Healthcare personnel find that they are better equipped to receiveand treat trauma patients after taking the Course in T rauma Nursing.

Sykepleien Forskning 2017 12(64387)(e-64387)DOI: 10.4220/Sykepleienf.2017.64387

Background: The Course in Trauma Nursing is a basic course in trauma nursing care that wasintroduced in South-Eastern Norway Regional Health Authority in 2011.

PEER-REVIEWED RESEARCH

Healthcare personnel’sassessment of theircompetence after acourse in trauma nursing

KeywordsSurvey Electronic questionnaire Competence Trauma course Evaluation

ABSTRACT

Jeanette FinstadAnestesisykepleier og fagutviklingssykepleierAvdeling for anestesisykepleie, akuttklinikken, Oslo universitetssykehus, Ullevål

Knut Magne KoldstadbråtenLedende traumekoordinatorAvdeling for traumatologi, akuttklinikken, Oslo universitetssykehus, Ullevål

Ragnhild HellesøProfessorAvdeling for sykepleievitenskap, Det medisinske fakultet, Universitetet i Oslo

Authors

Objective: The purpose of the study was to survey whether the course participants felt theywere better equipped to receive and treat trauma patients after completing the course. Thereis little Nordic research on nurses’ own assessment of their competence following a traumacourse.

Method: The study has a prospective survey design, where the pretest-posttest method isapplied to a single group. We collected data using an electronic questionnaire that contained23 questions divided into three areas of competence: medical competence, teamworkcompetence and choice and improvisation competence.

Results: The study shows that the course participants reported that the Course in TraumaNursing leads to improvements in the three competence areas. Gender, age, participation in atrauma team and number of years of further education have no impact on the results. Courseparticipants who had not previously participated in a trauma course reported an improvementin competence in about a quarter of the questions concerning medical competence,compared to those who had previously participated in a trauma course.

Conclusion: The Course in Trauma Nursing should continue to be a priority area for healthcarepersonnel in acute care hospitals with a trauma function, both for trauma team specialists andfor other professions involved in treating and rehabilitating trauma patients. 

Trauma is the leading global cause of death anddisability (1). In western countries, injuries are themain cause of death among people aged between 1 and44 (2). An organised and formalised trauma systemwith dedicated trauma teams has been shown tooptimise patients’ clinical outcomes after injury andlead to higher survival rates (3, 4).

Based on recommendations in a report on the traumasystem in Norway (Traumesystem i Norge), Norwegiantrauma hospitals must meet certain criteria forresources, and trauma team specialists must meetcompetence requirements (5).

Competence can be defined as ‘the aggregateknowledge, skills, abilities and attitudes that make itpossible to perform relevant functions and tasks inaccordance with defined requirements and goals’ (6, p.48). Self-perceived competence relates to howindividuals view their own competence in differentareas, and is not an objective measurement (7).

Background

Oslo University Hospital, Ullevål is Norway’s largesttrauma hospital, with around 2000 trauma patientsevery year. Its trauma team consists of 15 specialists,each with their own specific duties (8).

Trauma treatment at Oslo University Hospital, Ullevålbegan in 1984 with the activation of teams of traumaspecialists and the implementation of guidelines forreceiving and treating trauma patients in line with thehospital’s trauma manual (3, 8). The trauma manual isbased on Advanced Trauma Life Support (ATLS), acourse in life-saving treatment for doctors. The courseaims to provide theoretical knowledge and practicalskills in relation to trauma patients (9-11).

Advanced Trauma Care for Nurses (ATCN) is aninternational course for nurses in trauma teams. Thiscourse is based on ATLS. In Norway, the Course inTrauma Nursing is organised as a two-day basic coursein trauma treatment. The course model is based onATLS and ATCN, and provides an introduction tostandardised principles for receiving and treatinginjured trauma patients.

The Course in Trauma Nursing focuses on initialtreatment upon arrival at a hospital qualified to dealwith trauma patients. The course began in 2011 andhas since expanded its reach to 40 Norwegian hospitalswith a trauma function. The target group for the courseis nurses who are involved in the reception of traumapatients, but it is also offered to other professions withan active role in trauma treatment. The course has beenquality assured by the Department of Traumatology atOslo University Hospital, Ullevål and the NationalAdvisory Unit on Trauma.

«Oslo University Hospital, Ullevål isNorway’s largest trauma hospital, witharound 2000 trauma patients every year.»

Course in Trauma Nursing

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Several studies claim there is a need for moreknowledge about the impact of trauma courses andtrauma training on nurses (12-15). Evidence showsthat the level of professional knowledge increases afterparticipation in ATLS and ATCN (16-19). However,the literature identifies shortcomings in studies thathave evaluated the impact of self-perceivedcompetence in nurses after participating in traumacourses.

The objective of our study was to investigatehealthcare personnel’s (henceforth referred to ascourse participants) self-perceived change incompetence in the reception and treatment of traumapatients before and after completing the Course inTrauma Nursing.

We formed the following hypothesis: courseparticipants’ competence in the reception andtreatment of trauma patients will be improved twomonths after completing the Course in TraumaNursing. The aim of the study was to answer tworesearch questions:

To what extent does the Course in Trauma Nursingcontribute to self-perceived change of competence inthe reception and treatment of trauma patients?

What correlations are there between gender, age,number of years of further education, trauma teamparticipation, participation in previous traumacourses and changed competence after the Coursein Trauma Nursing?

The study has a prospective survey design, where wehave applied the pretest-posttest method to a singlegroup. We collected data in an electronic questionnairetwo weeks before the start of the course and twomonths after the end of the course.

Objective of the study

MethodDesign

Seven hospitals that arranged the Course in TraumaNursing in November and December 2014 wereinvited to participate in the study. One of the sevenhospitals did not provide consent to the study beforethe start of the course and was therefore excluded. Thehospitals varied in geographical location and size.

A coordinator for the course at each institution askedregistered course participants if they wanted toparticipate in the study, and 94 participants wereinvited. Inclusion criteria were nurses, specialistnurses, radiographers and ambulance workers whosigned up for the Course in Trauma Nursing.Exclusion criteria were course participants who did notcomplete the course or answered less than 50 per centof the questions in the questionnaire.

For this study, we further developed an existing,validated questionnaire (20). Figure 1 provides asummary of this.

The original questionnaire consisted of four parts. Part1 dealt with concordance between specialist nurses’self-perceived competence and job requirements. Part2 related to concordance between colleagues’expectations for competence and self-perceivedcompetence after completion of their education. In Part3, we asked for suggestions for improvements to theeducation programme, and in Part 4 we recordedbackground data.

We excluded Parts 2 and 3 because they were notrelevant to our study. Part 1 contained 36 closedquestions about self-perceived competence, dividedinto seven competence areas. Four of the seven areaswere excluded because they were not relevant to theCourse in Trauma Nursing.

Sample

Questionnaire

The three competence areas that we used in thequestionnaire for this study were medical competence,teamwork competence and choice and improvisationcompetence.

We revised and adapted the questions in Part 1 to thecourse syllabus in order to survey the competence ofthe course participants. The resulting questionnairewas given the title ‘Evaluation of self-perceivedcompetence in the reception and treatment of traumapatients before and after the Course in TraumaNursing’ (EVAKITS1 for the pretest and EVAKITS2for the posttest).

The questionnaire consisted of 23 closed questionsabout practical and theoretical competence in thereception and treatment of trauma patients. Of these,17 questions related to medical competence, threerelated to teamwork competence and three concernedchoice and improvisation competence.

The response alternatives were in the form of a seven-point Likert scale, where 1 = I do not feel verycompetent at all and 7 = I feel very competent. Weasked the course participants to evaluate their self-perceived competence using the scale for eachquestion within the three competence areas. Thequestionnaires were produced electronically using theQuestback computing program.

We created a panel of experts in order to reinforce thevalidity and reliability of the questionnaire. The remitof the panel was to use their experience to evaluate thequestionnaire as a data collection method (21). Twelvenurses from different hospital departments wereinvited to join the panel.

The panel was made up of nurses and specialist nurses,about half of whom had completed the Course inTrauma Nursing. They gave us feedback on thequestionnaire content and question formulation (22).This feedback led us to reformulating some questionsthat seemed unclear, without changing the areas ofcompetence and content.

We collected the data in the period from November2014 to February 2015. The Course in Trauma Nursingcoordinator instigated the first contact with the courseparticipants. We sent letters with information about thepurpose of the study and informed consent to therespondents before EVAKITS1 was distributed. Returnof the questionnaire was regarded as consent to takingpart in the study.

In order to investigate changes in competence, it wasnecessary to compare the course participants’responses from EVAKITS1 and EVAKITS2 and thenconsider the group’s overall change. Respondents whodid not answer EVAKITS1 were not therefore sentEVAKITS2.

Panel of experts

Data collection

The data were transferred electronically fromQuestback to the Statistical Package for the SocialSciences (SPSS), version 22.0 for Mac. We useddescriptive statistics with frequency and percentagesfor categorical variables to describe the demographicsof the course participants.

We also used mean and standard deviations forcontinuous variables. The response alternatives on theLikert scale were treated as continuous because theLikert scale was greater than 5 and summarised as atotal score (23).

Each question had a minimum score of 1 and amaximum score of 7. Medical competence gave amaximum score of 119. Teamwork competence andchoice and improvisation competence each had amaximum score of 21. The majority of the answers tothe questions had a normal distribution.

In order to answer the first research question, weexamined the change in competence with a pairedsample t-test. For the second research question, weexamined how the independent variables (number ofyears of further education, trauma team participation,age, trauma course participation and gender) impactedon the dependent variable (mean change examined for23 questions in the questionnaire). The mean changewas the differential between mean posttest and meanbaseline.

First, we tested the independent variables in univariateanalyses. We then performed a multiple regressionanalysis where we examined the variables that weresignificantly related to change in competence (thedependent variable). Only variables that achievedsignificance in the univariate analyses for the samequestion were controlled in the latter analysis. P-value<0.05 was considered statistically significant.

Analysis

Ethics

The study is approved by the Norwegian Centre forResearch Data (NSD). The data we collected werestored separately from personal identificationinformation and password-protected linked identifiersbetween course participants and the data material.

Of the 94 participants, 52 responded to the pretest(55.3 per cent). Forty-five of those who responded tothe pretest returned the posttest questionnaire (86.5 percent). A total of 16 men (31 per cent) and 35 women(69 per cent) took part.

Seventy-seven per cent of the course participants wereinvolved in a trauma team. The mean clinicalexperience for receiving and treating trauma patientswas 8.5 years (SD 8.3). Table 1 gives an overview ofthe participants’ socio-demographic variables.

ResultsSample

Competence after completed course

Course participants reported a significantly greaterincrease in medical competence and choice andimprovisation competence two months after theCourse in Trauma Nursing compared to the pretest (seeTable 2). Course participants also reported an increasein teamwork competence, but for the question relatingto knowledge of own area of responsibility in thetrauma team, the increase was not significant.

The individual variables that were controlled forchange are shown in Table 3.

How individual variables impact on changedcompetence

Regarding the questions ‘Receiving and treatingpregnant trauma patients’ and ‘Assessing traumapatients according to the Glasgow Coma Scale (GCS)’,men found that their competence improved to a greaterextent than women.

For the question ‘Having knowledge of your own areaof responsibility in the trauma team’, courseparticipants who were not part of a trauma teamreported a significantly greater improvement in theircompetence compared to those who did work in atrauma team.

Trauma course was the variable that impacted onchanges for most questions. Course participants whohad not participated in trauma courses other than theCourse reported an improvement in competence forfour of the questions, compared to those who hadattended other trauma courses.

Gender

Trauma team

Trauma course

All of the questions related to medical competence:‘Receiving trauma patients according to the ABCDEapproach’, ‘Fitting and adjusting neck collars’,‘Receiving and treating respiration and/or circulationin unstable trauma patients’ and ‘Receiving andtreating trauma patients with unstable head injuries’.

Three questions showed a significantly negativechange for age. When age increases by one year, thechange is reduced by 0.04 for the question ‘Initiatingmeasures to clear respiratory passages’. ‘Identifyingdifferent types of shock’ was reduced by 0.03 and‘Rapid prioritising/re-prioritising of tasks when thesituation so demands’ was reduced by 0.03.

As Table 3 shows, the changes for the answers to theaforementioned three questions were also adverselyaffected by the number of years of further education.Because the two variables showed significant changefor the same three questions, we performed a multiplelinear regression analysis to investigate whether thecombination of variables impacted on each other.

The analyses showed that when the number of years offurther education is constant and the age increased byone year, the course participants reported a reductionin competence for one of the questions: ‘Rapidprioritising/re-prioritising of tasks when the situationso demands’ (p = 0.044) (data not shown).

The combination of age and further education was notsignificant for the other two questions. None of theremaining independent variables showed change forthe same question, so a multiple regression analysiswas only performed for the aforementioned twovariables.

Age and number of years of furthereducation

Discussion

The results show that all course participants largelyreported a positive change in competence in allcompetence areas, from baseline to two months afterthe course.

As Table 2 shows, the course participants experiencedthe greatest change in competence in relation to thequestions ‘Fitting and adjusting neck collars’, ‘Logrolling patients’ (see the fact box), ‘Receiving andtreating pregnant trauma patients’ and ‘Initiatingmeasures to stop blood loss in accordance with themassive haemorrhage protocol’.

The practical exercise stations in the Course in TraumaNursing focus on teaching course participantsprocedures that are highly relevant to the reception andtreatment of trauma patients. Fitting a neck collar andlog rolling are themes of two of the exercise stations.Course participants are taught the theory beforepractising the procedures under the supervision of aninstructor.

In cases of a suspected vertebral fracture, the logrolling technique is used when patients need to bemoved onto their side. Log rolling is performed byfour people rolling the patient onto their side without�exing the body in a way that could aggravate thefracture (37).

The large differential in mean scores may indicate thatthe course participants find that the exercises help toimprove competence. The findings are supported bythe literature, which shows that training in technicalsimulation improves skills and increases the rate ofretention (24-25).

Questions showing the greatest change incompetence

LOG ROLL

The reception and treatment of trauma patients in theperiod between the baseline and the posttest may be afactor that impacts on the change of competence as aresult of course participants being able to put theirknowledge from the course into practice. The Coursein Trauma Nursing has a standardised, theoreticaleducation programme. Lectures are given on, forexample, injury mechanisms and special patient groupssuch as the elderly, children, burns patients andpregnant patients.

Pregnant trauma patients are a rare patient group (8,26). It is therefore considered unlikely that a markedchange in competence is correlated with two months ofexperience from practice. It is more likely that thelecture on pregnant trauma patients has contributed totheir knowledge. The improvement in courseparticipants’ competence is due to the fact that theyhave learned how to receive and treat this patientgroup.

Haemorrhages account for 40 per cent of trauma-related deaths, and the most challenging surgicalsituations in trauma treatment are caused by massivehaemorrhages (27, 28). Patients in haemorrhagic shockare critically ill and require immediate bloodtransfusion and surgical intervention (29).

On the Course in Trauma Nursing, the guidelines onmassive transfusion protocol are discussed in thelecture on shock treatment. The participants’ increasein self-perceived change in relation to the question‘Initiating measures to stop blood loss in accordancewith the massive haemorrhage protocol’ may be theresult of newly acquired knowledge from thetheoretical lecture.

Pregnant trauma patients 

Massive haemorrhage is greatest challenge

Positive change in competence

The questions about medical competence focusedspecifically on the theoretical lectures in the Course inTrauma Nursing. Teamwork competence and choiceand improvisation competence are not covered sospecifically in theoretical lectures. Nevertheless, theresults show a positive change of competence for bothareas of competence.

Teamwork competence entails the team members’ability to perform their duties in a flexible manner,among other things. The reception and treatment oftrauma patients can be challenging and resource-intensive because many parallel actions take placesimultaneously.

This requires every person in the trauma team to carryout their specific duties satisfactorily. At the sametime, knowledge about their own duties and the dutiesof others is a contributing factor in functionalteamwork (30).

The positive self-perceived change in relation to thequestion ‘Having knowledge of other trauma teammembers’ areas of responsibility’ may be due to thefact that the Course in Trauma Nursing is offered tospecialist nurses and other professions involved intrauma teams.

Joint training for the different professions involved ina trauma team can generate interest across the groups.The Course in Trauma Nursing instructors are nurseswith different specialities from trauma teams. Thisgives the course a broad scope in terms of areas ofresponsibility since the respective occupational groupscan provide more detailed descriptions of their duties.

«The reception and treatment of traumapatients can be challenging and resource-intensive because many parallel actions takeplace simultaneously.»

Knowledge of own area of responsibility in the traumateam was the only question that showed no statisticalsignificance after participants had completed thecourse. Mean baseline scores for this question had thehighest output value. This value indicates that thecourse participants felt that their competence wasalready very good prior to taking the course. Therewas therefore less potential for improvement.

Choice and improvisation competence also shows apositive change from baseline to posttest, and had thelowest mean change differential. In hindsight, theformulation of questions in this area of competencecould be called into question since the questions arerather vague and are open to interpretation.

The questions are not necessarily a good indicator ofthe effectiveness of the actual course. However, theoverall positive change may be due to the fact that theCourse in Trauma Nursing generally contributes toknowledge, which makes participants feel moreconfident and competent in making choices andimprovising.

The results for two of the questions showedsignificantly greater competence for courseparticipants who were not involved in a trauma teamthan for those who were part of a trauma team. Thesetwo questions were ‘Fitting and adjusting neck collars’and ‘Having knowledge of your own area ofresponsibility in the trauma team’.

All trauma patients received and treated by a traumateam must have a neck collar fitted prior to theirarrival in hospital. Patients who arrive without a neckcollar are fitted with one as a matter of urgency.

Questions without signi�cant change incompetence

Involvement in a trauma team as acontributing factor

The differential between the two groups can beexplained by the fact that course participants who arenot involved in a trauma team benefit more from thepractical exercise station because they are lessknowledgeable about the procedure in the first place.Even if a procedure has not been carried out in practiceafter the Course in Trauma Nursing, new knowledgecan contribute to a self-perception of greatercompetence.

The mean change in competence between the sexesshowed a significant differential in just one question.For the question ‘Receiving and treating pregnanttrauma patients’, men reported more of animprovement in competence than women.

Compared with course participants who had been on atrauma course, participants who had not participated ina trauma course showed a significant positive changefor four of the questions about medical competence.

The changes shown for the relevant questions mayindicate that the Course in Trauma Nursing learningcurve is steeper for participants who have not taken atrauma course than for those who have participated insuch a course. The reason may be that courseparticipants who have been on a trauma course, suchas ATCN, already have knowledge within the areascovered in the Course in Trauma Nursing. Thus, it isnot quite so apparent whether this group’s competencehas changed.

Gender as a contributing factor

Trauma course as a contributing factor

Age and number of years of furthereducation as a contributing factor

The course participants’ age and number of years offurther education showed a significantly negativechange for the same three questions: ‘Initiatingmeasures to clear respiratory passages’, ‘Identifyingdifferent types of shock’ and ‘Rapid prioritising/re-prioritising of tasks when the situation so demands’.

It is conceivable that newly qualified courseparticipants with less work experience have greaterself-confidence, and therefore give themselves higherscores. At the same time, younger participants mayhave a steeper learning curve because they tend tolearn faster than the older participants (31).

Nevertheless, it is difficult to explain why age andnumber of years of further education only affectedthree of the 23 questions when combined in theregression analysis. However, for the question ‘Rapidprioritising/re-prioritising of tasks when the situationso demands’, age had a negative effect on the changewhen the number of years of further education wasconstant.

This indicates that age is the variable in this questionthat had the greatest negative impact on the changes.Because both of the aforementioned variables relate toa small minority of the questions, we cannot concludethat age and further education were contributingfactors for changes in competence after the course.

«It is conceivable that newly qualified courseparticipants with less work experience havegreater self-confidence, and therefore givethemselves higher scores.»

Strengths and limitations

The biggest challenge in this study is the small sample.The sample size makes it particularly difficult toexamine sub-samples. We may not, therefore, be ableto identify statistical changes that could have beenshown in a larger sample. This particularly applies tothe results shown in Table 3. It was also difficult tomake a calculation of strength before the study startedas we lacked input data.

Course participants may be influenced by theirexpectations of the course, leading them to give theircompetence a higher score in the posttest (28). At thesame time, renewed knowledge may make participantsfeel that they are more competent. There may also be acorrelation between change in competence andmotivation, prior knowledge and the field of practice’sinterest in competence development (32).

These factors are important and must be taken intoconsideration when the results are to be generalisedvis-à-vis other samples or studies. In the linearregression analysis, we performed multiple analyses.This may be a weakness of the study since statisticalsignificance can be achieved by chance (33).

The sample is taken from hospitals that vary ingeographical location and size, something thatstrengthens the representativeness of the study. Theoriginal response rate of 55.4 per cent should ideallyhave been higher in order to be able to generalise (22,34).

The response rate for EVAKITS2 (85.6 per cent)strengthens the internal validity of the study. Thepurpose of the study is to measure the subjectivecompetence of course participants. The internalvalidity of the study is impaired because of the study’sinability to measure the changes without a controlgroup, and this is the greatest weakness of the study.

Good response rate

Control group recommended

The pretest-posttest design of the study, where thesame group is used without a control group, makes itdifficult to check for sources of error, bias andcontributing factors (35). We call on researchers whowish to carry out future studies to use a control group.

We further developed the validated questionnaireaimed at evaluating competence after further educationin anaesthesia nursing, paediatric nursing, critical carenursing and theatre nursing (Evaluering av kompetanseetter videreutdanning i anestesi-, barne-, intensiv- ogoperasjonssykepleie). As not all of the questions wererelevant to our study, a panel of experts evaluated therelevant part of the questionnaire to ensure that it wasclinically credible and valid (36).

Some working groups in the sample population weretoo small to investigate the mean change incompetence for different professions. Future studieswith larger samples are, however, encouraged toinvestigate change across the Course in TraumaNursing working groups.

The study shows that the Course in Trauma Nursingcontributes to increased self-perceived competence forcourse participants who receive and treat traumapatients, from baseline to two months after the course.The changes after completion of the course arestatistically significant for 22 of the 23 questionsconcerning medical competence, teamworkcompetence and choice and improvisation competence.Thus, we can conclude that the hypothesis that we putforward before the study is supported.

There is essentially no differential in self-perceivedchange in competence in relation to gender, age,participation in a trauma team and number of years offurther education.

Conclusion

Course participants who have not previouslyparticipated in trauma courses report a greaterimprovement in competence for about a quarter of themedical competence questions than those who haveattended a trauma course.

The Course in Trauma Nursing should continue to be apriority area for acute care hospitals with a traumafunction, both for trauma team specialists and for otherprofessions involved in the treatment of traumapatients.

Given the study’s positive finding two months after theCourse in Trauma Nursing, it would be interesting toinvestigate the long-term effect of the course. It wouldalso be useful to investigate whether taking part in thecourse increases participants’ interest in traumatology.

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«There is essentially no differential in self-perceived change in competence in relation togender, age, participation in a trauma teamand number of years of further education.»

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