Group E: Proficient 2 Group (≥ 16 years)

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in the final scale. The final scale used a self-report for- mat with participants responding on a 5-point rating scale, ranging from 0 to 4 points for convenience of in- terpretation (0 = never, 1 = rarely, 2 = sometimes, 3 = often, and 4 = always). Higher scores indicated higher ENCC (Supplementary Material 2). The mean score was 89.67 (SD = 18.46).

Discussion This study developed the first self-report scale designed to measure school nurses’ ENCC. The Emergency Nurs- ing Care Competency Scale for School Nurses (ENCCS_ SN) demonstrated good reliability and met criteria for content and construct validity. Additionally, the ENCC S_SN represents the first scale to incorporate items per- taining to the characteristics and contents of school

emergency nursing care. The validity of the scale was de- termined by identifying the constructs of the concepts and developing items that effectively measured each construct [11, 28]. In this study, the NCCCF [29] was used as a theoretical framework to clarify the scale’s composition. It is particularly meaningful that the ENCC S_SN was consistent with the nursing competencies, fac- tors, and behaviors identified in the NCCCF [29]. Since nursing competency is the ability to perform common and basic nursing tasks [49], these results suggest that overall nursing competencies remain the same across areas of specialization and practice. However, the sub-factors of the Emergency Care

Provision and Management factor in the ENCCS_SN were constructed differently from the NCCCF [29] since the item means related to assessment and diagnosis on

Table 5 Behavior Indicators of Competency in the Final Scale

Domain Behavior Indicator of Competency Item No.

First Version

Final Version

F1 Ethical Practice Maintains the confidentiality of the patient when delivering emergency nursing care.

6, 7 1, 2

Legal Practice Practices in accordance with related laws and regulations. 8 3

F2 F2– 1

Assessment & Diagnosis Collects subjective and objective data of patients promptly and systematically.

20, 21, 23, 18, 14

4, 5, 6, 7, 8

Analyzes the collected data comprehensively, considering the characteristics of school emergencies.

28 9

Prioritizes promptly based on evidence. 34 10

Promptly diagnoses health problems based on evidence. 32 11

Planning Promptly establishes an emergency nursing care plan considering school resources.

15 12

F2– 2

Intervention Promptly provides emergency nursing care interventions using school resources.

51, 38, 41, 43

13, 14, 15, 16

Evaluation Evaluates the progress of emergency nursing care. 59 17

Evaluates the outcome of emergency nursing care. 63 18

Therapeutic Communication & Relationships

Provides accurate detailed information to patients and parents. 69 19

Documents the emergency nursing intervention and the patient’s response. 62 20

Interacts in a manner that is respectful to patients and parents. 77 21

F2– 3

Safe Environment Prepares and maintains emergency supplies in accordance with regulations. 74 22

Identifies and prepares for emergencies at school. 79 23

Establishes a school emergency system. 81 24

Delegation & Supervision Establishes a delegation system for emergency nursing care in accordance with regulations.

66 25

Inter-professional Reasonably resolves conflicts related to school emergencies. 85 26

Health Care Makes an effort to enhance the staff’s emergency response abilities. 86 27

F3 Enhancement of the profession Continuously engages in education to enhance the profession. 91 28

Quality Improvement Participates in evidence-based research to improve emergency nursing care practice.

92 29

Identifies and improves problems in practice. 90 30

Note: F1: Ethical and Legal Practice; F2: Emergency Care Provision and Management; F2–1: Clinical Decision Making (Assessment, Diagnosis, Plan); F2–2: Care Provision (Intervention, Evaluation, Therapeutic Communication & Relationships); F2–3: Leadership and Management; F3: Professionalism and Quality Development

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the factor analysis were lower than the other items. This finding suggests that assessment and diagnosis is the most difficult part of emergency nursing care [50], and school nurses also find it challenging to assess emer- gency patients in the schools because schools have lim- ited medical resources [10]. Therefore, developing and providing an educational program or support strategies for school nurses that focus on assessment and diagnosis may need to be prioritized. Item 41 (Hospital Referral and Transfer) from the

intervention items had an SFL of .34 and an SMC of .12, which were lower than the criteria. However, an SFL of .34 was deemed acceptable by Tabachnick and Fidell [51]. The low convergent validity of Item 41 was due to its lower mean compared to the other intervention items, potentially owing to school nurses’ challenges with transferring patients [10]. Item 41 may also have been developed as a reverse-scored item, confusing re- spondents. Other studies have reported that reverse- scored items tend to have low consistency [28]. Thus, Item 41 was revised to be a positive item in the final scale to avoid confusion with the reverse wording. In fu- ture studies, Item 41 should be evaluated. In this study, the discriminative validity by experience

group was confirmed, which showed the usefulness of the scale in explaining the relationship between experi- ence and competency. The ENCC of the group with more than 6 years of experience was higher than other groups, whereas previous research on emergency room nurses’ ENCC reported that the ENCC of those with more than 2 years’ experience was higher than other groups [52]. One reason that school nurses take longer than hospital nurses to increase their competency could be that university curricula have not yet fully address school emergency nursing care competencies that re- quire extensive knowledge in the context of the schools’ limited medical resources [53]. In addition, insufficient on-site support for improving the nurses’ ENCC has been reported [54, 55]. Given most school nurses work alone, developing a competency-based education pro- gram [56] that can improve the school nurses’ ENCC at the beginning of their experience is necessary.

Limitations In this study, the same sample was used for both the EFA and CFA. Because of the number of items and fac- tors developed in the study, it was difficult to obtain suf- ficiently large samples that could be divided. In this study, EFA was applied as a process for refining scales with the limitation that CFA would be repeating rela- tionships established through the EFA [57]. The TCS [35] used to assess criterion validity in this

study is not the gold standard. It has been developed for emergency room nurses, not school nurses.

Nevertheless, the TCS [35] was used because, to date, there is no gold standard for emergency nursing care, and triage is an integral component of emergency nurs- ing care.

Conclusions The results demonstrated that the ENCCS_SN is a valid and reliable scale for measuring school nurses’ ENCC. The scale can be useful to assess school nurses’ ENCC and develop a competency-based education program and nursing curriculum for school nurses. Furthermore, the ENCCS_SN could help identify related factors in de- veloping effective interventions or policies as well as evaluate the policy outcomes or interventions related to school emergency nursing care. It is acknowledged that the cut-off value in this study

could not be presented due to the lack of gold standard in the ENCC. Therefore, further research should be con- sidered in order to identify what variables can be used to measure the outcomes of school nurses’ ENCC or to de- velop a scale used to measure them. In this study, the NCCCF [29] was applied as the research framework to develop a scale that can be used internationally even though each item was developed in the context of Ko- rean school emergency nursing care. The scale was de- veloped in Korean and then translated into English, but the validity of the translated scale was not verified. It should be further noted that, given the international dif- ferences in school nursing practices, the scale should be used once the scale’s validity has been verified following country-specific modification for school nursing practice.

Abbreviations ANCOVA: Analysis of Covariance; AVE: Average Variance Extracted; CFI: Comparative Fit Index; CFA: Confirmatory Factor Analysis; CVI-I: Content Validity Index for Item; CR: Critical Ratio; ENCC: Emergency Nursing Care Competency; ENCCS_SN: School Nurse’s Emergency Nursing Care Competency Scale; EFA: Exploratory Factor Analysis; ICN: International Council of Nurses; KMO: Kaiser–Meyer–Olkin; NCCCF: Nursing Care Continuum Competencies Framework; RMSEA: Root Mean Square Error of Approximation; SMC: Squared Multiple Correlation; SFL: Standardized Factor Loading; SRMR: Standardized Root Mean-square Residual; TCS: Triage Competency Scale; TLI: Turker Lewis Index

Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s12912-021-00580-9.

Additional file 1 Supplementary material 1: Result of the Confirmatory Factor Analysis. Supplementary material 2: The Emergency Nursing Care Competency Scale for School Nurse: ENCCS_SN.

Acknowledgements We appreciate Professor Insook Lee for reviewing and giving advice. We also would like to thank Editage (www.editage.co.kr) and Douglas Kim for English language editing.

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Author’s contributions Yoon contributed to the whole process of this study, including the study design, analysis, and drafting of the article. The author(s) read and approved the final manuscript.

Funding The research received no funding from any agency.

Availability of data and materials All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate The study was carried out with the approval of the Institutional Review Board of Seoul National University (IRB No. 1809/003–009). All methods were performed in accordance with regulations of the Institutional Review Board of Seoul National University. Study description and informed consent were provided by email to a panel of experts. The participants of the pilot test and main survey were asked to read the study description and provide informed consent before completing the questionnaire on online. Mobile vouchers were given to participants.

Consent for publication Not applicable.

Competing interests The author has no competing interests to declare.

Received: 30 November 2020 Accepted: 31 March 2021

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