Professional Documents
Culture Documents
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd 721
A. Lofmark et al.
Nursing education has been subject to many changes over the Evaluation of competence in the transition process from
years, and one educational change that has been questioned is university student to Registered Nurse was described three
the move into universities. Has it really equipped newly- decades ago by Kramer, who saw this period as shock-like
graduated nurses with the necessary knowledge, skills and reactions to work situations for which graduates thought they
confidence to function in contemporary healthcare settings? were prepared (Kramer 1974).
This issue has been discussed internationally (Maben & Recent studies have shown that nurses today feel better
Macleod Clark 1998, Gerrish 2000, Greenwood 2000, The prepared for their work. New graduates perceived themselves
Swedish Board of Health and Welfare 2002). as professional practitioners with theoretical knowledge,
Academic education has replaced vocational training and both holistically focused, and research-oriented (Macleod
gradually a new curriculum is replacing the old one Clark et al. 1997) and feelings of responsibility and
(Kapborg 1998, Pilhammar Andersson 1999). The aca- accountability (Maben & Macleod Clark 1998). In their
demic demands on nursing education are, for example, that final clinical period, students and their supervisors assessed
teaching should provide students with the ability to make the students’ clinical performance well above the expected
critical judgements, solve problems and follow the devel- level (Glover et al. 1997). Gerrish (2000) found that newly
opment of knowledge within the field of teaching, and to qualified nurses have developed a more active style of
develop students’ ability to exchange information on a learning and that they found the transition less stressful than
scientific level. Nursing education must normally follow a nurses had done over a decade earlier. Overall, the move into
state’s or country’s specific guidelines and in some cases higher education is regarded as positive. However, concerns
international directives, such as those from the European were expressed that newly qualified nurses do not have the
Union (Department of Education 1992). full range of necessary skills (Watson & Kiger 1994,
Meerabeau 2001, The Swedish Board of Health and Welfare
2002). Nurses who had just completed their preregistration
Background course found that they were not adequately prepared for
what they were likely to encounter, and that there was lack of
Competence
support (Gerrish 2000, Pigott 2001). They also expressed
Regulations for nursing education assume that nurses, at anxiety about making mistakes (Kelly 1998). Professional
registration, have reached a standard prepared for auton- socialization, experienced as difficulties with ‘fitting in’ as
omous practice and for which they can be held account- quickly as possible and being acknowledged as competent
able. However, what establishes this standard of by their more experienced colleagues was noted by Clare
competence is not always defined (Bradshaw 1997). Dis- (1993), while Gray and Smith (1999) found that the process
cussion around the meaning of competence in nursing of professional socialization during the students’ final place-
started in the United Kingdom (UK) in the late 1980s and ment was facilitated by a mentor and the learning environ-
continues internationally (Bradshaw 1997, 1998, Milligan ment.
1998, McMullan et al. 2003). The key words or constructs In Sweden, only one report has been published on the
within definitions of competence vary (Eraut 1988), proficiency of newly-graduated nurses in relation to health-
although there is a general consensus that competence is care needs, and this indicated that they had insufficient
based on a combination of components that reflect: (a) management and technical skills (The Swedish Board of
knowledge, understanding and judgement; (b) a range of Health and Welfare 2002). The sparse number of studies, as
skills – cognitive, technical or psychomotor and interper- well as the differences in opinions that have been highlighted
sonal; and (c) a range of personal attributes and attitudes in the literature, were the reasons for this study.
(Redfern et al. 2002, Alexander & Runciman 2003). Even
if the definition and use of the concept has led to confusion
The study
and contradiction, it is actively promoted and used (Girot
1993, While 1994, Milligan 1998). In the present study,
Aim
competence was described in terms of learning outcomes
and ability to perform nursing care (Alexander & Runci- The aim of this study was to compare final year student
man 2003) through the integration of cognitive, affective nurses’ views of their own competence with qualified nurses’
and psychomotor skills (Girot 1993). perceptions of newly-graduated nurses’ competence.
722 2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
Issues and innovations in nursing education Competence of newly-graduated nurses
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd 723
A. Lofmark et al.
items, Cronbach’s a ¼ 0Æ85); (iii) personality characteristics items, 75% or more of the experienced nurses (n ¼ 136)
(four items, Cronbach’s a ¼ 0Æ88); and (iv) knowledge rated the newly-graduated nurse as having a good or strongly
utilization (two items, Cronbach’s a ¼ 0Æ57; Table 3). The developed ability to provide nursing care. Three items were
strength of the intercorrelations indicated that the question- rated by <50% of the experienced nurses (n ¼ 136) as good
naire possessed good reliability as three of the domains or strongly developed. When the 18 items were combined
exceeded the 0Æ70 level. The only domain with an alpha into the four factors revealed in the factor analysis, nursing
co-efficient <0Æ70 was knowledge utilization. This might be students rated their competence to be higher in all factors
because of the fact that only two items were included in this compared with how experienced nurses rated the competence
domain. of newly-graduated nurses (Table 3).
Descriptive data are presented as percentages, mean Nurses who had graduated less than 5 years previously had
values and standard deviations. The response alternatives slightly higher ratings than those having graduated more than
‘good ability’ and ‘strongly developed ability’ in the ques- 5 years previously but the difference was statistically signifi-
tionnaire were grouped together (Table 2). Comparisons cant only in one of four factors, that of patient care (Table 4).
between groups were made using Student’s t-test and chi-
square-test. The level of significance was defined as
Competence of newly-graduated nurses compared with
P < 0Æ05.
those who graduated more than 5 years previously
Maximum score 3.
724 2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
Issues and innovations in nursing education Competence of newly-graduated nurses
Table 5 Students’ and nurses’ ratings of competence in newly- action and working speed were estimated as the strongest in
graduated nurses compared with nurses who had graduated >5– this group of nurses. Both groups considered competence to
10 years previously (%)
be good or strongly developed in more than half of the
How competent is the newly- examined fields. These findings are congruent with those of
graduated nurse when compared studies of the readiness of newly-graduated nurses to enter
with those who graduated
the nursing profession as competent Registered Nurses (Clark
>5–10 years previously? Students Nurses
et al. 1997, Gerrish 2000, Greenwood 2000).
More competent 18Æ0 11Æ1 These findings are of interest from both an educational and
As competent 51Æ1 47Æ6 a professional point of view. In the academic curriculum
Less competent 30Æ9 41Æ3
more emphasis has been placed on teaching students to ‘learn
how to learn’. The idea is to enable nurses without experience
to follow the development in contemporary healthcare
Table 6 Students’ and nurses’ ratings of competence in newly- settings where the demands are constantly changing. Fur-
graduated nurses in relation to the expected nursing role (%) thermore, nurses need to become lifelong learners. An idea
put forward by Watkins (2000) is that nurses need this
Competence Students Nurses
capability both for academic reward as well as to be
Very high 2Æ0 0Æ78 competent in nursing care. This means that students must
High 45Æ5 48Æ1
know how to keep learning and stay abreast of developments
Low 50Æ5 48Æ8
Very low 2Æ0 2Æ3 in nursing. Bradshaw (1997) considered educational policy in
academic curricula to be directed more towards self-directed
methods of learning. Students are assumed to be responsible
A final item in the questionnaire dealt with competence in for their own educational development. Areas where both
relation to the expected nursing role. About half of the students and experienced nurses rated ability as good or
students and experienced nurses rated competence as high or strongly developed were ethical awareness, ability to co-
very high, while the other half of the group rated competence operate and preparation for action. All are examples of
as low (Table 6). prominent aspects of nursing care and can be seen as crucial
for development of the profession. Outcomes of the present
study correspond with those of other studies that support
Discussion
newly-graduated nurses’ competence. An example is that
The main finding was that final year nursing students rated newly-graduated nurses are holistically focused (Macleod
themselves as having a good or strongly developed ability to Clark et al. 1997) and that skills that are demanded in
provide nursing care, and did so to a greater extent than healthcare will increase in the future (Greenwood 2000).
judged by experienced nurses in the 18 investigated areas of The findings may also question the accuracy of final year
nursing. Nursing students in their final week of education nursing students’ self-assessments. James (1995) discussed the
evaluated their ability as strongest in areas of ethical stereotyped images of nursing and proposed that the complex
awareness, communication with patients, ability to world could be seen as simple. Glover et al. (1997) pointed to
co-operate, preparing for action and working speed, and the fact that students may have unrealistic expectations of
self-knowledge. These areas were also assessed by experi- their ability to function as nurses. Löfmark et al. (2001)
enced nurses as good or strongly developed among new questioned students’ self-assessments when they perceived
graduates. Ability to co-operate and being prepared for themselves as being independent of supervision to a great
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd 725
A. Lofmark et al.
extent, both at the beginning and end of their clinical nursing lysis, judgement and in research utilization (Macmillan
practice. For that reason, feedback from supervisors during 1999). These are all competencies that are emphasized in
clinical periods is essential to make students aware of their academic nursing education.
ability in different areas. Our findings cite support from Connected to the move to academic nursing education,
experienced nurses for newly-graduated nurses’ competence there has been a general critique that newly-graduated nurses
when different areas were rated, although to a lower degree. are lacking in nursing skills (Meerabeau 2001). The only
There is therefore much variation of opinion as to whether Swedish report on this also revealed limited management and
nursing education prepares students for the demands of technical skills (The Swedish Board of Health and Welfare
working in the nursing profession. Further study is therefore 2002). An area that corresponded to management skills in the
needed with relevance for both nursing education and the questionnaire was planning the work and distribution of
healthcare sector. tasks, which was also rated low by both groups and showed
A second finding was that nurses with an academic nursing different ratings between the groups. A comparative study by
education and less than 5 years experience of nursing gave Gerrish (2000) in the UK covering a 10-year period pointed
higher ratings in all four factors covered in the questionnaire out that newly-graduated nurses felt inadequately prepared
(communication, patient care, personal characteristics and for their new roles and that the transition process remained
knowledge utilization), although only patient care differed stressful. She highlighted that the transition from student to
statistically significantly. This result is possibly supported by Registered Nurse is not always easy and straightforward.
the suggestion that nurses educated within the pre-academic Even if students in some sense feel inadequately prepared for
system might have difficulties with coping with today’s new responsibilities and expectations, their active learning
academic demands in nurse education, and resistance to style enables them to adapt to the new role and may also
change may influence their opinion (Maben & Macleod encourage them to manage the transition process better
Clark 1998, Wallin et al. 2003). Bradshaw (1997) concluded (Gerrish 2000, Pigott 2001). In order to counter criticism
that reforms in nursing education have brought shifts in the about the lack of nursing skills and of interprofessional
standard of competence in recent years. Our results might education, specific training wards and simulation laboratories
also have been influenced by lack of awareness among have been developed, enabling students to train in nursing
experienced nurses, who trained according to the pre- care under supervision. Experiences from training wards in
academic curricula, of the intentions and content of the Sweden and the UK are very positive (Fallsberg & Wijmaa
new curriculum. In the future this difference might be an 1999, Freeth et al. 2001).
interesting area for investigation. The area of nursing care rated as demonstrating the lowest
The third aspect of our findings was the opinions of final ability by both final year students and experienced nurses was
year students and experienced nurses concerning competence that of informing and teaching co-workers and students. This
among newly-graduated nurses and those who had graduated rating was lower than that for informing and teaching
more than 5–10 years previously. These findings could be patients and relatives. It may be that informing other
interpreted as suggesting that nursing education over the healthcare personnel and students is rarely dealt with during
years has led to about the same level of competence. Nurses nursing education programmes (Table 2). When health care
with work experience were more hesitant, and only 58% of needs are changing because of an ageing population, modi-
them rated newly-graduated nurses as competent/more com- fication of the healthcare delivery system and changing
petent. Seventy percentage of nursing students rated newly- professional roles will follow suit. Ability to teach healthcare
graduated nurses as competent or more competent. For personnel as well as patients and relatives is highlighted as a
nursing students this issue can only be a guess, but it is of goal in the guiding principles for nursing education, as well as
interest as this issue is often debated. in international guidelines for nursing education (SFS 1993,
The fourth area concerned competence in relation to ICN 1997, Salvage & Heijnen 1997, Alexander & Runciman
expectations about the nursing role. About half of the 2003). Looking towards the future, it is important that
participants in both groups regarded competence as low or healthcare professionals incorporate learning with and from
very low for newly-graduated nurses. This result might reflect each other, but also able to inform and teach patients
doubt about the demands of the nursing role in relation to (Mcilfatrick 2004).
expected competence. The workload of Registered Nurses Planning and prioritizing nursing interventions was an area
seems to be continually increasing. They need not only to be that was also rated low. In the development of team working
competent in clinical and technical skills, but must also be this is an important ability (Fallsberg & Wijmaa 1999). Our
competent in decision-making, priority setting, critical ana- results indicate that more effort has to be put into educating
726 2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
Issues and innovations in nursing education Competence of newly-graduated nurses
2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd 727
A. Lofmark et al.
Kapborg I. (1998) Nursing education in Sweden: development from Redfern S., Norman I., Calman L., Watson R. & Murrels T. (2002)
vocational training to higher level education. Journal of Advanced Assessing competence to practise in nursing: a review of the lit-
Nursing 27, 372–378. erature. Research Paper in Education 17(1), 51–77.
Kelly B. (1998) Preserving moral integrity: a follow-up study with Salvage J. & Heijnen S. (1997) Nursing in Europe: Recourse for
new graduates nurses. Journal of Advanced Nursing 28, 1134– Better Health. WHO Regional Publications, European Series,
1145. Copenhagen.
Kramer M. (1974) Reality Shock: Why Nurses Leave Nursing. CV SFS (1992) Higher Education Act 1992:1434. Utbildningsförlaget,
Mosby, St Louis. Stockholm (in Swedish).
Löfmark A. & Thorell-Ekstrand I. (2000) Evaluation by nurses and SFS (1993) The Higher Education Ordinance 1993:100. Ut-
students of a new assessment form for clinical nursing education. bildningsförlaget, Stockholm (in Swedish).
Scandinavian Journal of Caring Sciences 14, 89–96. SOSFS (1993) Socialstyrelsens allmänna råd om omvårdnad inom
Löfmark A., Carlsson M. & Wikblad K. (2001) Student nurses’ hälso – och sjukvården (General Recommendations for Patient
perception of independence of supervision during clinical nursing Care in the Healthcare System, Issued by the Swedish Board of
practice. Journal of Clinical Nursing 10, 86–93. Health and Welfare), SOSFS 1993:17. Socialstyrelsen, Stockholm
Maben J. & Macleod Clark J. (1998) Project 2000 diplomats’ per- (in Swedish).
ceptions of their experiences of transition from student to staff SOSFS (1995) Socialstyrelsens allmänna råd. Kompetenskrav för
nurse. Journal of Clinical Nursing 7, 145–153. tjänstgöring som sjuksköterska och barnmorska (Nurses Respon-
Macleod Clark J., Maben J. & Jones K. (1997) Project 2000: per- sible for General Care. Description of Required Competence.
ceptions of the philosophy and practice of nursing: shifting per- General Recommendations Issued by the Swedish Board of Health
ceptions – a new practitioner? Journal of Advanced Nursing 26, and Welfare) SOSFS 1995:15. Socialstyrelsen, Stockholm (in
161–168. Swedish).
Macmillan M. (1999) Rethinking nursing. Editorial. Collegian 6, 5. The Swedish Board of Health and Welfare (2002) Översyn av ny-
Mcilfatrick S. (2004) The future of nurse education: characterised by utexaminerade sjuksköterskors yrkeskunnande och kompetens i
paradoxes. Nurse Education Today 24, 79–83. förhållande till hälso – och sjukvårdens behov (Overhaul of Newly
McMullan M., Endacott R., Gray M., Jasper M., Miller C., Scoles J. Graduated Nurses’ Skills and Competence in Relation to the Needs
& Webb C. (2003) Portfolios and assessment of competence: in Health Care. Socialstyrelsen, Stockholm (in Swedish).
a review of the literature. Journal of Advanced Nursing 41, 283– Tulving E. & Thomson D.M. (1973) Encoding specificity and re-
293. trieval processes in episodic memory. Psycological Review 80,
Meerabeau E. (2001) Back to bedpans: the debates over preregis- 352–373.
tration nursing education in England. Journal of Advanced Nur- Wallin L., Bostrom A., Wikblad K. & Ewald U. (2003) Sustainability
sing 34, 427–435. in changing clinical practice promotes evidence-based nursing care.
Milligan F. (1998) Defining and assessing competence: the distraction Journal of Advanced Nursing 41, 509–518.
of outcomes and the importance of educational process. Nurse Watkins M.J. (2000) Competency for nursing practice. Journal of
Education Today 18, 273–280. Clinical Nursing 9, 338–346.
Pigott H. (2001) Facing reality: the transition from student to Watson L. & Kiger A. (1994) Clinical staff and the new student nurse
graduate nurse. Australian Nursing Journal 8, 24–26. anticipating change. Nurse Education Today 10, 457–464.
Pilhammar Andersson E.P. (1999) From vocational training to aca- While A.E. (1994) Competence versus performance: which is more
demic education: the situation of schools of nursing in Sweden. important. Journal of Advanced Nursing 20, 525–531.
Journal of Nursing Education 38, 33–38.
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