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CLINICAL PERFORMANCE EVALUATION OF NURSES OF APARRI PROVINCIAL HOSPITAL

An Action Research Proposal

Submitted to the
Graduate School of the
University of La Salette, Inc.
Santiago City, Philippines

In Partial Fulfilment
For the Degree of
Master of Arts in Nursing

MARINETH L. MIRANDA
2023

TABLE OF CONTENTS

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TITLE
TABLE OF CONTENTS

INTRODUCTION

Background of the Study

Research Questions/ Hypothesis
Significance of the Study
Theoretical Background
Theoretical Framework
Literature Review

METHODS

Research Design
Site and Participants
Population, Sample Size, Sampling Procedure
Instrument/Techniques
Data Gathering Procedure
Data Analysis
Ethical Considerations

REFERENCES

APPENDICES

Appendix A – Survey Questionnaire

Appendix B – Literature Matrices

INTRODUCTION

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Quality of nursing care rendered by a health institution/ facility is very

important in the delivery of health care. In guaranteeing that care is of good

quality depends on the performance of the most important personnel that renders

care – the nurses. High quality healthcare means very good nursing care

performance of these care givers. Ensuring quality nursing care needs

monitoring, evaluation and assessment of performance of duties regularly as well

as randomly using a quality, standard and realistic tool (Kahya & Oral, 2018).

Quality nursing care means high competence and clinical skills among

nurses in a healthcare facility. It is equated with nursing productivity (Tzeng &

Ketefian, 2003). Measuring nursing care quality through performance evaluation

has received a lot of questions from experts. Most of the time, the immediate

supervising nurse and the chief nurse are given the responsibility of doing the

evaluation. However, there is a variety of methods used thus evaluation is

subjective by nature (Franklin & Merville, 2013).

Competence is the effective use of knowledge and skills that leads to the

expected positive outcome. Performance of a duty or activity required for certain

situations and conditions is equated with competence (Flinkman et al. (2017).

There are many studies which deals with measuring nurse competencies and

nurse performance but generalization often is difficult to make because of the

different assessment tools being used. Thus this study, aimed to measure the

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clinical performance of nurses in a secondary government run hospital in

northern Luzon.

Background of the Study

The practice of nursing in the Philippines is governed by the Nursing Act

or 2002 and amended in 2012 to update and adapt the practice according to the

demands of the professions and that of international guidelines as well as

address the issues of healthcare delivery. Evaluation of competencies provided

in the law requires strict observance of the nursing process, the systematic guide

for nursing care (Wayne, 2023). Evaluation of the rendered nursing care must

focus on the effectiveness of nursing interventions by reviewing the patientcare

outcomes to determine if these were achieved in the time frame (American

Nurses Association, 2021).

Evaluating clinical performance of nurses is important to improve the work

done by nurses. It aims to help them solve problems, inform decision making as

well as build knowledge with main purpose to help nurses develop insights into

the ways and means to improve delivery of nursing care as well as collaborative

healthcare provisions (The Health Foundation, 2015).

Nursing managers evaluate the quality of service through evaluation of

clinical performance of nurses through patient satisfaction. It is geared towards

the development and improvement of nursing care through patients’

expectations. However, the nurses must be given the opportunity to evaluate

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their work and performance of duties as well as their needs and problems in the

performance of their duties for a better evaluation results (Karaca & Durna,

2019).

Evaluation of clinical performance of nurses in the Philippines are scarce

in terms of being published. It is an open and new topic for research because of

different measure tools being used by different researchers depending on the

area of competency being studies. In this regard, the present study would like to

find out the clinical evaluation performance of the nurses of a secondary

government hospital in northern Philippines using a tool used to find out the

satisfaction of the patients. As in the study of Karaca and Durna (2019), patient

satisfaction mirrors the level of performance of the nurses who took care of these

patients.

Research Questions/ Hypothesis

The study would like to answer the following research questions:

1. What is the demographic profile of the nurse respondents in terms of:

1.1 age

1.2 sex

1.3 civil status

1.4 highest educational attainment

1.5 years of service/practice

1.6 area assigned

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2. What is the perceived level of clinical performance of the nurses in terms

of:

2.1 Direct clinical

2.2 Professional development

2.3 Ethical decision making

2.4 Clinical leadership

2.5 Cooperation and consultation

2.6 Critical thinking

3. Is there a significant difference in the clinical performance of the nurses

when grouped according to profile?

Significance of the Study

The results of the study will be of benefit to the following:

To the staff nurses. The nurses will be able to understand better the

rationale for performance evaluation of their clinical duties as to make sure these

are at par with national and international standards.

To the supervisory/head nurses. The results of the study will give them the

insights on the strengths and weaknesses of job performance of their staff nurses

thus can be able to plan activities and programs to enhance their knowledge,

attitudes and practices in order to impact the overall quality of services being

rendered as well as improved patient satisfactions.

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To the hospital administration. The results of the study will make the

management to look into current organizational policy to improve the

performance of employees which can be translated into institutional success.

To the patient. Appraisal of performance of their nurses could mean better

provision of nursing care and improve healthcare services outcomes at their end

of the spectrum

To future researchers. The result of the study will open doors for future

studies to come up with a measurement tool that can be used universally as well

as look into other aspects of performance that is often missed in the assessment

of clinical duties.

Theoretical Background

Theoretical Framework

The theoretical foundations of performance appraisal of any worker in any

organization is the standard competencies of a professional discipline as

prescribed by law. In the Philippines, the Nursing Act 2002 and as amended by

the Nursing Act of 2012 specifically discussed the core competencies of nurses

so as to which their professional practice is based.

According to Fukuda (2018), nursing competencies are those abilities

required for optimum performance in the practice of nursing. The concept of

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competency involves two important components: a.) potential skills that are

effective under certain situations and conditions and b.) willingness to use those

skills and abilities when required. It is gained through experiences and the

motivation to use these abilities that is often influenced by attitudes and

motivation (Takase et al., 2011).

There are seven (7) elements of nursing performance competency which

must be satisfied to be able to provide the minimum standard of nursing care.

These are the following:

1. Able to apply knowledge of care;

2. Build interpersonal relationships;

3. Provision of optimum nursing care;

4. Observance of ethically sound practice;

5. Collaborate effectively with other professionals;

6. Expand professional capacity through constant training and development;

7. Ensure that nursing care delivered is of excellent quality.

Items 1 and 2 is a component of the ability to understand people; items 3,

4 and 5 is part of the ability to provide people centered care, and items 6 and 7 is

part of the ability to improve the quality of nursing care being rendered

(Matsutani et al., 2010).

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Evaluation of clinical performance of nurses in any healthcare institution

requires considerations of the core competencies needed for the provision of

optimum nursing care. Evaluation must be done regularly, randomly and within

special times in order to determine the needs and weaknesses of nursing care

practice in a certain situation. Without documented performance appraisal, the

clinical performance can only be speculated. There are many ways to evaluate

nurse performance of clinical duties. Direct ways include the evaluation of

superiors, peer group and subordinates. Indirect ways include patient

satisfaction. Combining these two method can eliminate biases that may give

false performance evaluation.

Another factor is the evaluation tool used for performance evaluation.

Many tools are being used by different health institutions, the most commonly

used is the clinical nursing competence self-assessment scale which allows the

nurse to evaluate his/her performance based on the core competencies needed

for the optimum practice of nursing.

Performance evaluation is valuable in many ways because it helps the

institution strategize and find ways to improve the services being rendered. It is

the responsibility of every health institution to evaluate not only the nurse but also

all employees who are have responsibilities that may limit the effectiveness of

nursing care provision. This is the efficient way of improving and maintaining

quality healthcare services.

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In the appraisal of clinical nursing performance, the six dimensions of

nursing performance is commonly used to evaluate the job done by the

professional nurse. The dimensions of clinical nursing performance are the direct

clinical practice which is to measure the clinical skills of the nurses. The second

dimension is the professional development which measures the intent to improve

performance through further trainings and self-growth. The other dimensions are

offshoot of the direct clinical practice such as ethical decision making, clinical

decision making, cooperation and consultation and critical thinking.

Literature Review

Clinical Performance

Clinical performance is a term used to denote nursing competence in the

practice of duties and responsibilities. It is describes as clinical because it is the

manifestation of the knowledge, skills and attitudes as well as the ability to

implement ways and means to improve these attributes to be able to provide the

optimum nursing care expected of them (Soares et al., 2019). The delivery of

healthcare requires different areas of care unique for each discipline. The scope

of practice of nursing profession has similar, overlapping and different areas to

which nursing performance must be taken into a different light if clinical

performance is to be taken into consideration. The nursing department is one of

the largest clinical areas of a healthcare institutions, thus to ensure optimum

care, cost effectiveness and effective clinical service, the healthcare institution

must take job performance of nurses must be taken into considerations through

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needs assessment, identification of strengths and weakness as well as methods

of operations and outcomes of the services rendered (Uy et al., 2016).

Clinical performance is a method of promoting organizational goals which

is based on professional competence of any occupational group making up the

institution. Job performance can be directly assessed through evaluation policy

and indirectly through the clients and how they are satisfied with the services

being rendered (Yusefi et al., 2022). A good nurse according to patients

interviewed in hospitals of developing countries, characterized the individual as

one who can provide standard care but also general and physical support –

caring behaviors (Salimi et al., 2012). To ensure that care is rendered on the

acceptable level and within the prescription of standards of practice, clinical

performance in all dimensions of competence must be evaluated regularly

(Nemeth, 2016).

Importance of Evaluating Clinical Performance

The evaluation of clinical performance is an organizational strategy to

make sure that quality care is being provided and standard care is maintained. It

is also to give insights to the managers and administrators on the strengths and

weaknesses of the nurses and other employees in the performance of their

duties. Indirectly, it gives the immediate supervisors and managers the idea on

how to manage and direct the line of work for excellent performance of all

(Moradi et al. 2017). Performance is an important behavior of the workforce and

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must be taken into consideration of an organization that would like to achieve its

mission and goals of care. Because of the importance of evaluating clinical

performance not only on the services rendered but also have value in retention,

ranking and promotion as well as giving of incentives to performing employees.

Evaluation of employees gives the administration the opportunity to strategize on

the aspect of human resource management as prescribed by laws (Kahya &

Oral, 2018).

It is universally recognized that performance appraisal is very important in

any organization. However, this imposes challenges of how and when evaluation

should be done. One challenge identified by studies conducted is the tool used to

measure the performance of the nurse or employee. There is not one

assessment tool that is agreed to be the standard. Different healthcare

institutions use varied tools for as long its reliability and validity is within

acceptable range (Khaya & Oral, 2018). Many studied several performance

evaluation tools and have found that different tools measures different aspects of

competences needed for acceptable job performance (Fukuda, 2018; Kate,

2023; Supri et al., 2019). It was agreed upon by research findings that regardless

of the tools used, appraising performance is still the best way to motivate and

monitor the performance of duties of nurses and employees (Moradi, 2017;

Nemeth, 2016; Soares et al., 2019).

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METHODS

Research Design

The study will use the descriptive survey design to determine the clinical

performance evaluation of the nurses. This design aims to describe the

phenomenon without intervention as well as describe it in its natural setting.

According to Polit & Beck (2008), descriptive research allows the population,

issues and any other phenomenon to be studied through different ways but are

made in their natural setting without intervening with the natural flow of things.

Using the survey is a method that allows the researcher to reach a large number

of participants in a shorter period of time as well as interpreting the data can be

treated easily with available statistical tools.

Site and Participants

The participants are the nurses of the Aparri Provincial Hospital and the

patients who were confined during the course of the conduct of the study. The

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hospital is a secondary hospital with basic medical and surgical capabilities

which also includes OBGYN and pediatrics services.

Population, Sample Size, Sampling Procedure

All nurses of the Aparri Provincial Hospital shall be included in the study. Non-

inclusion depends on their intent to participate in the research. Purposive

convenient sampling will be used to determine the sample size. There are 32

permanent staff nurses, 8 of whom are permanent and 4 are contractual.

Instrument/Techniques

The instrument of the study is a survey questionnaire adopted the

Professional Self-Assessment Scale (ProffNurse SAS) which using the Six

Dimension Scale of Performance which is a tool to assess the quality of nursing

care which has a reliability score of <0.90.

There will be 2 survey questionnaires: one for the patient and one for the

nurses. The questionnaire is composed of three (3) parts: Part 1 – demographic

profile of the nurses; Part 2 – professional nurse self-assessment scale in the

areas of direct clinical practice (19 items), professional development (5 items),

ethical decision making (11 items), clinical leadership (6 items), cooperation (6

items) and critical thinking (4 items). Part 2 is answered using a 4-point scale

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with the following: 4= always, expected to be done; 3= sometimes; 2= seldom; 1=

never, not expected to be done.

Data Gathering Procedure

The study will follow the prescribed guidelines of conducting research to

which the following procedures shall be the sequence the researcher will do:

a.) A letter will be sent to the Medical Director of the hospital through the

Chief nurse requesting for permission to conduct the study among the

nurses of the hospital;

b.) Upon approval, the letter will be given to the Chief Nurse for her to comply

with;

c.) A mini conference with the nurses will be conducted to discuss the

objectives of the study and ask for the cooperation and participation of the

nurses to be part of the study;

d.) After which informed consent shall be given to the nurses for signature;

after which the data collection will commence.

e.) The administering of the questionnaire will be done during the mini

conference so as for the respondents to have the opportunity to ask

questions about any item of the questionnaire and the researcher to

answer and clarify any confusing items in the survey;

f.) Retrieval of the answered questionnaire will be done during the mini

conference;

g.) Tallying, treatment of the data, analysis and interpretation shall follow;

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h.) Making of the draft of the manuscript.

Data Analysis

The data gathered shall be analyzed using descriptive and inferential

statistics. Descriptive statistics will use the frequency, percentage and weighted

mean to describe the numerical data. Correlations and associations shall be

analyzed using the inferential statistics which will use the t-test, chi-square and

ANOVA.

The weighted mean of scores shall be interpreted using the table below:
Scale Numerical Range Qualitative Interpretation
Description
4 3.50 – 4.00 Always Very good
3 2.50 - 3.49 Sometimes Good
2 1.75 – 2.49 Seldom Satisfactory
1 1.00 – 1.74 never Poor

Ethical Considerations

Ethical research guidelines shall be strictly observed especially on areas

of data privacy, voluntary participation, informed consent and safety of the

participants. In observance of such protocols, the participants have the right to

withdraw from the study anytime during the conduct of the research. All

documents shall be kept in strict custody of the researcher to make sure that no

violation of the privacy act will occur. The participants can ask for the documents

concerning his participation after the researcher has made the final draft of the

manuscript and given a copy of the results upon formal request is given.

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REFERENCES

American Nurses Association (2021). Nursing: Scope and standards of practice

4th edition. Retrieved from
https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-
nursing-process/

Flinkman M, Leino-Kilpi H, & Numminen O (2017). Nurse competence scale: a

systematic and psychometric review. Journal of Advanced Nursing. 73(5):1035-
1050. Retrieved from http://dx.doi.org/10.1111/jan.13183

Franklin N & Melville P (2013). Competency assessment too: an exploration of

the pedagogical issues facing competency assessment for nurses in clinical
setting. Collegian. 22:23-31. Retrieved from
https://doi.org/10.1016/j.colegn.2013.10.005

Fukada M (2018). Nursing competency: definition, structure and development.

Yonago Acta Medica: Review Article: Special Contribution pp 1-7

Kahya E & Oral N (2018). Measurement of clinical nurse performance:

Developing a tool including contextual items. Journal of Nursing Education and
Practice vol 8 no 6. Retrieved from http://jnep.sciencedupress.com

Karaca A & Durna Z (2019). Patient satisfaction with the quality of nursing care.
Nursing Open 6(2):535-545 doi: 10.1002/nop2.237 PMID: 30918704

Matsutani M, Miura Y, HIrabashi Y, Sakyo Y, Unoki T and Osumi K (2010).

Nursing competency: concept, structure of dimension and assessment. Serika
Kango Gakkaishi 14: 18-28.

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Moradi T, Meraban MA & Moeini M (2017). Comparison of the perceptions of

managers and nursing staff toward performance appraisal. Iranian Journal of
Nursing Midwifery Research 22:128-34

Nemeth LS (2016). Performance Appraisal. Chap 23. Nurse Key, evolve website.
Retrieved from https://nursekey.com/performance-appraisal/

Republic Act no. 9173, Philippine Nursing Act or 2002. Senate and the House of
Representative of the Philippines.

Salimi S, Azimpour A, Fesharaki M, & Mohammadzadeh S (2012). Nurses’

perception of importance of caring behaviors and its determinant factors. Journal
of Urmia Nursing and Midwifery Faculty 10(1):51-60

Soares MI, Leal LA, Terra FS, Resck ZMR, Chaves LDP & Henriques SH (2019).
Competence-based performance evaluation in hospital nurses. Rev Latina-Am.
Enfermagen 27:e3184 DOI: 10.1590/1518-8345.3173.3184

Takase M, Teraoka S, Miyakoshi Y, & Kawada A (2011). A concept of analysis of

nursing competence: A review of international literature. Nihon Kango Kenyu
Gakkai Zasshi 34:103-9. DOI: 10.15065/jjsnr.20110404011

The Health Foundation (2015). Evaluation: What to consider? Commonly asked

questions about how to approach evaluation of quality improvement in
healthcare. Health.org.uk

Tzeng HM & Ketefian S. (2003). Demand for nursing competencies: An

exploratory study in Taiwan’s hospital system. Journal of Clinical Nursing. 12: 1-
10. Retrieved from http://dx.doi.org/10.1046/j.1366-2702.2003.00738.x

Uy J, Lizarondo L & Atlas A (2016). ASPIRE for quality: a new evidence-based

tool to evaluate clinical service performance. BNC Research Notes, BioMed
Central 9:306 DOI:10.1186/s13104-016-2109-0

Yusefi AR, Sarvestani SR, Kavosi Z, Bahmaei J, Mehrizi MM & Mehralian G

(2022). Patients’ perception of the quality of nursing services BMC Nursing
21:131. Retrieved from https://doi.org/10.1186/s12912-022000906-1

Wayne G (2023). The Nursing Process: A comprehensive Guide.

Nurseslabs.com
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APPENDICES

Appendix A
SURVEY QUESTIONNAIRE
________________________________________________________________

Dear Respondents,

I, Marineth L. Miranda, a student of Master of Art in Nursing is currently on my

action research project entitled “Clinical Performance Evaluation of Nurses of
Aparri Provincial Hospital”. In connection, I would like to ask for your help and
cooperation so I could finish the project on time to be able to graduate. Please
answer the survey questionnaire below so I could start my manuscript. Thank
you very much for help and assistance.

Respectfully,

Marineth L. Miranda
Researcher

________________________________________________________________

SURVEY QUESTIONNAIRE

Part 1 – Demographic Profile

AGE: ____ SEX: [ ] MALE [ ] FEMALE

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CIVIL STATUS: [ ] SINGLE [ ] MARRIED [ ] OTHERS,

specify:___________

HIGHEST EDUCATIONAL ATTAINMENT: [ ] Bachelor’s Degree

[ ] Masters
[ ] Others/specify

AREA ASSIGNED: [ ] Medical [ ] Surgical

[ ] OBGYN [ ] Pediatrics
[ ] OR [ ] ER
[ ] OPD [ ] others,
specify:________________

POSITION: ______________________

YEARS OF SERVICE: [ ] 3 years and below [ ] 4 – 6 years

[ ] 7 – 9 years [ ] 10 – 12 years
[ ] 13 -15 years [ ] above 15 years

________________________________________________________________

Part 2 – Self- Assessment of Clinical Evaluation

INSTRUCTIONS: Please answer the given questions truthfully and honestly as

possible using the 4-point scale of performing the task: 4 = always, 3 =
sometimes, 2 = seldom,
1 = never
________________________________________________________________

Direct Clinical Practice Indicators 4 3 2 1

1. I am independently responsible for health assessment and
treatment of patients with complicated conditions
2. I am independently responsible for health assessment and
treatment of patients with uncomplicated conditions
3. I plan and prioritize nursing and medical interventions
4. I identify patient’s health problems
5. I assess patient’s symptoms
6. I evaluate and modify patient’s medical treatments
7. I exclude different diagnoses when assessing patients’ health
conditions
8. I interpret, analyze and reach alternative conclusions about
patient’s health conditions after a detailed mapping of health
history and health assessment
9. I apply both subjective and objective methods when
examining, treating and caring for patients
10. I carry out systematic clinical examinations of my patients

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11. I utilize medical equipment in an appropriate and accurate

manner
12. I have knowledge of the effects of medications and
treatments for the patients I am responsible for
13. I assess the patient’s health
14. I identify deviations in the patient’s state of health and state
the disease
15. I develop and administer health-promoting and illness-
preventive actions for patients
16. I assess changes in the patient’s pathological picture
17. I systematically gather information from each patient about
his/her health resources including financial capabilities
18. I have knowledge of the interactions of various types of
medications and what side effects they may cause for the
patients I am responsible for
19. I take preventive actions regarding patient’s medical
conditions
Professional Development Indicators
20. I generate a creative learning environment for my staff at my
workplace
21. I participate in quality development of work at my workplace
22. I take responsibility for competence development at my
workplace
23. I improve routines/systems that fail to meet the needs of
patients at my workplace
24. I take active responsibility for my own professional
development
Ethical Decision-Making Indicators
25. I take patients’ mental health needs (mood swings, feelings
of hopelessness, depression etc) into account when
assessing and planning for the health and life situation of
patients
26. I take patients’ spiritual needs (feeling of meaninglessness,
existential needs, beliefs, fear of death etc) into account
when assessing and planning for the health and life
situations of patients
27. I take patients’ physical health needs (illness, pain,
disabilities etc) into account when assessing and planning for
the health and life situation of patients
28. I adopt an ethical approach in my relationship with patients
29. I identify and assume responsibility for patients’ own health
resources in planning nursing care
30. I take patients’ social health needs (leisure, friends, financial
situation etc) into account when assessing and planning for
the health and life situation of patients
31. I support and guide patients in mastering their illness and

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health problems
32. I maintain an ethical approach towards my colleagues
33. I take active responsibility for creating good working
environment
34. I put emphasis on patients’ own wishes when assessing and
planning for nursing care and medical treatment
35. I act ethically when caring for patients
Clinical Leadership Indicators
36. I make my own decisions in my work
37. I work systematically
38. I work independently and autonomously
39. I take responsibility for my own actions
40. I am correct and accurate in speech and writing
41. I understand the consequences my decisions may have for
patients
Cooperation and Consultation Indicators
42. I experience a division of responsibility between the
physician and me as a nurse
43. I cooperate well with the physician
44. I consult other health professional experts when required
45. I cooperate actively with other health professionals when
coordinating the patient’s nursing care and treatment
46. I am cognizant of when my medical knowledge is insufficient
when assessing patient’s health conditions
47. I document the steps taken in assessing patients’ needs for
nursing care and treatment
Critical Thinking Indicators
48. I reflect on my actions
49. I analyze and evaluate my work continuously
50. I perceive opportunities and have visions for how nursing and
clinical paths for patients can be developed
51. I have a vision of how nursing should be developed at my
workplace

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Appendix B – Literature Matrices

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