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Newly graduated registered nurses’ clinical competence, professional development and work situationIn acute care hospital settings
Anna Willman
DOCTORAL THESIS | Karlstad University Studies | 2020:25
Faculty of Health, Science and Technology
Nursing Science
DOCTORAL THESIS | Karlstad University Studies | 2020:25
Newly graduated registered nurses’ clinical competence, professional development and work situationIn acute care hospital settings
Anna Willman
Print: Universitetstryckeriet, Karlstad 2020
Distribution:Karlstad University Faculty of Health, Science and TechnologyDepartment of Health ScienceSE-651 88 Karlstad, Sweden+46 54 700 10 00
© The author
ISSN 1403-8099
urn:nbn:se:kau:diva-79282
Karlstad University Studies | 2020:25
DOCTORAL THESIS
Anna Willman
Newly graduated registered nurses’ clinical competence, professional development and work situation - In acute care hospital settings
WWW.KAU.SE
ISBN 978-91-7867-145-8 (pdf)
ISBN 978-91-7867-140-3 (print)
1
Newly graduated registered nurses’ clinical competence,
professional development and work situation
In acute care hospital settings
Anna Willman
2
Abstract The overall aim of this thesis was to explore and describe newly grad-
uated registered nurses’ (NGRNs) self-assessed clinical competence,
professional development, work situation, and perceptions of manag-
ing nursing care in complex patient situations during their first 18
months of work experience in acute care hospital settings.
Methods: Cross-sectional and longitudinal data were collected from
NGRNs with 2-15 months of work experience using the instrument Pro-
fessional Nurse Self-Assessment Scale of clinical core competences II.
Qualitative data were collected through focus group interviews with
NGRNs after both six and 18 months of work experience.
Main results: After two months of work experience, participating
NGRNs rated their clinical competence as being highest in clinical lead-
ership and lowest in professional development. Need for further train-
ing was greatest in direct clinical practice and lowest in collaborating.
After 6 months of work experience, the NGRNs were not being suffi-
ciently prepared and supported to meet responsibilities and demands.
Between 2 and 15 months, clinical competence was assessed highest in
ethics, teamwork and clinical leadership, lowest in professional devel-
opment and critical thinking. The need for further training was highest
in direct clinical practice, lowest in ethics, teamwork and clinical lead-
ership. Self-rated clinical competence increased substantially when the
NGRNs had worked between 9-15 months and after 18 months, nurses
generally felt secure in their roles, but they faced challenges with regard
to work situations that hindered their professional development. Conclusion: These results demonstrates the importance of improving
NGRNs’ work situation and supporting their development of clinical
competence including their need for further training, which could con-
tribute to increased quality of care and patient safety as well as in-
creased professional development among NGRNs.
Key words: newly graduated nurses, nursing care, complex patient
situations, clinical competence, work situation, professional develop-
ment
3
Sammanfattning
Det övergripande syftet på avhandlingen var att undersöka och be-
skriva nyutbildade sjuksköterskors (NS) självskattade kliniska kompe-
tens, professionella utveckling, arbetssituation och uppfattning av de-
ras förmåga att hantera omvårdnad i komplexa patientsituationer un-
der de första 18 månaderna av yrkeserfarenhet på akutsjukhus.
Metod: En longitudinell design används och kvantitativa tvärsnitts-
data samlades in från NS med 2-15 månaders yrkeserfarenhet, med
hjälp av Professional Nurse Self-Assessment Scale of clinical core com-
petences II. Kvalitativa data samlades in med fokusgruppsintervjuer
med NS med 6 respektive 18 månaders yrkeserfarenhet
Huvudresultat: Med 2 månaders yrkeserfarenhet skattade NS kli-
nisk kompetens högst gällande teamarbete och lägst i professionell ut-
veckling. Behovet av mer utbildning var störst inom direkt klinisk
praxis och lägst inom teamarbete. Med 6 månaders yrkeserfarenhet var
NS inte tillräckligt förberedda för att kunna hantera ansvar och krav.
Mellan 2 och 15 månader skattades klinisk kompetens högst inom etik,
teamwork och kliniskt ledarskap, lägst inom professionell utveckling
och kritiskt tänkande. Behovet av mer utbildning var högst inom direkt
klinisk praxis, lägst inom etik, teamwork och kliniskt ledarskap. Klinisk
kompetens förbättrades väsentligt när NS hade arbetat mellan 9-15
månader och efter 18 månader kände de sig säkra i sin roll, men mötte
utmaningar i arbetssituationen som hindrade den professionella ut-
vecklingen.
Konklusion: Det är angeläget att förbättra NS arbetssituation och
stödja deras kliniska kompetensutveckling genom att beakta deras be-
hov av fortsatt träning. Detta för att stimulera NS fortsatta profession-
ella utveckling och därmed också bidra till en säker vård med god kva-
litet.
Nyckelord: nyutbildade sjuksköterskor, omvårdnad, komplexa pati-
ent situationer, klinisk kompetens, arbetssituation, professionell ut-
veckling
4
TABLE CONTENTS
ORIGINAL STUDIES ................................................................................... 6
INTRODUCTION ......................................................................................... 7
BACKGROUND ........................................................................................... 8
TRANSFORMATION OF THE HEALTHCARE SYSTEM ........................................... 8
Nursing shortage ................................................................................ 10
NEWLY GRADUATED REGISTERED NURSES (NGRNS) ................................. 11
Transformation of nursing education .................................................. 11
NEWLY GRADUATE REGISTERED NURSES DURING THEIR TRANSITION PERIOD 12
DEVELOPMENT OF CLINICAL COMPETENCE FROM NOVICE TO EXPERT ............. 14
THE CONCEPTS OF REGISTERED NURSES’ COMPETENCE .............................. 17
Professional competence ................................................................... 19
Clinical competence ........................................................................... 19
Core competences ............................................................................. 20
Academic competence ....................................................................... 20
Assessment and development of clinical competence ....................... 21
NURSING CARE IN COMPLEX PATIENT SITUATIONS ........................................ 25
REGISTERED NURSES’ WORK IN ACUTE CARE HOSPITALS SETTINGS ............... 26
RATIONALE .............................................................................................. 28
OVERALL AND SPECIFIC AIMS .............................................................. 29
METHODS ................................................................................................. 30
METHODOLOGICAL APPROACH ................................................................... 30
SETTING AND SAMPLES ............................................................................. 31
DATA COLLECTION .................................................................................... 34
DATA ANALYSIS ........................................................................................ 39
ETHICAL CONSIDERATIONS ........................................................................ 41
MAIN RESULTS ........................................................................................ 44
NGRNs’ clinical competence at the start of professional life .............. 44
NGRNs’ clinical competence development ........................................ 48
The NGRNs’ need for further training ................................................. 50
NGRNs’ experiences and managing of complex patient situations (II), their work situation, and perceptions of managing nursing care in complex patient situations (II, IV). ...................................................... 52
From chaos to control (II, IV) .............................................................. 53
From dependent to independent (II, IV) .............................................. 54
Shortage of RNs - consequences and demands (II, IV) ..................... 55
SUMMARY OF THE MAIN RESULTS ............................................................... 57
5
DISCUSSION ............................................................................................. 59
DISCUSSION OF RESULTS .......................................................................... 59
A pressured work situation ................................................................. 59
Increasing complexity in acute care hospital settings ......................... 60
Professional development .................................................................. 62
Need for collaboration and ethical nursing care ................................. 64
Clinical leadership in nursing care ...................................................... 66
METHODOLOGICAL CONSIDERATIONS ......................................................... 68
The quantitative studies (I, III) ............................................................ 68
The qualitative studies II and IV ......................................................... 72
CONCLUSIONS AND IMPLICATIONS .............................................................. 75
FUTURE RESEARCH ................................................................................... 76
ACKNOWLEDGMENTS ............................................................................ 77
REFERENCES .......................................................................................... 80
6
Original studies
This thesis is based on the following studies and will be referred to by
their Roman numerals throughout the thesis:
I. Willman, A., Bjuresäter, K. & Nilsson, J. (2020). Newly grad-
uated nurses’ clinical competencies and need for further
training in acute care hospitals. Journal of Clinical Nursing,
https://doi.org/10.1111/jocn.15207.
II. Willman, A., Bjuresäter, K. & Nilsson, J. (2020). Insuffi-
ciently supported in handling responsibility and demands:
Findings from a qualitative study of newly graduated nurses.
Accepted in Journal of Clinical Nursing.
III. Willman, A., Bjuresäter, K. & Nilsson, J. (2020). Newly grad-
uated registered nurses' self‐assessed clinical competence
and their need for further training. Open Nursing,
https://doi.org/10.1002/nop2.443.
IV. Willman, A., Nilsson, J., & Bjuresäter, K. Professional devel-
opment among newly graduated registered nurses working in
acute care hospital settings: A qualitative explorative study.
In manuscript.
Reprints were made with permission from the publishers.
7
Introduction
The main goal of healthcare is to provide the highest possible quality of
care and patient safety levels (International Council of Nurses (ICN,
2019), and universal access to healthcare for everyone is a substantial
goal of the World Health Organization (WHO, 2018b). However,
healthcare provided in acute care hospital settings is undergoing major
changes due to the increasing number of patients suffering from com-
plex conditions and multiple co-morbidities, and the shortening
lengths of hospital stays. These factors result in higher demands being
placed on complex nursing care (Aiken et al., 2017; Bandini et al., 2018;
Dharmarajan et al., 2016; Disch et al., 2016; National Board of Health
and Welfare, 2015). In addition, the widespread and long-term short-
ages of registered nurses (RNs) present a significant challenge for
healthcare nationally and internationally (ICN, 2019; WHO, 2013).
RNs’ professional competence is fundamental in ensuring that nursing
care of a high quality is provided and that patient safety levels are max-
imized (WHO, 2019). Due to RNs often being on the front-line in
healthcare settings, their work is vital. RNs with a high level of profes-
sional competence are associated with improved patient outcomes
(Aiken et al., 2012; ICN, 2019) and lower mortality rates (Aiken et al.,
2017; Aiken et al., 2014). Therefore, qualified, competent RNs need to
be available to meet changing population needs (WHO, 2020b). How-
ever, as the complexity of healthcare increases along with nursing
shortages, there is a large demand for newly graduated registered
nurses (NGRNs) with well-developed clinical competence and employ-
ment structures that support lifelong learning to secure quality of care
and patient safety (Aiken et al., 2012; Aiken et al., 2014; Sturmberg &
Lanham, 2014).
8
Background
Transformation of the healthcare system The healthcare context where nursing care is carried out has gone
through significant changes in Sweden (National Board of Health and
Welfare, 2015, 2018) as well as globally (Buchan, O'may, & Dussault,
2013; Butterworth, 2014). In Sweden, the healthcare system is divided
into three levels. The government is responsible for establishing prin-
ciples and guidelines that govern the first level, county administrative
boards are responsible for organising health and medical care at the
second level, and at the third level local municipalities are responsible
for organising elderly care and the care of people with physical or men-
tal disabilities (SFS 2017:30). Acute care hospital settings are part of
this complex healthcare system and can be defined as hospital wards
that provide specialised or general short-term care and treatment, such
as medical and surgical units, where intensive care/critical care and
emergency rooms are excluded (Charette, Goudreau, & Bourbonnais,
2019).
Changes to acute care hospital settings that have occurred in recent
years are the result of several factors such as the constantly increasing
number of patients admitted with acute diseases or chronic and com-
plex co-morbidities (Dharmarajan et al., 2016; D. Jones, Mitchell,
Hillman, & Story, 2013; WHO, 2015). The number of elderly frail pa-
tients suffering from multiple chronic diseases is also increasing
(Zwijsen, Nieuwenhuizen, Maarsingh, Depla, & Hertogh, 2016). Fur-
thermore, it has become more common for patients who would previ-
ously have been admitted to intensive care units to receive care on med-
ical or surgical wards in hospitals (Massey, Aitken, & Chaboyer, 2009).
In addition, the number of nosocomial infections such as pneumonia
and post-operative infections is increasing (Musau, Baumann,
Kolotylo, O'Shea, & Bialachowski, 2015). Other factors relating to the
increased complexity of cases in acute care hospital settings include the
constant evolvement of new medical advances, treatments, and tech-
nologies (Buchan et al., 2013; European Parliament, 2013; National
Board of Health and Welfare, 2018) and that treatments are becoming
more aggressive and invasive (Massey et al., 2009).
9
There has also been a shift in the organisation of healthcare, with a fo-
cus moving from hospital care to primary care. As a result of this, the
number of hospital beds has decreased in Sweden and the rest of Eu-
rope (OECD), which is another important reason behind the increase
in the complexity of providing acute care in hospitals as the length of
hospital stays has been shortened (Buchan et al., 2013; Massey et al.,
2009). The shortening of hospital stays together with the outsourcing
of patient and post-acute care has resulted in a higher proportion of
patients with acute conditions being in hospitals (Aiken et al., 2017;
Bandini et al., 2018; Kramer et al., 2013; Rettke et al., 2015). Complex
patient situations are associated with uncertainty and unpredictability,
such as unexpected emergencies, sudden health deterioration, comor-
bidity, medical errors, and unpredictable length of hospital stays
(Alexander & Kroposki, 2001; Kannampallil, Schauer, Cohen, & Patel,
2011; Kleinknecht-Dolf et al., 2015). In conclusion, severely ill patients
with complex and acute conditions and multiple co-morbidities receive
nursing care in acute care hospital settings for only short periods of
time, which contributes to the need for intense and complex nursing
care during their hospital stay. These changes are part of an on-going
process that is undergoing a fast-paced development (Butterworth,
2014) and is resulting in the need for more specialised and complex
healthcare (Disch et al., 2016; Musau et al., 2015). Lately, research has
highlighted that acute care hospital settings are demanding and chal-
lenging for newly graduated registered nurses (NGRNs) due to rapid
patient turnover, acute health conditions, advanced technology, and
demanding workloads (Hussein, Everett, Ramjan, Hu, & Salamonson,
2017). A serious and long-term shortage of experienced RNs (ICN,
2019; National Board of Health and Welfare, 2019; WHO, 2020c) is
also affecting healthcare organisations and is placing even greater de-
mands on NGRNs and their ability to provide adequate nursing care.
10
Nursing shortage In Sweden, 20 of the country’s 21 counties are currently reporting a
shortage of RNs and specialised RNs (National Board of Health and
Welfare, 2018). These shortages are expected to increase further
(National Board of Health and Welfare, 2019). A growing body of stud-
ies (Goh, Lee, Chan, & Chan, 2015; Kovner, Brewer, Fatehi, & Jun,
2014; Rudman, Gustavsson, & Hultell, 2014) shows that turnover
among NGRNs within their first five years is 17-22 %, and other studies
have reported turnover intentions among NGRNs in their first year to
be 50 % (Labrague et al., 2020) and 74.4 % (Zhang, Wu, Fang, Zhang,
& Wong, 2017). Despite the fact that there are more RNs than ever
graduating from nursing programmes in Sweden, counties have diffi-
culties in recruiting sufficient numbers and ensuring staff retention
(Swedish Higher Education Authority, 2018). Therefore, the shortage
and retention of nurses is unlikely to be solved simply by educating
more. Ball (2017) argues that the reasons behind the nursing shortages
are complex and multifaceted and that the work situation plays an im-
portant role in an organisation’s ability to retain qualified nurses. The
importance of improving the work situation for RNs in order to ensure
global access to effective and adequate nursing care has also been
stressed by WHO (2016a). High stress levels experienced by NGRNs in
their first years of professional life are especially critical as they can re-
sult in a greater rate of turnover (Laschinger et al., 2016; Rudman &
Gustavsson, 2020). Negative aspects of the working situation such as
unreasonable workloads and high stress levels have also been identi-
fied, which can result in further increases in turnover (Aiken et al.,
2012; Lee & Kim, 2020; Rudman et al., 2014). Furthermore, 60 % of
previous RNs reported poor working conditions as their main reason
for leaving the profession (SCB, 2017). The persistent high turnover of
RNs has led to an increase in the number of NGRNs employed, which
in turn has led to a higher ratio of NGRNs compared to experienced
RNs (Theisen & Sandau, 2013). For instance, the consequence of the
current large-scale generational shift (National Board of Health and
Welfare, 2015) and the growing number of RNs considering leaving the
profession (Lindqvist et al., 2014) will be a lack of experienced RNs
working in healthcare.
11
The increase in the ratio of NGRNs in relation to experienced RNs may
cause a more demanding and challenging work situation for NGRNs
(Hunsberger, Baumann, & Crea-Arsenio, 2013). In recent years, along
with a shortage of RNs, there has been a shortage of physicians. In or-
der to make more efficient use of resources in healthcare, there has
been a task shift involving the responsibility of specific tasks being
moved from physicians to RNs (Maier, Köppen, & Busse, 2018; WHO,
2016b). Niezen and Mathijssen (2014) suggested that professional
boundaries between physicians’ medical responsibilities and RNs’ re-
sponsibilities of nursing care have been pushed resulting in medical
care being divided and commonly becoming a shared responsibility.
Therefore, task shifting from nursing care to medical care can change
or have an impact on RNs’ professional role that requires capability,
knowledge, independent work, and decision-making abilities related to
medical care (Niezen & Mathijssen, 2014).
In summary, acute care hospital settings are going through significant
and rapid changes, resulting in a more specialised and complex
healthcare system. A combination of a shortage of RNs in general and
experienced RNs in particular may cause greater demands on NGRNs’
needs for clinical competence and their ability to work independently.
Newly Graduated Registered Nurses (NGRNs) In this thesis, NGRNs are defined as RNs who are in their first two years
of clinical practice. Accordingly to Benner (2001), RNs need to be active
in the same or similar clinical contexts for about two years to be con-
sidered competent in the area. Before NGRNs start professional life,
they complete a bachelor’s degree in nursing that consists of three years
of full-time study and constitutes 180 credits according to the Euro-
pean credit transfer system (ECTS). In line with directives from the Eu-
ropean Union (EU), nursing programmes should consist of 50% clini-
cal-based education (European Parliament, 2013).
Transformation of nursing education Many countries within the EU, including Sweden, have adapted their
nursing education programmes in accordance to the Bologna process
(European Parliament, 1999). The directives from the European
Higher Education Area (EHEA) and the EU guide nursing education
12
programmes across Europe to ensure comparable and compatible ed-
ucational systems that facilitate the mobility of nursing students and
employability for professional RNs throughout the EU (European
Higher Educational Area (EHEA), 2010; European Parliament, 2005).
Further, the process of Bologna and the collaboration of the EHEA and
the EU has led to a shift from vocational to academic nursing education
systems (Nilsson et al., 2019b). The majority of the member states of
the EU offer nursing education programmes that award bachelor’s de-
grees, and a full academic pathway – bachelor’s, master’s and doctoral
degrees are offered by 60% of nursing programmes within the EU
(Lahtinen, Leino-Kilpi, & Salminen, 2014).
The desired outcome of nursing education programmes in the curricula
within the EU (European Parliament, 2013), as well as in nursing edu-
cation programmes globally (Blažun, Kokol, & Vošner, 2015), is profes-
sional competence. The ongoing goal of nursing education programme
adaptation work is to ensure that nursing students are competent at
graduation (Fukada, 2018), and to produce NGRNs who have profes-
sional competence and who are ready for professional practice (Garside
& Nhemachena, 2013; Zieber & Sedgewick, 2018). Today, NGRNs’
work readiness and preparedness for professional practice has been
questioned (Laschinger et al., 2016; Missen, McKenna, & Beauchamp,
2016) due to the low self-confidence and level of clinical competence
needed to provide safe nursing care in complex patient situations seen
among NGRNs (AlMekkawi & El Khalil, 2020).
Newly Graduate Registered Nurses during their transition period The transition period of NGRNs refers to the first 12-24 months they
spend in the profession, post graduation (Duchscher, 2009). A transi-
tion means that a process is triggered by a change that leads to a pas-
sage through one state to another state – in this case it is the transition
of NGRNs from student life to professional life (Meleis, 2010). For
NGRNs, this means undergoing a period of learning while adapting to
a new culture and workplace (Phillips, Kenny, Esterman, & Smith,
2014). The transition period can be an experience of both development
and challenges (Duchscher, 2009; ten Hoeve, Kunnen, Brouwer, &
Roodbol, 2018) and includes experiences of professionalism and feel-
ings of pride and joy (Al Awaisi, Cooke, & Pryjmachuk, 2015). However,
13
NGRNs today report feelings of stress, anxiety, incompetence, and a
fear of failure during the transition period. This is thought to be due to
unexpected experiences and a mismatch of reality and expectations
caused by a gap between theory and practice (Al Awaisi et al., 2015;
Labrague & de Los Santos, 2020). This is not a new issue, these expe-
riences have already been identified as a concern and labelled as tran-
sition shock by Duchscher (2009). This concern is becoming more
widespread as studies suggest that NGRNs experience challenges and
difficulties during the transition period such as dealing with high pa-
tient workloads and experiencing a lack of competence (Labrague &
McEnroe‐Petitte, 2018), in particular among NGRNs working at acute
care hospital settings (Labrague & de Los Santos, 2020). Therefore, in
regard to NGRNs, these negative feelings can be related to a lack of
professional experience as they are facing new demands in the clinical
context such as nursing patients in challenging situations (Arrowsmith,
Lau‐Walker, Norman, & Maben, 2016; Walton, Lindsay, Hales, & Rook,
2018), and high levels of acuity and complex patient situations (Della
Ratta, 2016).
An introduction programme can prepare and support NGRNs to build
their confidence and competence as they develop professionally
(Duchscher, 2009; Gardiner & Sheen, 2016; Rush, Adamack, Gordon,
Lilly, & Janke, 2013; Wangensteen, Johansson, & Nordström, 2008;
Whitehead, Owen, Henshaw, Beddingham, & Simmons, 2016). These
programmes generally consist of a combination of components, for ex-
ample they might include unit-specific orientation elements, training,
formal or informal supervision, and support provision such as co-work-
ing with an experienced RN and mentoring (Rush, Janke, Duchscher,
Phillips, & Kaur, 2019). However, participation in an introduction pro-
gramme with lack of support, feedback, and unaddressed needs for
learning can contribute to insufficient nursing care and negative pa-
tient outcomes (Gardiner & Sheen, 2016). Further, it has been argued
that introduction programmes could be an obstacle that may hinder
NGRNs’ professional development depending on their content and if
the support activities are followed up or not (Bisholt, 2012). In a liter-
ature review, van Rooyen, Jordan, ten Ham-Baloyi, and Caka (2018)
found that NRGNs needed formal support and pointed out that the
14
clinical environment including need for socialisation, feeling of belong-
ing, and a positive atmosphere was important for the development of
their professional role.
Thus, the transition period is a time of change and adaption to a new
work environment and work situation. NGRNs find nursing care in
complex patient situations challenging and demanding but there is a
lack of knowledge about how they experience and perceive their work
situation in acute care hospital settings and how they handle nursing
care in complex patient situations.
Development of clinical competence from novice to expert The development of RNs’ clinical competence is a process that starts
when they are newly graduated novices and works towards them be-
coming expert RNs. It starts as soon as they enter the profession, and
advances stepwise in phases rather than as a linear development curve
(Benner, 2001). Dreyfus & Dreyfus (1980) model of direct skill acqui-
sition underpins Benner’s nursing theory ‘novice to expert’ (Benner,
2001). The theoretical framework novice to expert can be used to un-
derstand RNs’ learning and their development in clinical competence
and ability to problem solve in relation to their continuous professional
work experience. The clinical competence acquisition in Benner’s the-
ory is emphasised in the importance of knowing the patient and being
emotionally involved in their nursing care (Benner, 2001). This agrees
well with today’s nursing care that has its point of departure in person-
centred care as nursing should be based on a holistic and individual
view of patient needs (Byrne, Baldwin, & Harvey, 2020). Person-cen-
tred care has the prerequisites of recognising a patient as a human with
feelings and needs and seeing him/her as an active partner in his/her
own care (Ekman et al., 2011). Also central to Benner’s theory is the
importance of situational awareness and learning in the situation to
obtain a holistic and deep understanding (Benner, 2001).
The development of clinical competence in nursing care is divided into
five stages; Novice, advanced beginner, competent, skilled, and expert.
The novice stage is characterised by a lack of experience and situational
awareness (Benner, 2001). An important aspect of this stage is that
15
novice RNs learn from rules that are context free. As a result, the as-
sessment of patients’ needs for nursing care is fragmented and they
face difficulties such as limited understanding and inflexibility when
handling new situations. Advanced beginners have begun to learn how
to handle situations based on their previous experiences. The novice
and advanced beginner stages typically span the first two years of clin-
ical experience. NGRNs often have difficulty understanding situations
holistically and therefore experience difficulties in evaluating and pri-
oritising what is important in relation to patient health during this first
period. This means that NGRNs need rules, such as task lists, care
plans, and clear guidelines that can guide their decisions and actions in
nursing care (Benner, 2001). The competent stage is reached when RNs
have worked in the same or similar areas for two or three years. The
competent RN can handle various situations that arise and they have
developed long-term goals, resulting in an increased efficiency in the
nursing care they provide. Their clinical competence is now character-
ised by their ability to predict events as well as interpret situations from
a holistic view, which means that they are able to apply preventive
nursing care. The skilled RN perceives situations as a whole rather than
in aspects, and the significance of the situation and the absence of ex-
pected results. The expert RN’s performance is flexible and s/he finds
that rules and guidelines are no longer necessary to be able to under-
stand situations as a whole, and rather s/he will use instinctive thinking
(Benner, 2001). Even if the developing clinical competence to reach an
expert level is the goal for RNs, one can assume that this is not managed
by all RNs.
The development of clinical competence is achieved through RNs gain-
ing experience by being active in a clinical context over longer periods
(Benner, 2001). However, the general development of clinical compe-
tence is associated with the ability to think intellectually, make judg-
ments, and think critically, combined with experience. In contrast, ex-
perience alone does not automatically lead to increased clinical compe-
tence. It is when theoretical knowledge, experience, and exposure to
clinical situations are combined with a reflective ability and then these
factors are integrated with the RNs’ own personality that expert clinical
competence can be achieved (Benner, 2001). NGRNs have not yet de-
16
veloped critical thinking skills or an awareness of their clinical compe-
tence abilities (Benner, Tanner, & Chelsea, 2009). Hence, development
occurs when theoretical knowledge and experience are combined with
an ability to reflect – such as thinking critically and making judgments
– rather than simply as a result of the length of clinical experience
(Benner, 2001).
Despite the fact that Benner’s theory has its strengths and has been
used in a vast number of studies on professional development and RNs’
transition period (Della Ratta, 2016; Morrow, 2009; Murray, Sundin,
& Cope, 2019), it also has a number of weaknesses. Firstly, Benner’s
theory is based on the results of interviews with RNs in acute and emer-
gency care settings and it has been criticised for not being objectively
validated (Gobet & Chassy, 2008). This would have needed quantita-
tive data, which is absent in this case. On the other hand, transitioning
from novice to expert has been argued to be more of a philosophy than
a theory (Altmann, 2007). Secondly, each step in clinical competence
development and the process of moving from one stage to the next is
not extensively described (Gobet & Chassy, 2008), and neither is if
nursing education is part of the clinical experience or not. In this thesis,
NGRNs refer to novices or advanced beginners who need to have been
active for approximately two years in the same clinical context to be
considered competent. For instance, this can be confusing as literature
refers to new graduates both as professionals and as novice RNs
(Numminen et al., 2014) and sometimes nurses who are described as
novice RNs have worked for quite some time. Thirdly, the importance
of social interaction in the development of clinical competence is un-
clear as the focus is on context and interactions with patients (Dall’Alba
& Sandberg, 2006). Finally, the theory still being contemporary can be
questioned as it was developed more than thirty years ago and was
based on American professional RNs, which cannot be equated to, for
example, Swedish RNs due to their different areas of responsibility. It
was also developed during a period when nursing education pro-
grammes and the healthcare system were very different from what they
are today. Referring back to (Benner, 2001), when NGRNs enter the
profession, they are thought of as novices and they do not fit the de-
scription “competent” until they have completed approximately two
years of work experience, and two years of practice may seem to be a
17
long time to be referred to as a NGRN. On the other hand, Benner’s
theory is currently relevant in terms of today’s acute care hospital set-
tings where NGRNs’ development of clinical competence can be partic-
ularly challenging due to high patient acuity, the shortage of RNs, and
unmet learning needs (Hussein et al., 2017).
The concepts of registered nurses’ competence Competence refers to a state of being or quality, and in nursing compe-
tence is an essential component in providing safe nursing care (Aiken
et al., 2017). There is also an association between competence and qual-
ity of care (Takase, Nakayoshi, Yamamoto, Teraoka, & Imai, 2014;
Theander et al., 2016). In this thesis, it is the concept of clinical com-
petence in NGRNs, which is in focus.
According to Ellström (1992), competence is closely related to the con-
cepts of professionalism, competency, and skill. The difference be-
tween the concepts of competency and competence in nursing is not
clear and these concepts have been used synonymously in research lit-
erature. However, in most studies, competency is used to refer to the
skills themselves and competence to describe the ability to perform the
skills and the attributes of the performer (Calzone, Jenkins, Culp,
Caskey, & Badzek, 2014; Notarnicola, 2016). Being competent, on the
other hand, means being able to meet the requirements to fulfil nursing
care with positive outcomes in quality and patient safety (Takase et al.,
2014). This is in line with recent studies, suggesting an objective defi-
nition of competence, as observed in a performer’s ability or capability
(Bvumbwe & Mtshali, 2018; Nilsson et al., 2014). Competence is con-
nected to all nursing care and is recognised as a core component
(WHO, 2015). It forms the core of nursing education programmes and
nursing care in the healthcare system. To understand competence in
nursing care, several components are important to describe. First, the
nursing process is central in nursing care; it is flexible, adaptable to any
patient, setting, and variable, and the process includes assessing, diag-
nosing, planning, implementing, and evaluation (Kozier, Erb, &
Berman, 2008). Second, within the nursing processes, clinical reason-
ing skills such as problem solving, critical thinking, and clinical judg-
ment need to be possessed in order to perform competent nursing care
(Nilsson et al., 2014). Thirdly, further components that are important
18
are to be up-to-date with evidence-based nursing care (Mackey &
Bassendowski, 2017) and to integrate ethical guidelines into nursing
care (ICN, 2017). Despite this, there is no common understanding or
clear definition of the concept of competence (Cowan, Norman, &
Coopamah, 2005; Kajander-Unkuri, Salminen, Saarikoski, Suhonen, &
Leino-Kilpi, 2013; Liu & Aungsuroch, 2018), which complicates the un-
derstanding of the concept further. For example, the concepts compe-
tence, professional competence, and clinical competence have been
used interchangeably in previous studies, with the term competence
covering both professional and clinical competence. This has contrib-
uted to the lack of clarity with the concept (Kajander-Unkuri, 2015).
However, the trend is going towards a holistic approach that has been
described in several concept analyses of competence in nursing
(Calzone et al., 2014; Curuso, 2016; Kajander-Unkuri et al., 2014; Liu
& Aungsuroch, 2018; Notarnicola, 2016; Pijl-Zieber, Barton, Konkin,
Awosoga, & Caine, 2014). These studies show a coherent view that com-
petence in nursing is a dynamic process that requires individual char-
acteristics that include motivation, critical thinking, experience, atti-
tudes, pedagogical factors, knowledge, skills, and functional tasks and
judgment, which leads to overall competence in nursing. Competence
in nursing is seen as a holistic and dynamic process, meaning the result
is greater than the sum of different individual competences (Pijl-Zieber
et al., 2014).
In an attempt to understand the concept of RNs’ competence, the fol-
lowing paragraph describes how different parts of competence are
viewed in this thesis. Different concepts are used to describe RNs’ com-
petence, which comprises the concepts professional competence
(Kajander-Unkuri et al., 2013; SSF, 2017), clinical competence
(Benner, 2001; Kajander-Unkuri et al., 2014), core competences
(Institute of Medicine (U.S.), Greniner, & Knebel, 2003) and academic
competence (Aiken et al., 2014; Lahtinen et al., 2014) (Figure 1).
19
Figure 1. The concepts comprised by registered nurses’ competence.
Professional competence Professional competence refers to RNs’ expected levels of knowledge,
attitudes, skills, and values (Meretoja, Isoaho, & Leino‐Kilpi, 2004)
and is a gathered framework of skills which consists of reflecting on
knowledge, attitudes, and psychosocial and psycho-motor skills
(WHO, 2018a). Having nursing as a profession means that every indi-
vidual RN needs to take personal responsibility and professionalism is
a hallmark of professional competence. This means that professional-
ism includes practicing within professional standards, following a code
of ethics, taking responsibility for developing knowledge, serving as a
role model, mentoring, and building the foundation of nursing through
research and knowledge (Smith, 2012). In a review by Kajander-Unkuri
et al. (2013), professional competence was explained with eight main
approaches towards the concept 1) professional/ethical values and
practice, 2) nursing skills and intervention, 3) communication and in-
terpersonal skills, 4) knowledge and cognitive ability, 5) assessment
and improving quality in nursing, 6) professional development, 7) lead-
ership, management, and teamwork, and 8) research utilisation. Pro-
fessional competence is the basis for clinical competence.
Clinical competence In this thesis, a holistic approach is taken towards clinical competence.
Therefore, three main approaches towards the concept of clinical com-
petence from a holistic perspective are described. These are 1)
20
knowledge of task and skills, 2) generic focus on problem-solving and
critical thinking, and 3) a holistic approach that brings together
knowledge, skills, attitudes, values, and judgment, which is manifested
in performance (Kajander-Unkuri et al., 2014). In addition to the ho-
listic approach applied in this thesis, clinical competence refers to a de-
sirable outcome under various clinical context conditions in the real
world (Benner, 2001). The importance of clinical competence being de-
pendent on the context has been highlighted (Blanchet Garneau,
Lavoie, & Grondin, 2017; Kentischer, Kleinknecht‐Dolf, Spirig, Frei, &
Huber, 2018; Lima, Newall, Jordan, Hamilton, & Kinney, 2016), as it
can be conceptualised differently in various contexts (Garside &
Nhemachena, 2013). In conclusion, the concept of clinical competence
in this thesis is based on the Kajander-Unkuri et al. (2014) and Benner
(2001) definition.
Core competences The competency description for healthcare workers in Sweden, includ-
ing RNs, describes their independent areas of responsibility with the
six core competences person-centered care, teamwork, evidence-based
care, improvement and quality development, patient safety, and infor-
matics (SSF, 2017). These core competences derive from the Institute
of Medicine of the National Academies (Institute of Medicine (U.S.) et
al., 2003) and have been developed to define quality and safety in nurs-
ing. In addition, the Swedish Society of Nursing has added leadership
and care pedagogics into the competence description for RNs in Swe-
den (SSF, 2017). Competence in nursing also relates to RNs’ academic
competence.
Academic competence Academic competence in nursing care relates to lifelong learning, crit-
ical thinking, and evidence-based practice. Lifelong learning aims to
improve professional development and competence among nurses
(European Parliament, 2013). Lifelong learning in nursing care is a dy-
namic process that applies to both personal and professional life, which
includes both formal and informal learning processes that involve gain-
ing new perspectives to develop nursing (Davis, Taylor, & Reyes, 2014).
Characteristics that promote lifelong learning are reflection, question-
ing, and a willingness to learn and understand the dynamic nature of
21
knowledge and active learning by seeking learning opportunities. Life-
long learning means being open to new perspectives and questioning
context, knowledge, skills, and interactions (Davis, Taylor, & Reyes,
2014). Critical thinking is a part of lifelong learning and an essential
predictor of RNs’ competence development (Rizany, Hariyati, &
Handayani, 2018; Wangensteen, Johansson, Björkström, &
Nordström, 2012). Evidence-based practice is a process that combines
the best available research with knowledge and skills to make an overall
decision of the nursing care together with the patient within a specific
healthcare situation (Howlett, Shelton, & Rogo, 2020). Academic com-
petence in nursing research is commonly described in terms of RNs
holding a bachelor’s, master’s or doctoral degree (Lahtinen et al.,
2014). A bachelor’s degree in nursing was found to reduce patient mor-
tality in patients admitted to acute care hospitals (Aiken et al., 2014;
Audet, Bourgault, & Rochefort, 2018). As RNs’ competence and profes-
sional development have been shown to be vital for quality of care and
patient safety (Takase et al., 2014), the assessment of clinical compe-
tence can identify areas that need to be improved (Wangensteen et al.,
2018). However, a factor that can hinder the development of compe-
tence among RNs is the lack of an agreed definition of competence
(Liou, Chang, Tsai, & Cheng, 2013), as this makes the assessment of
clinical competence complex due to a lack of consensus (Cowan,
Wilson-Barnett, Norman, & Murrells, 2008; Garside & Nhemachena,
2013).
Assessment and development of clinical competence In recent years, different instruments have been developed to assess’
RNs clinical competence working in clinical settings (Yanhua &
Watson, 2011). Examples of instruments developed to assess clinical
competence are European Health Care Training and Accreditation Net-
work Questionnaire Tool (Cowan et al., 2008), Assessment of Clinical
Education (Engström, Löfmark, Vae, & Mårtensson, 2017), Nurse
Competence Scale (Meretoja et al., 2004), Nurse Professional Compe-
tence scale (Nilsson et al., 2014), and Professional Nurse Self-Assess-
ment Scale of clinical core competences II (Wangensteen et al., 2018).
These instruments are based on professional competence used to
measure clinical competence in different clinical contexts.
22
The development of clinical competence starts during nursing educa-
tion programmes. Research has shown that just prior to graduation,
nursing students rated their clinical competence as high or very high
(Gardulf et al., 2016; Theander et al., 2016). The clinical competence
areas rated highest by nursing students just prior to graduation were
value-based nursing care, acting ethically towards patients and col-
leges, and medical technical care. The competence areas ranked lowest
were following regulations, safety planning, and training and supervi-
sion of staff and students (Nilsson et al., 2019a).
Cross-sectional research among NGRNs with between zero and twelve
months of working experience in public healthcare showed that a pos-
itive perception of ethical climate, the ability of self-empowerment
such as self-efficacy and autonomy, high occupational commitment,
and positive perception of the work environment were associated with
higher clinical competence (Numminen, Leino-Kilpi, Isoaho, &
Meretoja, 2015a, 2015b; Numminen, Leino‐Kilpi, Isoaho, & Meretoja,
2016; Numminen, Ruoppa, et al., 2016). A cross-sectional study of
NGRNs with six weeks of working experience in an paediatric hospital
showed the highest areas of clinical competence were found in ensuring
quality, which refers to quality and safety, critical thinking, and evi-
dence-based practice. The lowest area was therapeutic intervention, for
example care planning (Lima, Newall, Kinney, Jordan, & Hamilton,
2014). While clinical competence among NGRNs with four to twelve
months of experience of working in home care, hospitals, nursing
homes, and community care showed the highest clinical competence
areas in the helping role such as providing comfort, being present, and
communicating, and the lowest competence area was ensuring quality
(Wangensteen, Johansson, Björkström, & Nordström, 2012).
A longitudinal study of NGRNs in their first year of practice in a paedi-
atric hospital found that clinical competences related to the helping
role such as providing comfort, being present, and communicating in-
creased most and the factors that increased least were in the area of
teaching-coaching such as readiness to learn, integrate illness and re-
covery, induce understanding, interpretation, and coaching. The
NGRNs’ overall clinical competence developed most during their first
six months (Lima et al., 2016). Results relating to clinical competence
23
development in another longitudinal study of NGRNs with three to
twelve months of experience in hospital settings found that clinical
competence grew rapidly in the first six months before slowing down
after this period (Takase et al., 2014). This study, however, did not pre-
sent separate clinical competence areas. In another longitudinal study
by Numminen, Leino-Kilpi, Isoaho, and Meretoja (2017), RNs’ devel-
opment of professional competence from one to three years of nursing
experience showed modest progress until their third year of practice
(Figure 2).
24
Fi
gure
2. P
revi
ous r
esea
rch
over
nur
sing
stud
ents
, NG
RN
s and
RN
s wor
k ex
peri
ence
and
clin
ical
com
pete
nce.
Gra
duat
ion
Sta
rt w
ork
as N
GR
Ns
0-12
mon
ths
4-12
mon
ths
12 m
onth
s-3
year
s
• N
ursi
ng s
tude
nt
poin
t of g
radu
atio
n,
Sw
eden
, NP
C
(Gar
dulf
et a
l., 2
016)
.
• N
ursi
ng s
tude
nt
poin
t of g
radu
atio
n,
Euro
pe, N
PC
(N
ilsso
n et
al.,
201
9).
• N
GR
Ns
cros
s-se
ctio
nal
clin
ical
com
pete
nce
wor
king
in n
ursi
ng
hom
es, h
ospi
tal,
com
mun
ity, N
CS
, (W
ange
nste
en, e
t al.,
20
12).
• N
GR
Ns
cros
s-se
ctio
nal,
clin
ical
com
pete
nce
in
asso
ciat
ion
to e
thic
al, N
CS
, (N
umm
inen
, Lei
no-K
ilpi,
Isoa
ho &
Mer
etoj
a, 2
015)
.
• N
GR
Ns
cros
s-se
ctio
nal,
clin
ical
com
pete
nce
in
asso
ciat
ion
to in
divi
dual
an
d or
gani
satio
n N
CS
, (N
umm
inen
, Lei
no-K
ilpi,
Isoa
ho &
Mer
etoj
a, 2
015)
.
• N
GR
Ns
cros
s-se
ctio
nal,
clin
ical
com
pete
nce
in
asso
ciat
ion
to p
ract
ice
envi
ronm
ent,
wor
k-re
late
d fa
ctor
s, N
CS
, (N
umm
inen
, Ruo
ppa
et a
l., 2
016)
.
• N
GR
Ns
cros
s-se
ctio
nal,
pedi
atric
ho
spita
l, N
CS
, (L
ima
et a
l., 2
014)
.
• N
GR
Ns
clin
ical
com
pten
ce, p
edia
tric
hosp
ital,
long
itudi
nal 0
-12
mon
ths,
NC
S, (
Lim
a et
al.,
201
6).
• N
GR
Ns
with
bac
helo
r and
non
-bac
helo
r deg
ree,
clin
ical
com
pete
nce,
hos
pita
l, lo
ngitu
dina
l 3-1
2 m
onth
s,
The
HN
CS
, (Ta
kase
, et a
l., 2
014)
.
• N
GR
Ns
and
RN
s de
velo
pmen
t of
prof
essi
oal c
ompe
tene
, ho
spita
l, N
CS
, (N
umm
inen
et a
l., 2
017)
25
In conclusion, previous studies looking at the period from the point of
graduation to the end of NGRNs’ first year of professional work indi-
cate that clinical competence areas and development of clinical compe-
tence can vary between different workplaces and work experiences.
Few studies have focused on clinical competence, regarding when de-
velopment takes place and in which clinical competence areas among
NGRNs working in various acute care hospital settings. Lately, studies
have paid attention to how the context of nursing practice can be cru-
cial when investigating NGRNs’ clinical competence (Blanchet
Garneau et al., 2017; Kentischer et al., 2018; Lima et al., 2016) and that
further longitudinal studies are needed. There is a need to investigate
NGRNs’ clinical competence, their need for further training, as further-
more, knowledge is needed regarding when and how clinical compe-
tence and the need for further training develops to identify in which
clinical competences NGRNs need to improve and be supported in, and
when they need support and training.
Nursing care in complex patient situations Nursing care in complex patient situations consists of a dynamic pa-
tient-nurse interaction related to the factors of instability, uncertainty,
and variability, where the degree of complexity is affected by intercon-
nected processes of nursing care characteristics and the impact of pa-
tients’ diseases and medical therapy (Huber, Kleinknecht‐Dolf, Kugler,
& Spirig, 2020). From the perspective of the patient, instability can re-
fer to unpredicted emergencies or events of sudden health deteriora-
tion (Alexander & Kroposki, 2001; Kleinknecht-Dolf et al., 2015), med-
ical errors, and clinical complications such as post-operative complica-
tions, infections, and irregular vital signs (D. Jones et al., 2013). Vari-
ability is caused by several different types of health problems or comor-
bidities and can be influenced by the patient's age (Alexander &
Kroposki, 2001; Kleinknecht-Dolf et al., 2015). Uncertainty is affected
by the diversity of health problems and patients’ knowledge and ability
to manage their health conditions (Alexander & Kroposki, 2001;
Kleinknecht-Dolf et al., 2015), for example, patients’ compliance
(Shippee, Shah, May, Mair, & Montori, 2012) and length of hospital
stay (Alexander & Kroposki, 2001). From the perspective of nursing
care, instability refers to the degree of unexpected changes in nursing
26
interventions related to work techniques and methods. Variability re-
fers to the degree of demands that RNs are confronted with due to the
diversity of the patient situations, such as decision-making for nursing
interventions based on the numbers of variables that RNs must take
into account. Uncertainty is determined by the degree of clarity, or lack
of clarity, in regard to decision-making and planning interventions in
patient situations that are difficult to analyse or understand (Huber et
al., 2020; Kleinknecht-Dolf et al., 2015). In addition, as the complexity
of nursing in complex patient situations is dynamic, it can be seen from
the perspective of the patient and the RNs to be made up of diverse
components such as personal, communication and cognitive, psycho-
social, ethical, and clinical processes interacting with each other caus-
ing uncertainty and unpredictability in a situation (Huber et al., 2020;
Kannampallil et al., 2011).
In regard to complex patients, there is no consistent definition
(Manning & Gagnon, 2017). Research began to detangle the concepts
of complex patient or patient complexity in the 1990s as a cause of
comorbidity, multi-morbidity, or multiple chronic conditions
(Manning & Gagnon, 2017). Schaink et al. (2012) argued that patient
situations can be complex for a variety of reasons and not solely due to
co-morbidity; additional reasons such as psychosocial mental health
issues and healthcare utilisation could also be explaining factors.
Therefore, in this thesis, nursing care in complex patient situations re-
fers to the interconnected processes in patient situations such as a pa-
tient’s disease and medical treatment and the demands placed on
nurses such as decision making and providing interventions in complex
patient situations (Huber et al., 2020; Kleinknecht-Dolf et al., 2015).
Registered nurses’ work in acute care hospitals settings RNs play a critical role in providing nursing care in acute care hospital
settings (WHO, 2018a). As gatekeepers, they plan, coordinate, provide,
and evaluate nursing care, and carry out interventions prescribed by
others (T. Jones, Hamilton, & Murry, 2015). They play a key role in
monitoring and observing patients’ health status in hospital settings
(Aiken, Clarke, Silber, & Sloane, 2003). To detect health deterioration
in patients, RNs need to be able to interpret vital signs and physiologi-
27
cal abnormalities (Massey, Aitken, & Chaboyer, 2010), however, recog-
nising and managing patients whose health is deteriorating is complex
and challenging (Massey, Chaboyer, & Aitken, 2014). A growing con-
cern, with a prevalence of 55%-98% among RNs in acute care hospitals,
is unfinished care, which is also referred to as missed care or care left
undone, and that has been shown to be associated with clinical decision
making and prioritisation of nursing care (T. Jones et al., 2015). Nurs-
ing care in complex situations was found to be experienced as a chal-
lenge or as overwhelming by RNs with several years of clinical experi-
ence (Kentischer et al., 2018). Research has shown from the perspec-
tive of preceptors that NGRNs had difficulty managing complex patient
situations (Shaw, Abbott, & King, 2018). Due to NGRNs’ lack of expe-
rience, it is difficult for them to interpret abnormal signs in deteriorat-
ing patients and for them to be able to make overall assessments or to
conduct appropriate nursing interventions. NGRNs can handle routine
tasks in their daily work but advanced clinical skills remain deficient
(Missen, McKenna, Beauchamp, & Larkins, 2016). NGRNs in their first
two years of professional life have expressed that patients presenting
with multiple diagnoses are outside their scope of competence and pa-
tients experiencing sudden health deterioration are challenging
(Gellerstedt, Moquist, Roos, Bergkvist, & Craftman, 2019). Walton et
al. (2018) found that NGRNs in the very beginning of their professional
career experienced work as demanding due to challenging situations.
NGRNs have limited experience of providing nursing care in complex
patient situations, but despite this they have the same professional re-
sponsibilities and are responsible for providing safe nursing care and
quality of care as experienced RNs, but NGRNs might not be fully pre-
pared for nursing practice in this complex context (Gardiner & Sheen,
2016; Kavanagh & Szweda, 2017).
28
Rationale
RNs’ clinical competence is of crucial importance in delivering safe,
high quality care to patients. The transformation of acute care in hos-
pitals settings along with a shortage of experienced RNs may have an
impacted on NGRNs’ clinical competence and professional develop-
ment. Research focusing on NGRNs with 0-12 months of work experi-
ence has shown that clinical competence can vary and is affected by the
clinical context and length of work experience. Further, research has
found that RNs with one to three years of nursing experience showed a
modest development through to their third year. Further, there are few
studies focusing on NGRNs’ need for further training, what content any
further training should include, and when training is needed. There is
also a lack of research providing knowledge on NGRNs’ clinical compe-
tence development working in acute care hospital settings, especially
where various areas of clinical competences are involved.
Previous research has found that during their first two years of profes-
sional life, NGRNs experience an increasingly complex healthcare sys-
tem which is described as demanding and difficult to manage, but stud-
ies concerning NGRNs experiences of managing complex patient situ-
ations are very few. More knowledge is needed about how NGRNs per-
ceive their work situation, how they manage nursing care in complex
patient situations, and how and when they develop professionally
working in acute care hospital settings. Such knowledge is important
for the development of interventions aiming to strengthen NGRNs’
clinical competence and professional development for working in acute
care hospital settings.
29
Overall and specific aims
The overall aim of this thesis was to explore and describe newly gradu-
ated registered nurses’ self-assessed clinical competence, professional
development, work situation, and perceptions of managing nursing
care in complex patient situations during their first 18 months of work
experience in acute care hospital settings.
The specific aims were:
I. To assess the self-reported clinical competence and need for
further training of newly graduated registered nurses work-
ing in Swedish acute care hospital settings.
II. To explore newly graduated registered nurses’ experiences
and management of complex patient situations.
III. To explore and describe changes in self-assessed clinical com-
petence and need for further training among newly graduated
registered nurses during their first 15 months of work in acute
care hospital settings.
IV. To explore newly graduated registered nurses’ perceptions of
their work situation and management of nursing care in com-
plex patient situations after 18 months of work experience.
30
Methods
Methodological approach In this thesis, in order to get a broad understanding of the phenomena,
descriptive and explorative approaches (Polit & Beck, 2021) with both
quantitative (Field, 2014) (I, III) and qualitative (Krippendorff, 2018)
(II, IV) methods were used. Quantitative research methods are deduc-
tive processes that investigate a pre-specified phenomenon and that
can enhance understanding and broaden knowledge of it; they are used
in studies I and III. The qualitative research methods use an inductive
approach that is oriented towards seeking in-depth understanding of
a phenomenon or a subject; these are used in studies II and IV (Polit &
Beck, 2021). A descriptive approach to nursing research is suitable
when little is known and can include defining a phenomenon and look-
ing at its prevalence and characteristics. Exploratory research is useful
for illuminating various ways a phenomenon or subject manifests itself
(Polit & Beck, 2021). An overview of studies I-IV is shown in Table 1.
31
Design study I-IV
The quantitative studies have cross-sectional (I) and longitudinal (III)
designs and are based on questionnaires answered by NGRNs after two
months (I) and up to 15 months (III) of working in acute care hospital
settings. The qualitative studies (II, IV) have an inductive design based
on focus group interviews (FGIs) with NGRNs with a work experience
of six months (II) and 18 months (IV) in acute care hospital settings.
Setting and samples The NGRNs were working in direct patient care in a central regional
acute care hospital or in various settings at two district hospitals in-
cluding medical, surgical, emergency, gynaecological, paediatric, psy-
chiatric, and oncological care. During the NGRNs’ first year of employ-
Table 1. Overview of the studies in this thesis. Study I Study II Study III Study IV
Approach/ Design
Quantitative/ Cross-sectional
Qualitative/ Explorative
Quantitative/ Longitudinal
Qualitative/ Explorative
Aim To assess the self-reported clinical competence and need for further training of newly graduated regis-tered nurses working in Swe-dish acute care hospital settings
To explore newly graduated regis-tered nurses’ ex-periences and how they manage complex patient situations
To explore and de-scribe changes in self-assessed clini-cal competence and need for further training in newly graduated regis-tered nurses during their first 15 months of clinical practice in acute care hospi-tal settings
To explore newly graduated regis-tered nurses’ per-ceptions of their work situation and management of nursing care in complex patient situations after 18 months of clinical experience
Sample/ work experi-ence/ setting
85a NGRNs/ 2 months /acute care hospital set-tings
16b NGRNs/ 6 months/ acute care hospital set-tings
45a NGRNs n=45,36,35,36/ 2,5,9,15 months/ acute care hospital settings
14b NGRNs/18 months/ acute care hospital set-tings
Data collection
Questionnaire/ ProffNurse SAS II/ September 2016, August 2017
Focus group interviews/ December 2016
Questionnaire ProffNurse SAS II/ September 2016- October 2017
Focus group interviews/ December 2017
Data analysis
Descriptive and analytic statistics
Qualitative con-tent analysis
Descriptive and an-alytic statistics
Qualitative con-tent analysis
a From study I n=85, n=45 also participating in study III.
b There are different individuals in the sample of study II and IV.
32
ment, they participated in a mandatory clinical development pro-
gramme organised by the county council. This programme included a
total of 12 days spread over the first year and consisted of lectures,
practical training, and seminars about the NGRNs new profession,
clinical skills, and patient safety.
The samples consist of NGRNs employed by a county council located
in central Sweden (I-IV). In study I and III a consecutive sampling was
used. In study I, the eligible number of NGRNs who started their first
employment position as RNs in an acute care hospital setting were 124
NGRNs, after graduating nursing programmes in June 2016 and June
2017. All of the 124 NGRNs employed by the county council were asked
to participate and out of these a total of 85 agreed (response rate 69 %).
Participants had a mean age of 26.2 years (SD 5.3) with a range of 21-
47 years. A total of 77 were women (90.6 %) and eight were men (9.4%).
The mean age of the participants who graduated in 2016 (n=45) was
25.5 years (SD 4.5) with a range of 21-39 years, and this group included
42 women (92.9 %) and three men (7.1). In regard to participants who
graduated in 2017 (n=40), their mean age was 26.9 years (SD 6.0) with
a range of 22-47 years and this group included 35 women (85.8 %) and
five men (14.4 %) (Table 2).
In study II-IV, the samples were derived from the 52 eligible NGRNs
employed by the county council in 2016. In study II, convenience sam-
pling was used for the 52 NGRNs mentioned above and the inclusion
criterion was NGRNs with six months of working experience in acute
care hospital settings. On their first day of the mandatory clinical de-
velopment programme, NGRNs were asked if they were interested in
participating in the FGIs and if they were they provided their contact
details (a telephone number) in the paper-and-pencil questionnaire. A
total of 20 were interested and 18 NGRNs voluntarily confirmed inter-
est to participate by telephone. Two of the NGRNs were unable to par-
ticipate due to work schedules. The sample (n=16) had a mean age of
24.6 years, with a range of 22-33 years and all of the sample’s partici-
pants were women (Table 2).
33
Table 2. Description of NGRNs participating in study I-IV. Study I II III IV n n n n Agreed to participate Year 2016 45 16 45/36/35/36 14 Year 2017 40 Age of participants 2016/2017
Range 21-47 Mean (SD) 26.2 (5.3) Sex Female (%) 77 (90.6) Male (%) 8 (9.4) Age of participants 2016 Range 21-39 22-33 21-39 24-30 Mean (SD) 25.5 (4.5) 24.6 25.5 (4.5) 26.8 Sex Female (%) 42 (92.9) 16 (100) 42 (92.9) 12(83.4) Male (%) 3 (7.1) 3 (7.1) 2 (16.6) Age of participants 2017 Range 22-47 Mean (SD) 26.9 (6.0) Sex Female (%) 35 (85.8) Male (%) 5 (14.2) Total 85 16 45/36/35/36 14
In study III, of the 52 eligible NGRNs, the sample had 45 participants
at the first data collection and the following three data collections had
36, 35, and 36 participants respectively. NGRNs agreed to voluntarily
participate and the response rate ranged from 67-86 % (Table 3).
Table 3. Overview of the four data collections (study III), including date, number of respondents, response rate and length of NGRNs´ work experience. Data Collection
Date n Response rate
Work Experience of NGRNs
I September 2016
45 86% 2 months
II November 2016
36 69% 5 months
III April 2017
35 67% 9 months
IV October 2017
36 69% 15 months
The inclusion criteria was NGRNs with two months of work experience
in acute care hospital settings at the first data collection occasion, at
34
the second five months, at the third nine months, and at the fourth 15
months. The mean age was 25.5 years (SD 4.5) with a range of 21-39
years, and the sample included 42 women (92.9 %) and three men (7.1)
(Table 2).
In study IV, convenience sampling was used on the 52 eligible NGRNs
and the inclusion criterion was NGRNs with a work experience in acute
care hospital setting of 18 months. Head nurses on wards identified
NGRNs who met the inclusion criterion. Fourteen NGRNs, 12 women
(83.4 %) and two men (16.6 %), voluntarily participated. They had a
mean age of 26.8 years, with a range of 24-30 years (Table 2).
Data collection In study I and III, data were collected through a questionnaire that in-
cluded the Professional Nurse Self-Assessment Scale of clinical core
competences (ProffNurse SAS II) (Wangensteen et al., 2018) and de-
mographic and educational information. In study II and IV, data were
collected with FGIs (Morgan, 1997).
The questionnaire
The questionnaire consisted of the 50-item instrument ProffNurse SAS
II (Wangensteen et al., 2018) and an additional four questions about
background characteristics: age, sex, and year and month of nursing
exams (I, III). ProffNurse SAS II aims to measure RNs’ clinical compe-
tence from a holistic and lifelong learning perspective of nursing at dif-
ferent educational levels, with the nurse-patient relationship playing a
central role (Wangensteen et al., 2018). ProffNurse SAS II consists of
50 items and has two responding scales; the A-scale for self-assessed
clinical competence and the B-scale for self-assessed need for further
training. Of these 50 items, 44 of them are sorted in six components;
Direct clinical practice, Professional development, Ethical decision-
making, Clinical leadership, Cooperation and consultation, and Critical
thinking (Table 4).
35
Table 4. A brief explanation of the six components in ProffNurse SAS II and num-ber of items in each component. Components Brief explanation Number
of items Direct clinical practice
Independently identify, assess, imple-ment, and evaluate nursing in patient-centred work. Knowledge of the effect of medicines, side effects, interactions, and effects on patient health.
15
Professional development
Being involved and taking responsibility for oneself, patients, and the development of workplace skills.
5
Ethical decision-making
Taking ethical responsibility in the care of patients’ physical, mental, and social health. Taking ethical responsibility for colleagues and the work environment.
10
Clinical leadership
Taking responsibility for your own deci-sions, actions, and nursing care.
4
Cooperation and consultation
Having the ability to collaborate with and consult colleagues and other staff mem-bers, delimitations to other professions.
6
Critical thinking Being able to reflect on one’s own actions and evaluate work, development, and vi-sions on how nursing can be further de-veloped for patients and the workplace.
4
Six single items are also included in ProffNurse SAS II; these items ad-
dress assessing, prevention or promoting patients’ health, using tele-
phone, e-mail, or computer, providing support and guidance to pa-
tients and relatives, and the reporting of incidents in patient safety sys-
tems (Wangensteen et al., 2018).
All 50 items and components have the same A and B scales, thus an-
swered respectively. The A-scale has response alternatives ranging
from 1 to 10, with 1 indicating a very low level and 10 indicating a very
high level of self-assessed clinical competence. The B-scale has re-
sponse alternatives ranging from 1 to 10, with 1 indicating a very low
level and 10 indicating a very high level of self-assessed need for further
training. The items could be answered on the ten-point A and B scales
by making a self-assessment of a statement, for example ‘I have
knowledge of the effects of medication and treatment for the patients I
36
am responsible for’. Statistical analyses were performed on both the
items (I) and component levels (I, III).
Internal consistency was assessed by Cronbach's alpha (Cronbach,
1951). The desirable level is > 0.70 as a measure of achieved internal
consistency according to Field (2014). In previous studies using
ProffNurse SAS I among RNs in home-care and long-term contexts, re-
liability of the A-scale in regard to the six components ranges from
0.77-0.94 (Finnbakk, Wangensteen, Skovdahl, & Fagerström, 2015),
and using ProffNurse SAS II among RNs with post-master’s degrees for
the A-scale as a whole was 0.96 (Wangensteen et al., 2018). Further,
Cronbach’s alpha values, among operating theatre RNs on the A-scale
in a modified version of the six components, ranged from 0.67-0.87
(Blomberg, Lindwall, & Bisholt, 2019).
In study I, Cronbach’s alpha values ranged between 0.68 and 0.89 for
the six components in the A-scale, and for the components in the B-
scale between 0.79 and 0.92. In study III, Cronbach’s alpha values
ranged at the four data collection occasions for the components in the
A-scale between 0.65 and 0.92, and in the B-scale between 0.71 and
0.96.
The development of ProffNurse SAS II
The theoretical framework of ProffNurse SAS I and II is based on the
Nurse Clinical Competence Scale (NCCS) (Finnbakk et al., 2015). The
NCCS covers the central competence domains in nursing (Hamric,
Spross, & Hanson, 2009) and are inspired by the Nurse Competence
Scale (NCS) (Meretoja et al., 2004) and Benner’s professional compe-
tence framework novice to expert (Benner, 2001). The NCCS scale con-
sisted of 74 items and was psychometrically tested, which resulted in a
51-item solution sorted in six components and the scale was renamed
ProffNurse SAS I (Finnbakk et al., 2015). In Wangensteen et al. (2018),
one item was removed from ProffNurses SAS I and the B-scale, self-
assessed need for further training, was added to the instrument that
was then renamed ProffNurse SAS II. The NCCS scale and ProffNurse
SAS I was developed in Swedish language (Finnbakk et al., 2015). Fur-
ther, the ProffNurse SAS I was translated to Norwegian and English
language, the translating process was conducted by the authors in
37
Finnbakk et al. (2015) and guided by the procedure described in Wild
et al. (2005).
Procedure
In study I-IV, participating NGRNs were given oral and written infor-
mation about the studies on their first day of the clinical development
programme, and in study III, oral and written information was pro-
vided prior to the following three data collection occasions. Written in-
formation was attached to the questionnaires and contained the aim of
the studies, that participation was voluntarily, and that each partici-
pant signed a written consent form.
In study I and III, data were collected during the first session of the
clinical development programme. A questionnaire was sent out by post
to those who could not attend (2016) and two reminders were sent out
ten days apart. The first reminder resulted in five additional answered
questionnaires being submitted and none after the second reminder.
In 2017, no reminders were sent out. The NGRNs graduated in June
2016, and received their registration from the Swedish National Board
of Health and Welfare after approximately two weeks. Therefore, at the
first data collection occasion in September 2016, the NGRNs had had
about two months of work experience. In addition, there were two more
data collection occasions (III) in connection with activities included in
the clinical development programme. The clinical development pro-
gramme was one year in length but the data collection lasted for a pe-
riod of 15 months, so questionnaires for the last data collection occa-
sion were sent out by post to the participants’ home addresses and sent
back to the author in a prepaid envelope. Two reminders in a prepaid
envelope were sent out 10 days apart. The first reminders resulted in 3-
5 more questionnaires being sent in but none resulted from the second
one, with the exception of the fourth data collection when the second
reminder resulted in three more questionnaires being submitted. Data
collections were carried out in connection with planed activities in the
clinical development programme, and the completed questionnaires
were coded and returned in a sealed envelope to maintain confidenti-
ality.
38
In study II and IV, data were collected through FGIs (Morgan, 1997).
The FGIs were semi-structured discussions that aim to capture and ex-
plore the interaction in the group. In order to gain access to rich data
and to get a deeper understanding of the participants’ experiences,
views, and perceptions on a predetermined subject using their own
words (Kreuger & Casey, 2009; Morgan, 1997). This means the FGIs
focused on the interactions and discussions between the group mem-
bers, rather than the interaction between the participants and the mod-
erator (Jayasekara, 2012). FGIs are an appropriate data collection
method to explore opinions on specific subjects when participants
share the same experiences (Morgan, 1997).
The FGIs were conducted in a private meeting room at the NGRNs’
workplace with the author as a moderator at all FGIs and an experi-
enced researcher as assistant moderator at all except for two FGIs. The
moderator created a non-threatening environment and encouraged
participants to speak freely. Prior to all FGIs, the NGRNs were asked to
describe their understanding of nursing care in complex patient situa-
tions in relation to the factors instability, variability, and uncertainty.
The NGRNs gave examples of these situations and they were discussed.
A semi-structured interview guide was used in all of the FGIs, which
started with an opening question followed by key questions and a clos-
ing question. The assistant moderator took notes during the discus-
sions to support the moderator and gave an oral summary at the end of
each interview. All of the FGIs were audio recorded and later the re-
cordings were transcribed verbatim.
In study II, the FGIs consisted of five participants in one group, four
participants in two groups and three participants in the final group.
The opening question was; ‘Can you please tell us what it is like to be a
newly graduated nurse?’, followed by the key questions: ‘Can you
please tell us about your experience of nursing care in complex patient
situations?’, and ‘Can you please tell us about how you manage nursing
care in complex patient situations?’ The closing question was ‘Is there
anything else you want to add?’ Probing questions were used when
needed, such as: ‘Can you please tell us more about that’ and ‘Can you
please give an example’. The FGIs lasted for between 62 and 75
minutes (mean 66 minutes).
39
In study IV, the FGIs consisted of two groups of four participants and
two groups of three participants. The opening question was; ‘Can you
please tell us how you perceive your work situation?’, followed by the
transition and key questions: ‘Can you describe a patient situation that
you perceived as complex?’, ‘Can you describe how you perceive and
manage nursing care in complex patient situations?’, ‘Can you describe
a work situation in a complex patient situation that worked well?’, and
‘Can you describe a work situation in a complex patient situation that
did not work well?’. The closing question was ‘Is there anything else
you would like to add?’ The FGIs lasted from 43-62 minutes (mean 56
minutes).
Data analysis
For study I, data were analysed using Statistical Package for the Social
Sciences version 24.0 (SPSS) and in study III, version 26.0 SPSS Word
2018 (IBM) was used. To present background data, age, sex, and re-
sponse rate, descriptive analyses such as percent and the frequencies
mean, standard deviation (SD), and range were used (Field, 2014; Polit
& Beck, 2021). To calculate the internal consistency of the scales,
Cronbach’s alpha was used (Cronbach, 1951). The significance level was
set at p<0.05 (Pallant, 2013) (I,III). In study I, Pearson’s Chi-square
test was used to examine statistically significant differences in person-
related conditions (sex) between participants on nominal data among
the NGRNs in regard to self-assessed clinical competence and need for
further training. Student’s t-tests were used to compare person-related
differences between two sample means, age, sex, and participants in
2016 and 2017, in regard to the NGRNs self-assessed clinical compe-
tence and need for further training (Field, 2014). In the two single
items ‘I am assessing the patients’ needs for health care using the tele-
phone, e-mail, or computer’ and ‘I give health promotion advice using
the telephone, e-mail, or computer’ there was an internal dropout with
missing answers in both the A and B scales of 8%.
In study III, the changes in the six components in the respective A and
B scales between the four different data collections were analysed by
paired samples t-test (Field, 2014; Streiner & Norman, 2008). Regard-
ing internal dropouts, there were few dropouts in the items of the A and
B scales analysing data on a group level. However, in the paired t-test,
40
the required data need to be complete in all items to be able to measure
the changes between the two different data collections. This resulted in
an internal dropout of six percent in between the second and third data
collection.
For study II and IV, data were analysed using a text-driven, interpretive
qualitative manifest and latent content analysis according to
Krippendorff (2018). Firstly, the transcript text was read through sev-
eral times to gain an overall understanding until it became immersed.
Secondly, the transcript text was read carefully to identify meaning
units (II) that represented NGRNs’ experiences and management of
nursing care in complex patient situations with six months of working
experience. In study IV, meaning units were identified that represented
the NGRNs’ perception of their work situation and management of
nursing care in complex patient situations after 18 months of working
experience. Thirdly, from the identified meaning units, codes were con-
densed. Fourthly, the various codes were then abstracted into subcate-
gories based on similarities and differences. Fifthly, the subcategories
were sorted into three latent homogeneous categories and a theme
emerged (II, IV). In the first steps of the analysis, the identified mean-
ing units and the codes were based on manifest content in the text that
are clear and obvious. Later in the analysis, the subcategories, catego-
ries, and themes were based on latent content such as the interpreta-
tion of the meaning of the underlying text. This method aims to follow
a process going back and forth in the text to find different levels of ab-
straction and to increase the ability to see contexts and patterns. This
means that interpretation of the text can be made at different levels of
abstraction. The relevance of the results was finally confirmed by the
relationship between the aim of the study, the categories, and the
themes (Krippendorff, 2018). Two of the authors of the articles (AW
and KB) coded two interviews in study II and two interviews in study
IV independently, the codes were compared later and a high consensus
was found. All of the authors of the articles have been involved in the
analysis process and discussed the tentative subcategories, categories,
and themes until consensus was reached.
41
Ethical considerations The studies (I-IV) followed the ethical principles in accordance stated
in the ICN Code of Ethics for Nurses (ICN, 2012) and The ethical guide-
lines for nursing research in the Nordic countries (Northern Nurses
Federation, 2003). The four ethical principles autonomy, beneficence,
non-maleficence, and justice according to the (Northern Nurses
Federation, 2003) have been considered throughout this thesis.
Autonomy is central in the ethical principles and refers to participation
being voluntary and based on informed consent (Northern Nurses
Federation, 2003). In this thesis, autonomy was respected and this is
seen in voluntary participation, informed consent, and confidentiality.
An oral information session was arranged in connection with the
NGRNs’ first mandatory day of the clinical development programme
and prior to every data collection occasion (I-IV). Written information
and consent were attached to the paper-and-pencil questionnaires (I,
III) and handed out to the NGRNs prior to the focus group interviews
taking place (II, VI). Verbal and written information was given on the
design and purpose of the studies, and the NGRNs were informed both
orally and in writing that participation was voluntary and that they
could withdraw their participation at any time without giving any rea-
son or experiencing any negative consequences. At the oral information
session, NGRNs had the opportunity to ask questions. In addition, par-
ticipants were informed that the research would be used in this thesis
and in a series of published articles. All participation was voluntary and
written informed consent was obtained for all participants (I-IV).
In regard to confidentiality, the NGRNs were asked if they were inter-
ested in participating in a FGI on their first day of the mandatory clin-
ical development programme (II, IV). The author then contacted the
head nurses of the NGRNs’ wards to get permission for the NGRNs to
participate in a FGI during their working hours. Furthermore, in study
IV, it turned out that it was not possible to conduct interviews again
with the same NGRNs as in study II, because most of them had stopped
working in acute care settings or stopped working as RNs. Therefore,
the author needed to be assessed by each ward’s head nurse to get ac-
cess of NGRNs with 18 months of work experience who were eligible
for the study. The NGRNs were informed that their ward’s head nurse
42
had been involved in the identification of eligible potential participants
and agreed to the arrangement of being interviewed during working
hours. The principles of confidentiality were assured as the question-
naires were coded and the code list and names were stored separately
(I, III). The transcribed interviews were also kept confidential and re-
spondents cannot be identified by their answers (II, VI).
Beneficence (doing well) concerns the research of potential benefit to
the individuals or the group of NGRNs (Northern Nurses Federation,
2003). The outcome of these studies can contribute towards new
knowledge and a deeper understanding that can benefit NGRNs, as
well the healthcare system at an organisational level. According to the
beneficence of the target group, the research results of these studies
should be communicated at congresses and conferences, in forums
there health managers are present, and published in international jour-
nals. This research may also lead to an increased awareness among
nurse educators who are responsible for clinical education in the nurs-
ing education programmes and facilitate customising further support
and education that will benefit NGRNs’ competence development and
preparedness.
Non-maleficence aims to reflect on research not causing any harm to
participants (Northern Nurses Federation, 2003). The participants in
these studies may not be considered as vulnerable or weak, as they are
young and working as independent RNs. Indeed, no questions about
their health status or general wellbeing were asked. However, the
NGRNs were asked questions and took part in discussions in FGIs on
the topic of their own clinical experiences and management of nursing
complex patient situations. This might have caused confronting nega-
tive thoughts and feelings concerning their experiences of eventual low
clinical competences. On the other hand, this might have also led to
feelings of relief to hear other NGRNs talk about similar experiences to
theirs in their daily work. The questionnaires were lengthy due to them
including two scales and they were handed out four times. However,
participants were given time to fill in the questionnaires in their work-
ing hours and the FGIs were also conducted within their working
hours.
43
Principles of justice concern protecting weak and vulnerable groups
and ensuring that they are not exploited in research (Northern Nurses
Federation, 2003). Justice also refers to treating all participants
equally and that all NGRNs starting their first clinical positions in the
county council in the summer of 2016 and 2017 were asked to partici-
pate. Questionnaires and interviews were treated with respect and only
distributed/conducted after oral and written consent was received, and
all participation was voluntary. All included studies were approved ac-
cording to the Research Ethics Committee of the University of Uppsala
Regional Ethical Review Board (reg. no. 2011/071 and 2011/071/2) and
(reg. no. 2011/071 and 2011/071/2). Permission was obtained from re-
spective developers before using the ProffNurse SAS II instrument.
44
Main results
Study I focused on NGRNs’ self-reported clinical competence and need
for further training. Study III explored and described how their self-
assessed clinical competence and need for further training developed
during their two to 15 months of work experience. Study II, which was
conducted after participating NGRNs had worked for six months, ex-
plored NGRNs’ experiences and management of complex patient situ-
ations. Study IV was conducted after participating NGRNs had 18
months of work experience and it focused on their work situation and
perceptions of management of nursing care in complex patient situa-
tions.
NGRNs’ clinical competence at the start of professional life After two months of working experience, participating NGRNs rated
their clinical competence as highest in the items ‘I consult other pro-
fessional experts when required’, ‘I act ethically when caring for pa-
tients’, and ‘I cooperate actively with other health professionals when
coordinating patients’ nursing, care and treatment’ (Table 5). With two
months of work experience, the highest scores in regard to the NGRNs’
clinical competence were found in the components ‘clinical leadership’,
‘cooperative and consultation’, and ‘ethical decision-making’ (I, III)
(Tables 5 and 6).
45
Table 5. The NGRNs’ self-assessed highest and lowest items in the A-scale, clinical competences, after two months of work experience. Mean values (M) and standard de-viations (SD). Highest rated clinical competences Lowest rated clinical compe-
tences
Content M SD Content M SD
1 I consult other profes-sional experts when re-quired
8.92 1.82 I give health promo-tion advice and rec-ommendations to pa-tients by using tele-phone, e-mail, or computer
3.76 2.41
2 I act ethically when caring for patients
8.51 1.44 I assess patients’ health needs by using telephone, e-mail, or computer
3.87 2.52
3 I cooperate actively with other health pro-fessionals when coor-dinating patients’ nursing, care and treatment
8.32 1.67 I have knowledge of the interactions of various types of medi-cation and what side-effects they may cause for the patients I am responsible for
4.27 1.94
4 I am aware of when my medical knowledge is insufficient when as-sessing patients’ health conditions
8.29 1.85 I generate a creative learning environment for staff at my work-place
4.54 2.52
5 I maintain an ethical approach towards my colleagues
8.26 1.62 I report all incidents in accordance with the actual patient safety system
4.59 2.50
6
I take full responsibil-ity for my own actions
8.19 2.00 I improve rou-tines/systems that fail to meet the needs of patients at my work-place
4.71 2.43
7 I take patients’ physi-cal health needs (ill-ness, pain, disabilities, etc.) into account when assessing and planning for the health and life situation of patients
8.07 1.79 I participate in qual-ity development at my workplace
4.73 2.48
8 I put emphasis on pa-tients’ own wishes when assessing and planning for nursing care and medical treat-ment
7.88 1.81 I exclude differential diagnoses when as-sessing patients’ health conditions
4.93 1.79
46
9 I take active responsi-bility for creating a good working environ-ment
7.82 1.77 I have a vision of how nursing should be de-veloped at my work-place
5.38 2.12
10 I have a supportive on-going dialogue with patients about their needs and wishes
7.79 1.69 I have knowledge of the effects of medica-tion and treatment for the patients I am responsible for
5.52 1.95
Values ranging from 1 to 10, where 1=a very low level and 10=a very high level.
After two months of work experience, participating NGRNs’ stated that
their lowest clinical competence was in the items ‘I give health promo-
tion advice and recommendations to patients using the telephone, e-
mail, or computer’, ‘I assess patients’ health needs using the telephone,
e-mail, or computer’, and ‘I have knowledge of the interactions of vari-
ous types of medication and what side-effects they may cause for the
patients I am responsible for’ (I) (Table 5). The lowest scores concern-
ing the NGRNs’ self-assessed clinical competence after two months of
work experience were found in the components ‘professional develop-
ment’ and ‘direct clinical practice’ (I, III) (Tables 5 and 6).
47
T
ab
le 6
. T
he
NG
RN
s’ s
elf-
ass
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d c
om
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ts i
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II.
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M)
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(SD
).
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S
tud
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II*
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dy
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Stu
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III
2
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15
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M
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M/S
D
M
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M/S
D
Dir
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t
cli
nic
al
pr
ac
tic
e
A
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44
6
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8
34
7
.53
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4
32
8
.46
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9
33
B
6.7
6/1
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8
3
6.9
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4
1 6
.81/
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Pr
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34
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.90
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7
29
8
.40
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34
B
6
.71/
1.3
2
81
6.7
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.38
4
0
5.9
0/1
.47
3
2
5.9
8/1
.25
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4
4.0
0/2
.20
3
2
Eth
ica
l
de
cis
ion
m
ak
ing
A
7
.46
/1.0
1 8
4
7.7
7/0
.96
4
4
7.7
7/0
.98
3
3
7.8
8/0
.98
3
1 8
.77
/0.7
4
32
B
5
.89
/1.9
8
82
5
.85
/1.8
8
43
5
.59
/1.5
8
29
5
.75
/1.8
2
29
3
.11/
1.8
8
31
Cli
nic
al
le
ad
er
sh
ip
A
7
.67
/1.5
6
83
7
.50
/1.1
1 4
4
7.7
5/1
.01
34
8
.50
/1.1
0
32
9
.20
/0.8
2
34
B
6
.30
/2.1
4
82
6
.40
/2.3
2
41
5.4
8/1
.06
3
3
5.0
9/2
.51
29
2
.87
/1.8
9
32
Co
op
er
ati
on
a
nd
c
on
su
lta
tio
n
A
7
.62
/1.2
5
84
7
.50
/1.1
5
42
8
.00
/0.9
5
35
8
.16
/0.9
8
31
8.6
6/0
.77
3
3
B
6.1
4/2
.41
83
6
.05
/2.0
4
41
5.5
5/2
.52
3
4
4.6
6/2
.36
3
0
3.3
6/1
.42
3
2
Cr
itic
al
thin
kin
g
A
7
.47
/1.3
8
82
6
.75
/1.2
0
43
6
.75
/1.3
7
34
7
.50
/1.0
9
33
7
.25
/2.5
5
33
B
6.4
4/2
.26
8
1 6
.00
/2.0
7
4
1 5
.50
/1.7
8
32
5
.75
/1.0
9
32
3
.75
/2.9
5
33
*Stu
dy I
cons
ist o
f NG
RN
s em
ploy
ed b
y th
e co
unty
cou
ncil
in 2
016
and
2017
. *S
tydy
III c
onsi
st o
f NG
RN
s em
ploy
ed b
y th
e co
unty
cou
ncil
in 2
016.
48
NGRNs’ clinical competence development After five months of work experience, participating NGRNs scored
their highest clinical competence in the components ‘cooperation and
consultation’ and ‘ethical decision-making’ (III). After nine months of
work experience the highest clinical competences were found in the
components ‘clinical leadership’ and ‘cooperation and consultation’,
and after 15 months the highest scores were found in ‘clinical leader-
ship’ and ‘ethical decision-making’ (III) (Table 6). After five months of
work experience, participating NGRNs’ lowest self-assessed clinical
competence was found in the components ‘critical thinking’ followed
by ‘professional development’. After working for nine months, they
rated their lowest clinical competence components to be ‘professional
development’ and ‘critical thinking’. After working for 15 months, par-
ticipating NGRNs rated the components ‘critical thinking’ and ‘profes-
sional development’ to be the lowest (III) (Table 6).
There were no statistically significant changes found regarding the in-
creases in the components of clinical competence between two and five
months of work experience. Between five and nine months of work ex-
perience there were significant changes found in clinical competence in
the components ‘professional development’ and ‘critical thinking’.
There was a statistically significant change in the increase in all of the
components in clinical competence between nine and fifteen months.
However, the component ‘critical thinking’ was the only component
that numerically decreased in clinical competence during that period
(III) (Table 7).
49
Ta
ble
7.
NG
RN
s’ s
elf-
ass
ess
ed d
eve
lop
men
t b
etw
een
da
ta c
oll
ecti
on
s fo
r C
lin
ica
l co
mp
eten
ce (
A-s
cale
) a
nd
Nee
d f
or
furt
her
tra
inin
g (
B-s
cale
) in
th
e fo
ur
da
ta c
oll
ecti
on
occ
asi
on
s. M
ean
sco
re
dif
fere
nce
s, t
-va
lue
s, n
um
ber
of
resp
on
den
ts a
nd
p-v
alu
es
are
sh
ow
n.
Co
mp
on
en
t
Da
ta c
oll
ec
tio
n 1
-2
D
ata
co
lle
cti
on
2-3
D
ata
co
lle
cti
on
3-4
S
cale
M
ean
d
iffr
ence
t-
valu
e
n
p-v
alu
e
Mea
n
dif
fren
ce
t-va
lue
n
p
-va
lue
M
ean
d
iffr
ence
t-
va
lue
n
p
-va
lue
Dir
ect
clin
ica
l p
ract
ice
A
-sca
le
0.3
38
1
.76
8
32
0
.08
7
0.4
47
1
.99
7
25
0
.05
7
0.8
30
4
.50
9
30
<
0.0
01*
B
-sca
le
-0.1
59
-0
.64
3
29
0
.52
5
-0.0
16
-0.0
51
22
0
.96
0
-1.9
02
-2
.55
4
28
<
0.0
01*
P
rofe
ssio
na
l d
eve
lop
men
t A
-sca
le
0.2
58
0
.94
4
31
0.3
53
0
.57
6
2.8
23
2
5
0.0
09
*
1.4
46
2
.82
3
30
<
0.0
01*
B
-sca
le
-0.2
62
-0
.617
3
0
0.5
42
0
.53
9
1.7
19
22
0
.10
0
-1.2
75
-2
.30
0
24
0.0
31*
E
thic
al
dec
isio
n m
ak
ing
A
-sca
le
0.0
26
0
.16
1 3
3
0.8
73
0
.08
6
0.6
21
26
0
.54
0
0.9
77
5
.57
6
29
<
0.0
01*
B
-sca
le
-0.0
13
-0.3
81
24
0
.97
0
0.2
73
0
.75
8
24
0
.45
6
-2.2
55
-5
.29
1 2
7
<0
.00
1*
Cli
nic
al
lea
der
ship
A
-sca
le
0.2
35
1
.03
7
34
0
.30
7
0.3
75
1
.62
6
27
0
.115
0
.86
7
3.8
39
3
1
0.0
01*
B
-sca
le
-0.9
69
-2
.94
0
33
0
.00
6*
-0
.26
7
-0.6
86
2
8
0.4
99
-1
.43
1 -2
.65
9
29
0.0
13*
C
oo
per
ati
on
an
d c
on
sult
ati
on
A
-sca
le
0.3
43
1
.60
6
34
0
.118
0
.04
5
0.2
26
2
9
0.8
23
0
.54
4
2.6
62
3
0
0
.013
*
B-s
cale
-0
.30
8
-0.8
25
3
4
0.4
16
-0.3
91
-0.9
25
2
6
0.3
64
-1
.57
7
-3.5
47
3
0
0
.00
1*
Cri
tica
l th
ink
ing
A
-sca
le
0.2
50
1
.16
2
33
0
.25
4
0.6
07
2
.38
7
28
0
.02
4*
-0
.37
9
-1.9
05
2
9
0
.06
7
B-s
cale
-0
.64
8
-1.8
35
3
2
0.7
60
0
.04
6
0.1
16
27
0
.90
8
-0.9
00
-1
.48
2
30
0.1
49
*Sta
tistic
ally
sig
nific
ant p
-val
ues
(p<0
.05)
50
The NGRNs’ need for further training After two months of work experience, participating NGRNs rated their
highest need for further training in the items ‘I report all incidents in
accordance with the actual patient safety system’, ‘I have knowledge of
the interactions of various types of medication and what side-effects
they may cause for the patients I am responsible for’, and ‘I exclude
differential diagnoses when assessing patients’ health conditions’ (I)
(Table 8). The highest scores in the need for further training after two
months of experience were found in the components ‘direct clinical
practice’ and ‘professional development’ (I, III). After five, nine, and 15
months of work experience, the highest self-assessed need for further
training was found in the components ‘direct clinical practice’ followed
by the component ‘professional development’ (III) (Table 8).
51
Table 8. NGRNs’ self-assessed highest and lowest items in the B-scale showing need for further training, after two months of work experience. Mean values (M) and stand-ard deviations (SD). Highest need for further training Lowest need for further training
Content M SD Content M SD
1 I report all incidents in accordance with the ac-tual patient safety sys-tem
8.35 2.02 I maintain an ethical approach towards my colleagues
5.04 2.74
2 I have knowledge of the interactions of vari-ous types of medication and what side-effects they may cause for the patients I am responsi-ble for
8.15 2.05 I take active responsi-bility for creating a good working envi-ronment
5.21 2.57
3 I exclude differential diagnoses when as-sessing patients’ health conditions
7.77 2.03 I consult other profes-sional experts when required
5.25 1.82
4 I have knowledge of the effects of medication and treatment for the patients I am responsi-ble for
7.72 2.34 I act ethically when caring for patients
5.32 2.74
5 I assess patients’ health needs by telephone
7.61 2.31 I am independently responsible for health assessment (system-atic physical examina-tion), examinations and treatment of pa-tients with uncompli-cated medical condi-tions
5.58 2.71
6
I give health promotion advice and recommen-dations to patients by using telephone, e-mail or computer
7.51 2.50 I identify and assume responsibility for pa-tients’ own health re-sources in planning nursing care
5.67 2.37
7 I improve routines/sys-tems that fail to meet the needs of patients at my workplace
7.14 2.10 I take patients’ physi-cal health needs (ill-ness, pain, disabili-ties, etc.) into account when assessing and planning for the health and life situa-tion of patients
5.77 2.51
8 I interpret, analyse and reach alternative con-clusions about patients’ health conditions after a detailed mapping of health history and
7.11 1.96 I put emphasis on pa-tients’ own wishes when assessing and planning for nursing care and medical treatment
5.82 2.71
52
health assessment (physical examination)
9 I identify changes in patients’ health and medical conditions
7.05 2.18 I have a supportive on-going dialogue with patients about their needs and wishes
5.93 2.35
10 I experience a division of responsibility be-tween the physician and me as a nurse
6.68 2.52 I document the steps taken in assessing pa-tients’ needs for nurs-ing care and treatment
5.95 2.74
Values range from 1 to 10, where 1= a very low level and 10= a very high level.
After two months of work experience, participating NGRNs scored
their lowest need for further training in the following items; ‘I maintain
an ethical approach towards my colleagues’, ‘I take active responsibility
for creating a good working environment’, and ‘I consult other profes-
sional experts when required’ (I) (Table 8). Participating NGRNs’ low-
est need for further training after two months of work experience was
seen in the components, ‘ethical decision-making’ and ‘cooperation
and consultation’ (I, III). After five months of work experience, their
lowest need for further training was seen in the components ‘clinical
leadership’ and ‘cooperation and consultation’ (III). After nine months,
their lowest need for further training was seen in the components ‘co-
operation and consultation’ and ‘clinical leadership’, and after fifteen
months their lowest need was found in ‘clinical leadership’ and ‘ethical
decision-making’ (III) (Table 6).
Significant changes were seen between two and five months of work
experience as a decrease in the need for further training in the compo-
nent ‘clinical leadership’. In the period between nine and 15 months,
there was a statistically significant change seen as a decrease in all of
the components with the exception of ‘critical thinking’ (Table 7).
NGRNs’ experiences and managing of complex patient situations (II), their work situation, and perceptions of managing nursing care in complex patient situations (II, IV). After six months of work experience, participating NGRNs experienced
that they were ‘Not being sufficiently prepared and supported to meet
responsibilities and demands’, which constituted the overarching
53
theme representing the content in NGRNs’ experiences and manage-
ment of nursing in complex patient situations (II). After 18 months the
NRGNs perceived a ‘Clarity and security in own nursing role despite
facing challenges that hinder professional development’, which consti-
tuted the overarching theme representing the content in the NGRNs’
work situation and perception of managing nursing care in complex
patient situations (IV) (Table 10).
Table 10. A description of the categories and overarching themes in Studies II and IV. Study I a
Study IV b
Categories Overarching Theme
Categories Overarching Theme
Responsibility is not in proportion to the competence
Not being suffi-ciently pre-pared and sup-ported to meet responsibilities and demand
Independency due to own efforts and experience
Clarity and secu-rity in own nurs-ing role despite facing challenges that hinder pro-fessional develop-ment
Lack of medical competence and experience compli-cates patient safety
Well-functioning teamwork
Strives for control to manage and or-ganise nursing care
Challenges in the work situation
a NGRNs working experience of six months
b NGRNs working experience of 18 months
From chaos to control (II, IV) After six months of professional life, participating NGRNs experienced
that the responsibility and the demands placed on them when provid-
ing nursing care in complex patient situations far exceeded their com-
petence. The NGRNs were striving for control when providing nursing
care in complex patient situations but they experienced these situations
as difficult and that they did not have the control they needed. They
experienced not being able to spend time with their patients to the ex-
tent they needed to due to having responsibility for several complex
patient situations and difficulties in assessing and organizing nursing
care and therefore lack of time, which made it difficult to manage these
54
situations and that resulted in what they experienced as chaos. To man-
age the responsibility of nursing care in complex patient situations,
they were pushing themselves by setting patients’ needs prior to their
own needs by starting their work shifts early or by skipping their sched-
uled breaks for meals. This resulted in putting their own health at risk
and they expressed guilt over not having the energy to care for their
patients or themselves and for having negative thoughts about how
long they could carry on working as a RN. They experienced that they
were ill prepared and lacked medical competence that resulted in in-
sufficient management of medication administration, which poten-
tially compromised patient safety. As many patients were prescribed
several different medications, participating NGRNs had difficulties in
making decisions, reflecting, or finding the time to read about medica-
tions, which complicated its administration and made them feel wor-
ried and insecure. They experienced being fearful of making mistakes
when administering medication and they had also experienced making
mistakes. They tried to manage this by not rushing, double checking,
and trying to be critical about their patients’ prescriptions (II). After
18 months of work experience, participating NGRNs perceived that
they had achieved clarity and security in their roles as RNs as they had
gained competence and confidence. The NGRNs perceived that they
could manage several complex patient situations of which they had pre-
vious experienced of in their work settings resulted in a feeling of over-
all control in these situations. As they had gained experience of several
different complex patient situations, had these become familiar and
were now viewed as positive challenges. Participating NGRNs were
aware that their level of competence was important and could affect
their patients’ health. They had become comfortable and secure in their
professional role and could manage complex patient situations in the
knowledge that they had the skills required for the task.
From dependent to independent (II, IV) At the beginning of their careers, participating NGRNs experienced a
lack of the support they needed to independently manage complex pa-
tient situations. They experienced their competence as insufficient and
they needed support from more experienced RNs to help them manage
complex patient situations. Experienced RNs were needed to guide, re-
assure, and make the nursing interventions eligible and safe before the
55
NGRNs felt confident in carrying out nursing care in complex patient
situations. Without support from experienced RNs, participating
NGRNs felt alone with responsibilities and demands that were beyond
their clinical competence level, they tried to manage and put high ex-
pectations on themselves to do so but if they got criticised, they blamed
themselves for their mistakes and asked for help from experienced as-
sistant nurses (II). After 18 months of working and being exposed to a
variation of complex patient situations, the NGRNs found that they
were able to work independently, make decisions, and prioritise what
was best for their patients. Their experiences resulted in being able to
work independently and they gained a sense of security that allowed
them to lead nursing care in complex patient situations together in a
team that also included the patient. Within the team and with well-
functioned collaboration, participating NGRNs could manage complex
patient situations more effectively. They could do this by leading and
coordinating the nursing care being provided. They were determined
and driven and expressed their views in inter-professional collabora-
tion. They were delegating tasks, following up, and monitoring nursing
care carried out by assistant nurses (IV).
Shortage of RNs - consequences and demands (II, IV) When there was a shortage of experienced RNs, NGRNs were made re-
sponsible for managing nursing care in several complex patient situa-
tions simultaneously (II, IV). High expectations were placed on NGRNs
and to be able to manage several complex patient situations simultane-
ously, and these expectations were hard to live up to. These situations
could lead to the NGRNs not being able to find time for their own basic
needs such as eating or taking breaks, and they tried to get on top of
their workloads by starting shifts early. This also meant that basic nurs-
ing care was not prioritised as medical needs were taken care of first,
which made them deliberately avoid meeting some of the patient's
needs or resulting in a task shift among the NGRNs, the physician, and
the nurse assistants. This created ethical stress along with feelings of
failure, despite them pushing themselves to work harder. This also re-
sulted in low energy levels and thoughts about leaving the profession
already after six months of work experience (II). After 18 months of
work experience, the NGRNs were among the most experienced of all
the RNs on their wards. They found it difficult to manage assessments,
56
the prioritising of nursing care, and delegating work to assistant
nurses, as they were responsible for several complex patient situations
at the same time or outsourced, new patient groups they had no expe-
rience of. NGRNs were also made responsible for supervising novice
RNs and nursing students at the same time as they were expected to
manage patient situations that were complex enough for them to re-
quire support from experienced RNs. These challenges resulted in
NGRNs regressing in their professional development, suffering from
increased stress levels, and expressed views of being afraid of burning
out (IV).
57
Summary of the main results Participating NGRNs had challenging and demanding starts to their
careers, especially where direct patient and medical nursing care was
concerned when they started out as RNs, however, they developed pro-
fessionally to become secure in their roles and in their ability to manage
nursing care in complex patient situations.
After two months of work experience, participating NGRNs rated their
highest clinical competence to be ‘clinical leadership’, ‘professional
team collaboration’ and ‘ethical decision-making’, which were also
rated as lowest in the need for further training. After five to 15 months
of working in their professional roles, they still rated their clinical com-
petence as being highest in the areas of ‘professional team collabora-
tion’, ‘ethical decision-making’, and ‘clinical leadership’ and lowest in
the need for further training. After two months of work experience,
they rated their clinical competence as being lowest in the areas of ‘pro-
fessional development’ and ‘direct clinical practice’, and these areas
were rated as highest in their need for further training. After five to 15
months of work experience, they rated their lowest clinical competence
components to be ‘professional development’ and ‘critical thinking’,
with their highest need for further training in ‘direct clinical practice’.
Participating NGRNs’ development of clinical competence increased
substantially between nine and 15 months of working experience, with
the exception of ‘critical thinking’, and their need for further training
decreased the most between nine and 15 months, with the exception of
‘critical thinking’.
After 6 months of work experience, participating NGRNs experienced
that they were not being sufficiently prepared or supported to meet the
responsibilities and demands placed on them when providing nursing
care in complex patient situations. They were striving for control but
experienced these situations as difficult and that they did not have the
control they needed to manage them, which resulted in experiencing
chaos. They needed support from experienced RNs when nursing in
complex patient situations, with extra focus on medical competence
such as knowledge of medication, interaction, and side effects, and in
assessing, planning, prioritising, leading, distributing, and organizing
nursing care in complex patient situations.
58
After 18 months of working experience, participating NGRNs had
achieved clarity and independency in nursing care in complex patients’
situations due to increased experience gained through their own efforts
and struggles. They were capable of leading nursing care within well-
functioning collaborations that were a prerequisite for managing com-
plex patient situations. They perceived that they were facing challenges
in their work situation that hindered professional development. This
meant managing and organising nursing care of several complex pa-
tient situations or outsourced, new patient groups, as well as supervis-
ing students and novice RNs, was challenging and the NGRNs needed
further support from experienced RNs to develop in their profession.
59
Discussion
Discussion of results The overall aim of this thesis was to provide knowledge about NGRNs’
self-assessed clinical competence, professional development, work sit-
uation, and perceptions of managing nursing care in complex patient
situations during their first 18 months of work experience in acute care
hospital settings. Such knowledge is important for providers of nursing
education programmes and hospital managers to ensure an optimal
transition for NGRNs from education to practice, which in turn can
contribute to improved professional development, patient safety and
quality of care.
The results showed that the NGRNs expressed their clinical compe-
tence to be highest in collaboration, taking responsibility for ethical de-
cisions, and leadership. However, to to collaborate, take responsibility
and lead nursing care became more difficult due their work situation
with a high workload, limited support and insufficient clinical compe-
tence in the direct patient care.
A pressured work situation This thesis showed that the NGRNs experienced both high levels of re-
sponsibility and challenging demands being placed on them to manage
nursing care in complex patient situations without having access to
support from experienced RNs. They tried to manage patient needs by
prioritising medical care before nursing care, which meant that they
deliberately avoided meeting some of their patients’ needs or that tasks
were shifted between NGRNs, physicians, and assistant nurses. De-
manding workloads and a lack of experienced RNs for support caused
negative feelings among participating NGRNs as they felt they were not
doing a good job. Not being able to provide all the nursing care their
patients needed and feel forced to leave nursing care undone caused
frustration and led to thoughts about leaving the profession, this has
also been found in Karlsson, Gunningberg, Bäckström, and Pöder
(2019). Nursing care left undone has been demonstrated to be a pre-
dictor for intentions for turnover among RNs (Ausserhofer et al., 2014;
T. Jones et al., 2015). Challenging job demands and low control levels
can generate job strain (Karasek, 1979). According to Karasek, (1979),
60
responsibility can result in stimulating jobs with high productivity or
job strain. It is important to reach a balance in the mix of both the as-
pects job demands and job control. However, these results showed that
in the NGRNs first nine months of clinical practice, the work situation
did cause job strain as their clinical competence were fragmented in
complex patient situations, leaving them feeling alone with their re-
sponsibilities and pressured themselves to put their own health at risk.
Demanding workloads can lead to more job-related stress and strain,
which in turn can decrease patient safety (Kakemam et al., 2019; Sturm
et al., 2019).
Important factors impacting on RNs’ willingness to remain in the pro-
fession are support and cooperation from experienced colleagues when
dealing with complex patient situations, which includes making quick
decisions and prioritising tasks (Karlsson et al., 2019). Further, to stim-
ulate RNs retention in clinical work, it is important for them to engage
in knowledge exchange and receive positive feedback that contributes
to learning. These factors are also associated with a positive work situ-
ation (Ahlstedt, Lindvall, Holmström, & Athlin, 2019). Work environ-
ment have been found to be a key factor and could be crucial to RNs
remaining or leaving their jobs (Ausserhofer et al., 2014; Karlsson et
al., 2019; Nei, Snyder, & Litwiller, 2015). Despite the fact that introduc-
tion and mentorship programmes are needed to support NGRNs, they
also need support from experienced RNs in their daily work. Lack of
experienced RNs and high turnover of RNs is therefore a threat to qual-
ity of care and patient safety. Still, the shortage of nurses is expected to
increase considerably between 2025 and 2030 (WHO, 2016a). This
thesis showed that NGRNs with 18 months of work experience were
often considered to be among the most experienced RNs in acute care
hospital settings.
Increasing complexity in acute care hospital settings An intense transformation of acute care hospitals has led to major
changes for RNs, with a higher proportion of patients in need of more
demanding and complex nursing care (Bandini et al., 2018;
Dharmarajan et al., 2016; Disch et al., 2016). Shorter patient stays in
hospitals contribute to an increasingly complex healthcare system as
61
outsourced patient and post-acute care increases the number of pa-
tients with acute conditions and demanding nursing care needs in
acute care hospital settings (Aiken et al., 2017; Bandini et al., 2018;
Kramer et al., 2013; Rettke et al., 2015). In this thesis, unexpected acute
situations were described by participating NGRNs as unmanageable
and frightening as they were not prepared for these kinds of complex
patient situations. This is in line with previous research that has shown
that acute or unexpected complex patient situations are difficult and
challenging for NGRNs (Gellerstedt et al., 2019; Walton et al., 2018).
In regard to medical aspects, these results show that NGRNs need fur-
ther training in the effects of medications, how different medications
interact with each other, and the side effects of medications, for pa-
tients’ health as well as for the NGRNs’ development of competence in
administrating medication, managing different medications, and un-
derstanding and judging prescriptions. This thesis also showed that
participating NGRNs expressed lack of competence in these areas and
had a fear of making mistakes, which they had done. These results are
consistent with previous studies showing that medication errors are
frequent among NGRNs (Makary & Daniel, 2016; Treiber & Jones,
2018) and that this is related to demanding patients’ nursing care
needs and high workloads (Saintsing, Gibson, & Pennington, 2011). As
nursing care in complex patient situations is an interconnected process
with patients’ needs and resultant demands on nursing care as the
overall competence of the RNs providing nursing care is important for
the outcome in complex patient situations (Huber et al., 2020;
Kleinknecht-Dolf et al., 2015).
Another finding in this research was that participating NGRNs ex-
pressed that their greatest need for further training was in providing
direct patient-centred nursing care. As NGRNs have limited experience
of nursing care in complex patient situations, they need to spend more
time learning from these patient situations, relate to these complex pa-
tient situations, and use them in critical thinking, reflection, and self-
reflection to further develop professionally (Benner, 2001). This thesis
has shown that participating NGRNs expressed a low clinical compe-
tences in regard to assessing, planning, prioritising, leading, and dis-
tributing nursing care in complex patient situations. These compe-
tences are of great importance for quality of care and patient safety, and
62
are vital in nursing care in complex patient situations (Fagerström &
Glasberg, 2011; Massey et al., 2010; Massey et al., 2014), which is fun-
damental in the nursing process (Kozier et al., 2008). Being unable to
make clinical decisions and prioritise tasks is associated with nursing
care undone, which is a predictor for negative patient outcomes such
as adverse events (T. Jones et al., 2015). This thesis showed that par-
ticipating NGRNs had a need for further training in incident reporting.
Hospital managers have an important responsibility to ensure that
NGRNs will get adequate training in reporting incidents. Previous re-
search has shown that ward managers’ behaviour, leadership style, and
lack of error feedback contributes to barriers in reporting medication
errors (Farag, Blegen, Gedney-Lose, Lose, & Perkhounkova, 2017;
Vrbnjak, Denieffe, O’Gorman, & Pajnkihar, 2016). As heavy workloads
have been found to hinder RNs from reporting incidents, adverse
events can go unreported (Karlsson et al., 2019). In this thesis, the re-
sults showed that participating NGRNs were concerned about report-
ing incidents. Therefor, this would be a great opportunity for hospital
managers to highlight patient safety risks and prevent adverse events
in the future at the same time as they could support evidence-based
nursing care and professional development.
Professional development Professional development, including gaining clinical competence,
takes place according to Benner (2001) through working as a RN in the
same context over a longer period. This has also been described in re-
search later on, which demonstrates that clinical competence can differ
according to length of work experience (Meretoja, Numminen, Isoaho,
& Leino‐Kilpi, 2015). In addition, when gaining experience, it is also
important to get support from experienced RNs. The current results
showed that participating NGRNs had a general need for support from
experienced RNs due to their work situation, and a specific need for
support in managing and organising the nursing care of several com-
plex patient situations or providing nursing care to new patient groups.
There is a large body of research demonstrating that supporting
NGRNs is essential for their clinical competence development as well
as their professional development (Gardiner & Sheen, 2016; Irwin,
Bliss, & Poole, 2018; Page, Pool, Crick, & Leahy, 2020; Pasila, Elo, &
63
Kääriäinen, 2017). In this thesis, participating NGRNs’ clinical compe-
tence increased over time, with a statistically significant increase be-
tween nine and 15 months of experience. This is a contradictory result;
in other longitudinal studies conducted over 12 months, the clinical
competence increased most during the NGRNs’ first six months of
work experience (Lima et al., 2016; Takase et al., 2014). One reason
why the results in this thesis showed that it takes longer for NGRNs to
develop professionally than what other studies have found may be due
to the rapid changes that have taken place in the healthcare system in
recent years. Factors such as newly developed medical advances, new
treatments, new technology, shorter patient stays, and outsourced pa-
tients, just to mention a few, in connection with high staff turnover,
have resulted in a higher ratio of NGRNs to experienced RNs than what
has been seen earlier. These factors in combination may have created
a synergy effect of increased complexity, and research may not corre-
spond to the knowledge of the rapid developments we see in acute care
hospital settings these days. This can indicate that different hospital
settings can have a different impact on NGRNs’ professional develop-
ment, and that clinical competence in acute care hospital settings takes
more time to develop.
Another important aspect of NGRNs’ professional development is as-
sociated with critical thinking and reflection (Benner, 2001). In this
thesis, the development of critical thinking did not follow the same pat-
tern as other clinical competence. These results is in line with another
study that showed that critical thinking and reflection did not develop
over time like other clinical competences Lima et al. (2016).
Wangensteen et al. (2012) also found critical thinking and reflection as
the lowest rated clinical competence and an issue for NGRNs in the
very beginning of their careers. A possible explanation for the weak de-
velopment of critical thinking skills seen in this thesis may be that par-
ticipating NGRNs expressed that they did not get enough time to reflect
on a daily basis. This is an important, and worrying, finding, as the
development of competences occurs when the NGRNs’ experiences of
clinical patient situations are combined with critical thinking and re-
flection (Benner, 2001). The ability to think critically is fundamental
for professional development (Rizany, Hariyati, & Handayani, 2018).
64
Further, critical thinking and reflection among colleagues may be es-
sential to develop self-reflection and life-long learning as it is argued
that these are a predictor for the development of clinical competence
(Forsman et al., 2019; Nilsson et al., 2019b).
This thesis showed that NGRNs had developed professionally after 18
months of work experience and gained clarity and security in their roles
as they managed and had experience of providing nursing care in com-
plex patient situations through leading and collaborating with col-
leagues and patients. Collaboration among RNs to provide person-cen-
tred nursing care were also found to improve professional development
(Ahlstedt et al., 2019; Karlsson et al., 2019). To further stimulate pro-
fessional development, a self-assessment instrument tool such as
ProffNurse SAS II can be used for co-assessment, meaning NGRNs
self-assessment that is also assessed, discussed and reflected together
with an experienced RN or manager to ensure self-awareness and pro-
fessional development.
Need for collaboration and ethical nursing care This thesis showed how the NGRNs expressed collaboration and con-
sultation with other colleagues as their highest clinical competences.
However, they had difficulties putting these competences into practice,
as they were not sufficiently supported by experienced RNs and felt
alone with the demands and responsibilities placed on them when
managing nursing care in complex patient situations. It has previously
been shown in research that support from colleagues is vastly im-
portant, and that highlighted support from and collaboration with ex-
perienced colleagues is associated with higher clinical competence
among NGRNs (Lima et al., 2016; Numminen, Ruoppa, et al., 2016;
Pasila et al., 2017). Further, that inter-professional teamwork is an im-
portant strength in a well-functioning healthcare system that also in-
creases professionals’ work satisfaction (Karam, Brault, Van Durme, &
Macq, 2018). Supportive colleagues and constructive feedback are im-
portant for NGRNs’ ability to handle challenges and demands in the
work (Irwin, Bliss, & Poole, 2018; Lima, Jordan, Kinney, Hamilton, &
Newall, 2016). A supportive atmosphere, positive socialisation, and be-
ing part of a team are also important for NGRNs as these factors reduce
anxiety and enhance job satisfaction (van Rooyen, Jordan, ten Ham-
65
Baloyi, & Caka, 2018). In contrast, as shown in this thesis, not getting
the support needed can lead to insecurity for both NGRNs and patients,
and the experience of loneliness and chaos among NGRNs who have
not developed the clinical competences required to manage complex
patient situations. Low competences may lead to unaddressed or
poorly provided nursing care in complex patient situations, which can
result in negative patient outcomes. It has been shown that if experi-
enced RNs not were interested in sharing their knowledge and experi-
ence with NGRNs, they provided inadequate supervision (Gardiner &
Sheen, 2016). However, it might not have be a lack of interest in sup-
porting the NGRNs that is the issue, but rather the severe shortage of
experienced RNs. This thesis showed the NGRNs find supervising even
more novice NGRNs as challenging. Another cause can be that NGRNs
often lack the time needed to utilise feedback from peers to improve
their clinical competences (Phillips, Esterman, & Kenny, 2015).
In this thesis, the NGRNs expressed high clinical competence in ethical
decision making and taking ethical responsibility for the nursing care
of patients’ physical, mental, and social health. Having patient needs
as a starting point is fundamental to providing safe nursing care that is
person-centred (Byrne et al., 2020; Ekman et al., 2011). However, this
thesis showed that NGRNs wanted to provide a person-centered ap-
proach but failed to establish nursing care based on patients’ needs by
not having enough time for bedside nursing care, due to difficulties of
organizing nursing care and being dependent of experienced RNs. This
can reduce patient safety as well as integrity and the interpersonal re-
lationship between RNs and the patient (Jangland, Teodorsson,
Molander, & Muntlin Athlin, 2018). To prioritise patient medical-re-
lated needs over psychosocial needs and care planning due to high
workload and lack of experienced RNs were common in European hos-
pitals (Ausserhofer et al., 2014). Ahlstedt et al. (2019), found how
moral and ethical stress increased the experience of not doing a good
job despite putting oneself and patients’ needs aside, which could also
constrain patient safety, professional development, the RNs’ health,
and reduce the chances of keeping staff in the profession. Still, as
shown in this thesis, NGRNs had difficulties in putting their ethical
competences into practice due to their problems in prioritising and or-
ganising nursing care and high workload. The fact that medical care
66
had first priority resulted in nursing care being left undone or that they
carried out tasks that were usually the physicians’ responsibilities while
assistant nurses took over NGRNs’ responsibilities.
Clinical leadership in nursing care In this thesis, competence in clinical leadership in terms of taking re-
sponsibility for one’s own decisions and actions as well as nursing care
were rated high by participating NGRNs. However, the result also
showed that the leading, planning, prioritising, organising, and distrib-
uting nursing care in complex patient situations within the team, were
expressed as difficult and beyond the NGRNs’ own competence and re-
sulted in difficulties to gain control. High rates seen in taking respon-
sibility for one’s own nursing actions is consistent with other research
studies using the ProffNurse SAS II, when assessing post graduate RNs
(Wangensteen et al., 2018) and advanced practicing nursing students
(Taylor et al., 2020). Leadership and organisation of nursing care were
competence areas that have a potential to be developed among newly-
graduated nursing students (Gardulf et al., 2019) as well as RNs
(Halabi, Lepp, & Nilsson, 2020). The importance of RNs’ leadership
competences is highlighted by a need to be prioritised and supported
within all levels of healthcare (WHO, 2020a).
It became evident in this thesis that participating NGRNs were ex-
pected to supervise even more novice NGRNs after only six months of
work experience, and were also made responsible for supervising nurs-
ing students after even less time. Supervising novice RNs and nursing
students was perceived as a challenge. Low scores of self-rated clinical
competence in supervising students and staff has also been found
among novice RNs (Nilsson et al., 2019a) and newly-graduated nursing
students (Gardulf et al., 2019). This finding is of importance for leaders
responsible for nursing education programmes as it points to a need to
have a greater focus on nursing leadership and supervision throughout
the programme and not only in the latter part (Theander et al., 2016),
as this could contribute to NGRNs’ readiness and performance in their
new profession. To prepare future NGRNs for clinical practice, nursing
education programmes need to adapt to today’s increased demands,
complex nature and constant changes seen in the healthcare system.
Both theoretical and practical nursing care and direct patient care need
67
to be further integrated into nursing education programmes, and it is
vital that experienced RNs with well developed clinical competences
supervise nursing students during their clinical placements. Nursing
students need to be further prepared in the area of medication admin-
istration, its side effects, interactions, and effects on patient health.
These are all competences needed to manage nursing care in complex
patient situations, as well as in assessing, planning, prioritising, lead-
ing, and distributing nursing care. However, employers in the
healthcare system have the responsibility to assure that inexperienced
NGRNs will not have to practice beyond their level of clinical compe-
tence (ICN, 2013). It is also important to utilise research evidence when
organising nursing care in terms of composing teams with a range of
experience and clinical competence (National Board of Health and
Welfare, 2015). Further, it is important to strengthen women's leader-
ship, as the majority of RNs working in healthcare are women. WHO
(2020c) emphasises the importance of supporting female leadership at
all levels in the healthcare system. Supporting female leadership may
also strengthen female RNs, as Carlsson (2020) found that female
nursing students assessed their leadership abilities lower than their
male counterparts.
Experienced RNs are essential in well-functioning acute care hospital
settings as they are like a catalyst that generates general support in the
NGRNs’ work situation on a daily basis, giving them feedback and op-
portunities for reflection and critical thinking – which increases
NGRNs professional development and in turn provides work satisfac-
tion and retention. Experienced RNs are also fundamental to providing
specific support in terms of strengthening NGRNs’ competences in
managing nursing care in complex patient situations with special at-
tention to medical competence and the assessing, planning, prioritis-
ing, leading, and distributing of nursing care in these situations. There-
fore, one of the greatest challenges of the healthcare system in upcom-
ing years will be the retention of RNs, as the current high turnover has
led to a vicious cycle developing. There is a need for powerful and ur-
gent action to be taken at a national level to establish a sustainable
work situation for all RNs, regardless of work experience, and RNs
need to be given central leadership positions in our healthcare systems
68
so that they can have an impact of RNs work situation and facilitate a
sustainable working life.
Methodological considerations This thesis has applied a combination of quantitative (I, III) and qual-
itative (II, IV) methods, responding to different aims and contributing
to a more comprehensive knowledge of the phenomenon (Polit & Beck,
2021). The methodological considerations are discussed in relation to
validity and reliability in quantitative studies I and III and in relation
to trustworthiness of the qualitative studies II and IV using the con-
cepts of credibility, confirmability, dependability, and transferability.
The quantitative studies (I, III) Validity means the extent to which an instrument measures what it in-
tended to measure and how accurate and well founded the inference is
in regards to the relationships and differences in the results (Polit &
Beck, 2021), and how measurement errors are minimised.
Statistical conclusion validity refers to whether inferences of depend-
ent and independent variables are accurate (Polit & Beck, 2021), and
also refers to type I and type II errors (Pallant, 2013). In the current
studies, the level of significance was set at p < 0.05, which may have
reduced the risk of type I errors of falsely rejecting the null hypotheses.
However, this may have increased the risk of type II errors – of reject-
ing the effect there really is, giving a false non-significant result. The
sample sizes in the studies were considered to be appropriate for the
data analyses performed (Hair, Black, Babin, & Anderson, 2014). The
use of parametric analyses was considered to be appropriate due to the
assumption that mean scores were normally distributed and the vari-
ance of data was met (Field, 2014). Type II errors are dependent on the
sample size and can be calculated by a power analysis. However, not
doing this can be seen as a weakness as it can be a threat to statistical
conclusion validity.
Internal validity reflects on the problem that can interfere with results
that are caused by independent variables rather than other conditions
(Polit & Beck, 2021). In order to minimise the risk for bias in the selec-
tion, consecutive sampling was used, meaning all eligible NGRNs were
69
recruited (Polit & Beck, 2021). A strength in these studies is that the
response rate was considered to be high and the internal dropout was
low with the exception of the two single items related to health promo-
tion and health assessment by telephone, e-mail, or computer. A reason
for the high response rate may have been the repeated face-to-face oral
information that was given to participants when conducting the data
collections and that participating NGRNs had time given to them to
complete the questionnaires. Other possible threats to internal validity
could be events that concern external processes such as events in soci-
ety or maturation that concerns processes within individuals such as
maturity or stress levels. In study III, data collection spanned a period
of 15 months, and with participating NGRNs being young adults, there
may have been several changes in regard to events and maturity that
may have influenced the outcome during this period.
In this thesis, the ProffNurse SAS II (Wangensteen et al., 2018) was
used and has been used in different Scandinavian contexts. ProffNurse
SAS II stands apart from other instruments measuring clinical compe-
tence due to having two scales; the A-scale measures RNs’ self-assessed
clinical competence and the B-scale measures their self-assessed need
for further training in the respective areas. Face-validity was imple-
mented by independent experts concerning the relevance of the instru-
ment among RNs working in nursing homes (Finnbakk et al., 2015).
Thus, a weakness about the internal validity of the thesis could be that
ProffNurse SAS II has not been psychometrically tested specifically
among NGRNs in acute care hospital settings.
Clinical competence in nursing practice is complex and there is no con-
sensus regarding the definition of competence. It is therefore difficult
to measure, and there is a lack of psychometrically tested instruments
used to measure it (Charette et al., 2020; Nilsson et al., 2014; Yanhua
& Watson, 2011). Despite this, there are several instruments developed
and being used today. The assessment tool AssCE is used for the self-
assessment of nursing students’ clinical competence during their clini-
cal placements in nursing education programmes (Engström, Löfmark,
Vae, & Mårtensson, 2017). The Finnish Nurse Competence Scale (NCS)
(Meretoja et al., 2004) is an instrument used in several continents in-
cluding Europe (Flinkman et al., 2017) to measure clinical competence
70
among practicing RNs. The European Health Care Training and Ac-
creditation Network Questionnaire Tool (Cowan et al., 2008) measures
RNs’ clinical competence in practice in an European context. The
Nurse Professional Competence (NPC) scale in its original version
(Nilsson et al., 2014) and short form (Nilsson, Engström, Florin,
Gardulf, & Carlsson, 2018) aims to measure professional competence
among nursing students and practicing nurses and is also used inter-
nationally. Despite there being a range of instruments used to measure
nurses’ competence, the ProffNurse SAS II was deemed to be the most
useful for these studies as its focus was on clinical competence as well
as the need for further training.
The most common method to assess the competence of RNs is self-as-
sessment (Kajander-Unkuri, 2015) and in studies I and III, levels of
clinical competence were evaluated by the NGRNs themselves. Due to
this method of data collection, the subjectivity of self-assessment needs
be considered. Self-assessment could start a reflective process that
might lead to the development of the NGRNs’ clinical competence. Yet,
self-assessed competence has been criticised for not reflecting real
competence due to self-bias and subjectivity. In study III, due to the
subjective nature of self-assessment, participating NGRNs may have
overestimated their assessments, possibly due to their own expecta-
tions of clinical competence or possibly due to others’ expectations that
may have led to an overestimation of their own clinical competence.
However, one should have in mind that clinical competence being as-
sessed by others is also subject to variability and bias (Hensel, Meijers,
van der Leeden, & Kessels, 2010).
External validity refers to what extent observed findings can be gener-
alised beyond the study sample in different settings and with different
conditions and participants (Polit & Beck, 2021). External validity can
be enhanced by a representative sample (Field, 2014). A strength in the
studies was that participating NGRNs worked in different acute care
hospitals settings on both general medical and surgery wards as well as
in specialised settings. The hospitals were located in both rural and ur-
ban areas. More women than men participated, but this reflects the dis-
tribution of female and male RNs at a national level (National Board of
71
Health and Welfare, 2018). However, this could have affected the re-
sults as females and males may self-assess differently. A threat to ex-
ternal validity that needs to be considered as a weakness was the
changes that might have occurred during the data collection periods
(studies I and III). In study I, data were collected one year apart in 2016
and 2017. This was done to minimise measurement error, as it proba-
bly would have meant a greater difference in conditions if the NGRNs
had graduated and started their employment in the summer and in the
winter, instead of only in the summer. Data were collected in both 2016
and 2017 before their mandatory clinical development programmes
started. In study III, data were collected over a 15-month period and
many changes may have occurred during this period. That participat-
ing NGRNs were part of a clinical development programme could have
affected the results. However, they were all participating in the same
clinical development programme and the programme was planned in
advance in regard to activities and who was responsible for each activ-
ity. Lack of information regarding which acute care setting participat-
ing NGRNs worked in could be considered as a limitation, however, the
author got this information from the person coordinating the clinical
development programme. Background questions about which acute
care setting the NGRNs worked in may have given a clearer description
of the participants. Furthermore, the sample size was relatively small
(III). As no other comparison was made to strengthen the external va-
lidity, a paired t-test was used and was based on individuals’ changes
i.e. the NGRNs’ increase or decrease in clinical competence and need
for further training (III) (Streiner & Norman, 2008). Consequently,
generalisability of the results needs to be interpreted with caution, but
the knowledge gained could well be important to NGRNs working in
different acute care hospital settings in Sweden.
Reliability refers to what degree of accuracy and consistency is ob-
tained for the measured information (Polit & Beck, 2021). An accepta-
ble value with respect to Cronbach’s alpha is above 0.7 (Hair et al.,
2014; Tavakol & Dennick, 2011). Reliability was tested using an inter-
nal consistency test, Cronbach’s α (I, III). Overall, Cronbach’s α in the
A-scale and the B-scale as well as the six components was considered
to be good (I, III). The exception to this was the component clinical
leadership (0.68) in the A-scale (I), which was also rated as being the
72
lowest of Cronbach’s α value (0.65) in the four data collations (III). Low
Cronbach’s α values can be explained by a low number of items in the
component (Field, 2014). As mentioned earlier, an overall weakness is
that no extensive psychometric analysis has yet been carried out due to
ProffNurse SAS II being a relatively newly developed instrument.
There is an uneven distribution of items included in the different com-
ponents, ranging from four items in ‘Clinical leadership’ and ‘Critical
thinking’ up to 15 items in the component ‘Direct clinical practice’. For
an increased robustness and reliability, it could be considered whether
the low number of items in some components should be increased and
the high number in others decreased. Therefore, further psychometric
analyses need to be conducted on ProffNurse SAS II with larger sample
numbers of NGRNs.
The qualitative studies II and IV Credibility refers to the results’ truthfulness; if the studies are well de-
scribed in terms of design and analysis with the risk of bias (Lincoln &
Guba, 1986). In study II and IV, participants had a prolonged engage-
ment of the studied phenomena. The aim of the studies was suitable for
qualitative content analysis to gain a deeper understanding of NGRNs’
experience and management of complex patient situations after six
months of work experience (II), and perceptions of their work situation
and management of nursing care in complex patient situations after 18
months of work experience (IV). In order to capture interactions
within a group and group dynamics, focus group interviews (FGIs) can
assist participants in expressing and clarifying their views in a way that
is less likely in individual interviews. In the FGIs, participating NGRNs
were encouraged to describe their understanding and express and clar-
ify their views, thoughts, and behaviour related to the aim of the study
(Jayasekara, 2012). Semi-structured questions were used in FGIs in
studies II and IV, as well as probing and encouraging questions such
as; ‘Can you please give an example?’ or ‘Can you tell us more about
that?’ to avoid misunderstandings and to achieve more detailed an-
swers (Polit & Beck, 2021). In order to obtain a suitable sampling size
in the FGIs, a goal was to try to organise groups of four to six partici-
pants, as suggested by (Morgan, 1997). This was not possible in all FGIs
due to difficulties to coordinate schedules and illness among the par-
73
ticipants; this could have served as a bias to credibility. However, in-
formation from the FGIs was sufficient to achieved data saturation. A
strength in study II and IV was that participating NGRNs interacted
with each other and shared their own views, and during the FGIs
participants nodded, added details, and joined in the conversations. A
convenient sampling was chosen, which could be a weakness to
credability and that may have affected the results (II) as only female
NGRNs paticipated; male NGRNs may have had other experiences or
views.
Confirmability refers to the objectivity of the results. In order to
strenghten confirmablity, all authors have been involved throughout in
the analysis process, and striving for objectivity, this may have reduced
the risk of bias. During the data analysis, all of the authors were en-
gaged in the entire process and continuously discussed each step in the
process as well as the emerging categories and themes (II, IV). The first
author, however, has experience of nursing in complex patient
situations and her pre-understanding may have affected the analysis.
The authors of the articles were all RNs with experience from different
areas of nursing care in complex patient situations and their experience
also varied in length. This could be a strength due to their different pre-
understandings. However, all authors discussed their pre-
understandings thoroughly and study II and IV have been critically
discussed in research seminars including both the authors and outside
researchers to accentutate the objectivity of the analysis. In addition,
to strengthen credibility and confirmability, participating NGRNs’
own voices were used in quotes (II, IV).
Dependability refers to the stability of data over time and circum-
stances (Lincoln & Guba, 1986). Therefore, the interviewing situations
were organised to be as equal as possible and the moderator strived for
participants to open up, talk freely, and feel comfortable (Polit & Beck,
2021). Further, each FGI within the respective study had the same
opening question and the same question guide with follow-up ques-
tions. During six of the eight interviews, an assistant moderator was
present. This may have influenced the interviews. Regarding the anal-
ysis process (II, IV), codes were extracted from the meaning units and
74
the first author and one of the co-authors coded the same two inter-
views separately in both studies and then compared the codes, result-
ing in high congruity.
Transferability refers to whether the results can be transferred to other
groups or to other similar contexts (Lincoln & Guba, 1986). Transfera-
bility was assured by descriptions of the participants and the context.
The concept, nursing care in complex patient situations, was discussed
and participating NGRNs gave examples of these situations before all
the FGIs to assure that everyone in the group had the same perception.
The NGRNs worked at different acute care hospital settings. A weak-
ness in the description of the participants was that details regarding
which acute care hospital settings the NGRNs were working at were not
collected. The NGRNs were considered to be a homogenous group in
terms of age, sex, and experience of the subject; this could have affected
the result and transferability as the reduced variation in the FGIs could
be seen as bias.
75
Conclusions and implications NGRNs had high demands on them, as they were expected to take on
the responsibilities of an experienced nurse right from the start. This
led to experiences of chaos and difficulties in gaining control. In addi-
tion, providing holistic, person-centred care is difficult for NGRNs who
are in a work situation that does not allow them to spend time at pa-
tients’ bedsides due to an extremely high workload. There is a need for
action to be taken to establish a sustainable work situation for all RNs,
regardless of work experience.
Lack of support and being in an exposed work situation with high de-
mands hinders NGRNs’ development of clinical competence when
working with complex patient situations, which in turn affects quality
of care and patient safety negatively. Improved support is needed from
the start to improve NGRNs’ work situation and reduce the pressure
and demands placed upon them.
With sufficient support from experienced RNs and if given the oppor-
tunity to reflection and receive daily feedback, NGRNs’ work situation
could be improved. NGRNs need to experience a sense of security in
their profession and at the same time be given the opportunity to grow
and develop into competent RNs.
Regular use of the instrument ProffNurse SAS II could contribute to-
wards identifying NGRNs’ needs for further training and to improve
NGRNs’ development of clinical competence during their first two
years of clinical practice, which would lead to increased professional
development.
Introduction programmes based on NGRNs’ needs for further training
in combination with individual daily support need to be further devel-
oped and implemented.
The findings from this thesis can also be used to direct and develop
nursing education programmes to respond towards NGRNs’ needs in
regards to further preparing and strengthening NGRNs’ clinical com-
petence.
76
Future research Further longitudinal studies of NGRNs’ clinical competence is needed
to strengthen the evidence base in order to further support the devel-
opment of NGRNs’ clinical competence.
An intervention study is needed to evaluate the effect that introduction
programmes have on NGRNs’ clinical competence and professional de-
velopment.
Further psychometric evaluation on the instrument ProffNurse SAS II
is needed. A short form of the ProffNurse SAS II would be beneficial to
use as a co-assessment instrument for measuring professional devel-
opment.
More knowledge is needed in regard to NGRNs’ clinical competence
and need for further training in comparison to gender and in different
acute care clinical contexts such as internal medicine and surgery set-
tings.
Studies on NGRNs’ clinical competence from a patient perspective and
how this might contribute to development of person-centred care
would be valuable.
More knowledge is needed about NGRNs’ perceptions of important fac-
tors for their work situations related to remaining in the nursing pro-
fession for the long term.
77
Acknowledgments
It was the best of times, it was the worst of times, it was the age of wis-
dom, it was the age of foolishness, it was the epoch of belief, it was the
epoch of incredulity, it was the season of Light, it was the season of
Darkness, it was the spring of hope, it was the winter of despair…
-A Tail of Two Cites- By Charles Dickens
As I finally finish my thesis, now at the very end of my doctoral educa-
tion, I think back on these years and can only say ‘Wow what a journey
in research and in life’.
There are many people who have made this journey possible and sup-
ported me to whom I would like to express my sincere gratitude to.
I wish to thank all the NGRNs who took their time to respond to the
questionnaires not only once but four times, and many who also gen-
erously shared experiences, thoughts and concerns in the interviews.
Thank you!
To my supervisors, Associate Professor Jan Nilsson and Senior Lec-
turer Kaisa Bjuresäter. I feel very fortunate to have been supervised by
such genuinely nice and decent people, and I want to thank you for
sharing your sharp intellects, research experience, knowledge and con-
structive feedback with me. For encouraging growth and creativity, I
thank you! For being my rocks and guiding light, I respect you! For tak-
ing my hand and believing in me, I am forever grateful!
Karlstad University and Professor Bodil Wilde-Larsson for accepting
me as a PhD student, and Professor Maria Larsson for organising in-
spiring and creative seminars, I looked forward to every one of them!
Thanks to Head of Department Helene Hjalmarsson for bringing light
on the possibilities.
Many thanks to ALL my fellow PhD students who have been involved
in the seminars and come up with constructive feedback and generally
gilded my existence as a PhD student. To my PhD colleagues at the
Writing Boot Camp, thanks for the writing and dancing! Cheers!
78
To Professor Gunilla Borglin, who made me discover the creativity of
academic work and the infinite learning of methods, thank you.
Thank you to Ingrid Andersson, Maria Andersson, Annika Skoogh, Ul-
rik Terp, Brian Unis, Katarina Karlsson, and Divya Stephen for all the
walks, talks, and lunches.
To Jari Appelgren, thank you for being a master at turning statistics
into something exciting, understandable, and tangible ... over and over
again. Your patience and pedagogical abilities are incredible.
As a person who likes books but not libraries, reading and finding arti-
cles but not referencing, Librarian Annelie Ekberg Andersson has been
an invaluable support, helping and guiding me through EndNote and
the jungle otherwise known as the library. Thank you.
An important goal for me during my PhD education was to improve my
English in speech and writing; Gabrielle Mackay Thomsson has con-
tributed to that by reviewing all my articles and now by helping me dur-
ing the intensive final work with the thesis, all the way from New Zea-
land in lockdown with all that entails, it has been superb.
Philip Gille for being my mentor – with you, I have shared success and
setbacks and you have shared your wisdom and strength, thank you for
your valuable and kind advice.
Thank you to all my good friends outside the academic world for en-
couraging me along the way with laughter, fun, and sometimes a free
zone, none forgotten.
Our co-family, Linda, Daniel, Elin and Enar Wit for your hospitality,
for always having an open door and a supply of everything for everyone,
breathing room, and great fun included. I could not have done this
without you.
And Anna Abelsson, my dear, dear friend and colleague, I cannot thank
you enough for your support in all conceivable and unexpected forms,
79
when I lost my grit or needed proper Champagne, or simply a kick in
the butt! Yet the best is still ahead of us, I am so looking forward to our
collaborating in research and life. Thank you from the bottom of my
heart for your kindness, energy, knowledge, inspiration and generosity.
To my dear family including all of you Willmans, thank you for your
help and curiosity during this process, and to mormor Maj for being
my greatest supporter, thank you all.
To my mum Lena, and Göran, and my dad Kjell and Ingelie for always
being supportive no matter what and helping with all kinds of practical
things to make my life go around, and to my brother Tobias for your
encouragement and interest, I will always love you.
To my love and darling soul mate Anders, thank you for loving me back.
For showing patience, encouragement and for helping me make this
sometimes bumpy journey less uncomfortable. And to my dearest The-
odor, thank you for always reminding me what life is all about – you
mean the world to me.
80
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Newly graduated registered nurses’ clinical competence, professional development and work situation
Newly graduated registered nurses working in acute care hospital settings need to be able to provide safe nursing care in a fast-changing healthcare system with an increasing number of complex patient situations and ongoing nursing shortages. The overall aim of this thesis was to explore and describe newly graduated registered nurses’ self-assessed clinical competence, professional development, work situation, and perception of their ability to manage nursing care in complex patient situations during their first 18 months of clinical practice in acute care hospital settings. Newly graduated registered nurses’ clinical competence increased over time, however, they continued to need support from experienced nurses to manage nursing care in complex patient situations. It is important to improve NGRNs’ work situation and support their clinical competence development based on their need for further training, which would contribute to increasing the quality of care they provide, patient safety, and professional development.
DOCTORAL THESIS | Karlstad University Studies | 2020:25
ISSN 1403-8099
ISBN 978-91-7867-145-8 (pdf)
ISBN 978-91-7867-140-3 (print)
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