Relationship between emergency nurses’ professional competencies and the Nursing care product

Objective: to relate urgency and emergency nurses’ professional competencies with the Nursing care product. Method: a cross-sectional study conducted in the urgency and emergency units of two public hospitals. The participants were 91 nurses, 3 Nursing residents, 4 coordinators and 1 manager. Two validated instruments were used: 1) Competence Scale of Actions of Nurses in Emergencies and 2) Nursing Care Product Evaluation. Factors and domains were used, respectively. Descriptive statistics were applied, as well as Cronbach’s alpha, Wilcoxon and Spearman’s correlation tests (p<0.05). Results: in the professional competencies, higher values were verified for self-evaluation (p<0.001). In all 1,410 Nursing care product assessments, there was predominance of the “Good” score (n=1,034 - 73.33%). The “Nursing staffing” domain was related to the “Professional practice” (r=0.52719), “Relationships at work” (r=0.54319), “Positive challenge” (r=0.51199), “Targeted action” (r=0.43229), “Constructive behavior” (r=0.25601) and “Adaptation to change” (r=0.22095) factors; the “Care monitoring and transfer” domain, with “Professional practice” (r=0.47244), “Relationships at work” (r=0.46993), “Positive challenge” (r=0.41660) and “Adaptation to change” (r=0.31905) and the “Meeting care needs” domain, with “Professional practice” (r=0.32933), “Relationships at work” (r=0.31168), “Positive challenge” (r=0.29845) and “Adaptation to change” (r=0.28817). Conclusion: there is a relationship between professional competencies and the Nursing care product domains.


Introduction
Nurses operates in various segments in the intra-and extra-hospital spheres, preparing, organizing, coordinating and implementing care actions, whose purpose is to enable rehabilitation of the patients as well as their reintegration into family and social life (1) . These professionals provide care as a science and as an art, grounding their actions on technical-scientific knowledge and raising the bar of the profession's assumptions (2) .
In their centrality, urgency and emergency units have certain complexity that characterizes the Brazilian health system which, considering the service as one of the gateways to the Unified Health System (Sistema Único de Saúde, SUS), requires professionals who are skilled and dynamic in clinical reasoning as well as in decisionmaking, in order to perform effectively and efficiently in the problems presented by the patients, who seek care for their health conditions (3) .
In this sense, nurses act as care managers in urgency and emergency units, through the specific competencies required, such as leadership, decision-making, clinical reasoning and effective communication, among others, for operationalization in the unit's care process. In their role as care managers, nurses plan a range of actions that will be transformed into assistance, centralizing these activities into specific demands, where the patients will be the main consumers, that is, directed care is consumed as soon as produced (4)(5) .
Therefore, it is evident that, in order to manage care, specific competencies are required, skills that, supported on knowledge, will enable the patient's rehabilitation and integration process. In this case, nurses are care providers to the extent that they develop and employ competencies to turn it into a consumable. Such competencies were described in a matrix (6) which identified them as crucial for nurses' performance in urgency and emergency units, gathering and consolidating the dimensions of the care provided in these units from a theoretical framework.
After designing and implementing the care measures, these professionals work with the multiprofessional team in order to share the required work demand, by means of the treatment and rehabilitation possibilities and, with this, conferring even more robustness to the action plan which will be demanded from standardization of the language spoken by the entire multiprofessional team, characterizing the patients' real health needs (7) .
That said, it becomes imperative to qualify care and verify how much the implemented actions are exerting an impact on meeting the patients' needs, delivering what is indispensable through the competencies that guide this entire process. Once planning is concluded, it is expected to deliver a product (5) worthy of the efforts undertaken in its elaboration and that then be used by the patient.
New studies should be carried out with a view to further exploring the nurses' competencies in urgencies and emergencies, strengthening their skills with a view to the care product that they should deliver at the end of the work period.
Based on the aforementioned proposals, the specific question of the current study was as follows: Is there any relationship between urgency and emergency nurses' competencies and the Nursing care product?
A systematic review identified nonexistence of such relationship (8) . Consequently, in order to answer this question, the objective defined was to relate urgency and emergency nurses' professional competencies with the Nursing care product.

Study design
This is a cross-sectional and correlational study (9) , with its design based on the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guideline (10) .

Data collection locus
The study was carried out in the urgency and emergency units of two public hospitals, one of them a university hospital and the other one a secondary-level hospital with tertiary-level characteristics, both references of the Urgency and Emergencies Network (Rede de Urgências e Emergências, RUE) care line. The hospitals are respectively located in the South and Southwest regions of the municipality of São Paulo-SP, Brazil and they were identified as Hospital A and Hospital B. Both services were randomly chosen to provide for the inclusion of more participants.

Period
The study was developed between June and December 2020.

Sample
The convenience sample consisted of 91 nurses, 3 Nursing residents, 4 coordinators and 1 manager.

Selection criteria
The professionals included were those working in urgency and emergency units with a minimum employment contract of three months, as well as Nursing residents attending second year of the same area. Nurses working in the sector only as a stopover were excluded, as well as Nursing residents from other areas and those who were on vacation and on leave.
In the emergency sector of Hospital A, 53 nurses were eligible and were invited to take part in the study. The ECAEE (6) is made up of 78 items representing nurses' actions in emergencies, divided into seven factors: Factor 1 -"Professional practice" (33 items); Factor 2 -"Relationships at work" (19 items); Factor 3 -"Positive challenge" (10 items); Factor 4 -"Targeted action" (7 items); Factor 5 -"Constructive behavior" (2 items); Factor 6 -"Professional excellence" (4 items) and Factor 7 -"Adaptation to change" (3 items). For each item mentioned, the nurses answered considering their self-evaluation according to a Likert scale from 1 to 5 (Extremely Competent, Very competent, Competent, Little competent, and Not competent). In the hetero-evaluation, the Nursing coordinators and managers answered the instruments with the same items applied to the nurses; however, in their assessment, the nurses' performance was considered.

Study variables
The variables used were age, gender, marital status, year of graduation in Nursing, lato sensu and stricto sensu graduate studies, improvement, certification, residency, Bachelor's degree, emergency courses, other participations in courses and events, scientific activities, allocation sector, work shift and double employment contract, as well as the final scores and the domains and factors from the data collection instruments were used.

Data collection
A pre-test were performed, in which 10 nurses (Hospital A=5; Hospital B=5) were randomly selected in order to verify possible difficulties answering the instruments. After raising awareness about the study, its importance and feasibility for the Nursing practice, ECAEE (6) was handed in and, after verifying there were no difficulties filling it out, the participants received the APROCENF scale (5) , not finding any difficulties. After this phase, data collection was initiated at Hospital A, where awareness was again raised with an explanation of the research objectives and clarification of how to answer www.eerp.usp.br/rlae 4 Rev. Latino-Am. Enfermagem 2023;31:e3939. the instrument ECAEE. Concomitantly, the managers also received the same guidelines and instrument to conduct the nurses' hetero-evaluation. Subsequently, the research was applied in Hospital B, with the same guidelines and explanations.
Once this stage was concluded, application of the APROCENF scale was initiated. The nurses were instructed in relation to its filling-in, always at the end of the work shift and on alternating days. All 94 nurses were instructed to answer the APROCENF scale fifteen times, that is, after fifteen shifts, to obtain more assessments portraying the sector's reality as well as based on the validation study corresponding to the APROCENF scale (5) , generating a total of 1,410 assessments of the care product. It is worth noting that the nurses took turns in all the urgency and emergency sectors. The 5 nurses performing coordination and management roles did not answer the APROCENF scale.

Data treatment and analysis
To describe the sample profile, tables of variables were prepared with absolute (n) and percentage (%) frequency values, as well as descriptive statistics with mean values, standard deviation, minimum and maximum values, median and quartiles. In order to assess internal consistency of the scales, Cronbach's alpha coefficient was used, with values from 0.70 considered satisfactory (11) . Spearman's correlation coefficient (9)  The significance level adopted for the statistical tests was 5%, that is, p<0.05.

Ethical aspects
The study was developed according to the following The nurses and residents working in the emergency sectors were invited to take part in the research. They accepted by signing the Free and Informed Consent Form. The data collection instruments were handed in to these professionals, printed and in envelopes, to be later collected on an agreed upon day.

Results
The hospitals where the study was developed were identified as A and B. The total number of professionals who answered the survey was n=99 nurses, distributed as follows: Hospital A, n=55; and Hospital B, n=44.
The nurses' overall descriptive analysis was performed considering both hospitals. Thus, regarding age, n=52 (55.32%) respondents were between 30 and 39 years old, with predominance of females, n=70 (74.47%); n=49 (52.13%) declared themselves to be single, to the detriment of n=32 (34.04%) who stated being married. Table 1 indicates the characterization of the sample.      Good internal consistency was obtained (alpha>0.70) (10) in the following ECAEE factors: Factor 1 (0.790) and Factor 2 (0.720); this difference was significant in the heteroevaluation carried out by the Nursing service managers. In  correlation coefficient; ║ Self-F2 Relationships at work; ¶ Self-F3 Positive challenge; ** Self-F4 Targeted action; † † Self-F5 Constructive behavior; ‡ ‡ Self-F6 Professional excellence; § § Self-F7 Adaptation to change  (14) . A sociodemographic analysis was also carried out in this study, evidencing the gaps that might be improved and where greater efforts should be concentrated, especially in a profession that has at its core the qualification and instrumentalization of managerial processes, which lead to improvement in care aspects. In delivering their competencies, nurses equate basic constructs of the profession that guide and encourage their actions (15) .
These professionals seek to qualify their knowledge in the pursuit of professional improvement, both through short-term technical courses and through courses with longer hour loads, such as lato sensu specializations, where most of the nurses who answered the instruments stated that they were specialized in some specific Nursing area. In this sense, a very positive movement can be seen focused on adding value to the professional profile and technical competence to the curriculum, with professional development as a guideline for actions. In identifying the courses where these professionals specialized the most, for more than 50%, the specialization in urgency and emergency was highlighted; in other words, nurses chose to specialize in the area where they perform their care functions, which certainly qualifies the assistance provided and, therefore, care provision, the final assistance product.
Another aspect worth noting is the fact that the professionals attend training/improvement courses in the urgency and emergency area, such as BLS, ACLS, ATCN and PHTLS, among others, which shows interest in improving the technique to act more effectively in the urgency and emergency sector, where these skills are required, due to its dynamism and complexity.
Linked to this, rapid and assertive reasoning demands training, qualification and hours of dedication and studies.
The professionals are committed to seeking qualifications that underlie their daily practice and exercise, which are also forms of support and personal commitment to professional growth, further raising the assumptions of the profession (16) . A similar movement was identified in a study where the nurses identified the need for training through self-perception (17) .
A study evidenced the need for standardization of the training opportunities in the urgency and emergency sectors (18) , precisely because for understanding that the actions carried out by those who are submerged in the art of care go beyond prescriptive approaches, as they deepen and ground knowledge. Qualifying the assistance provided means being completely devoted to care and finding ways and possibilities to contribute to it, also through reflective thinking, which seeks new, technologydriven ways that serve research and development (19)(20) .
This is a construction that should be sharpened in nurses, as their contribution to the growth and development of society is paramount. Their academic background already points to this factor, pointing out the social dimension of the nursing profession (21) .
When comparing self-assessment and heteroassessment, in most factors, nurses self-assessed better than their managers, however, in some factors, the assessment made by the manager (hetero-assessment) was higher than that performed by the nurse. This result was different from the one found in the ECAEE validation study (6) . It is worth noting that the instruments were filled out during working hours and that, even due to the dynamics of the urgency and emergency sector, some items may have gone unnoticed.
In the comparison between the self-and heteroevaluation scores, the factors with the highest scores were as follows: in the self-evaluation, Professional practice and Targeted action and in the hetero-evaluation, Professional excellence. In fact, nurses' professional competencies are supported by actions that tend to qualify them (22) , as these professionals, through all the investment they make in their career, do not seek anything more than materializing these competences. They face these challenges because they know that, in order to carry out an emancipating and rehabilitating professional practice for the patients, it is necessary to surround themselves with theoretical and practical knowledge with a view to professional excellence (23) . A similar movement was found in a study carried out in Chinese military hospitals, where the need for professional qualification based on nurses' experiences and expectations was evidenced (24) .

Realizing this coherence of answers between clinical
nurses and managers is a positive aspect, as it shows concern between the parties, which means that those who care are having their actions observed and those who observe are guiding their managerial perspective by instruments validated in the scientific literature, that is, Nursing using instruments validated in the category studies to assess the group itself.
Relationships at work confront the knowledge of Being a nurse, as they need to manage their team of nursing technicians and have a good experience with the multiprofessional team, without losing their professional identity, being authentic in the name of the care they elaborate, articulate and provide to the patients (25) . In this sense, the challenge becomes positive and, at the same time, provocative, as nurses direct their actions towards care, which will be crowned with professional excellence, which confers even more authenticity and strengthening to identification of the category.
instrument fifteen times as a way of portraying their daily routine in the urgency and emergency sector as accurately as possible. It is noteworthy that this scale was evaluated in all sectors of the urgency and emergency unit, reflecting assistance from the emergency room to medication.
Although it had not yet been tested in urgency and emergency units, a "Good" APROCENF score was obtained -such response was reflected in the eight domains of the scale -which means that the final product of the nurses' actions required towards the patients in this study was quite expressive. Obviously, an "Excellent" score in the APROCENF scale would be the most appropriate; however, it is understood that this indication is already a starting point for the managers of these units to work with the permanent education sector on these issues, with the purpose of training professionals to deliver a care product based on even more solid competencies and be encouraged to develop those they do not yet have. In this sense, this study does meet the scope, when comparing its results to another research in which the APROCENF scale was applied in specialized units (26) , where the result of the care product delivered by Nursing was also predominantly "Good".
In Factors such as Professional practice (6) , Relationships at work, Positive challenge, Targeted action, Constructive behavior and Adaptation to change were directly related to Nursing staffing, as they enable processes that require specific human resources to act directly in the health- On the other hand, a study showed that an adequate number of nurses in patient care reduced mortality, readmissions and the patients' hospitalization times (27) .
Patient satisfaction in a hospital unit involves a set of actions, reflecting the care provided by nurses as well as the implementation and execution of care actions by their team. Nurses provide quality care when the conditions of the service are favorable for them to carry out their routine, and this makes the care processes possible, developing a chain reaction where the professionals' satisfaction has its direct reflection in the care provided to the patients, consecutively resulting in improvements in their rehabilitation process (28) .
In the aforementioned study (28) , the fact of having good Nursing staffing met the demand of the patients participating in the research. With this assumption as a starting point, we conceive that the APROCENF scale (5) would possibly have a more expressive evaluation, showing excellence in the quality of service provision and delivery of the most effective care product, as long as there are enough nurses in urgencies and emergencies.
Likewise, care monitoring and transfer (5) (31) since, at the same time that it enables and leverages the care process, its absence can impair this process.
Failures in this process imply an increase in hospitalization costs, stress for patients and their families and blockage in bed turnover (31) . Regarding care transfer in relation to the APROCENF scale (5) , a "Good" level was obtained in the score, which implies a closer analysis by the managers who, along with the permanent education Rev. Latino-Am. Enfermagem 2023;31:e3939.
sector, should create conditions that optimize this process, so that patient care is not impaired and their transfers and discharges are not postponed.
It is noticed that all the highlighted competencies converge to meet the care needs, with a view to promoting the health and well-being of the patients, who find support for their real health needs in Nursing care (5) . Prioritizing care focused on the patients' real health needs, through targeted care planning, will meet their health demands (32) and, with that, nurses reassert their competencies in the perspective of developing many others that find shelter in the patients in the scope of the needs that they bring to the service in search of resolution.
The "Nursing staffing" and "Care transfer" domains were related to several competencies, pointing out that, in order to provide effective assistance, an adequate number of professionals is necessary, so that they can transfer care in the safest possible way, which implies coordination between Nursing management and the unit's permanent education service to make this process viable.
The limitation of this study is due to the fact that the instruments are answered without fail during the shifts, which is why, considering the dynamics of the urgency and emergency unit, some items may not have reflected exactly what the nurses wanted to express. However, it was found that the APROCENF scale can be used in emergency units, especially in association with ECAEE, where, in addition to confronting the competencies they have, the professionals will strive to develop those that are limiting factors in the assistance they provide, precluding better delivery of the Nursing care product.

Conclusion
The nurses' competencies are related to delivery of the Nursing care product in the urgency and emergency context. Such competencies were identified in the seven factors: however, there was greater emphasis on "Professional practice", "Relationships at work", "Positive challenge", "Targeted action", "Constructive behavior" and "Professional excellence" both in the in self-and in the hetero-evaluation. While identifying the competencies, the nurses carried out their self-evaluation based on the specificity of the urgency and emergency service, taking into account the complexity of the sector and grounding their critical perspective on unusual events that arrive at the unit and require specific competencies for an effective and efficient approach.
The APROCENF scale identified the Nursing care product as "Good", showing that delivery of Nursing care is well evaluated by those who are providing this service.
Given the above, we found that there is a relationship between professional competencies distributed in the ECAEE factors through the dimensions of the APROCENF scale, highlighting "Nursing staffing", "Care monitoring and transfer" and "Meeting the care needs" which, when directly interfering in the assistance that generates a product to be consumed by the patients, characterizing the profile of the nurses who guide their care actions through the competencies listed in this study.