Content area
Aim
To focus learning through clarity of the enrolled nurse (EN) role (a second tier nurse position) through development of a user-friendly workplace performance assessment tool commensurate with EN standards for practice.
BackgroundInternationally, the nursing workforce comprises regulated and unregulated staff. In Australia, similar to other western countries, there are two tiers of regulated workforce, namely Registered Nurses (RNs) and Enrolled Nurses (ENs). Differences in RN and EN standards based on the education preparation are not always clearly differentiated in workplace practice. Roles are often seen as interchangeable: Improved clarity of both regulated and unregulated roles, when numbers of healthcare workers are burgeoning, assists performance assessment that guides further learning and safe practice.
DesignTwo phase sequential, non-experimental design.
MethodsPhase one used focus groups (n=48), expert reference panel (n=8) and end-users (n=16) to develop simple language statements. Phase two involved field testing of the statements.
FindingsA 30-item, criterion-based workplace performance tool was developed. Principal component analysis of completed tools indicated work could be organised around three key areas of practice, namely, higher order thinking and problem solving, routine daily activities of care and personal and social attributes.
DiscussionParticipants reported the statement items assisted in determining suitable activities and accompanying cues in discussing learning needs. Analysis assisted with discriminating broader elements of EN workplace performance.
ConclusionsWorkplace learning is important for nurses to continue to build their capacity to deliver optimum care. Assessment tools that describe professional capability in plain language statements and provide examples of supportive behavioural cues help guide on-going learning through improving the validity and thereby consistency of assessment processes. Furthermore, comprehensible and meaningful statements and cues can readily be adopted by students and educators to target learning and feedback thereby enhancing clarity of the EN role, to distinguish from other nursing roles.
Internationally there is increasing demand for a highly skilled nursing workforce. The increased need for a healthcare workforce following the transition of nursing education to the higher education sector resulted in a significant deregulated workforce in the early 1990s and 2000s. There is now recognition and acknowledgement that support for a skilled nursing workforce both unregulated and regulated is required to ensure cost-effective quality care provision (Devereux, 2023; Murray-Parahi et al., 2017). Guidance and clarity for all levels of individual healthcare workers is paramount for safe patient care (Devereux, 2023). Currently, a second level/tier of regulated nursing positions, referred to as Licensed Practical Nurse, LPN (USA), Enrolled Nurse, EN (Australia, Hong Kong, Israel), Nursing Associate (United Kingdom), or Associate Nurse in other countries are being recruited to address nursing shortages (Blay and Smith, 2020; Murray-Parahi et al., 2017). These second level/tier positions are designed to support Registered Nurses’ complex decision-making through the provision of timely, knowledgeable information about patient status and situation (Nursing and Midwifery Board of Australia, 2016; Nursing and Midwifery Council, 2018). While their role is explicit in the Standards statements issued by the respective governing bodies, there is value in clear articulation of work behaviours so that their engagement with Registered Nurses and patients is of the highest quality.
In Australia, the EN course is offered through Registered Training Organisations which are regulated by the Australian Skills Quality Authority (ASQA). Similar to Registered Nurses (RNs), these second-tier nurses are regulated with set standards for education and expected performance to protect the health and well-being of the public, namely, the EN standards for practice (Nursing and Midwifery Board of Australia, 2016) and accredited by the Australian Nursing and Midwifery Accreditation Council (ANMAC). The distinct, quite separate approach to the training of ENs has resulted in poor understanding of the specific elements of education and consequently, how these are managed by RNs required to delegate and supervise this workforce (Endacott et al., 2018). The scope of practice of the EN is subject to considerable debate in workplaces that are not cognisant of their education – this can lead to collegial confusion, limiting the scope of practice and ultimately negative consequences for the EN (Blay and Smith, 2020). There is an urgent need to better articulate the role to optimise learning of the EN and supervision guidance by the RN in the workplace.
2 BackgroundIn practice, RNs and ENs often work ‘seamlessly’ to collectively deliver quality care (Ossenberg et al., 2021). When the roles and clinical contributions of RNs and ENs are perceived as equivalent they are at risk of being used interchangeably (Mueller et al., 2018). Therefore, it is important to make explicit the behaviours and contributions of the nurses’ role, especially for educators and clinical supervisors responsible for learning in practice settings. Increased clarity and less subjectivity are important as “…raised awareness of nurses’ interpretation of the EN standards assists in less ambiguity regarding expectations of performance…” (Ossenberg et al., 2021, p. 279). This is important for ENs where there is complexity in determining satisfactory performance; that necessitates not only safe completion of specific tasks but also demonstration of professional codes of conduct and behaviours (Dalton et al., 2018; Nursing and Midwifery Board of Australia, 2016).
Students preparing to be an EN are placed in workplace settings during their programme of study. The Diploma of Nursing programme, which is the national training package that requires completion for entry to the register as an EN, is required to meet both ASQA and ANMAC assessment requirements. The course requires completion of 25 units, delivered over 18 months to two years with 400 hours of placement hours in a variety of health (acute, subacute, palliative, mental health), aged, and community facilities. The intent of these placements is for students to better understand what their work involves, engage in real-world practice and develop capability. Clinical and academic educators responsible for facilitating student learning seek to engage students to self-reflect to draw on concepts and other knowledge to make sense of realistic situations (Bok et al., 2016; Hanson et al., 2018; Maude et al., 2021). Guiding and advancing workplace performance in the Diploma of Nursing Programme is complex. A user-friendly tool, collaboratively developed across education and clinical sectors, that provides clarity to educators and their teams in workplaces can play a pivotal role in harmonising perceptions of role and capability (Endacott et al., 2018).
Carefully considered and constructed workplace performance tools can assist sound judgement and facilitate constructive feedback and discussion between the learner and coach to advance further capability (Kogan and Holmboe, 2013; Massie and Ali, 2016).
Internationally, health professionals have standards for practice important for communicating what the public can expect of professional practice that inform workplace performance (Nursing and Midwifery Board of Australia, 2016; Nursing and Midwifery Council, 2018). In Australia, allied health, nursing and midwifery, have developed workplace performance assessment tools that provide everyday language to explain expected behaviours consistent with professional practice standards (Dalton et al., 2012; Ossenberg et al., 2016; Sweet et al., 2020). For Registered Nurses it is called the Australian Nursing Standards Assessment Tool for RNs, ANSAT for RNS (Ossenberg et al., 2020); and for midwives it is called the Australian Midwifery Standards Assessment Tool, AMSAT (Sweet et al., 2020). The tool comprises a set of items that pertain to each standard statement and accompanying cues that describe behaviours commensurate with the item.
There is value in an Australian Nursing Standards Assessment Tool (ANSAT) for ENs since the traditional focus of performance appraisal has been oriented toward the tasks embedded in each course (Dalton et al., 2018). As previously indicated, ENs are also required to demonstrate compliance with EN standards of practice, the core practice standards that provide the framework for determining enrolled nurse (EN) fitness to practice.
Standards of practice are broad terms that can vary with individual interpretation. This study describes the collaborative development of a workplace performance assessment tool designed to enhance role clarity through outlining specific behaviours. This is important for affirmation of the facets of enrolled nurse education and scope of practice by a range of stakeholders, namely, health service providers, policy makers and education institutions (Endacott et al., 2018). These suggested behaviours are intended to work alongside the requisite skill sets; that is professional performance expected during skill acquisition. Professional achievements are important for employability, and it is associated with attitudes and how nurses conduct themselves and manage situations.
3 AimTo enhance clarity of EN role through collaborative development of a valid, user-friendly workplace performance assessment tool commensurate with EN standards for practice, comprising simple language criterion (items) and accompanying behaviours (cues). The objective was an accessible, easy-to-use tool (no more than three pages) that could be readily adopted for use across all health care settings.
4 Method4.1 Design
This non-experimental study used a two-phase sequential approach to develop a user-friendly assessment tool that describes expected practice behaviours. Non-probability, convenience sampling was employed.
4.2 EthicsThis study received ethics approval from the Central Queensland University ethics committee. Involvement was through an open invitation therefore participation was voluntary; informed consent was collected from participants prior to study commencement. Anonymity was maintained through the study as no identifying information of participants was collected nor recorded during the conduct of the study. Strengthening the Reporting Guidelines of Observational Studies in Epidemiology (STROBE) checklist was used to inform planning and reporting of the study (Von Elm et al., 2007).
4.3 Phase one: development of a workplace performance assessment toolA multi-step process was undertaken with collaboration from key stakeholders (students, educators, supervisors, clinical directors, education providers, accreditation authorities) to develop a workplace performance assessment tool based on the EN standards for practice (Fig. 1). This process that sought stakeholder engagement assisted in reducing bias in developing the tool and contributed to the acceptability and validity of the agreed format and content. Initial focus groups comprising student ENs (across each clinical placement stage) and teaching staff from two geographically separate regional sites of the same education provider that offered a Diploma of Nursing were held. The two sites, metropolitan and regional, are located over 1500 kilometres from each other and accordingly were representative of different characteristics. A preliminary version of the tool was shared with the participants to determine suitability of the proposed format, types of assessment items and behavioural cues (Ossenberg et al., 2021). To assure the rigour of this phase, the moderator of the focus groups summarised what was said by participants. The moderator also provided opportunity for participants to offer additional information or comments on the summary. Confirmation of the summary was indicative of participants’ agreement with the summation. Comments from the focus groups were similar despite the geographical separation of sites. Students expressed the document captured the intent of the EN standards for practice (Nursing and Midwifery Board of Australia, 2016); for example, ‘it is self-explanatory’; ‘useful as it states the things we should be doing’; ‘promotes communication’. Teaching staff thought the tool would provide greater consistency across EN cohorts and that students would have clarity about their progress or lack thereof; for example, ‘helps us to guide students’.
Following the initial positive appraisal of the preliminary draft, an expert reference group, comprising a broad range of stakeholders (clinical directors, education co-ordinators, programme leads and supervisors), reviewed the wording of simple language statements under each standard to ensure that the tool was comprehensive and inclusive. Revisions were made through collaborating and making suggestions regarding wording; for example, discussions occurred around, whether ‘cultural diversity’ was sufficiently inclusive, or whether specific cultures should be named and also, the use of terminology such as ‘continuing’ or ‘professional’ development. Consensus was achieved when collectively the expert reference group agreed that the final version was comprehensive and in clear plain language described the expected standards as detailed in the EN standards of practice. Two members of the key research team cross checked whether requisite performance identified in the EN Standards for Practice were included in the statements in the draft document (Fig. 1). Meetings of the expert reference group were conducted to review language, specifically considering the content was comprehensive without being too verbose. Extra words and dot points were inserted to assist clarity; for example, when referring to communication methods in standard seven, the words ‘report on and handover patient cares and status’ were added. A further dot point was added to standard eight that refers to care informed by evidence; specifically, the dot point stated ‘demonstrates problem solving and analytical skills to plan, provide and evaluate care’ to elaborate the contribution of evidence. After two meetings of the expert reference group consensus was achieved regarding inclusion of fundamental components of practice. This resulted in 30 items.
After the expert reference group achievement of consensus, the draft was distributed with an electronic survey to an end-user group consisting of industry and university representatives (e.g., nursing director, nurse educators, clinical facilitators, teaching staff) for final comment (Fig. 1). This group identified the degree (strongly disagree to strongly agree) to which the statements comprehensively and clearly reflected the intent of the EN standards for practice; all respondents (n = 16) either agreed or strongly agreed. The Likert scoring system was subsequently developed to associate performance observations with a specific descriptor. The likert scale was selected as its sequential progression strengthens the statistical analysis process (Streiner et al., 2015). The outcome of phase one, the 30-item draft version, was called the ANSAT for ENs, the Australian Nursing Standards Assessment Tool for enrolled nurses. It was subsequently field tested with students.
4.4 Phase two: field testing of the ANSAT for ENs for validity and utilityA quantitative, non-experimental design was used to determine the validity and internal consistency of the ANSAT for ENs (students). Teaching staff at all university campus sites (n=5) and the assessors at clinical placement sites (n=30) were invited to participate in field testing the ANSAT for EN students [total n=35]. Teaching staff and supervisors at the clinical sites who assessed student performance during clinical placements were provided with the ANSAT for EN students and information explaining its use. The ANSAT for EN students was to be completed at both interim and summative assessment times; ideally informing any specific student learning plans required. Assessment of student performance was based on multiple occasions of observations of practice (e.g., performing and recording of clinical observations, using policy to direct practice, reporting back when warranted, appropriately engaging with others) and interactions with the assessor. The ANSAT for EN students tool was included in student workbooks that they routinely took on placement.
4.5 Data collection4.5.1 Internal validity
Data were collected from students (n=157) on placement during stage 1 (two-week aged care placement), stage 2 (two-week GP clinics) and stage 3 (four-week acute care placement), commencing September 2020 through March 2021. The completed tools were collected in student record books and returned as usual when students completed their clinical placement. Data pertaining to scores on the ANSAT for EN students, together with clinical placement stage (i.e., stage 1, 2, 3) depending on the semester of study was collected.
4.5.2 UtilityTeaching staff at all university campus sites (n=5) and the assessors at clinical placement sites (n=30) who participated in field testing the ANSAT for EN students were invited to complete an on-line survey where they could provide feedback on the tool. The tool collected information about their role, qualifications and experience; then asked ten simple questions about the utility of components of the tool. Respondents were asked to rate these questions on a five-point Likert scale (Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree).
4.6 Data analysisTo rank the items, ANSAT for EN student scores were reported using mean and standard deviation, over median and interquartile range. Exploratory factor analysis using Principal Component Analysis (PCA) was used to determine internal validity and consistency and analysed using IBM® SPSS® Statistics (version 26 for Windows). The suitability of PCA was assessed prior to analysis. Inspection of the correlation matrix showed that all variables had at least one correlation coefficient greater than 0.3. The overall Kaiser-Meyer-Olkin (KMO) measure was 0.978. Bartlett's test of sphericity was statistically significant (p <.0001), indicating that data were likely factorisable. Subsequently, a PCA was run on data from 351 tools. Items were considered to have loaded if they had a factor loading of ≥ 0.4. Equimax rotation with Kaiser Normalisation was used in this analysis. The extraction of factors was based on Kaiser’s criterion for Eigenvalues of equal or greater than 1.5 and scree plot. Cronbach’s alpha scores were calculated for each construct. This statistic is an overall item correlation where the values range between 0 and 1; values above 0.7 are often considered to be acceptable (Kaiser, 1974).
Changes between interim and summative assessments were analysed using mixed effects linear regression with each participant set as random effect. Linear mixed-effects models are robust and flexible, accepting all available data to provide estimates (Xu and Blozis, 2011). An alpha value of p < 0.01 was considered statistically significant due to multiple testing. Data were analysed using Stata (version 13; StataCorp, College Station, TX).
5 Results5.1 ANSAT data
Analysis was conducted on completed tools for a total of 157 students across the three placement stages of the diploma course. Students were assessed twice during each placement. [The tool was used to assess some students in two consecutive stages of the course, thereby resulting in four assessments pertaining to one student]. Two assessment tools were not labelled as either interim or summative and were excluded, thereby providing 363 scored assessments for analysis. There were 215 (60 %) interim assessments and 148 (40 %) summative assessments.
5.2 Internal consistencies of the ANSAT items by theoretical constructsIn accordance with the analysis strategy, PCA was employed to reduce the 30-item scale to meaningful components. Examining the scree plot confirmed that a 3-component solution (Supplemental material 2) was the best, explaining 83 % of the total variance (Supplemental material 3). All items were retained pending the results of internal consistency and reliability testing. Cronbach's alpha coefficient for the whole scale was 0.99; this is considered excellent (Kline, 1999) and demonstrates the tool measures the construct of interest consistently. Cronbach's alphas for reliability were calculated for each component generated: Component 1, 0.98; Component 2, 0.98; and Component 3, 0.97 (Table 1).
5.3 Changes between interim and summative assessmentChanges between interim and summative assessments were assessed using a mixed effect multiple linear regression model (Table 2). All components had statistically significant improvement on scores between interim and summative assessments (Component 1, 5.86 (95 % CI: 4.80–6.92); Component 2, 5.38. (95 % CI: 4.39–6.38); Component 3, 4.12 (95 % CI: 3.28–4.96)). As the same criteria and measures are used through the placement this increase is expected because student learning has progressed and this is evident in their workplace behaviours.
5.4 Feedback survey dataTwenty-two responses were received from the 35 teaching staff and clinical placement assessors completing the on-line survey regarding its utility. A response rate of 62 %. All of the respondents except one indicated that they were experienced in assessing EN students. Teaching staff regularly completed the tool to assess student performance; Alternatively clinical placement assessors only used the tool two to four times prior to providing feedback. The six questions that asked whether the tool was: easy to use; language easily understood; could be completed in a timely manner; had sufficient statements to accurately assess; helpful scoring rules; and behavioural cues assisted communication; were strongly positive. There was only one respondent who indicated they disagreed with any of these sentiments. The value of the global rating scale was mixed. This scale did not have the same clarity as the other aspects of the tool.
6 DiscussionThe process of developing a tool for performance appraisal for ENs, a second-tier nurse, called the Australian Nursing Standards Assessment Tool (ANSAT) for ENs and tested with students through use with an appropriate scoring system, has added value through its capacity to differentiate performance and improve validity of workplace assessment. The broad consultation and collaboration process in stage one and feedback and comments received in phase two following testing with students, affirm the utility of the form with key stakeholders, including educators in both health facilities and education institutions, important for harmonisation of expectations from ENs (Endacott et al., 2018). Supervisors, teaching staff, clinicians and students appreciated plain language statements to inform their decisions when supervising and making judgements about workplace performance. Assessment for learning is most effective when students have a clear understanding of expectations and therefore it is not surprising that plain language statements were well received (Carless and Boud, 2018; Ramani et al., 2019).
Of note, the item statements and accompanying cues were also sufficient for assessors to differentiate performance across the placement. The finding that workplace performance shifted from interim assessment (commonly mid-placement) to summative assessment (end placement) according to the statistical significance of empirical results indicates that the tool has a degree of sensitivity across the placement period.
The three groupings of the statements that emerged through PCA provides information about how skill sets can be logically collated. Item statements grouped in Component 1 refer to a higher order group of tasks, namely problem-solving and taking action in adverse situations. These can be seen as the more challenging aspects of workplace practice requiring targeted coaching to optimise development. Item statements that converge in Component 2 predominantly described skills and behaviours that are frequently encountered during clinical practice and are largely representative of the routine daily activities of EN work. The ability of the EN to perform commonly delegated tasks and appropriately communicate with the RN who has oversight of their work is fundamental and readily achieved during well organised placements and good practice. The final group of item statements clustered in Component 3 reflect skills, most important for sustained employability, that can be demonstrated without a necessarily detailed level of health delivery specific competence for a requisite work task. Rather, these skills often develop through enhanced self-awareness, particularly in generic work-based contexts (Wise et al., 2022).
7 LimitationsThe restricted time frames and piloting of ANSAT for ENs during COVID limited the number of students of placement and the degree of collaboration between the education institutions and the health facilities. Any further work should consider detailed preparation of assessors as no inter-rater testing was conducted in this study. Although participants were geographically separated, all were from the one participating training organisation. As such, generalisability should be carefully considered.
8 ConclusionThis study sought to improve validity of workplace assessment through clarity of the EN role. Accordingly, the approach was collaborative seeking input from a range of key stakeholders to develop the ANSAT for ENs. With the addition of an appropriate scoring system this was tested in a student population. Given its demonstrated value in day-to-day use and also potential merit in collective analysis further research is warranted expanding use to other Diploma of Nursing programmes and to the graduate workforce. The value of any workplace performance appraisal form is based on how it is incorporated and used in practice. There is immense potential to reduce role confusion between ENs and Registered Nurses within teams and their supervisors.
CRediT authorship contribution statementSue King: Resources, Investigation, Data curation. Simone Ohlin: Writing – review & editing, Project administration, Investigation, Data curation. Christine Ossenberg: Writing – review & editing, Conceptualization. Mari Takashima: Writing – review & editing, Methodology, Formal analysis. Amanda Henderson: Writing – original draft, Methodology, Investigation, Conceptualization.
Declaration of Competing InterestThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Appendix A Supporting informationSupplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2024.103983.
Appendix A Supplementary materialSupplementary material
| 2.2 | Demonstrates respect for others regardless of values and beliefs and accommodates needs as required | 4.42 (0.67) | 5 (4−5) | C3 |
| 2.3 | Provides care maintaining privacy, dignity, confidentiality; Also, ensures provision of care equitable | 4.42 (0.67) | 5 (4−5) | C3 |
| 3.3 | Demonstrates responsibility and accountability for nursing care provided | 4.35 (0.71) | 5 (4−5) | C2 |
| 2.1 | Practices culturally safe care for Aboriginal and Torres Strait Islander people and other cultures | 4.33 (0.72) | 4 (4−5) | C3 |
| 2.4 | Clarifies with RN and healthcare team when interventions are unclear or inappropriate | 4.33 (0.70) | 4 (4−5) | C3 |
| 5.1 | Develops and promotes positive professional relationships with members of the team | 4.32 (0.69) | 5 (4−5) | C2 |
| 3.4 | Collaborates with RN to ensure delegated responsibilities are within own scope of practice | 4.32 (0.71) | 4 (4−5) | C2 |
| 1.2 | Fulfils duty of care within EN scope of practice to ensure safe outcomes | 4.30 (0.73) | 4 (4−5) | C2 |
| 1.3 | Identifies and clarifies EN responsibilities for aspects of delegated care in collaboration with RN | 4.29 (0.73) | 4 (4−5) | C2 |
| 3.2 | Demonstrates responsibility and accountability for nursing care provided | 4.28 (0.73) | 4 (4−5) | C2 |
| 3.1 | Practices within the EN scope of practice relevant to competence, legislation, education and experience | 4.27 (0.73) | 4 (4−5) | C2 |
| 6.1 | Provides care to people who are unable to meet own physical and / or mental health needs | 4.25 (0.71) | 4 (4−5) | C3 |
| 10.1 | Participates in ongoing professional development of self and others | 4.24 (0.71) | 4 (4−5) | C3 |
| 8.1 | Seeks assistance and additional knowledge and information when presented with unfamiliar situations | 4.24 (0.75) | 4 (4−5) | C1 |
| 10.2 | Identifies learning needs through critical reflection and consideration of evidence-based practice in consultation with the RNs and the multidisciplinary healthcare team | 4.23 (0.71) | 4 (4−5) | C3 |
| 1.1 | Demonstrates knowledge and understanding of the implications of the NMBA EN standards and complies with practices according to relevant legislation and local policy, codes and guidelines | 4.22 (0.76) | 4 (4−5) | C3 |
| 4.2 | Collaborates with RN to develop, monitor and maintain plan of care | 4.20 (0.72) | 4 (4−5) | C1 |
| 6.4 | Demonstrates currency and competency in the safe use of healthcare technology | 4.17 (0.72) | 4 (4−5) | C2 |
| 6.2 | Participates with RN to evaluate person’s progress toward expected outcomes and seeks appropriate assistance as required | 4.16 (0.74) | 4 (4−5) | C2 |
| 8.2 | Incorporates evidence for best practice as guided by RN and healthcare team | 4.15 (0.75) | 4 (4−5) | C1 |
| 6.3 | Exercises time management and workload prioritisation as per level of education and training | 4.15 (0.74) | 4 (4−5) | C2 |
| 5.2 | Manages and prioritises workload in accordance with plan of care and person receiving care | 4.15 (0.74) | 4 (4−5) | C1 |
| 4.1 | Uses range of skills including technology that accurately collects, interprets, utilises, monitors and reports information | 4.13 (0.75) | 4 (4−5) | C2 |
| 7.2 | Collects data, reviews and documents accurately and clearly to enable informed decision making by the multidisciplinary team | 4.12 (0.75) | 4 (4−5) | C1 |
| 7.1 | Uses a variety of communication methods to, report on and handover, patient cares and status to RN and healthcare team | 4.12 (0.78) | 4 (4−5) | C1 |
| 5.3 | Contributes to and collaborates with multidisciplinary health care team meetings and case conferences to plan care. | 4.08 (0.75) | 4 (4−5) | C1 |
| 9.3 | Demonstrates willingness to participate in quality improvement programmes and accreditation standards relevant to accreditation | 4.08 (0.74) | 4 (4−5) | C1 |
| 8.3 | Demonstrates problem solving and analytical skills to plan provide and evaluate care | 4.07 (0.78) | 4 (4−5) | C1 |
| 9.1 | Contributes and consults in analysing risk and implementing strategies to minimise risk | 4.04 (0.76) | 4 (4−5) | C1 |
| 9.2 | Reports and documents unsafe care safety breaches and hazards as according to legislative requirements and institutional policies and procedures | 4.03 (0.75) | 4 (4−5) | C1 |
| Component 1b | 4.2, 5.2, 5.3, 7.1, 7.2, 8.1, 8.2, 8.3, 9.1, 9.2, 9.3 | 42.64 (7.16) | 48.74 (6.31) | 6.27 (4.99–7.56) | <.0001 |
| Component 2b | 1.2, 1.3, 3.1, 3.2, 3.3, 3.4, 4.1, 5.1, 6.2, 6.3, 6.4 | 44.47 (7.06) | 49.99 (6.18) | 5.73 (4.51–6.94) | <.0001 |
| Component 3c | 1.1, 2.1, 2.2, 2.3, 2.4, 6.1, 10.1, 10.2 | 32.75 (5.18) | 36.59 (4.42) | 3.97 (3.05–4.90) | <.0001 |
©2024. The Authors