Nurses Perceptions of their Competence in Managing Patient Situations in Acute Care

Nurses are at the forefront of recognizing and managing patient situations which may be potentially life-threatening. This study examines the nature and extent to which nursing experience and selected educational variables have on nurses’ perceptions of their competence in managing deteriorating patient situations in acute care. Self-awareness of nurses’ competence in managing these types of patient situations is critical. Benner’s Novice to Expert Model of developmental competency is the theoretical framework for this study. A survey methodology was used to gather data on the variables: years of experience in nursing, years working in current specialty, educational preparation, national certification, area of specialization, crosstraining in more than one specialty, and advanced life support or rapid response team member training. Attendance at a case review session where actual cases were reviewed was also a variable. Instrumentation included an adapted version of the Nurse Competence Scale, a thirteenitem scale related to managing patient situations. Content validity was established by an expert panel of nurses practicing in acute care in the roles of Clinical Nurse Specialist, Nurse Manager, and staff nurses. The setting for the study was an acute care community hospital in the Northeast. Of 212 registered nurses eligible to participate in the survey, the data producing sample of 74 subjects resulted in a 35% return rate. Using SAS, data analysis included univariate descriptive statistics and logistic regression to determine predictive values on nurses’ self-perceived competence in managing deteriorating patient situations. Of special interest was the potential association with attendance at case review sessions. Results indicate the overall score for nurses’ competence in managing patient situations is in the “good” range (between 8 and 9 on the study scale). Those who attended a case review session had higher overall scores in eleven of the thirteen aspects on the study scale. Cross-training to more than one specialty was predictive of nurses’ self-perceived competence in managing patient situations. Limitations of this study include the small sample size, and that it was conducted in one community hospital and so findings may not be generalizable to other settings. This study contributes to the knowledge base in nurse competence and nurses’ role in managing patient deterioration. Implications for nursing education and practice include integrating such competencies in program planning for orientation and continuing education.

patient situations. Of special interest was the potential association with attendance at case review sessions.
Results indicate the overall score for nurses' competence in managing patient situations is in the "good" range (between 8 and 9 on the study scale). Those who attended a case review session had higher overall scores in eleven of the thirteen aspects on the study scale. Cross-training to more than one specialty was predictive of nurses' self-perceived competence in managing patient situations.
Limitations of this study include the small sample size, and that it was conducted in one community hospital and so findings may not be generalizable to other settings.
This study contributes to the knowledge base in nurse competence and nurses' role in managing patient deterioration. Implications for nursing education and practice include integrating such competencies in program planning for orientation and continuing education.   Misses." Because of nurses 24/7 patient contact, they have significant responsibility in identifying those subtle cues indicating deterioration in patients' condition prior to these sentinel events or near misses.
Self-awareness of nurses' own competency in managing such situations presents a host of challenges for staff development educators in hospitals. Ensuring competence in recognizing and managing these events is a major priority. Hospitals have developed costly programs such as case review sessions (where sentinel events or near misses are analyzed), certification programs in Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and training as "Rapid Response" team members, amongst others.
A host of factors have been identified as possible variables associated with nurses' self-perceived competency in preventing and managing near misses and sentinel events. However, no studies to date examine the extent to which these multiple variables are associated with nurses' perceived competency in recognizing and managing such events. The purpose of this step-wise descriptive study is to examine the extent and the manner in which the following variables: -years of nursing experience -years of working in a specialized area -cross-training in more than one specialty -type of educational preparation (associate degree, diploma, baccalaureate, or advanced degrees) -national certification -participation in the care of a patient discussed at a case review session -attendance at a case review session -and participation in advanced life support training such as ACLS, PALS, or rapid response team member training are associated with nurses' self-perceived competency in recognizing and managing potentially life-threatening situations. The knowledge gained in this study will assist in: (1) determining the relative value of educational programs aimed at increasing nurse self-perceived competency in managing these situations; and (2) when to begin this training.
Competence in nursing practice is vital to ensuring the delivery of safe patient care. The outcome of care delivery in a competent manner is a complex myriad of knowledge and skills within the Registered Nurse's scope of practice. Developing educational methods that will predict competent practice is a challenge for Nurse Educators. The concern for competent nursing practice is evident in the literature as well as in the clinical setting (Del Bueno, 2001;Flanagan, Baldwin & Clark, 2000).
Areas impacted by nursing competency include patient outcomes, leadership development, quality, accountability, patient, nurse and physician satisfaction, and the fiscal health of the organization (Alspach, 2000;Del Bueno, 2001;Maynard, 1996).

Nurse competence is a component of the American Nurses Credentialing Center's
Magnet and Pathway to Excellence Programs® (ANCC, 2004;ANCC 2008).
Ensuring competence in nursing practice is a major priority for staff development departments in hospitals. In accordance with the American Nurses Association (ANA) Scope and Standards of Practice, nurses are accountable to deliver the best possible care to patients (ANA, 2004), a significant component of which is to recognize and respond to subtle cues and changes in patient's condition.
methodologies to assess competence (While, 1994). Although it is clear that safety for the patient and nurse in the delivery of care is of prominent concern, methods to promote the development and refinement of these abilities in nurses is not always so apparent.
Although there is not a universal definition of competency, Alspach captures common elements which are referred to throughout the nursing literature. Alspach (2000) describes competency as a "simultaneous integration of the knowledge, skills and attitudes that are required for performance in a designated role and setting" (p.2).
Competency assessment is "the review and documentation of an individual's demonstrated ability to achieve the expectations stated in his or her job description" (Alspach, 2000, p.2). The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) describes competency as "a determination of an individual's capability to perform up to defined expectations" (JCAHO, 2002, p. 333). The report of the American Nurse's Association, Expert Panel on Continuing Competence defines professional nursing competency as "behavior based on beliefs, attitudes, and knowledge matched to and in the context of a set of expected outcomes as defined by nursing scope of practice policy, code of ethics, standards, guidelines, and benchmarks that assure safe performance of professional activities" (Whitaker, 2000, p. 11).
Notable in the initiative on competency, the Taskforce on Health Care Workforce Regulation Pew Commission in 1995-1998 declared that practice acts should be based on demonstrated initial and continuing competence (Whitaker, 2000, p. 15). The National League for Nursing included in its research priorities for the 21st century the competencies of graduates for practice (AACN, 2002). The National Council of State Boards of Nursing defines competency as " the application of knowledge and the interpersonal, decision making, and psychomotor skills expected for the nurse's practice role, within the context of health, welfare and safety" (Green & Ogden, 2002).
The attributes of a clinically competent nurse were described in a study from interviews with staff nurses in Magnet Hospitals (Schmalenberg, Kramer, Brewer, Burke, Chmielewski, Cox, Kishner, Krugman, Meeks-Sjostrom & Waldo, 2008). Six domains of competent performance were identified in this study. In order of highest to lowest frequency, the domains were: autonomous decision making; prioritizing and multitasking; interpersonal competence; technical skill competence; knowledge competence; and quality of patient outcomes (Schmalenberg et al., 2008). The importance of synthesis and application of knowledge to managing patient situations is highlighted by this statement from one of the nurses interviewed: A clinically competent nurse is able to assess the level of acuity, pick up subtle changes in the patient's condition, effectively communicate this, and deliver the proper treatment and care with compassion and understanding. (Schmalenberg et al., 2008, p. 57)

Theoretical Framework
As competent practice is of utmost concern in all areas of nursing, identification of a theoretical framework is needed to provide a foundation for the description, development and assessment of competency in nursing. A model of knowledge and skill acquisition was developed by Patricia Benner in 1984 and described in the book "From Novice to Expert: Excellence and Power in Clinical Nursing Practice". The model is based on Benner's research with beginning nurses and nurses who were considered expert by their staff development instructors with input from head nurses and peers. Hospital settings included community, teaching and inner city. Based on an interpretative, phenomenological epistemology, the research utilized interviews and observations to identify the process of knowledge acquisition and nature of knowledge that is acquired through nursing practice and experience. The notion of knowledge being embedded in practice is an underlying assumption of the research. Outcomes of the study provide a delineation of practical and theoretical knowledge denoted in levels of proficiency, competencies of nursing practice, and aspects, or attributes, of practical knowledge (Benner, 1984, p. 2).
The Dreyfus Model of Skill Acquisition provides the theoretical framework for Benner's research. Stuart Dreyfus and his brother, Hubert Dreyfus, developed the Model of Skill Acquisition from work they had done in their respective fields of mathematics and philosophy. Their work was done in the 1960's and focused on knowledge acquisition related to pilots and automobile drivers (Dreyfus & Dreyfus, 1986). They found that "a person usually passes thorough at least five stages of qualitatively different perceptions of his task and/ or mode of decision making as his skill improves (Dreyfus & Dreyfus, 1986, p. 19). The five stages are: novice, advanced beginner, competent, proficient, and expert. Not all will reach the level of expert. Stages are referred to because "(1) each individual, when confronting a particular type of situation in his or her skill domain, will usually approach it first in the manner of the novice, then of the advanced beginner, and so on through the five stages, and, (2) the most talented individuals employing the kind of thinking that characterizes a certain stage will perform more skillfully than the most talented individuals at an earlier stage in the model" (Dreyfus & Dreyfus, 1986, p. 21). An outcome of the study was the delineation of the levels of proficiency in skill acquisition development.
With the complexities of nursing practice and the knowledge required to deliver competent, safe care, it is imperative to identify the "knowing -how" in nursing knowledge and skill acquisition. The rationale for generalizing the Dreyfus model to nursing by Patricia Benner as a theoretical framework is "it takes into account increments in skilled performance based on experience as well as education.
It also provides a basis for clinical knowledge development and career progression in clinical nursing" (Benner, 1982, p. 402). Underlying assumptions of Benner's Novice to Expert Model are: 1. In the acquisition of knowledge, a student passes through five levels of proficiency: novice, advanced beginner, competent, proficient and expert 2. These different levels reflect changes in three general aspects of skill performance: a. A movement from reliance on abstract principles to the use of past concrete experience as paradigms.
b. A change in the learners perception of the demands of a situation from a compilation of equally relevant bits to a complete whole in which only certain bits are relevant.
3. Movement from detached observer to involved performer. (Benner, 1984, p. 13) Through a deductive process that is generalizable to new graduate nurses as well as experienced nurses in new clinical situations or specialties, the theory presents overriding principles that describe a process and stages that the learner progresses through with outcomes for each stage as described in an analysis of concepts. The assumptions outline relational statements of progression with resultant prediction of the outcome of knowledge acquisition as a result of experience. The statements relate the concepts of clinical situation, experience, level of proficiency, skill performance, and competencies. The concepts are related in a consistent manner through the focus on the impact of each to knowledge and performance.
Analysis of the concepts within the theory begins with a description of the stages of proficiency. In the novice stage, learners are inexperienced and practice according to rules as they have no contextual basis on which to make judgments.
Nursing students and new graduate nurses are novices, as well as nurses who may be experienced but are new to a particular specialty area. This stage illustrates the premise that there is a difference in knowledge gained in a classroom setting and that attained through context dependent situations in practice (Benner, 1984, p. 21).
As the learner is exposed to and manages more clinical situations, experience is gained and the level of proficiency progresses to the second stage of the model, the advanced beginner stage. The nurse at this stage has been exposed to enough situations to be knowledgeable about recurring components that have meaning. These are termed "aspects of the situation". Experience with similar situations affords the nurse the ability to assign meaning to these aspects, as opposed to following contextfree procedures of the novice stage. "Aspects include overall, global characteristics that can be identified only through prior experience" (Benner, 1984, p.22).
In the competent or third stage, the nurse has two to three years of experience and is able to evaluate the importance of aspects of the situation and establish a plan "based on considerable, abstract, analytic contemplation of the problem" (Benner, 1982, p. 404). The nurse in the competent stage has confidence in managing the prioritization necessary in a clinical assignment, although speed and flexibility are not mastered at this stage.
In the proficient stage, the nurse's perspective shifts from viewing aspects of the situation to seeing the situation as a whole, with the ability to recognize aspects that are different than what would normally be expected. The nurse in this stage has worked with a similar population for three to five years. The broader perspective of the nurse in this stage includes a strong analytical component and facilitates decision making based on judgment of the importance of particular aspects. Progression from the competent stage to the proficient stage involves a transformation whereby the nurse is not following the rules and guidelines of earlier stages, but rather is using past experiences as the reference to guide practice (Benner, 1982, p. 406). The nurse at the proficient stage has a keen awareness to changes in patient condition before vital signs changes become explicit (Benner, 1984, p. 31). Despite performance being guided by maxims in this stage, the nurse will need more experience before maxims can be used to decipher the nuances of situations. "Maxims reflect what would appear to the competent or novice performer as unintelligible nuances of the situation; they can mean one thing at one time and quite another thing later. Once one has a deep understanding of the situation, however, the maxim provides direction as to what must be taken into consideration" (Benner, 1984, p. 29).
Intuition guides the nurse at the expert level, as opposed to the rules, guidelines and maxims of the earlier stages. The nurse in this stage has assimilated knowledge through experience, and no longer proceeds in a formal, analytical fashion before making a decision. Nurses at the expert level are able to utilize their analytical skills in situations that are new or not occurring according to their expectations (Benner, 1982, p. 406). Due to the intuitive nature of practice at the expert stage, it may be difficult for nurses in this stage to articulate the rationale for their decisions.
Knowledge is embedded in practice at the expert level, and through the discovery of this knowledge "it is possible to obtain a rich description of the kinds of goals and patient outcomes that are possible in excellent nursing practice" (Benner, 1982, p. 406). Benner notes that the interpretive, narrative approach using exemplars to describe the characteristics of nursing practice is especially important and useful with nurses at the expert stage.
Experience is a major concept in the in the Novice to Expert Model. An underlying assumption is that the expert stage is attained through experience in situations in the clinical arena. Benner describes the meaning of experience as it relates to the model. "Experience, as the word is used here, does not refer to the mere passage of time or longevity. Rather, it is the refinement of preconceived notions and theory through encounters with many actual practical situations that add nuances or shades of differences to theory. Theory offers what can be made explicit and formalized, but clinical practice is always more complex and presents many more realities than can be captured by theory alone" (Benner, 1984, p. 36).
In the progression toward the expert level of practice, a change occurs from reliance on rules and guidelines in the novice, advanced beginner and competent stages to decision making based on contextual, situational experience that becomes intuitive in nature. An underlying assumption in the Dreyfus Model and applied in Benner's work is that this change involves a transformation that improves skill. The concept of transformation relates to "a change that brings about improvement in performance" (Benner, 1984, p. 38).
As noted previously, the development of Benner's model was inductively derived through interviews and observations with nurses in a variety of clinical settings. Exemplars were used to extract the "knowledge embedded in practice" (Benner, 1984). The research process yielded seven domains of nursing practice.
These domains were derived inductively from 31 competencies that emerged from an analysis of descriptive patient care episodes. The domains are: the helping role, the teaching-coaching function; the diagnostic and patient monitoring function; effective management of rapidly changing situations; administering and monitoring therapeutic interventions and regimens; monitoring and ensuring the quality of health-care practices; and organizational and work-role competencies (Carlson, Crawford & Contrades, 1989, p. 188). Within each domain, concepts and "relational steps" became evident from which competencies for each domain were identified.
With competency as a goal of clinical orientation and nursing practice, it is important to evaluate the causal relationships among the variables in the process.
Experience is the major element of causation in Benner's model, with increases in the level of proficiency being the outcome. Attainment of the expert level of practice may occur naturally as an effect of experience, as was extracted from the interviews and exemplars noted by Benner. It may occur and be embedded in the normal course of events of caring for patients (Benner, 1984). Based on the evidence by Benner and Dreyfus which documents the effect of experience in causing increasing levels of proficiency, practitioners may benefit from this knowledge through the development of programs to enhance the effect of causation on competency in practice. In this respect, a structure would be in place to facilitate causation of the outcome of progressive proficiency in practice. The power of experience as a causative mechanism has strength based on the complexity of skills, knowledge, and clinical scenarios that the nurse needs in order to manage diverse clinical scenarios and events.
The complexity of the clinical area, however, adds the possibility of other factors also having a role in the development or impedance of proficiency. Benner identifies strategies to assist the learner during each level of proficiency. For example, case studies are noted to be useful in refining clinical thinking for the nurse at the proficient level of practice, whereas use of rule based protocols may result in frustration (Benner, 1984, p. 31).
The Novice to Expert Model provides a foundation that describes concepts related to the acquisition of expertise. It describes the impact of experience on the refinement of clinical practice. In addition, the model offers strategies to enhance the development of expertise based on the level of proficiency of the nurse. The model predicts that through the experiential process, a transformation from rule based judgment to intuitive knowledge will occur as the nurse moves toward being an expert practitioner. The model is parsimonious in description, but in analysis is complex due to the external influences that affect the concepts in the model. External influences include the level of development of the preceptor, support of the process by nursing education and nursing leadership, degree to which the hospital and unit support a culture of mentoring and healthy work environment. Throughout the description of the model, Benner (1984) frequently notes that the model is a start to guiding the complex process of the acquisition of expertise, but that more work is needed to continue to uncover and expand the knowledge base related to developing and describing the concepts involved in the process of skill acquisition.

Critical Thinking
Critical thinking in nursing practice is an integral component of competency, and essential for the delivery of safe, quality patient care. Patient's problems are complex, multifaceted, and changes can occur rapidly. It is rare that a patient presents with one problem, rather in an age of technological and pharmaceutical advances, patients frequently present with a myriad of conditions that require identification of the problems, and development of the patient care plan to optimize patient outcomes.
Even in patients who present with non-complicated histories or conditions, complications can arise and the nurse needs to have keen assessment skills to identify and act on what often are subtle cues. Nurse Educators face the challenge of structuring an environment and experience in situations that support the development and refinement of the ability to recognize problems, plan, act and evaluate results.
This process begins in the undergraduate program, continues when the novice nurse enters clinical practice, and is ongoing in professional development. In the effort to support and enhance new nurses' ability to think through patient care scenarios, nurse educators struggle with devising programs that facilitate the astute nature of assessing, analyzing assessment data, and delivering patient care in a safe manner.
As with the term "competency", there is not one universal definition of the term "critical thinking". In 1990, Facione and Facione developed the following definition of critical thinking for the American Psychological Association (APA): We understand critical thinking to be purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. (Facione & Facione, 1996, p.129) While this definition is not specific to nursing, Facione & Facione (1996) (Facione & Facione, 1996, p.131).
The process of critical thinking as integral to the outcome of competent practice is noted by several authors. May, Edell, Butell, Doughty and Langford (1999) discuss the relationship of competency to critical thinking. "National nursing organizations and nurses in the workplace identify critical thinking skills as essential to competent nursing practice" (May et al., 1999, p. 100). Their findings in the literature conclude that clinical competence includes decision making, clinical performance, and clinical judgment, attained through a developmental process involving cognitive, affective and psychomotor domains (May et al., 1999, p.101).
" The literature suggests clinical judgment, decision-making, problem solving, clinical performance, nursing process, and clinical competences are various terms to capture the essence of what it takes to practice nursing effectively (May et al., 1999, p. 101).
Del Bueno (1990; defines competency in the domains of critical thinking skills, interpersonal skills and technical skills. According to Del Bueno, competency is measured qualitatively, and the effectiveness of competency includes improvement in patient outcomes (p.6). Del Bueno (1990; Bevis (1993) discusses the importance of reflection and awareness as an integral element of the critical thinking process and knowledge development. Price (2004) agrees that critical thinking involves reflection, but emphasizes that critical thinking is not limited to reflection. While reflection is an approach to practice, critical thinking involves considering the relationships between events. Price (2004) describes critical thinking as being comprised of explicit reasoning, analysis, linked to knowledge base, deconstructing and examining processes, and understanding the differences between empirical information, or facts, and attributed meanings, or perceptions.
Following a review of definitions in the literature for critical thinking, Bittner (1998) described critical thinking as a process influenced by knowledge and experience using strategies such as reflective thinking as a part of learning. Bittner describes clinical decisions as being reached through multiple steps that include the opportunity for ongoing evaluation. Bittner (1998) describes two levels of knowledge that must be present in order for critical thinking to occur. Situational knowledge is knowledge gained from, or having access to, specifics of a situation. Practical knowledge is knowledge gained through experience, such as described by Benner.
Once having attained the knowledge, the critical thinker must be able to apply the knowledge, be inquisitive, open-minded and look at the whole while choosing from a multitude of possible solutions (Bittner, 1998, p. 2).
In 2001, Bittner utilized interviews and participatory observation to study critical thinking in nurses working in a cardiac rehabilitation setting. Bittner (2001) identified eight phases of critical thinking. identified: knowledge seeking and problem solving. This study was based on a pilot study using interviews from which four processes of knowledge utilization emerged.
The four processes that emerged were: Traditional, Comparative Questioning, Active Comparison/ Analysis, Personal Experiential.
Nurses are at the forefront for recognizing changes in patients' conditions, and determining actions to prevent or minimize injury. As noted by Fero, Witsberg, Wesmiller, Zullo and Hoffman (2008), "Patient safety can be directly affected by the critical thinking ability of a nurse. Nurses must have the ability to recognize changes in patient condition, perform independent nursing interventions, anticipate order and prioritize" (p. 140). Fero et al. (2008) utilized the PBDS assessment to assess critical thinking in 214 newly hired nurses in a university-affiliated healthcare system (p. 139). The results of their study showed better outcomes in critical thinking than Del Bueno's findings. In their study, 74.9% of nurses met expectations on the assessment, with nurses having greater than 10 years experience having better success in meeting expectations than new graduates (Fero et al., 2008, p. 139).
Critical thinking is an integral component of nursing competency. Further research is needed to identify methods to develop and measure this element in the cognitive domain of competency. An instrument for measurement of critical thinking has been developed by Watson and Glaser (Ennis, 1958;Maynard, 1996). This instrument is used in many disciplines, including nursing, to assess critical thinking (Maynard, 1996). Watson and Glaser describe critical thinking as being influenced by knowledge, attitude and skills (Kataoka-Yahiro & Saylor, 1994). According to Maynard (1996), attitude as described by Watson and Glaser refers to the ability to recognize the existence of a problem, and acceptance of the need to have evidence to support what is asserted to be true. Watson and Glaser's definition of knowledge refers to inferences, abstractions and generalizations in which the weight of accuracy and different kinds of evidence are logically determined (Maynard, 1996, p. 13).
Skills are the application of knowledge and attitude (Maynard, 1996, p. 13).

Measuring Nurse Competence
In addition to the lack of consensus on definition, there is also a need for consensus and an evidence base in measurement regarding the most effective methods for performing competency assessment as well as the outcomes of competency on patient care, quality and nursing practice (Allen, Lauchner, Bridges, Francis-Johnson, McBride, & Olivarez, 2008;Jordan, Thomas, Evans, & Green, 2008;Meretoja & Leino-Kilpi, 2001). Meretoja and Leino-Kilpi (2001) identified the need for instruments to measure competency, noting that a lack of psychometric data makes it difficult for nursing administrators and practicing nurses to benefit from research in the area of competency. "Although competence recognition offers a way to motivate practicing nurses to produce quality care, few measuring tools are available for this purpose" (Meretoja, Isoaho & Leino-Kilpi, 2004, p. 124 visual analogue scale with rating from 0 to 100, with 0 being the self-assessment that the respondent has a low level of competence in the item, and 100 being the perception of the highest level of competence (Meretoja, Isoaho, & Leino-Kilpi, 2004). The Nurse Competence Scale has established reliability and validity.
Another scale used to measure competency is The Six-Dimension Scale of Performance (6D Scale).  referenced the 6D Scale in the development of the Nurse Competence Scale Meretoja & Leino-Kilpi, 2001). The 6D Scale is comprised of 52 items within six categories (Schwirian, 1978;1981 applicable for self-assessment as well as assessment by nurse managers of where they believe their staff is performing relative to each item on the scale (Rafferty & Lindell, 2011). The 6D Scale has established validity and reliability.
Due to established reliability and validity of the 6D Scale and The Nurse Competence Scale, these are important to consider for use in nursing research Meretoja & Leino-Kilpi, 2001

Patient Centered Care in Nursing Competency
The work by Tanner and Benner in Expertise in Nursing Practice (1996) provides an in-depth study of the significance of the nurse's experience and interaction with patients in fostering nursing expertise, understanding the unique and salient aspects of each patient, and meeting individual patient needs. At the expert level of practice, the nurse has a global and comprehensive understanding of the complexities of patient needs. Experience has afforded the nurse the ability and know how concerning technical, interpersonal and moral agency aspects of patient care. In an earlier study by Tanner, Benner, Chesla & Gordon, (1993), 130 nurses interviewed individually and in groups were asked to describe the meaning and importance of knowing their patient. The narratives revealed "knowing the patient means both knowing the patient's typical pattern of responses and knowing the patient as a person.
Knowing the patient is central to skilled clinical judgment, requires involvement, and sets up the possibility for patient advocacy and for learning about patient populations"  with the highest self-perceived competency in the domains of managing patient situations, diagnostic functions and the helping role. Differences were found in the frequency of use of the competencies in the domains between work areas (Meretoja & Leino-Kilpi, 2004, p. 329). The Nurse Competence Scale was also used by Salonen,

Nurses' Perceptions of Competence
Kaunonen, Meretoja and Tarkka (2007) to assess self-perceived competency of nurses working in emergency and intensive care settings. A statistically significant relationship was demonstrated between length of current work experience and frequency of using the competencies in the domains (Salonen et al., 2007, p. 792). Lofmark, Smide and Wikblad (2006) found newly graduated nurses perceived their competence in practice to be higher than perceived by nursing peers who had graduated in the previous 5 years. Meretoja and Koponen (2011) utilized the Nurse Competence Scale to study nurses' self-perceived competence and nurse manager assessed level of actual competence. Using a group consensus method to determine the optimal level of competence in the setting, the findings were that the optimal competence level was significantly higher than the nurses' self-perceived and nurse manager assessed level of staff competence (Meretoja & Koponen, 2011, p. 414).
Assessing nurses' perceptions of their competence provides an opportunity for nurses to reflect on their practice (Meretoja, Isoaho & Leino-Kilpi, 2004). As an active participant in the assessment, areas for development as well as areas of achievement may be identified by the nurse. Information from the self-perceived competency assessment may assist in identifying areas for professional development to meet goals. Self-perceptions of competency provide information for the nurse regarding the level of competency in knowledge, skills and attitude, and if the nurse's performance matches the self-report on the assessment. Utilizing nurses' selfperceptions in research offers an understanding of nurses' perceptions of their needs and can be useful in providing professional development initiatives to assist nurses on the novice to expert continuum (Marshburn, Engelke & Swanson, 2009).

Reflection in Practice
Reflection has been identified as an important component in the development of nursing competence (Bevis, 1993;Forneris & Peden-McAlpine, C., 2007;Gustafsson & Fagerberg, 2004;Kuiper & Pesut, 2004;Price, 2004;Tanner, 2006;Teekman, 2000). As described in Benner's model, as the nurse gains experience, a transformation takes place from detached observer to involved performer. As the nurse gains knowledge and skill through being involved in clinical situations, proficiency develops based on the ability to draw from previous experience, synthesize and apply knowledge. As the nurse gains experience, a rich background of information develops that is available for reference to current clinical scenarios. In addition to developing a broadened experience base, the nurse must also assimilate the knowledge gained through experience into their framework of reference, as well as develop knowledge about the applicability of past experiences to current patient care situations. In the process of gaining experience, an internal recognition and assimilation of knowledge occurs.
Self -reflection is an important aspect of the transformation from detached learner to involved performer.
Clarke, James and Kelly (1996) discuss the work of Donald Schon who explored and described the importance of reflection on professional practice. Schon (Clark et al., 1996) describes the complexities and intricacies of professional practice, specifically that skills alone do not signify professional practice, context is significant and knowledge is multifaceted (Clark et al., 1996, p. 172). At the time of action, practitioners utilize "reflectionin-action", whereby knowledge from previous experience interacts with the context of the situation. The decision making process may not be articulated at the time. Reflectionon-action is when the practitioner considers aspects of situations at times other than the moment in practice. Reflectionon-action "brings about a greater understanding of practice and is an important way in which practitioners learn from their experience" (Clarke et al., 1996, p. 172).
The process of reflection allows the nurse the opportunity to think about practice and the rationale for actions, as well as alternatives based on experience or new insights.
Reflection in nursing practice has several purposes. It affords the nurse the opportunity to examine the meaning of actions in patient care situations and make linkages to previous experiences. Alternatives can be considered, learning needs identified and professional growth assessed.

Action Science
Nursing is a complex, dynamic field with a myriad of patient care needs. In order to respond to these needs, the foundation of experience must be combined with an integration of knowledge, skills and affective attributes. Due to the complexity of nursing, it is not possible to predict all the situations that the nurse may need to respond to in the process of patient care delivery. Competency assessment, therefore, must include an evaluation of the nurse's ability to integrate attributes of particular Intentions for action and actual action sometimes differ. There may be many reasons for this, such as distraction, knowledge deficit or human error. Argyris and Schon (1974) define professional practice as "a sequence of actions undertaken by a person to serve others, who are considered clients, and further propose a theory of practice as consisting of a set of interrelated theories of action that will, under the relevant assumptions, yield intended consequences" (p. 135). The term "theories" in this model refer to meanings, schemata, mental constructs and generalized frameworks for action (Kim, 1994, p. 135). Four areas of theories for action in professional practice are the treatment of client information, who controls the situations or action, commitment to the client, situation or organization and communication appropriate for the situation (Kim, 1994, p. 135). Two types of theories are utilized by practitioners: espoused theories and theories in use. Espoused theories are the articulated basis for action, such as rationales for actions and intentions. Theories in use are theories that are actually used in the situation, and the practitioner may not be able to articulate them, or have awareness of them except through self-reflection (Kim, 1994).
Two types of theories in use have been identified by Argyris and Schon (1974;1985). These are Model 1 and Model II. Model I theory in use is not conducive to new learning as it is focused on maintaining comfort and stability. The governing principles of Model I are control, winning, suppression of feelings and rationality.
"Practitioners entrenched within this type of theory-inuse are routinized in their actions and not actively involved in seeking new solutions and new knowledge to deal with problems of practice" ( Kim, 1994, p. 135). Model II theoryinuse has the principles of valid information, free and informed choice and internal commitment.
Whereas Model I results in miscommunication, self-fulfilling prophecies and escalating error, Model II promotes learning, collaboration and openness ( Kim, 1994, p. 135). Reflection and design are key elements in the transformation from Model I to Model II (Kim, 1994, p. 135).

Nursing practice environment
Nursing educators and nurse managers are challenged with designing and implementing programs that will support the development of competent nurses. As a major outcome of competent nursing practice is safe patient care, identification of patient outcomes that are directly related to nursing care is essential.  describe the importance of isolating outcomes that are directly related to nursing practice, as many outcomes are interdisciplinary in nature. The American Nurses Association (ANA) has developed the National Database for Nursing Quality Indicators (NDNQI). Hospitals that participate in this database follow outcomes for indicators that have been selected as specifically impacted by nursing care. Data is submitted and benchmarks are provided in order to learn and implement best practice (ANA, 2012). Educational programs in the areas being measured are provided to assist in professional development and nursing staff competency.
A nursing structure that promotes nurses' autonomy and involvement in decisions on the clinical unit positively influences nursing practice and patient outcomes (Hume, 2011;Laschinger & Leiter, 2006). Shared governance provides the framework for a structure in which nurses are empowered in decisions regarding nursing practice. It is based on the principles of partnership, accountability, equity, and ownership (Porter-O'Grady, 2001, p. 470 greater sense of personal accomplishment in their work, which in turn translated into more positive nurse-sensitive patient outcomes" (Laschinger & Leiter, 2006, p. 265).
The ability to ask questions within a culture of collaboration is essential for Critical reflective inquiry is a method that examines influences and processes external and internal to the nurse's decision making process. With a basis in Habermas' critical philosophy, and Bourdieu's theory of practice ( Kim, 1999), critical reflective inquiry takes into consideration influences that a novice nurse experiences during the orientation process, as well as a method for examination of practice for the experienced nurse. The culture of the unit toward new nurses may be welcoming and open to learning, or inflexible with the goals to have the nurse proceed as rapidly as possible off orientation without regard to the learning process.
Emancipation through openness to learning and inquiry are important steps toward professional growth. Kim (1999) cites Habermas (1984), "Hence, any study of practice needs to incorporate an emancipation project through which social life can be freed from domination and distortions (p. 1207). The degree to which a unit is supportive to new nurses may impact the level of emancipation that occurs. Inquiry and learning may be suppressed if an emancipatory culture is not present on the unit (Cervero in Keiner & Hentschel, 1997;Kim, 1999). Organizational support and the inclusion of preceptor and management development programs are important initiatives for facilitation of a mentorship culture.
Kim describes the context of nursing action as being comprised of two phases: the deliberative phase and the enactment phase (Kim, 1994, p. 134). Within the practice domain, Kim (1994) identifies the goal of nursing action is to produce outcomes that positively impact the patient. The process toward this goal is complex due to patient issues and organizational culture (Kim, 1994). The dynamic and challenging environment of the unit may contribute to the nursing actions being organized or haphazard, familiar or unfamiliar, patient specific or routinized (Kim, 1994). Espoused theories versus theories in use are further challenged by rapidly changing healthcare technologies (Kim, 1994).

Nursing Administration and education concerns
The concern for competent nursing practice is evident in the literature as well as in the clinical setting. Quality patient care, clinical outcomes and patient satisfaction are impacted by competent practice. Nurse satisfaction is impacted which may effect recruitment and retention. Nursing administrators are among the stakeholders in the competency initiative due to the potential effect of competency on quality outcomes, nursing turnover, and the resultant fiscal impact. The Advisory Board (1999) cites a study by Jones in 2005 describing the cost of replacing a professional nurse as being $48,000-$62,000.
It is the responsibility of nurse educators and managers to structure nurses for success by designing a system to ensure opportunities for knowledge and skill acquisition for the goal of safe nursing practice and the delivery of the highest quality of patient care. This is highlighted in the Institute of Medicine (IOM) report: "The Future of Nursing: Leading Change, Advancing Health" issued in October 2010. In order to meet the challenges of the complexity of patient needs in a rapidly changing healthcare system, the IOM (2010) report recommends that nurses practice to the full extent of their education and training. In addition, the IOM (2010) recommends that nurses achieve higher levels of education "to ensure the delivery of safe, patientcentered care across settings. Patient needs have become more complicated, and nurses need to attain requisite competencies to deliver high quality care. These competencies include leadership, health policy, system improvement, research and evidence-based practice, and teamwork and collaboration, as well as competency in specific content areas" (IOM, 2010, p. 2). In recognition of the range of competencies included in baccalaureate education, the IOM (2010) report recommends an increase in the number of baccalaureate prepared nurses to be better equipped to meet the increasing demands of the healthcare system. The IOM (2010) reports: "Care within the hospital continues to grow more complex, with nurses having to make critical decisions associated with care for sicker, frailer patients and having to use more sophisticated, life-saving technology coupled with information management systems that require skills in analysis and synthesis" (p.3).
Aiken, Clarke, Cheung, Sloane and Silber (2003) found lower mortality associated with a greater proportion of baccalaureate prepared nurses. In this study, outcomes data for 232, 342 patients in 168 hospitals were evaluated for risk adjusted mortality and failure to rescue within 30 days of admission and associated with nurse educational level (Aiken et al., , p. 1617. The findings of the study were that each 10% increase in the proportion of nurses with BSN (baccalaureate of science in nursing) degrees or higher decreased the risk of mortality and failure to rescue by 5%, after controlling for patient and hospital characteristics (Aiken et al., , p. 1620).
Years of experience in nursing was not found to be a significant predictor of mortality or failure to rescue (Aiken et al., , p. 1620).
The impact of baccalaureate education was also highlighted in the study by Kendall-Gallagher, Aiken, Sloan and Cimiotti (2011) who utilized a logistic regression model to study the effects of specialty certification and educational preparation on mortality and failure to rescue in surgical inpatients. Baccalaureate preparation was found to be associated with lower mortality and failure to rescue.
Nursing specialty certification was also found to be similarly associated, but only when combined with a baccalaureate degree in nursing, " A 10% increase in hospital proportion of baccalaureate and certified baccalaureate staff nurses, respectively, decreased the odds of adjusted inpatient 30-day mortality by 6% and 2%; results for failure to rescue were identical" ( Kendall-Gallagher et al., 2011, p. 188).
The American Nurses Credentialing Center (ANCC) offers certification in many nursing specialties. According to the ANCC, certification "validates your nursing skills, knowledge and abilities. ANCC certification empowers nurses in their professional specialty and contributes to better patient outcomes" (ANCC, 2012).
Specialty certification is a goal of many hospitals and nurses. The number of certified nurses, and support for attainment of certification, are questions on the application for Pathway to Excellence® designation. "As of 2000, 410,000 nurses throughout the United States and Canada had attained certifications from 134 specialties" (Watts, 2010). Intrinsic benefits of specialty certification have been demonstrated to include increased confidence in clinical abilities and validation of specialized knowledge (Haskins, Hnatiuk & Yoder, 2011). Safe patient care is a major impetus for nurses to become certified. "Along with safeguarding the public, certification also promotes quality nursing care and excellence. Certification demonstrates clinical expertise, knowledge, and professionalism to patients, the public and nursing peers (Watts, 2010, p. 55). Kendall-Gallagher and Blegen (2009)  perceptions of the effect of certification on their practice. This study was based on a random sample of 19, 452 nurses from the registries of 23 certifying organizations in the United States, Canada and the U.S territories (Cary, 2001, p. 44). When asked in a survey how certification contributes to their professional development, over 40% of nurses who had been certified less than five years identified areas of high impact being on aspects of care that include nursing surveillance: "detecting complications and initiating early interventions; effective communication, control of practice, collaboration and autonomy; fewer adverse incidents and errors in patient care; higher patient satisfaction rates" (Cary 2001, p. 49). This study indicates certification may increase the nurse's ability and confidence in recognizing and responding to changes in patient condition.
In accordance with Benner's model of exposure to clinical experiences fostering knowledge and skill acquisition, it would seem that nurses who work on various units would have an in-depth experiential base from which to practice.
Advantages to having nurses cross train to other areas increases the pool of nurses able to staff units across the nursing department. Quality and safety of care may be positively impacted by supporting the number of nurses on the unit. In addition, the nurse is familiar with the hospital policies, procedures and resources. Cross-training hospital nurses potentially avoids the need to hire agency nurses who are unfamiliar with the routines and resources in the hospital. Inman, Blumenfeld and Ko (2005) cite, "Buchan and Seccombe report that using agency nurses represented the biggest negative impact on continuity and quality of care because agency nurses were often unfamiliar with the particular work environment and care setting" (p. 117). Morale may be increased for nurses who find working in various areas enjoyable, challenging and an opportunity to increase their knowledge and skill set. Inman et al. (2005) stipulate that in order for a net benefit to be gained from cross-training, it must be carefully planned and followed. Some nurses are not comfortable going to units outside their usual unit. Nurses who cross-train may become overwhelmed with the volume of skill required. If the nurse does not go to a specific area for a prolonged period of time, proficiency in specific skills may be lost and unit protocols may have changed. Inman et al. (2005) recommend cross-training nurses who are agreeable to be cross-trained, work frequently enough to maintain skills in the various areas of cross-training, and have low absenteeism. The primary consideration, however, is that the nurse has the prerequisites to be able to work in the specific area, such as having the prerequisite of acute care nursing experience ( Inman et al., 2005, p. 124). Haag-Heitman (2008)

Managing Changes in Patient Situations
Through her interviews with nurses, in addition to delineating the novice to expert stages of skill acquisition in nursing, Benner identified seven domains of nursing practice with related competencies (Benner, 1984). The domain "Effective Management of Rapidly Changing Situations" specifically addresses recognizing and responding to changes in patient conditions. Benner states, "Because it is the nurse who most often picks up the first signs of deterioration in a patient's condition, it is the nurse who must often manage rapidly changing situations until the physician arrives" Benner, 1984, p. 109). The competencies in this domain are: skilled performance in extreme life-threatening situations; contingency management; rapid matching of demands and resources in emergency situations; identifying and managing a patient crisis until physician assistance is available (Benner, 1984, p. 111) The " Diagnostic and Monitoring Functioning" identified by Benner (1984) describes the nurse's role in being attuned to subtle changes in patients, knowing the patient in order to be able to detect variations for that patient, anticipating what could happen, and communicating clearly and confidently to other nurses and physicians. Benner (1984) discusses that there is need for attention in these domains due to the increasing acuity levels and "sophisticated treatment regimens that have narrowed margins of therapeutic safety" (p. 166). Benner (1984) offers that for development in this area, nurses could keep a log of their recognition of changes in patient conditions, as well as those situations in which signs of deterioration were missed (p. 167). The competencies in the Diagnostic and Monitoring Function are: detection and documentation of significant changes in a patient condition; providing an early warning signal; anticipating breakdown and deterioration prior to explicit confirming diagnostic signs; anticipating problems: future think; understanding the particular demands and experiences of an illness: anticipating patient care needs; assessing the patient's potential for wellness and for responding to various treatment strategies (Benner, 1984, p. 97 Research in the realm of Rapid Response would be facilitated through the use of a refined terminology specific to life-threatening events (Wong, 2009). The recommendations are for The North American Diagnosis Association International Classification to include: critical incident nursing diagnosis ( CIND) " defined as the recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment or medication; and critical incident nursing intervention (CINI) defined as any indirect or direct care registered nurse-initiated treatment , based upon clinical judgment and knowledge that a registered nurse performs in response to a CIND; and critical incident control, defined as a response that attempts to reverse a life-threatening condition. (Wong, 2009, p. 53)

Failure to Rescue
Patient deterioration is a phenomenon of relevance for the client population in the acute medical-surgical population. In the course of caring for a patient, it is possible that the patient may develop deterioration in condition. The nurse caring for the patient needs to be knowledgeable and aware of the subtle changes that may indicate deterioration in the patient's condition. Subtle changes that take place in a patient may not be recognized until the patient is physically decompensated. Nurse educators are challenged to educate staff nurses about problems a patient may present with and the accompanying signs and symptoms indicating deterioration in condition to be alert to.
While it is not possible to address every situation the nurse may encounter in clinical practice, the broad ranges of possible clinical problems are presented with the intent of applying knowledge learned in a classroom setting and in the clinical arena to a wide range of situations. It is important for the nurse to be able to critically think through signs and symptoms and put the "big picture" together. Even if the nurse is unsure of what the problem is, just knowing that there is a problem and summoning assistance is crucial to the patient's wellbeing.  (Bobay, Fiorelli &Anderson, 2008;Manojlovich & Talsma, 2007). The failure to rescue indicator has been studied for linkages to specific patient populations, organizational structure and patient characteristics. Silber initially identified the five complications of failure to rescue within the hospitalized surgical patient population. "Elective patients are the most frequently studied population because these are typically healthy patients on admission who can reasonably expect to have surgery, recover, and be discharged to home" (Bobay et al., 2008, p. 211). Needleman and colleagues expanded the definition to include patients in the medical population, with the criticism that patients in this population are often sicker and with co-morbid conditions that blur the issue of failure to rescue (Manojlovich & Talsma, 2007). (2007) (Bobay et al., 2008, p. 212). Subbe et al. found that certain physiological parameters were often abnormal up to three days before the patient deteriorated (Bobay et al., 2008). These parameters included blood pressure, heart rate, respiratory rate, body temperature, neurologic status and urine output (Bobay et al., 2008, p. 212 (Bleyer et al., 2011(Bleyer et al., , p. 1387. The use of an early warning score was validated in this study. Vital signs were shown to change at any time in the hospital stay, but more likely to occur within 48 hours of the admission (Bleyer et al., 2011(Bleyer et al., , p.1392. This study demonstrates the importance of nursing vigilance in monitoring patient status, and recognizing changes that necessitate early intervention, such as the activation of a Rapid Response Team.

Manojlovich and Talsma
In 2005, the Institute for Healthcare Improvement (IHI) launched the 100,000 Lives Campaign (IHI, 2010). The goal of the campaign is to significantly reduce morbidity and mortality in American health care, apply best practices across the country to save as many as 100,000 lives (IHI, 2010). The IHI encouraged hospitals to implement steps to reduce harm and deaths. One of the steps was to implement Rapid Response Teams in order to respond to patients at the first sign of decline (IHI, 2010). Simmonds (2005) cites three problems that may lead to a failure to rescue.
These are a failure to plan, such as through assessments, treatments and goals; failure to communicate among the staff, and failure to recognize deterioration in the patient's Registered nurses (RN's) are in a position to recognize subtle and critical changes in order to rescue patients and make decisions to intervene at the most opportune moments to prevent adverse outcomes. Rescuing involves recognition of diagnostic cues and patient risks, intensive resource application and prevention of life-threatening events. RN's are authorized to and responsible for observing the patient condition, determining abnormal signs and symptoms, and making decisions to act in the best interests of the patient. However, since clinical diagnostic cues are not always distinct when they first emerge, and initial cues are may be subtle, disparate and unrelated, there are times when rescuing requires expert clinical decision making to prevent an adverse outcome. (Leach et al., 2010, p. 1) Strategies to enhance nurses' recognition of changes in patient condition are needed to decrease the failure to rescue potential in the acute care setting. Courses in Advanced Cardiac Life Support provide knowledge about signs, symptoms and treatments for critical conditions. Case study reviews have been demonstrated to be effective in increasing nurses' self-perceived competence and confidence in recognizing and managing changes in patient conditions (Jacobson, Belcher, Sarr, Riutta, Ferrier, & Botten, 2010). The nurse acts as a vigilant guardian by recognizing the significance of subtle changes in a patient's condition. Early recognition may be enhanced when nurses know their patients directly through the family and are attentive to subtle changes in patients (Minick andHarvey, 2003, in Jacobson et al., 2010). The skill set identified as important to enhancing the role of the nurse as a vigilant guardian includes assessment, synthesis of data, ability to think critically, specialty knowledge, advocacy, communication and collaboration. (Jacobson et al., 2010, p. 348)

Case reviews
Case reviews of actual patient cases with nurses provides an opportunity for nurses to reflect on their nursing actions, discuss the rationale for these actions and identify alternative actions that might impact patient outcomes. It is also an opportunity for nurses to share knowledge that may be helpful in future situations. In addition to an educational strategy, system issues such as the need for policy changes or global education across clinical units may be identified. The few studies that reference the use of case studies as a method in nursing education describe the creating of cases to use as a case review (Davidson, 2009;Hasegawa, Ogasawara & Katz, 2007;Jones & Sheridan, 1999;Kim, Phillips, Pinsky, Brock, Phillips, & Keary, 2006). The nursing literature sporadically addresses the use of actual patient cases in nursing education, most often in the form of nursing grand rounds (Armola, Brandeburg, & Tucker, 2010;Lannon, 2005).
The use of actual cases in clinical vignettes has been shown to increase nurses' confidence and skill in managing critical patient situations (Jacobson, Belcher, Sarr, Riutta, Ferrier & Botten, 2010). The study by Jacobson et al. (2010) using actual patient cases as an educational strategy to enhance nursing competence and critical thinking is unique in the nursing literature. Winkelman, Kelley and Savrin, (2012) also identify the use of actual case scenarios as a specific strategy for developing critical thinking in nurses. Referring to the use of actual case situations as "case histories", they state: Because case histories are usually based on individuals, they provide contextual nuances that address variability in patients' conditions, situations, and communities. Surprisingly, the use of case histories does not have a long history in the education of nurses but is recommended by expert teachers Case-based teaching is advocated to help nurses develop habits of thought essential to practice, case-based methods are congruent with adult learning theory as they present knowledge and skills that are contextual and engaging. Case histories provide opportunity for educators to facilitate clinical reasoning-the cognitive and self-reflective skills to solve clinical problems. (Winkelman, Kelley and Savrin, 2012, p This study will add to the nursing knowledge base through research, and provide information that will be used to develop future educational programs to enhance nurses' perceptions of competence in practice.

Research Design
This study was a step-wise, multivariate, descriptive study to examine the To achieve this aim, a survey was utilized to collect information on nurses who work in the acute care hospital setting and may encounter changes in patients' conditions. The survey was designed following a review of the literature using the databases of CINAHL and Medline from 1981-2012, using the key words of nursing competency, critical thinking, and failure to rescue. The survey questions were drafted and checked for face validity with nurse managers, a clinical nurse specialist, a clinical educator and registered nurses practicing in the acute care setting; registered nurses in a leadership nursing course in a college of nursing; and the core dissertation committee.

Setting, Population, and Sample
The study was conducted at a 100-bed acute care community hospital in the Northeast. The study population was all registered nurses who provide direct patient care and who work in the following specialties at the study hospital: format.

Dependent Variable
Utilizing information collected in the survey, an outcome variable summarizing nurses' perceived self-competency was created. To do this, responses were dichotomized on a scale of weak, moderate, good and excellent. The nurse assigned a numerical score based on a visual analogue scale (VAS) to each survey question. The scale indicated the numerical scores for weak (0 -2), moderate (3)(4)(5), good (6)(7)(8) and excellent (9)(10)). An average of the scores for each individual was calculated to obtain an overall perceived self-competence score. Averages of scores for each question on the survey were also calculated. For multivariable analyses, these average scores were categorized into a dichotomous variable comparing excellent perceived self-competency (average score > 9) versus weak/moderate/good (average score <9).

Independent Variables
From the survey, information was gathered on years of nursing experience, years of working in a specialized area, cross-training to more than one specialty, type of educational preparation (associate degree, diploma, baccalaureate, or advanced degrees), national certification, attendance at a case review session, participation in the care of a patient discussed at a case review session, and participation in advanced life support training such as ACLS, PALS, or rapid response team member training. These factors were considered as potential independent predictors of nurses' self-perceived competency in recognizing and managing potentially life-threatening situations.

Instrument
The instrument for this study was inspired by the Nurse Competence Scale (NCS)  A visual analogue scale (VAS) is used to rate each item in the NCS. In the VAS, 0 is the lowest level indicating low perception of self-competence, and 100 being the highest indicating high level of self-competence. Further division of the scale for descriptive purposes is a rating of 0-25 as weak, >25-50 as moderate; >50-75 as good, and >75-100 as excellent (Meretoja & Koponen, 2011;Salonen, 2007).
The NCS has established construct and content validity. Internal consistency reliability using Cronbach's alpha for the NCS was 0.79-0.91 . The range for Cronbach's alpha is between .00 and 1.00, with higher values reflecting a higher internal consistency (Polit and Beck, 2008). Burns and Grove (2009) state, "If the Cronbach's alpha coefficient value were 1.00, each item in the instrument would be measuring exactly the same thing. When this occurs, one might question the need for more than one item. A slightly lower coefficient (0.8-0.9) indicates an instrument that will reflect more richly the fine discriminations of the construct" (p. 379). Concurrent validity was established through correlation with the Six-Dimension Scale of Nursing Performance Schwirian, 1978). Concurrent validity is "the degree to which scores on an instrument are correlated with an external criterion, measured at the same time" (Polit & Beck, 2008, p. 750). The NCS was found to be more useful in delineating levels of nurse competence, and more sensitive to a wider scope of level of experience and work environments than the Six-Dimension Scale. Meretoja and Koponen, 2011).
In addition to the items in the NCS, two of Benner's seven domains of nursing practice provided a basis for developing questions for the survey. The domains "Effective Management of Rapidly Changing Situations" and "Diagnostic and Monitoring Functioning" focus on awareness, anticipation and detection of changes in patient condition, actions to manage these changes, communication and documentation of changes (Benner, 1984). The study instrument was comprised of a total of 24 questions (Appendix C). The first 11 questions focused on information related to the independent variable: number of years practicing nursing, number of years in current specialty, educational preparation as a registered nurse, holding national certification, attendance at a case review session, cared for a patient presented at the case review session, perception of case review benefitting the nurse's practice, cross-trained in more than one specialty, and participated in advance life support training. These were followed by 13 questions which related to aspects of managing patient situations. These aspects were identified through the literature review, Benner's domains, and the validated NCS scale. Following development of the questions in the scale, each question was reviewed for correlation to the categories of the validated NCS. This revealed the two domains questions most closely correlated to were the Managing Patient Situations and Therapeutic Intervention categories. For this part of the survey, participants were asked to assign a score to their perceptions of their own competence in aspects of managing patient situations on a scale of 0-10, with 0 being the lowest, and 10 being the highest. The scale was further described as: 0-2 (weak); 3-5 (moderate); 6-8 (good); 9-10(excellent).

Definition of the most important terms and concepts
Case review: The process of reviewing the nursing care rendered to a patient for the purpose of staff education.
Competent: The integration of the cognitive, affective and psychomotor domains of practice that are required for performance in a particular role (Alspach,1984;Del Bueno et al., 1987,Gurvis & Grey, 1995Jeska,1998;Nagelsmith, 1995 Critical Thinking: The use of interpretation, analysis, evaluation, and inference to make a judgment and determine action.
Managing situations: Recognition of and responding to changes in the clinical condition of a patient.

Data Considerations
The use of case review sessions utilizing actual patient cases has been noted in the nursing literature as a tool to enhance the critical thinking domain of nursing competency (Jacobson, Belcher, Sarr, Riutta, Ferrier & Botten, 2010 Anecdotal feedback from participants in the case review sessions has been positive. An increase in knowledge, perception of increased competency in practice and confidence has been verbally reported from staff nurses who attended.
While the reports from attendees are promising in the use of case review sessions of actual patient cases as an educational strategy to enhance nurses' perceptions of their competency, this study will provide data to measure this variable related to staff attendance at a case review and the association with nurses' self-perceived competency in recognizing and managing potentially life-threatening situations. To achieve this aim, attending and not attending a case review session will be considered in the data.

The study investigator and major professor completed Human Subject Protection
Training, and submitted certificates of completion to the university and hospital IRB's.
Additionally, permission was granted for the study to be conducted at the study hospital from nursing administration.
The specific exempt criteria pertinent to this study were that the study was of minimal risk, and "conducted involving research on the effectiveness of or comparison were not linked to a particular unit.

Risks and Benefits
For those participants, the risk of participation in the study was minimal, and associated with the inconvenience of completing the survey itself. Benefits were that the study provided an opportunity for the individual participant to reflect on practice.
Participation in the study provided data that will be used to develop educational offerings for nursing staff related to nursing competence.

Data analysis
Bivariate analyses was conducted to describe the characteristics of the sample and summarize responses to individual survey questions utilizing means, medians, ranges and frequencies. An overall mean and standard deviation was calculated for each question in the survey. The sample was then analyzed by those who attended and did not attend a case review session. Means and standard deviations were calculated for each independent variable. For the dependent variable, a mean score was calculated for all participants across all questions to determine the overall mean score for nurses' perceptions of their competence in managing patient situations. Then, an overall mean score for each question in the scale was calculated. A mean score was calculated for each participant, and categorized into attended or did not attend a case review session. Each question was further analyzed by determining a mean overall score for those who attended and did not attend a case review session. For each question, a t-test (p-value< 0.05) was calculated and analyzed between the mean scores of those who attended and those who did not attend a case review session. The purpose of the t-test is to examine if there is any difference between the groups (Munro, 2005, p. 138).
Frequencies of the total number of nurses who responded to each score on the scale of 0-10 were calculated, and further calculated by the number who had attended or not attended a case review session.
The questions were then categorized into two domains as correlated with the NCS, Managing Patient Situations and Therapeutic Interventions, which were determined during instrument development. Overall mean scores were calculated and analyzed for each domain, and then for the categories of attended and did not attend a case review session within each domain.
To identify independent predictors, multivariate statistical modeling was used.
Step-wise multiple regression was used to analyze and predict these relationships.  Nursing specialty certification was held by 23.3% (N=17) of the participants.
A goal of the nursing department at the study hospital is to increase the number of nurses who are certified in their specialty. Nursing specialty certification has been shown to increase nurses' intrinsic perceptions of knowledge, skill and confidence (Haag-Heitman, 2008;Haskins, Hnatiuk & Yoder, 2011). Specialty certification provides validation of knowledge, professional practice and commitment to one's profession for the nurse and the public (Watts, 2010 Knowledge and skill in nursing practice is acquired through experience in clinical practice (Benner, 1984). While experience in a specialty area adds depth to knowledge, exposure to situations across specialties adds breadth. This depth and breadth of knowledge leads to an experiential knowledge base on which to base critical thinking, and transferability of knowledge across situations. Working in more than one specialty offers the nurse more diverse opportunities for learning, which may decrease feelings of discomfort when faced with new clinical situations or when having to float from one unit to another (Haag-Heitman, 2008;Inman, Blumenfeld & Ko, 2005).
Of the 24 nurses who attended a case review session, 62.5 %( N=15) had been cross-trained in more than one specialty. This may indicate that nurses who are crosstrained recognize the benefit of discussing actual patient scenarios in building a skill set to care for patients across populations with a variety of complex needs. If an area of practice is very specialized, the nurse may not encounter the wide spectrum of illnesses seen on other units. If nurses practice in more than one specialty, expertise in being able to recognize changes and manage patient conditions increases.
Of the 50 participants who did not attend a case review session, 76% (N=38) had been practice greater than 6 years. Twenty nine of these nurses (58%) had been in their current specialty for greater than 6 years, and 51% (N=25) had been cross-trained to more than one specialty. Those who did not attend a case review session were more highly representative of the critical and urgent care areas (55%, N=27), and 87.8% (N=43) of these nurses had advanced life support training. Baccalaureate preparation as a registered nurse was held by 56% (N=28) of the nurses who did not attend a case review session, and 26.5% (N=13) held national certification. Based on these findings, nurses who work in a critical care or urgent care area are less likely to attend a case review session than those working in the inpatient area. Nurses who work in critical care or urgent areas generally are required to have previous experience, whereas the inpatient area is usually where new nurses begin clinical practice.
Inpatient nurses, therefore, may perceive the case review session as more beneficial in development of their knowledge and skill base.

Aspects of managing patient situations
Nurses who attended a case review session scored themselves higher in selfperceived competency than those who did not attend a case review session in several aspects of managing patient situations. None of the scores in the individual aspects of managing patient situations were statistically significant at the p<.05 level for nurses who attended a case review session. Similarly, the overall score for the two domains in the study, Managing Patient Situations and Therapeutic Interventions, did not demonstrate statistical significance at the p <.05 level for nurses who attended a case review session. Despite the lack of statistical significance, the scores of the nurses on each aspect of managing patient situations, and overall in each domain is useful in exploring nurses perceptions of their competence.
The overall score of participants' perceptions of their competence in managing patient situations in acute care on the scale of 0 (lowest self-perceived competence) to 10 (highest self-perceived competence) was 8.56+/ -1.13 ( Table 2). The majority of nurses scored themselves between 8 and 9 ( Figure 1). This is in the 'good" range for the scale: 0-2 (weak); 3-5 (moderate); 6-8 (good); 9-10(excellent). For those attending a case review session, the overall score was 8.71+/-.912. Those who did not attend a case review session had an overall score of 8.52+/-1.23. The t-test value for these two groups was t = .72. While those attending a case review session scored themselves somewhat higher in their self-perceived competence, the p-value was 0.4769, which was not significant at p<.05 level. While attendance at a case review session was not statistically significant, those who assigned themselves lower scores (at the "moderate" level and at the lower range of the "good" level), had not attended a case review session ( Figure 2).
The variable of managing patient situations with the highest overall score was "Reporting findings to the healthcare team". This variable was in the Therapeutic Interventions domain ( Table 3). The overall score for this variable was 9.03+/-1.06.
Scores for this variable were similar for nurses who attended (9.04+/-1.16) or did not attend (9.02+/-1.02) a case review session. Within the past year the study hospital has undergone a major initiative in the re-education of all nursing staff in hand-off communication. The study hospital has developed tools for the consistent application of the SBAR (Situation, Background, Assessment, and Recommendation) methodology for when communicating about patient care. Hand-off communication is followed closely as a quality measure at the study hospital to ensure accurate patient information is conveyed among members of the healthcare team. The high score of perceived self-competence in this aspect of managing patient situations is reflective of the work that has been done with the nursing staff at the study hospital in reporting findings to members of the healthcare team. This is essential in managing patient situations to ensure information is conveyed in a manner that facilitates accuracy and consistency in communication.
While the overall score in communication was high, nurses who attended a case review session scored themselves higher (8.96+/-1.08) in the variable of clearly communicating pertinent information about the patient's status than those who did not attend a case review session (8.72+/ -1.28). The case review session focuses on specific signs and symptoms that indicate the patient is experiencing deterioration.
Reporting findings to the physician and communicating a sense of urgency are educational goals of the case review sessions.
Scores were higher for nurses who attended a case review session in the variable "Evaluating the patient's response to interventions" (8.75 +/-1.07), and "Updating the plan of care to reflect the patient's current condition" (8.54+/-1.10) than for those who did not attend a case review session (Evaluating the patient's response  (Benner, 1984). Case review sessions provide the opportunity to discuss recognition, nursing actions, as well as patient reassessment in order to evaluate the effectiveness of interventions. In using actual patient cases for case review sessions, documentation in the medical record is accessible and an integral part of the case review. Nurses are able to view the documentation and determine if it accurately reflected nursing care, or was not complete enough to provide a comprehensive picture of the patient's clinical condition, including response to treatment. The use of decision making skills to determine the plan of care for patients is critical in managing patient situations.
Utilizing decision making skills was scored slightly higher by nurses who had attended a case review session (8.58+/-1.28) than those who did not attend (8.28+/1.57).
A goal of the case review sessions is to provide the opportunity for nurses to review clinical situations, and develop knowledge that can be drawn upon for use in future situations. Knowledge develops from the factors involved in the case, as well as the discussion with peers during the discussion at the case review sessions. This is especially useful for novice nurses who may learn through the interactive process with more experienced staff. Nurses who attended the case review sessions had a higher self-perceived competence score (8.75+/.99) in extrapolating knowledge from the reflection process to apply in managing future patient situations than those who did not attend (8.25+/-1.54).
In the Managing Patient Situations Domain, the variable of recognizing signs and symptoms of deterioration in patient's clinical condition was scored similarly in nurses who attended (8.5+/-1.35) and did not attend (8.52+/-1.45) a case review session (Table 4). Proceeding with taking action, prioritizing actions and understanding the rationale for those actions were all scored higher by nurses who attended a case review session: taking action to manage patient's changing situations (8.5+/1.38 attended; 8.22+/-1.64 not attended), prioritizing actions based on assessment findings (8.79+/.93 attended; 8.38+/1.54 not attended), understanding rationale for actions and orders (8.71+/-1.08 attended; 8.58+/-1.31 not attended). A goal of the case review sessions is to assist the nurses with critical thinking development. Using assessment findings to determine action, prioritize, and understand the reason or rationale for those actions are components of critical thinking. The cognitive aspect of nursing practice, critical thinking, is essential to the ability to determine clinical judgment in patient care and vital to safe nursing practice (Del Bueno, 1990).
Nurses who attended a case review session scored their self-perceived competency higher (8.67+/-1.01) in reflecting on their process of managing rapidly changing patient situations than those who did not attend (8.14+/-1.58). Reflection on practice is a key component of critical thinking and nursing competence (Bevis, 1993;Forneris & Peden-McAlpine, C., 2007;Gustafsson & Fagerberg, 2004;Kuiper & Pesut, 2004;Price, 2004;Tanner, 2006;Teekman, 2000). The case review session is a forum for nurses to reflect on their nursing process to identify opportunities for improvement in practice.
Overall scores of nurses self-perceived competence in managing patient situations scored were higher in the Therapeutic Interventions (_T) domain ( perceptions of their competence in each domain, as well as similarities and differences for those attending or not attending a case review session. The scores, while not statistically significant, provide important knowledge upon which to structure further educational opportunities.

Prediction Model
Logistic regression was used to examine if the variables in the study were predictive of the outcomes of nurses self-perceived competency in managing patient situations. Polit and Beck (2008) define logistic regression as "a multivariate regression procedure that analyzes relationships between one or more independent variables and categorical dependent variables" (p. 757). Munro (2005) describes the use of logistic regression "to determine which variables affect the probability of a particular outcome (p.

306).
The only variable that was predictive of nurses' perceptions of competence in managing patient situations was being been cross-trained to more than one specialty (Table 5). Cross-training to more than one specialty affords the nurse experience with a wider spectrum of clinical situations than having experience in one specialty. Benner's Novice to Expert model illustrates the importance of clinical experiences for the development of expertise in practice. Benner (1984) also notes that specialty practice is important in order to become familiar with the nuances among patients of similar populations (p.180). A balance between familiarity with patient population to understand changes in condition, and having enough diversity in the populations cared for to gain a strong foundation in the clinical experiences, is essential in nursing education.
In a qualitative descriptive study exploring the development of expert performance in nursing, Haag-Heitman (2008) found that nurses who were recognized as experts cited practicing in more than one area of clinical care was instrumental in the development of expert practice. Other factors included deliberate practice which involves the nurse being goal oriented and achievement motivated (Haag-Heitman, 2008, p. 204). Inman, Blumenfeld and Ko (2005) describe cross training as adding to morale due to the increase in knowledge, skills and professional growth (p. 117). Snyder and Nethersole-Chong (1999) and Dunbar (2000) describe the benefits of cross-training being voluntary for staff to perceive the opportunities and growth potential of working in more than one area.

Summary
The study survey was completed by 74 registered nurses. This represented a 35% response rate. The overall score of nurses' perceptions of their competence in managing patient situations in acute care was 8.56+/1.13. The highest overall average score was in the variable "Reporting findings to members of the healthcare team" (9.03+/-1.06). The lowest overall average score was in the variable "Updating the plan of care to reflect the patient's current condition" (8.24+/-1.44). While the scores were generally higher for nurses who attended a case review session, there was no statistical significance at the p<.05 level. The case review sessions were more highly attended by nurses working in the inpatient area than in critical or urgent care areas. Logistic regression was used to examine predictors of nurses' self perceived competence in managing patient situations.
Cross-training to more than one specialty area was the only variable predictive of this outcome. Statistical significance may have been impacted by the small sample size, and the scores being skewed toward the higher end of the scale. Despite the data not demonstrating statistical significance for nurses attending a case review session, the data provides information about nurses who attend, and do not attend the case review session that is important for the development of future educational programs.

Discussion of Findings
The findings of this study indicate that nurses in the study sample perceive their competence in managing patient situations is in the "good range" as indicated by the most frequent scores being 8 -9, on the scale of 6-8 being "good", and 9-10 being "excellent", with the overall average score being 8.56+/-1.13. The overall score for nurses' self-perceived competence is on the higher end of the scale, indicating nurses in the study feel competent in managing patient situations in acute care. The findings provide insight into the level of nurses' self-perceived competence in specific aspects of managing patient situations.
The highest scored aspect was in the area of communication. Reporting findings to the healthcare provider, clearly communicating pertinent information about the patient's status, and seeking clarification from the physician or licensed healthcare provider for questions or concerns regarding the treatment plan were the aspects of managing patient situations with the highest overall average scores. Being able to communicate clearly and concisely is an essential component of managing patient situations and preventing failure to rescue (Manojlovich & Talsma, 2007). To accurately and effectively convey patient assessment data, communicate a sense of urgency and summon help when needed, nurses need to be competent in such Scores related to taking action, including accessing resources to assist in managing patient situations, were scored lower than those related to communication or critical thinking. One of the actions in managing patient situations is calling for help, such as activating the Rapid Response Team. An important component in rescuing patients is for nurses to feel confident and supported in calling for assistance. The findings of the study indicate that there is an opportunity for improvement for nurses to increase their self-perceived competence in accessing resources to assist in managing deteriorating patient situations. Further exploration would be to delineate if an increase in self-perceived competence in recognition of signs and symptoms regarding patient deterioration would improve the score from the "good" range to the "excellent" range, or if support for calling for assistance is a factor (Cioffi, 2000;Ebright, Urden, Patterson & Chalko, 2004;Purling & King, 2012).
The overall score on the aspect of taking action to manage patients' changing situation indicates nurses' self-perceived competence in the "good" range, although not as highly scored as that of communication and critical thinking items. Clarke and Aiken (2003) describe taking action as one of the key components of rescuing patients. Early recognition of signs of deterioration and activating assistance needs to be timely in order to treat conditions that may lead to further patient deterioration. To assist nurses in recognizing early signs of patient deterioration, several hospitals have implemented track and trigger strategies, or early warning systems, in their medical record to alert the nurse of downward changes in patient vital signs and other parameters of assessment (Andrews & Waterman, 2006;Bobay, Fiorelli & Anderson, 2008;Duncan, McMullan & Mills, 2012;Jacques, Harrison, McLaws & Kilborn, 2006). While early warning systems are useful tools for alerting to deterioration, nursing assessment remains vital in recognizing the subtleties of patient changes (Andrews & Waterman, 2006).

Reassessment of the patient's response to treatments is a key element in
Benner's Therapeutic Interventions domain (Benner, 1984). Monitoring for therapeutic responses as well as untoward effects can have "life and death implications" (Benner, 1984, p. 127). Evaluating the patient's response to treatment was scored higher than the aspect of taking action. Nurses' self-perceived competence in evaluating response to treatment as "good" is important to ensuring patients continued monitoring for deterioration, or for signs of improvement. Reassessment and evaluating responses to treatments has been an area of focus at the study hospital, specifically in pain management. Education and an alert in the clinical computer system to remind nurses to reassess patients following pain medication administration has been an initiative that has impacted all nursing staff. Reassessment has been an important focus and the findings of the study indicate nurses have self-perceived competence in this aspect. It is also an area to include as part of ongoing education in managing patient situations to ensure nurses continue to reassess patients for responses to interventions.
The study findings indicate nurses have lower self-perceived competence in updating the plan of care to reflect the patient's current condition than in any of the other aspects of managing patient situations. An updated plan of care is essential to document the patient's condition, carrying out interventions and responding to those interventions. Documentation reflects the clinical course of the patient and the work done by nursing. With the transition from paper charting to computer documentation, there has been a learning curve in assimilation of the technology into clinical practice.
Studies have demonstrated nurses' perceptions of the use of computers as complex and time consuming (Carrington & Effken, 2011;Kelley, Brandon & Docherty, 2011;Stevenson & Nilsson, 2011). Benefits of computerized clinical documentation include improved legibility and fewer documentation errors, and retrievability of information (Carrington & Effken, 2011). Including nurses in the development of screens to ensure they accurately reflect care, and continued monitoring of user efficiency to identify barriers, will work toward nurses' improved perception of their competence in updating the plan of care. The implications for patient safety are essential to stress when teaching documentation skills. The importance of monitoring trends in patient vital signs and other assessment parameters is crucial to identifying patient deterioration, and how to navigate the computer to view those trends, is a critical element in educating staff about patient deterioration and managing patient situations (Bobay, Fiorelli & Anderson, 2008).
The nurse participants perceived ability to "reflect on the process of managing patient situations", and "extrapolating knowledge from the reflection process for use in future situations", both scored in the "good" range. A fundamental tenet of Benner's Novice to Expert Model is that expertise in nursing practice is developed through experience in clinical situations. The process of reflection allows the nurse to review the situation, identify gaps in knowledge or approach, and develop new insights for future situations (Asselin & Cullen, 2011). Reflection can "improve critical thinking, change an approach to patient care, promote self-awareness and improve communication skills" (Asselin & Cullen, 2011). Asselin and Cullen (2011) note that reflection is a deliberative process, and it is helpful to have a facilitator for the process of reflection, such as an educator. Although scored in the "good" range, the skill of reflecting on the process of managing patient situations was the second lowest scored item on the study scale. Utilizing the process of reflection as an educational strategy is an area that is ripe for opportunity in the area of managing patient situations. As nurses encounter situations of patient deterioration they are required to manage, selfperceived competence can be enhanced by having reflection as a goal in the review of nursing practice.
Scores for nurses' self-perceptions of managing patient situations were higher for those who had attended a case review session than for those who did not attend in all aspects except "seeking clarification from the physician or licensed independent provider for questions or concerns regarding the treatment plan". This finding may be caused by the significant focus on communication and the use of SBAR at the study hospital. Team training has also been implemented at the study hospital which included teaching about seeking clarification when needed. Scoring on the item "recognizing signs and symptoms of deterioration in the patient's clinical condition" was also slightly lower score for those attending the case review session than for those who did not attend. A goal of the case review session is to improve recognition of signs and symptoms, so this is an area that would require more focus in future case reviews.
With the aim of this study being to explore the nature and extent of the relationship of several potential variables to nurses' self-perceived competence in managing potentially life-threatening patient situations, only one variable was found to be predictive of the outcome. Using a logistic regression model, being cross-trained to more than one specialty was found to be the only statistically significant predictor of nurses' self-perceived competence in managing patient situations. While the literature search did not reveal studies specific to cross-training and nursing competence, Haag-Heitman (2008) conducted an exploratory descriptive study to examine expert nurses' perceptions of factors which influenced the attainment of expert performance. Findings included practicing in more than one specialty area, or cross-training, as one of the factors that influenced the development of expert practice.
With the acquisition of experience as an essential component in the development of expertise, having experience in more than one specialty would assist in the growth of the experiential base. Benner (1984) points out however, that in order for a novice nurse to become familiar with nuances and subtleties of recognizing patient changes, it is important for the novice nurse to become familiar with one area of clinical practice. This is an important consideration for orienting novice nurses to clinical practice. In order to allow for the novice nurse to become accustomed to the process of recognizing changes in patients' condition, limiting orientation to one unit would be beneficial. It would also be beneficial to include in orientation the opportunity to rotate to other areas so the nurse is exposed to a variety of clinical conditions while still having a home unit to bring back experiences and reflect upon for continued development. In a review of the research on expert performance in nursing, Ericsson, Whyte and Ward (2007) found that the deliberative process of seeking out opportunities for growth is important for the development of expertise.
"To improve their performance, future experts need to seek out particular kinds of experiences-activities designed, typically by a teacher, for the sole purpose of effectively improving specific aspects of an individual's performance by offering opportunities to reach performance goals with repetitions, immediate feedback, and time for reflection and problem solving" ( Ericsson, Whyte & Ward, 2007, p. E61).
As the nurse continues along the novice to expert continuum, reaching out to become specialized in more than one area would continue to expand the experiential base of the nurse who has progressed beyond the novice stage.
Although attendance at a case review session was not statistically significant as a predictor of nurses' self-perceived competence in managing patient situations, the use of case review sessions as an educational strategy, and the findings of this study, provide meaningful information. Munro (2005) (2010) conducted a quantitative study to examine knowledge, skill and situation awareness of final year nursing students responding to patient deterioration. The study was conducted in a simulation lab. Findings were that the students had a satisfactory knowledge base, but skill performance declined as the simulated patient's condition deteriorated (Cooper et al., 2010).
Further research is needed to examine the impact of case review sessions on components of nurse competence.

Summary
Study findings indicate nurses have the highest self-perceived competence in the aspect of communication when managing patient situations that may be of a lifethreatening nature. The aspects of critical thinking were the next highest, followed by reflection, and updating the plan of care. In most cases, scores were higher in those who attended a case review session than for those who did not attend. Variables were tested for statistical significance for prediction of self-perceived competence in managing patient situations using a logistic regression model. The aspect of specialty practice, specifically being cross-trained to more than one specialty, was the only predictor of nurses' self-perceived competence in managing patient situations in acute care. Although not statistically significant, attendance at the case review is meaningful as an opportunity for knowledge enhancement, critical thinking development, reflection and collegial support.

Implications for Nursing
Competence in nursing is essential to providing safe, quality patient care.
Nurses are at the forefront of recognizing and responding to changes in patient condition which may be life-threatening, and often subtle. Educational strategies that facilitate the development of nurses' knowledge, skill and competence in managing patient situations are important to identify and measure. As adult learners, having educational programs that are intentional and focused on meeting the learner's needs is beneficial to the learning process (Swihart, 2007 With the knowledge to be gained from reflection, and the benefits of reflection as a deliberative process, opportunities for this to occur need to be identified. The case review sessions provide an opportunity reflection. An explanation about the process of reflection, and the knowledge to be gained for use in future situations, would be beneficial as an integral part of the case review sessions. Another opportunity would be to consider the debriefings that occur after a Rapid Response Team call as a process of reflection. Providing education about the reflection process, and consideration of changing the name from "debriefing" to "reflection" may further enhance the benefits to be gained from the review process following these events.
The finding of cross-training to more than one specialty as a predictor of nurses' perceptions of competence in managing patient situations has implications for structuring nursing orientation and ongoing education. In accordance with Benner's model, an experiential base is integral to the development of nursing expertise.
Having experience in more than one specialty increases the likelihood of an expanded knowledge base from which to draw for making clinical decisions. The implications from this study for nursing education are that the development of expertise requires recognition of variations in patients' clinical condition, including subtle changes that may occur. As Benner (1984) describes, refinement of this knowledge is benefitted by working in one specialty area (p.180). Nurses identified as experts who were interviewed in Haag-Heitman's (2008) study indicated cross-training, or working in more than one clinical specialty, was instrumental in the development of expertise.
They also emphasized that the development of expertise is a deliberative process that requires focus and planning.
The findings of this study are important to the development of orientation programs, as well as ongoing education. In designing an orientation schedule for nurses, it is important to ascertain the stage the nurse is at on the Novice to Expert continuum. For the Novice nurse, orientation on a specific unit with a preceptor would allow for becoming familiar with the patient population, clinical conditions seen on the particular unit, and variations that indicate patient deterioration. Having a structured orientation with a preceptor on a specific unit affords the nurse the opportunity to set goals and track progress toward becoming an autonomous, competent nurse. Including rotation to a unit other than the home unit would be a beneficial addition to the orientation process in order to begin to expand knowledge of another specialty within a structured framework. This is especially beneficial if the nurse is working on a very specialized unit, such as an orthopedic unit. Working within a structured orientation format would afford the assessment of readiness by the orienting nurse, in collaboration with the preceptor or educator, for rotating to another unit for educational purposes. While the nurse may gain familiarity with the one specialty, such as the orthopedic population, and with variations that indicate problems, experience with patients with other conditions will expand the nurse's experiential base of knowledge and skill. This would be helpful to the nurse if assigned to float to another unit, or if patients in the specialized area, such as orthopedics, develop conditions not normally seen on that unit but had been encountered on the unit the novice nurse rotated to. In addition to the enhancement in knowledge and skill, the nurses' competence and professional development are supported.
For nurses who are beyond the Novice stage, offering the opportunity to crosstrain to other areas is an incentive for professional growth. As noted by Snyder and Nethersole-Chong (1999), and Dunbar (2000), offering this on a voluntary basis allows the nurse to determine if working in more than one specialty is an avenue to professional growth. It would be important to share research findings, such as those from this study, to demonstrate the impact of expanding out to more than one specialty has on nurse competence. Consideration for inclusion in initiatives such as a Clinical Ladder would provide recognition for cross-training as a professional goal. As described by Dunbar (2000), and highlighted in adult learning principles (Swihart, 2007), the benefits of cross-training to more than one specialty would be greater if the nurse is motivated and ready for the experience.
Nursing specialty certification is a professional goal for many nurses. It is also recognized as an indicator of excellence and commitment to professional practice by professional organizations such as the American Nurses Credentialing Center, the Pathway to Excellence and Magnet Programs. While the findings of this study do not demonstrate specialty certification to be predictive of nurses' self-perceived competence in managing patient situations, other studies have demonstrated increased knowledge, clinical skills and confidence (Haskins, Hnatiuk & Yoder, 2011;Haag-Heitman, 2008). The pursuit of specialty certification should be encouraged. The impact of nursing specialty certification on nurse competence and patient outcomes is an area that needs further study.
Implications from this study for nursing practice are on the recognition and management of patient deterioration which may be life-threatening. The information from this study provides insight into where nurses perceive their strengths and areas for growth in managing patient situations. Educational programs can be tailored to improve areas that have been identified by nurses as "good" to "excellent". perceptions of their competence with measures of performance would identify gaps in knowledge, or in the ability to apply knowledge to practice. Following quality measures, such as those associated with Rapid Response events, would provide patient outcomes measurement which could be correlated with nurses perceptions of their competence, and educational strategies to foster nurse competence.

Study Limitations
A limitation of this study is that it was conducted with a small sample size in one community hospital setting. Due to this limitation, the study may not be generalizable to the larger population of nurses practicing in other acute care hospitals.
It does, however, provide information that may be useful in developing educational programs to improve nurse competence in management of patient situations. The design and scale of the study provides a framework for researching nurse competence in managing patient situations which may be life-threatening, as well as nursing's role in preventing failure to rescue.

Future Directions for Advancing Nursing Knowledge
Competence in nursing practice is vital to safe patient care. Further research is needed to identify educational strategies that will facilitate the development of nursing competence. Educators are in need of an evidence base of research findings on which to base programs to meet the competency needs of nursing staff. An evidence base of research provides justification for the implementation of content and methods to meet the educational needs of nurses.
Nurses' perceptions of their competence are essential to consider when examining nursing competency. Self-assessment of where the nurse perceives his or her competence is meaningful for identification of areas of growth to ensure delivery of excellence in patient care. Further research which correlates nurses' perceptions of their competence with specific educational strategies and patient outcomes would expand the knowledge and theoretical base in nursing education and practice.
Further development of tools is needed to measure nurse competence, identify predictors of nurse competence and its impact on patient outcomes. Tools specific to nursing's role in managing patient deterioration are also needed. The study scale was inspired from a combination of Benner's Novice to Expert Model, the literature on nurse competence, critical thinking and failure to rescue. Input for questions was sought from a Clinical Nurse Specialist, and face validity established with content experts. Further use of the scale would lend support to its validity. As stated by Polit and Beck (2008), "The more evidence that can be gathered that an instrument is measuring what it is supposed to be measuring, the more confidence researchers will have in its validity" (p. 464).

Concluding Remarks
This study contributes to the knowledge base in nursing by providing data on the nature and extent to which variables influence nurses' perceptions of their competence in managing patient situations in acute care. Benner's Novice to Expert Model provided the theoretical framework for the study and highlighted the importance of experience as a foundation to expertise in nursing practice. Strategies to foster nursing competence were examined for influence and prediction of nurses' perceptions of their competence in managing situations of patient deterioration.
Participants who attended a case study review session scored themselves higher in self-perceived competency than those who did not attend. Cross-training to more than one specialty area was found to be predictive on nurses' perceptions of competence in managing patient situations. The information that emerged from the study can be used to structure nursing education programs focused on areas that nurses perceive their competency to be lower in than others. Replication of the study following implementation of programs based on study findings will add further to the knowledge base in nursing competency.
The study findings contribute to the knowledge base of caring for patients who are experiencing potentially life-threatening events. With nurses at the forefront of care, they are in a vital role for recognizing and managing these situations. Research into the components of this process, and how to best educate nurses in this area, is critical for nursing education and practice.
Topics and initiatives addressed in nursing staff development are driven by patients needs and ultimately measured by patient outcomes. The patient is at the center of all nursing practice, whether it is direct patient care or indirect, such as teaching nurses about patient safety and strategies for optimizing patient outcomes.
Competence in nursing practice is essential to meet the goals of quality, safety and satisfaction for the patient. Nursing's knowledge base regarding the role of education about the care of patients who are experiencing deterioration has been expanded through the findings of this study. You are invited to participate in a survey examining nurses' perceptions of their competence in managing patient situations, and factors that impact these perceptions. This survey is part of a nursing research study being conducted by Donna Donilon, MS, RN, as part of a doctoral dissertation in the College of Nursing at the University of Rhode Island. The factors being studied include years of experience practicing nursing, years of practice on your current clinical unit, and educational preparation as a registered nurse. Attendance at a case review session that was facilitated by the Education Department, and if you participated in the care of the patient being discussed in the review session, are also part of the survey. Aspects of managing patient situations are included as part of the survey.

APPENDICES
The results of this survey will provide information for developing educational programs related to nursing competence and critical thinking. The study will provide program evaluation information about the use of case review sessions as an education tool.
The risk of participation in the study is minimal and is associated with the inconvenience of completing the survey itself. Benefits include the opportunity to reflect on your practice. Research has demonstrated reflection to be beneficial in nursing practice. Your responses will provide important information for nursing education program development. Your participation will also be beneficial as an evaluation of the current use of case reviews in education. Participation in this survey is voluntary. You do not have to participate. If you do decide to participate, your access to and responses in the survey will remain anonymous and confidential.
This information is provided so you may make your decision about participation. There is no form to sign for consent to participate in this study.
If you decide to participate, your access to and completion of the survey will serve as your consent. Again, your access to the survey and responses are anonymous and confidential. Care, Post-Anesthesia Care Unit).
If you are interested in participating, you will be asked to complete a one-time survey that will take approximately 10 minutes. The survey is available on the hospital Intranet home page in the box titled "Nursing Research study-Survey".
Your participation in the survey is anonymous, confidential and voluntary.
If you are interested, please read the Information sheet on the survey site on the Intranet. You will not need to sign any form to participate. Reading the information sheet and participating in the survey conveys your consent.
This survey will provide information that will be important in evaluating current educational programs, and developing future programs related to competency in nursing practice. a. Yes b. No 11. The following have been identified through nursing research as aspects of managing patient situations. With 0 being the lowest, and 10 being the highest, please indicate your perception of your competence in each aspect by giving yourself a number (score) between 0 and 10.
for questions or concerns regarding the treatment plan. 10. Evaluating the patient's response to interventions. 11. Updating the plan of care to reflect the patient's current clinical condition. 12. Reflecting on your process of managing rapidly changing patient situations. 13. Extrapolate knowledge from the reflection process to apply in managing future patient situations?
Appendix D