Comparison between Highly-Talented and Low-Talented Nurses on their Characteristics and Quality of Nursing Care

Purpose: This study aims to compare between highly-talented and low-talented nurses in regard to the quality of nursing care they provide as perceived by the nurses themselves. Methods: A descriptive comparative design was used to recruit all the available Kuwaiti nurses (N=72 nurses) from the 6 medical regions in Kuwait. Nurses’ talent was measured by using the self-assessment Nurse Competence Scale, the Gardner Career Commitment Scale, and the Nurses’ Contribution Scale. The quality of care was measured by the Nurses’ Assessment of Quality Scale. Results: 43 (59.7%) nurses were highly-talented. The findings revealed that there were no significant differences between the low-talented and the highly-talented nurses in terms of their characteristics. However, the quality of nursing care was better among the group of highly-talented nurses. Conclusion: One way to assess talent in nursing is by assessing the competence, the commitment, and the contribution of the nurses.


Introduction
Talented individuals, who are successful in their workplace, hold many of the following attributes: Creativity, imagination, conjecture, readiness for new experiences, zeal, and desire to work in a domain [1]. They also have volition, discernment, determination, flexibility, adventuresome spirit, and self-control [2]. Moreover, there are elements indicated by Raghavan that can map talented individuals. Some of these elements are as follows: Having the flexibility in enhancing their performance, having practical knowledge to run their work, having tolerance and time management attitude, having experience in their work, and being diligent [3].
Chabault et al. stated that some authors grouped particular resources to describe talented individuals and the characteristics that make up an exceptional individual [4]. First, the cognitive resources, that is, the talented individual's skills in dealing with information and seeking out and choosing which pieces are fit to use [5]. Second, the emotional resources, that is, their skills in sympathy and integration with others, their ability to handle problematic situations and to utilize good coping mechanisms, and their ability to be their own person [6]. Third, the instinctive resources, that is, their capability to handle emergency situations and their ways of empowering others [7].
In other disciplines such as Education and Business, researchers have studied and examined "talent" [2], while in nursing the concept of talent needs to be further explored. However, despite the fact that the concept of talent is used widely by other disciplines, the simple question of "What is talent?" has been left unanswered [1,8] pointed out that there is a deficiency in the "theoretical foundations for talent-identification" (p.180) in the Human Resources Management (HRM) literature and great difficulty in measuring talent with precision, according to what the organizations had reported. Moreover, Zhao and Du [9] added that quality certification and standardization are lacking from the assessment of talent. McDonnell [10] highlighted the necessity of developing an instrument to detect talent successfully. Talent identification and development is receiving tremendous attention at all levels, for example, from prearranged sports programs for youngsters to professional union scouting. Researchers are trying to construct reliable and valid strategies to find talented individuals [11,12].
In "The Talent Trifecta", an article by Ulrich [13], the author mentioned that individual competence, which is a part of the talent equation, obviously matters because an individual's poor decision-making is a consequence of that individual incompetence. Moreover, he highlighted the need to have a talented leader to manage talented employees. If the talented employees were managed by a low-talented leader, those employees will be burned out or will be driven out of the organization.
In the Kuwaiti Ministry of Health (KMOH), the manpower evaluation for the ministry from 2009 to 2013 showed that the nursing staff had the largest proportion of personnel compared with other healthcare workers other than the administrators who worked in the KMOH (16,649 nurses out of the total of 49,350 healthcare workers). Additionally, the number of nurses increased from 13,554 in 2009 to 16,649 in 2013, which indicated that more focus should be placed on the nursing staff [14]. In Kuwaiti hospitals, where there are nurses from 41 different nations and only 6% of the nurses are Kuwaiti [15]. More attention should be given to that minority as they will be the future leaders in Kuwaiti hospitals as well as the top managers in the KMOH.
Few articles were found about talent management in nursing, Diversity and Equality in Health and Care (2019) 16(2): 30-35 DOI: 10.36648/2049-5471. 16.2.190 with a recommendation that research about talent management in the profession of nursing is needed [16]. Some questions were apparent to the researchers in order to find the proper starting point in the research and to solve the current KMOH problem, which is the need to find and recruit talented Kuwaiti nurses. These questions were as follows: Who is to be recruited to nursing? What are the criteria for those nurses? How can they assist in raising the quality of care in the organization and be the change agents? How does the recruiter find and then fit the right nurse into the right place? Many more questions were considered until the idea crystallized as to assess if there were talented Kuwaiti nurses and their relationship with the quality of nursing care. Accordingly, it was important at that stage to assess the presence of talent among Kuwaiti nurses in Kuwaiti healthcare settings, identify their personal characteristics, and examine the correlation between their presence and the provided quality of nursing care.

Research questions
1. Are there differences between highly-talented and lowtalented nurses in terms of their personal characteristics?
2. Are there any differences between highly-talented and lowtalented nurses in regard to the quality of nursing care they provide as perceived by the nurses themselves?

Methods and Materials Design
In this study a descriptive comparative design was used to examine the differences quality of nursing care between highlytalented and low-talented nurses from the nurses themselves.

Sample and settings
This study was conducted in six medical regions in Kuwait. The number of the available Kuwaiti nurses who fit the eligibility criteria in all Kuwait state was 72 nurses only. The eligibility criterion in this study was nurses who had at least three months of experience and more. Nurses who were working in clinics or casualties were excluded because they were not providing the long-term care due to the short patient visits.

Ethical issues
The ethical committee at the university has approved the study. The approval was obtained also from the research committee at the KMOH. Additionally, permissions from the six regional medical directors and regional nursing directors in Kuwait to gain access to the hospitals were obtained. Explanation of the study purpose, reason to participate, duration of the study, risks and benefits, voluntary participation and ability to withdraw at any time without penalty, were all explained to nurses before they signed the informed consent. The participants were given a guarantee that the collected instruments as hard copies as well as their responses were kept in a locked cabinet. Their identity was covered with codes. This step was performed for the reason of protecting the privacy and the confidentiality of the provided information. Therefore, no one, except the researcher, had access to the study data.

Measures
The first part of measures was questions on nurses' characteristics (age, gender, educational level, years of experience, and if attended any educational courses). In addition, a combination of three scales was used to assess talent among nurses. These scales are the Nurse Competence Scale (NCS), the Gardner Career Commitment Scale (GCCS), The Nurse Contribution Scale-VAS (NCS-VAS). The fourth scale was the Nurses' Assessment of Quality Scale-Acute Care Version (NAQS-ACV), which reflects on the quality of nursing care.
The NCS is 73 items with seven subscales: helping role (seven items), teaching-coaching (16 items), diagnostic functions (seven items), managing situations (eight items), therapeutic interventions (10 items), ensuring quality (six items), and work role (19 items) [17]. The authors of NCS divided the scale into four parts to indicate the level of competence as "low (VAS 0-25), fair (VAS 25-50), good (VAS 50-75) and very good (VAS 75-100)" [17]. Content validity was established by the judgment of six experts. The Cronbach's alpha for the NCS in our study ranged between 0.79 and 0.91.
The GCCS consists of seven items designed to measure commitment among nurses in hospital [18]. It is a five-point Likert-scale, ranging from 'strongly disagree' to 'strongly agree'. The higher the total score, the greater the level of career commitment. Content validity was established through factor analysis and a panel of four experts. The Cronbach's alpha coefficient for GCCS in this study was 0.77.
The NCS-VAS was developed to measure nurses' contribution to their workplace by the researchers because there was no other available scales in this regard. It is constructed from two items following Ulrich's definition of contribution: The employees find meaning and purpose in their work. It can occur when the individuals feel that their personal desires are being met by their input in their organization [13]. Each item is measured in a horizontal line (0-100 millimeters), with two anchors labeled as no contribution and highest contribution. The total score is the summing up of the two items with the cut-off score ≤ 10 out of 20.
The NAQS-ACV is 77 items used in this study by nurses to assess the quality of nursing care they provided by themselves [19]. The scale is composed from eight factors with three sections. The first section has 45 items with 4 factors (Interaction=19 items, Vigilance=10 items, Individualization=6 items, Advocate=10 items). The second section has 21 items, with 2 factors (Work environment=12 items, Unit collaboration=9 items). The third section has 11 items, and 2 factors (Personal characteristics=7 items, Mood=4 items). The NAQS-ACV is a 5-point Likert scale with ranges from 1 (strongly disagree) to 5 (strongly agree). The Cronbach's alpha for the scales in this study were ranged between 0.82 and 0.93. Content validity of the NAQS-ACV was accomplished by a panel of six experts [19].

The Kuwaiti nurses characteristics
The Kuwaiti nurses who participants in this study were a total of 72 nurses. Almost two-thirds of the nurses were female nurses (n=45, 62% To answer the study questions, the researchers went through two steps to calculate the level of talent among Kuwaiti nurses. Step one, computation of the total scores for each of the three talent components (competence, commitment, and contribution) was performed by splitting the nurses' scores into two groups (with scores of either 0 or 1). The results showed that out of 72 nurses, 50 (69.4%) nurses were competent in the NCS.
On the commitment scale, the majority of the Kuwaiti nurses were committed to their career (n=62, 86.1%). In the third part of talent scales, 69 nurses (93.1%) contributed to their work. Based on the levels of talent, the scores range between 0 and 3 (0=low-talented, 1=mildly talented, 2=moderately talented, and 3=highly-talented).
In the second step, nurses who got "1" in each of the 3 scales (NCS, GCCS, and NCS-VAS) were considered as highlytalented nurses, thus, they got a total score of "3". Accordingly, the highly-talented Kuwaiti nurses in this study were 43 (59.7%).
Question 1: Are there any differences between highly-talented and low-talented nurses in terms of their personal characteristics?
To answer this research question, an Independent sample t-test was utilized to compare highly-talented and low-talented nurses (coded as: 0=low-talented, and =talented) with the following continuous dependent variables: age, GPA, and years of experience. Chi-square test was utilized for the following categorical dependent variables: gender, marital status, and educational attainment.
The assumptions for the independent sample t-test were examined. The assumption of normality test showed that the three dependent variables were not normally distributed. The skewednesses were 1.13 for the age, 0.81 for the GPA, and 2.14 for the years of experience. Therefore, arithmetic (Log 10) transformations were performed for these variables [20]. These variables demonstrated acceptable levels of skewedness and indicated that all variables were approximately normally distributed (skewedness=-1 to +1) [21].
The Independent sample t-test results revealed that the mean scores for the age, GPA, and years of experience did not differ significantly between the low-talented and the highly-talented nurses. Moreover, the χ 2 test results revealed that there were no significant differences between the low-talented and the highlytalented nurses in relation to their gender, marital status, and educational attainment (Table 1).
Question 2: Are there any differences between highly-talented and low-talented nurses in regard to the quality of nursing care they provided for their patients as perceived by the nurses themselves?
To answer this research question, the researchers used the computed total scores for NAQS-ACV. The independent sample t-test was utilized. The assumptions of the independent sample t-test were examined. Table 2 shows significant differences in the mean scores between the highly-talented and the lowtalented nurses' in terms of the quality of care they provided for their patients, t(70)=-3.76, p=< 0.001.

Discussion
A total of 72 Kuwaiti nurses were recruited to participate in the study from eight hospitals distributed all over Kuwait. The result of this study regarding the numbers of female and male nurses is harmonious with the actual numbers of female versus male Kuwaiti nurses in the KMOH. According to the statistics of the nursing department in the Kuwaiti MOH, out of 1059 Kuwaiti nurses, 987 were female nurses [15]. Additionally in this study, the age of the participating nurses ranged between 21 and 39 years, and more than half of them were single. The majority of the Kuwaiti nurses in this study earned a diploma, followed by bachelor's degree, and only two participants have master's degree in nursing. As there is only one school of nursing that graduates the bachelor's degree-holding nurses and this school is for females only, the MOH started to send Kuwaiti nurses, especially the male nurses, to study abroad to complete *M = mean, SD = standard deviation educational inventions that help the learners to function as a part of that context and to try to create that context. Second, the methods of assessments are varied; in this study it was nurses' self-assessments rather than employee annual appraisal. Third, nurses' self-image and self-satisfaction about their profession may affect their self-assessments. The presence of nurses' self-image and self-satisfaction will lead to a high selfassessment, which places them in the talent level. The findings in this study show that almost all the nurses were satisfied from their profession, which might have impacted positively on their evaluation of themselves and their profession.
The "quality of nursing care" as an outcome of nurses' performance could be an indicator of nurses' talent [26].
O'Boyle and Aguinis [27] concluded that when there are small percentages of increases in the top performers' productivities, this increment outweighs the moderate percentage increases in the other employees' productivities. In the current study, the highly-talented and low-talented nurses differed in how they perceived the quality of care they provide to their patients [28]. The mean score for the highly-talented nurses was higher than the low-talented nurses, which indicated that the more talented the nurse, the higher or the better the quality of care they provide to their patients, from their perspectives. From the researcher's standpoint, the differences between the highlytalented and the low-talented nurses' perspectives on how they perceived the care provided to their patients might be due to the following: nurses' different degrees of experience and knowledge regarding the standards of care, their variations in their talent levels (competence, commitment, contribution), and the highly-talented nurses' ambitions to provide talented care. Meyers et al., [1] proposed that people who are highlytalented have the aptitude to achieve their work to a level that places their accomplishment within at least the highest 10% of their colleagues who are energetic in that work and this was corroborated by the present study [29][30][31].

Limitations
The use of Likert's scale, the low power, the possibility of bias in self-assessments are some limitations of the study. Furthermore, talent assessment is limited to the bedside nurses, which may limit the generalizability of the findings to other nurses who are working in units and other areas.

Implications
To assess the levels of talent in nurses could help the organizations to know the deficiency in the nurses' characteristics and could give an idea of how and about what to educate these nurses to elevate their levels to high level of talent. The application of their bachelor's degree after either the diploma or the nursing certificate level.
It was surprising to find that all participants' characteristics: gender, marital status, educational attainment, age, GPA, and years of working experience did not differ significantly between the highly-talented and low-talented nurses. This could be attributed to the fact that the nurses were nearly homogeneous in their culture, schools of nursing that they graduated from, and the nursing rules and regulations that they followed in their hospitals. These rules usually are centralized and regulated by the nursing department of the KMOH.
When this study was conducted no other studies were found in nursing assessing the prevalence of talent among nurses worldwide. In the present study, about two-thirds of the Kuwaiti nurses were highly-talented. Bjo¨rkman, et al. [22] stated in their management articles that they asked the participants, "Are you formally identified by the multinational enterprises as belonging to a talent pool?" (p.8), in order to assess if the participants are identified as talent or not according to the official annual corporate talent review systems. They initiated three groups of participants: The first group was the talented (high-performing and high-potential) group, which was constituted of the employees who perceived that they are identified as talent. The second group was the employees who do not know if they are identified as talent or not. The third group was the employees who perceived that they are not identified as talent and they were the minority. Comparing the current research results about the highly-talented and the low-talented nurses with Bjo¨rkman, et al.'s [22] results, the highly-talented in both studies were more than the low-talented group.
To clarify the idea of talented employee prevalence in general, Meyers, et al. [1] and Howe, et al. [23] identified that only a small number of employees are highly-talented, specifically those who accomplish high performance or have high potential. Additionally, Ulrich and Smallwood [24] estimated that around 10 to 15% of the employees are high-potential future talent who can be found in key positions of organizations. These three studies were inconsistent with the finding of our study in relation to the ratio of the talented employees.
The ratio of highly-talented nurses in this study was different from Ulrich and Smallwood's [24] estimation for future talented employees. This difference may be due to many factors. First, this study was conducted hospitals settings rather than economic or educational organizations. Each setting has its own environment, technologies, load, and creativeness in advancing its employees' performance. This reason is consistent with Barab and Plucker [25] who declared that the whole gifted context can create talented learners if the educators develop *M = mean, SD = standard deviation talent assessment during the external recruitment period may assist the administrators to select the top level expatriate nurses for the benefits of the patients and healthcare organizations. In research, working on a new concept such as talent in nursing could stimulate others to start searching for all the other aspects of talent within nursing. In addition, researchers may start to correlate different variables to talent in order to investigate these relationships.

Recommendations
Talent is a new and fertile concept in the world of scientific nursing research. The study findings pave the way for additional studies, which are required to discover the holistic picture of talented nurses' presence in the healthcare settings and the benefits they bring. The results of the current study propose that it may be essential to replicate this study with different wards/units, with large and randomized samples from different nationalities or in different countries.

Conclusion
The finding revealed that about two-thirds of the participating nurses were highly-talented nurses. One way to assess talent in nursing is by assessing the competence, the commitment, and the contribution of the nurses. All the highly-talented and the low-talented nurses were having approximately similar personal characteristics such as age, marital status, educational attainment, and GPA. The hospital administrators may enhance the performance of these to reach high-talent level by starting continuous and focused practice and training sessions.