Newly graduated registered nurses’ clinical competence ...kau.diva-portal.org/smash/get/diva2:1460328/FULLTEXT02.pdffessional Nurse Self -Assessment Scale of clinical core competences

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


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

esse

d c

om

po

nen

ts i

n c

lin

ica

l co

mp

eten

ces,

th

e A

-sca

le,

an

d n

eed

fo

r fu

rth

er t

rain

ing

th

e B

-sca

le a

fter

2

mo

nth

s (I

) a

nd

aft

er 2

-15

mo

nth

s o

f w

ork

ex

per

ien

ce I

II.

Mea

n v

alu

es (

M)

an

d s

tan

da

rd d

evia

tio

ns

(SD

).

Co

mp

on

en

ts

Sc

ale

S

tud

y I

* S

tud

y I

II*

Stu

dy

III

S

tud

y I

II

Stu

dy

III

2

mo

nth

s

N

2 m

on

ths

N

5 m

on

ths

N

9 m

on

ths

N

15

mo

nth

s

N

M/S

D

M

/SD

M/S

D

M

/SD

M/S

D

Dir

ec

t

cli

nic

al

pr

ac

tic

e

A

6

.59

/1.5

2

84

6

.60

/1.0

6

44

6

.93

/0.9

8

34

7

.53

/1.0

4

32

8

.46

/0.7

9

33

B

6.7

6/1

.23

8

3

6.9

3/1

.39

4

1 6

.81/

1.3

8

31

6.4

0/1

.44

3

0

4.3

0/1

.49

3

0

Pr

ofe

ssio

na

l

de

ve

lop

me

nt

A

5.7

0/1

.57

8

3

6.0

0/1

.46

4

1 6

.76

/1.4

5

34

6

.90

/1.3

7

29

8

.40

/0.7

4

34

B

6

.71/

1.3

2

81

6.7

0/1

.38

4

0

5.9

0/1

.47

3

2

5.9

8/1

.25

2

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

References

Ahlstedt, C., Lindvall, C. E., Holmström, I. K., & Athlin, Å. M. (2019).

What makes registered nurses remain in work? An ethnographic study. International Journal of Nursing Studies, 89, 32-38. doi:10.1016/j.ijnurstu.2018.09.008

Aiken, L. H., Clarke, S. P., Silber, J. H., & Sloane, D. (2003). Hospital nurse staffing, education, and patient mortality. LDI Issue Brief, 9(2), 1-4. doi:10.1056/nejmc1104381

Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., . . . Moreno-Casbas, M. T. (2012). Patient safety, satisfaction, and quality of hospital care: Cross sectional surveys of nurses and patients in 12 countries in Europe and the united states. British Medical Journal, 344, e1717. doi:10.1136/bmj.e1717

Aiken, L. H., Sloane, D., Griffiths, P., Rafferty, A. M., Bruyneel, L., McHugh, M., . . . Ausserhofer, D. (2017). Nursing skill mix in European hospitals: Cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Quality & Safety, 26(7), 559-568. doi:10.1136/bmjqs-2016-005567

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., . . . Lesaffre, E. (2014). Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. The Lancet, 383(9931), 1824-1830. doi:10.1016/S0140-6736(13)62631-8

Al Awaisi, H., Cooke, H., & Pryjmachuk, S. (2015). The experiences of newly graduated nurses during their first year of practice in the sultanate of oman–a case study. International Journal of Nursing Studies, 52(11), 1723-1734. doi:10.1016/j.ijnurstu.2015.06.009

Alexander, J. W., & Kroposki, M. (2001). Using a management perspective to define and measure changes in nursing technology. Journal of Advanced Nursing, 35(5), 776-783. doi:10.1046/j.1365-2648.2001.01910.x

AlMekkawi, M., & El Khalil, R. (2020). New graduate nurses’ readiness to practise: A narrative literature review. Health Professions Education. doi:10.1016/j.hpe.2020.05.008

Altmann, T. K. (2007). An evaluation of the seminal work of patricia benner: Theory or philosophy? Contemporary Nurse, 25(1-2), 114-123. doi:10.5172/conu.2007.25.1-2.114

Arrowsmith, V., Lau‐Walker, M., Norman, I., & Maben, J. (2016). Nurses' perceptions and experiences of work role transitions: A mixed methods systematic review of the literature. Journal of Advanced Nursing, 72(8), 1735-1750. doi:10.1111/jan.12912

81

Audet, L.-A., Bourgault, P., & Rochefort, C. M. (2018). Associations between nurse education and experience and the risk of mortality and adverse events in acute care hospitals: A systematic review of observational studies. International Journal of Nursing Studies, 80, 128-146. doi:10.1016/j.ijnurstu.2018.01.007

Ausserhofer, D., Zander, B., Busse, R., Schubert, M., De Geest, S., Rafferty, A. M., . . . Heinen, M. (2014). Prevalence, patterns and predictors of nursing care left undone in European hospitals: Results from the multicountry cross-sectional rn4cast study. BMJ quality & safety, 23(2), 126-135. doi:10.1136/bmjqs-2013-002318S

Ball, J. (2017). Special collection editorial:‘Enough nurses?’. Journal of Research in Nursing, 22(8), 566-571. doi:doi.org/10.1177/1744987117740421

Bandini, F., Guidi, S., Blaszczyk, S., Fumarulo, A., Pierini, M., Pratesi, P., . . . Zoppi, P. (2018). Complexity in internal medicine wards: A novel screening method and implications for management. Journal of Evaluation in Clinical Practice, 24(1), 285-292. doi:10.1111/jep.12875

Benner, P. E. (2001). From novice to expert : Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.

Benner, P. E., Tanner, C. A., & Chelsea, C. A. (2009). Expertise in nursing practice, caring, clinical judgment & ethics (2 ed.). New York: Springer.

Bisholt. (2012). The professional socialization of recently graduated nurses—experiences of an introduction program. Nurse Education Today, 32(3), 278-282. doi:10.1016/j.nedt.2011.04.001

Blanchet Garneau, A., Lavoie, P., & Grondin, M. (2017). Dichotomy and dialogue in conceptualizations of competency in health professionals’ education. Journal of nursing education and practice, 7(6). doi:10.5430/jnep.v7n6p18

Blažun, H., Kokol, P., & Vošner, J. (2015). Research literature production on nursing competences from 1981 till 2012: A bibliometric snapshot. Nurse Education Today, 35(5), 673-679. doi:10.1016/j.nedt.2015.01.002

Blomberg, A. C., Lindwall, L., & Bisholt, B. (2019). Operating theatre nurses’ self‐reported clinical competence in perioperative nursing: A mixed method study. Nursing open, 6(4), 1510-1518. doi:10.1002/nop2.352

Buchan, J., O'may, F., & Dussault, G. (2013). Nursing workforce policy and the economic crisis: A global overview. Journal of Nursing Scholarship, 45(3), 298-307. doi:10.1111/jnu.12028

82

Butterworth, T. (2014). Board editorial: The nursing profession and its leaders–hiding in plain sight? Journal of Research in Nursing, 19(7-8), 533-536. doi:10.1177/1744987114561351

Bvumbwe, T. M., & Mtshali, N. G. (2018). A middle-range model for improving quality of nursing education in malawi. Curationis, 41(1), 1-11. doi:10.4102/curationis.v41i1.1766

Byrne, A.-L., Baldwin, A., & Harvey, C. (2020). Whose centre is it anyway? Defining person-centred care in nursing: An integrative review. PloS One, 15(3), e0229923. doi:10.1371/journal.pone.0229923

Calzone, K. A., Jenkins, J., Culp, S., Caskey, S., & Badzek, L. (2014). Introducing a new competency into nursing practice. Journal of nursing regulation, 5(1), 40. doi:10.1016/s2155-8256(15)30098-3

Carlsson, M. (2020). Self‐reported competence in female and male nursing students in the light of theories of hegemonic masculinity and femininity. Journal of Advanced Nursing, 76(1), 191-198. doi:10.1111/jan.14220

Charette, M., Goudreau, J., & Bourbonnais, A. (2019). Factors influencing the practice of new graduate nurses: A focused ethnography of acute care settings. Journal of Clinical Nursing, 28(19-20), 3618-3631. doi:10.1111/jocn.14959

Charette, M., McKenna, L. G., Maheu-Cadotte, M.-A., Deschênes, M.-F., Laurence, H., & Merisier, S. (2020). Measurement properties of scales assessing new graduate nurses'clinical competence: A systematic review of psychometric properties. International Journal of Nursing Studies, 103734. doi:10.1016/j.ijnurstu.2020.103734

Cowan, D. T., Norman, I., & Coopamah, V. P. (2005). Competence in nursing practice: A controversial concept–a focused review of literature. Nurse Education Today, 25(5), 355-362. doi:10.1016/j.nedt.2005.03.002

Cowan, D. T., Wilson-Barnett, D. J., Norman, I. J., & Murrells, T. (2008). Measuring nursing competence: Development of a self-assessment tool for general nurses across Europe. International Journal of Nursing Studies, 45(6), 902-913. doi:10.1016/j.ijnurstu.2007.03.004

Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16(3), 297-334. doi:10.1007/bf02310555

Curuso, R., Fida, R,. Sili, A., Arrigoni, C,. (2016). Towards an intergrated model of nursing compentene: An overview of the literature reviews and concept analysis. Professioni Intermieristiche, 69(1), 35-43. doi:10.7429/pi.2016.691035

Dall’Alba, G., & Sandberg, J. (2006). Unveiling professional development: A critical review of stage models. Review of

83

educational research, 76(3), 383-412. doi:10.3102/00346543076003383

Davis, L., Taylor, H., & Reyes, H. (2014). Lifelong learning in nursing: A delphi study. Nurse Education Today, 34(3), 441-445. doi:10.1016/j.nedt.2013.04.014

Della Ratta, C. (2016). Challenging graduate nurses' transition: Care of the deteriorating patient. Journal of Clinical Nursing, 25(19-20), 3036-3048. doi:10.1111/jocn.13358

Dharmarajan, K., Strait, K. M., Tinetti, M. E., Lagu, T., Lindenauer, P. K., Lynn, J., . . . Krumholz, H. M. (2016). Treatment for multiple acute cardiopulmonary conditions in older adults hospitalized with pneumonia, chronic obstructive pulmonary disease, or heart failure. Journal of the American Geriatrics Society, 64(8), 1574-1582. doi:10.1111/jgs.14303

Disch, J., Feeley, T. W., Mason, D. J., Schilsky, R. L., Stovall, E. L., & Nasso, S. F. (2016). Transformation of health care–perspectives of opinion leaders. Seminars in Oncology Nursing, 2(32), 172-182. doi:10.1016/j.soncn.2016.03.001

Dreyfus & Dreyfus. (1980). A five model of the mental activities involved in directed skill acquisition. Retrieved from https://apps.dtic.mil/dtic/tr/fulltext/u2/a084551.pdf

Duchscher, J. E. B. (2009). Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 65(5), 1103-1113. doi:10.1111/j.1365-2648.2008.04898.x

Ekman, I., Swedberg, K., Taft, C., Lindseth, A., Norberg, A., Brink, E., . . . Kjellgren, K. (2011). Person-centered care—ready for prime time. European Journal of Cardiovascular Nursing, 10(4), 248-251. doi:10.1016/j.ejcnurse.2011.06.008

Ellström, P.-E. (1992). Kompetens, utbildning och lärande i arbetslivet: Problem, begrepp och teoretiska perspektiv. Stockholm: Publica.

Engström, M., Löfmark, A., Vae, K. J. U., & Mårtensson, G. (2017). Nursing students' perceptions of using the clinical education assessment tool assce and their overall perceptions of the clinical learning environment-a cross-sectional correlational study. Nurse Education Today, 51, 63-67. doi:10.1016/j.nedt.2017.01.009

European Higher Educational Area (EHEA). (2010). Budapest-vienna declaration on the European higher education area. Retrieved from http://www.ehea.info/media.ehea.info/file/2010_Budapest_Vienna/64/0/Budapest-Vienna_Declaration_598640.pdf

European Parliament. (1999). The European higher education the Bologna declatation of 19 june 1999. European ministers of

84

education. Retrieved from http://ehea.info/Upload/document/ministerial_declarations/1999_Bologna_Declaration_English_553028.pdf

European Parliament. (2005). Directive 2005/36/ec of the European Parliament and of the Council of 7 september 2005 on the recognition of professional qualifications. Official Journal of the European Union, 30(Sept), L255/222–142.

European Parliament. (2013). Directive 2013/55/eu of the European Parliament and of the council of 20 november 2013 amending directive 2005/36/ec on the recognition of professional qualifications and regulation (eu) no 1024/2012 on administrative cooperation through the internal market information system text with eea relevance. Official Journal of the European Union, 132–170.

Fagerström, L., & Glasberg, A. L. (2011). The first evaluation of the advanced practice nurse role in finland–the perspective of nurse leaders. Journal of Nursing Management, 19(7), 925-932. doi:10.1111/j.1365-2834.2011.01280.x

Field, A. (2014). Discovering statistics using IBM SPSS statistics (4 ed.). Los Angeles CA: Sage.

Finnbakk, E., Wangensteen, S., Skovdahl, K., & Fagerström, L. (2015). The professional nurse self-assessment scale: Psychometric testing in norwegian long term and home care contexts. BMC Nursing, 14(1), 59. doi:10.1186/s12912-015-0109-3

Flinkman, M., Leino‐Kilpi, H., Numminen, O., Jeon, Y., Kuokkanen, L., & Meretoja, R. (2017). Nurse competence scale: A systematic and psychometric review. Journal of Advanced Nursing, 73(5), 1035-1050. doi:10.1111/jan.13183

Forsman, H., Jansson, I., Leksell, J., Lepp, M., Sundin Andersson, C., Engström, M., & Nilsson, J. (2019). Clusters of competence: Relationship between self‐reported professional competence and achievement on a national examination among graduating nursing students. Journal of Advanced Nursing, 76(1), 199-208. doi:10.1111/jan.14222

Fukada, M. (2018). Nursing competency: Definition, structure and development. Yonago Acta Medica, 61(1), 001-007. doi:10.33160/yam.2018.03.001

Gardiner, I., & Sheen, J. (2016). Graduate nurse experiences of support: A review. Nurse Education Today, 40, 7-12. doi:10.1016/j.nedt.2016.01.016

Gardulf, A., Florin, J., Carlsson, M., Leksell, J., Lepp, M., Lindholm, C., . . . Nilsson, J. (2019). The nurse professional competence (npc) scale: A tool that can be used in national and international assessments of nursing education programmes. Nordic Journal

85

of Nursing Research, 39(3), 137-142. doi:10.1177/2057158518824530

Gardulf, A., Nilsson, J., Florin, J., Leksell, J., Lepp, M., Lindholm, C., . . . Carlsson, M. (2016). The nurse professional competence (npc) scale: Self-reported competence among nursing students on the point of graduation. Nurse Education Today, 36, 165-171. doi:10.1016/j.nedt.2015.09.013

Garside, J. R., & Nhemachena, J. Z. (2013). A concept analysis of competence and its transition in nursing. Nurse Education Today, 33(5), 541-545. doi:10.1016/j.nedt.2011.12.007

Gellerstedt, L., Moquist, A., Roos, A., Bergkvist, K., & Craftman, Å. G. (2019). Newly graduated nurses' experiences of a trainee programme regarding the introduction process and leadership in a hospital setting—a qualitative interview study. Journal of Clinical Nursing, 28(9-10), 1685-1694. doi:10.1111/jocn.14733

Gobet, F., & Chassy, P. (2008). Towards an alternative to benner's theory of expert intuition in nursing: A discussion paper. International Journal of Nursing Studies, 45(1), 129-139. doi:10.1016/j.ijnurstu.2007.01.005

Goh, Y. S., Lee, A., Chan, S. W. C., & Chan, M. F. (2015). Profiling nurses' job satisfaction, acculturation, work environment, stress, cultural values and coping abilities: A cluster analysis. International Journal of Nursing Practice, 21(4), 443-452. doi:doi.org/10.1111/ijn.12318

Hair, J. F., Black, W. C., Babin, B. J., & Anderson, R. E. (2014). Multivariate data analysis. Harlow, Essex: Pearson.

Halabi, J., Lepp, M., & Nilsson, J. (2020). Assessing self-reported competence among registered nurses working as a culturally diverse work force in public hospitals in the kingdom of saudi arabia. Journal of Transcultural Nursing,, 00(0), 1-8. doi:10.1177/1043659620921222

Hamric, A. B., Spross, J. A., & Hanson, C. M. (2009). Advanced practice nursing : An integrative approach. St. Louis, Mo.: Saunders/Elsevier.

Hensel, R., Meijers, F., van der Leeden, R., & Kessels, J. (2010). 360 degree feedback: How many raters are needed for reliable ratings on the capacity to develop competences, with personal qualities as developmental goals? The International Journal of Human Resource Management, 21(15), 2813-2830. doi:10.1080/09585192.2010.528664

Howlett, B., Shelton, T. G., & Rogo, E. (2020). Evidence based practice for health professionals: An interprofessionall approache: Jones & Bartlett Publishers.

Huber, E., Kleinknecht‐Dolf, M., Kugler, C., & Spirig, R. (2020). Patient‐related complexity of nursing care in acute care hospitals–an

86

updated concept. Scandinavian Journal of Caring Sciences. doi:doi.org/10.1111/scs.12833

Hunsberger, M., Baumann, A., & Crea-Arsenio, M. (2013). The road to providing quality care: Orientation and mentorship for new graduate nurses. Canadian Journal of Nursing Research Archive, 45(4), 72-87. doi:10.1177/084456211304500407

Hussein, R., Everett, B., Ramjan, L. M., Hu, W., & Salamonson, Y. (2017). New graduate nurses’ experiences in a clinical specialty: A follow up study of newcomer perceptions of transitional support. BMC Nursing, 16(1), 1-9. doi:10.1186/s12912-017-0236-0

ICN. (2012). The ICN codes of ethics for nurses. Retrieved from https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf

ICN. (2013). Position statement: Scope of nurse practice. Retrieved from https://www.icn.ch/sites/default/files/inline-files/B07_Scope_Nsg_Practice.pdf

ICN. (2017). Nursing definition: Definition of nursing. Retrieved from https://www.icn.ch/nursing-policy/nursing-definitions

ICN. (2019). International workforce forum calls for urgent action from governments to address global nursing shortage. Retrieved from https://www.icn.ch/news/icn-international-workforce-forum-calls-urgent-action-governments-address-global-nursing

Institute of Medicine (U.S.), Greniner, A., & Knebel, E. (2003). Health professions education: A bridge to quality. Washingtion: National Academies Press.

Irwin, C., Bliss, J., & Poole, K. (2018). Does preceptorship improve confidence and competence in newly qualified nurses: A systematic literature review. Nurse Education Today, 60, 35-46. doi:10.1016/j.nedt.2017.09.011

Jangland, E., Teodorsson, T., Molander, K., & Muntlin Athlin, Å. (2018). Inadequate environment, resources and values lead to missed nursing care: A focused ethnographic study on the surgical ward using the fundamentals of care framework. Journal of Clinical Nursing, 27(11-12), 2311-2321. doi:10.1111/jocn.14095

Jayasekara, R. S. (2012). Focus groups in nursing research: Methodological perspectives. Nursing Outlook, 60(6), 411-416. doi:10.1016/j.outlook.2012.02.001

Jones, D., Mitchell, I., Hillman, K., & Story, D. (2013). Defining clinical deterioration. Resuscitation, 84(8), 1029-1034. doi:10.1016/j.resuscitation.2013.01.013

Jones, T., Hamilton, P., & Murry, N. (2015). Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. International Journal of Nursing Studies, 52(6), 1121-1137. doi:10.1016/j.ijnurstu.2015.02.012

87

Kajander-Unkuri, S. (2015). Nurse competence of graduating nursing students. (Doctoral dissertation ), University of Turku, Turku.

Kajander-Unkuri, S., Meretoja, R., Katajisto, J., Saarikoski, M., Salminen, L., Suhonen, R., & Leino-Kilpi, H. (2014). Nurse competence of graduating nursing students. Nurse Education Today, 34(5), 795-801. doi:10.1016/j.nedt.2013.08.009

Kajander-Unkuri, S., Salminen, L., Saarikoski, M., Suhonen, R., & Leino-Kilpi, H. (2013). Competence areas of nursing students in Europe. Nurse Education Today, 33(6), 625-632.

Kakemam, E., Kalhor, R., Khakdel, Z., Khezri, A., West, S., Visentin, D., & Cleary, M. (2019). Occupational stress and cognitive failure of nurses and associations with self‐reported adverse events: A national cross‐sectional survey. Journal of Advanced Nursing, 75(12), 3609-3618. doi:doi.org/10.1111/jan.14201

Kannampallil, T. G., Schauer, G. F., Cohen, T., & Patel, V. L. (2011). Considering complexity in healthcare systems. Journal of biomedical informatics, 44(6), 943-947. doi:10.1016/j.jbi.2011.06.006

Karam, M., Brault, I., Van Durme, T., & Macq, J. (2018). Comparing interprofessional and interorganizational collaboration in healthcare: A systematic review of the qualitative research. International Journal of Nursing Studies, 79, 70-83. doi:10.1016/j.ijnurstu.2017.11.002

Karlsson, A. C., Gunningberg, L., Bäckström, J., & Pöder, U. (2019). Registered nurses’ perspectives of work satisfaction, patient safety and intention to stay–a double‐edged sword. Journal of Nursing Management, 27(7), 1359-1365. doi:10.1111/jonm.12816

Kavanagh, J. M., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nursing Education Perspectives, 38(2), 57-62. doi:10.1097/01.nep.0000000000000123

Kentischer, F., Kleinknecht‐Dolf, M., Spirig, R., Frei, I. A., & Huber, E. (2018). Patient‐related complexity of care: A challenge or overwhelming burden for nurses–a qualitative study. Scandinavian Journal of Caring Sciences, 32(1), 204-212. doi:10.1111/scs.12449

Kleinknecht-Dolf, M., Grand, F., Spichiger, E., Müller, M., Martin, J. S., & Spirig, R. (2015). Complexity of nursing care in acute care hospital patients: Results of a pilot study with a newly developed questionnaire. Scandinavian Journal of Caring Sciences, 29(3), 591-602. doi:10.1111/scs.12180

Kovner, C. T., Brewer, C. S., Fatehi, F., & Jun, J. (2014). What does nurse turnover rate mean and what is the rate? Policy, Politics,

88

& Nursing Practice, 15(3-4), 64-71. doi:doi.org/10.1177/1527154414547953

Kozier, B., Erb, G., & Berman, A. (2008). Kozier & erb's fundamentals of nursing: Concepts, process, and practice. (8 ed.). Upper Saddle River, N.J: Pearson education.

Kramer, M., Brewer, B. B., Halfer, D., Maguire, P., Beausoleil, S., Claman, K., . . . Duchscher, J. B. (2013). Changing our lens: Seeing the chaos of professional practice as complexity. Journal of Nursing Management, 21(4), 690-704. doi:10.1111/jonm.12082

Kreuger, R., & Casey, M. (2009). Focus grups, a practional guide for applied research (4 ed.). Thousand Oaks CA,: Sage Publications Inc.

Krippendorff, K. (2018). Content analysis : An introduction to its methodology. Thousand Oaks: SAGE.

Labrague, L., & de Los Santos, J. (2020). Transition shock and newly graduated nurses’ job outcomes and select patient outcomes: A cross‐sectional study. Journal of Nursing Management, 28(5), 1070-1079. doi:10.1111/jonm.13033

Labrague, L., De los Santos, J., Falguera, C., Nwafor, C., Galabay, J., Rosales, R., & Firmo, C. (2020). Predictors of nurses’ turnover intention at one and five years’ time. International Nursing Review, 67(2), 191-198. doi:10.1111/inr.12581

Labrague, L., & McEnroe‐Petitte, D. (2018). Job stress in new nurses during the transition period: An integrative review. International Nursing Review, 65(4), 491-504. doi:10.1111/inr.12425

Lahtinen, P., Leino-Kilpi, H., & Salminen, L. (2014). Nursing education in the European higher education area—variations in implementation. Nurse Education Today, 34(6), 1040-1047. doi:10.1016/j.nedt.2013.09.011

Laschinger, H. K. S., Cummings, G., Leiter, M., Wong, C., MacPhee, M., Ritchie, J., . . . Jeffs, L. (2016). Starting out: A time-lagged study of new graduate nurses’ transition to practice. International Journal of Nursing Studies, 57, 82-95. doi:10.1016/j.ijnurstu.2016.01.005

Lee, E. K., & Kim, J. S. (2020). Nursing stress factors affecting turnover intention among hospital nurses. International Journal of Nursing Practice, e12819. doi:10.1111/ijn.12819

Lima, S., Newall, F., Jordan, H. L., Hamilton, B., & Kinney, S. (2016). Development of competence in the first year of graduate nursing practice: A longitudinal study. Journal of Advanced Nursing, 72(4), 878-888. doi:10.1111/jan.12874

Lima, S., Newall, F., Kinney, S., Jordan, H. L., & Hamilton, B. (2014). How competent are they? Graduate nurses self-assessment of

89

competence at the start of their careers. Collegian, 21(4), 353-358. doi:10.1016/j.colegn.2013.09.001

Lincoln, Y. S., & Guba, E. G. (1986). But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New directions for program evaluation, 1986(30), 73-84.

Lindqvist, R., Alenius, L. S., Runesdotter, S., Ensio, A., Jylhä, V., Kinnunen, J., . . . Tishelman, C. (2014). Organization of nursing care in three Nordic countries: Relationships between nurses’ workload, level of involvement in direct patient care, job satisfaction, and intention to leave. BMC Nursing, 13(1), 27. doi:10.1186/1472-6955-13-27

Liou, S.-R., Chang, C.-H., Tsai, H.-M., & Cheng, C.-Y. (2013). The effects of a deliberate practice program on nursing students' perception of clinical competence. Nurse Education Today, 33(4), 358-363. doi:10.1016/j.nedt.2012.07.007

Liu, Y., & Aungsuroch, Y. (2018). Current literature review of registered nurses’ competency in the global community. Journal of Nursing Scholarship, 50(2), 191-199. doi:10.1111/jnu.12361

Mackey, A., & Bassendowski, S. (2017). The history of evidence-based practice in nursing education and practice. Journal of Professional Nursing, 33(1), 51-55. doi:10.1016/j.profnurs.2016.05.009

Maier, C. B., Köppen, J., & Busse, R. (2018). Task shifting between physicians and nurses in acute care hospitals: Cross-sectional study in nine countries. Human resources for health, 16(1), 24. doi:doi.org/10.1186/s12960-018-0285-9

Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the us. BMJ: British Medical Journal (Online), 353, i2139. doi:10.1136/bmj.i2139

Manning, E., & Gagnon, M. (2017). The complex patient: A concept clarification. Nursing & Health Sciences, 19(1), 13-21. doi:10.1111/nhs.12320

Massey, D., Aitken, L. M., & Chaboyer, W. (2009). What factors influence suboptimal ward care in the acutely ill ward patient? Intensive and Critical Care Nursing, 25(4), 169-180. doi:10.1016/j.iccn.2009.03.005

Massey, D., Aitken, L. M., & Chaboyer, W. (2010). Literature review: Do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient? Journal of Clinical Nursing, 19(23‐24), 3260-3273. doi:10.1111/j.1365-2702.2010.03394.x

Massey, D., Chaboyer, W., & Aitken, L. (2014). Nurses’ perceptions of accessing a medical emergency team: A qualitative study. Australian Critical Care, 27(3), 133-138. doi:10.1016/j.aucc.2013.11.001

90

Meleis, A. L. (2010). Transitions theory: Middle range and situations specific theories in nursing research and practise. New York, NY: Springer.

Meretoja, R., Isoaho, H., & Leino‐Kilpi, H. (2004). Nurse competence scale: Development and psychometric testing. Journal of Advanced Nursing, 47(2), 124-133. doi:10.1111/j.1365-2648.2004.03071.x

Meretoja, R., Numminen, O., Isoaho, H., & Leino‐Kilpi, H. (2015). Nurse competence between three generational nurse cohorts: A cross‐sectional study. International Journal of Nursing Practice, 21(4), 350-358. doi:10.1111/ijn.12297

Missen, K., McKenna, L., & Beauchamp, A. (2016). Registered nurses’ perceptions of new nursing graduates’ clinical competence: A systematic integrative review. Nursing & Health Sciences, 18(2), 143-153. doi:10.1111/nhs.12249

Missen, K., McKenna, L., Beauchamp, A., & Larkins, J.-A. (2016). Qualified nurses' perceptions of nursing graduates' abilities vary according to specific demographic and clinical characteristics. A descriptive quantitative study. Nurse Education Today, 45, 108-113. doi:10.1016/j.nedt.2016.07.001

Morgan, D. L. (1997). Focus groups as qualitative research (2 ed.). Thousand Oaks, Calif,: Sage publications.

Morrow, S. (2009). New graduate transitions: Leaving the nest, joining the flight. Journal of Nursing Management, 17(3), 278-287. doi:10.1111/j.1365-2834.2008.00886

Murray, M., Sundin, D., & Cope, V. (2019). Benner's model and duchscher's theory: Providing the framework for understanding new graduate nurses' transition to practice. Nurse Education in Practice, 34, 199-203. doi:10.1016/j.nepr.2018.12.003

Musau, J., Baumann, A., Kolotylo, C., O'Shea, T., & Bialachowski, A. (2015). Infectious disease outbreaks and increased complexity of care. International Nursing Review, 62(3), 404-411. doi:10.1111/inr.12188

National Board of Health and Welfare. (2015). Kompetensförsörjning och patientsäkerhet – hur brister i bemanning och kompetens påverkar patientsäkerheten [provision of competence and patient safety - how deficiencies in staffing and competence affect patient safety]. Stockholm, Sweden: Socialstyrelsen.

National Board of Health and Welfare. (2018). Bedömning av tillgång och efterfrågan på personal i hälso- och sjukvård och tandvård - nationella planeringsstödet 2018 [assessment of supply and demand of staff in healthcare and dental care]. . Stockholm, Sweden: Socialstyreslsen

National Board of Health and Welfare. (2019). Bedömning av tillgång och efterfrågan på personal i hälso- och sjukvård och tandvård -

91

nationella planeringsstödet 2018 (assessment of supply and demand of staff in healthcare and dental care). Retrieved from https://www.Socialstyrelsen.Se/globalassets/sharepoint-dokument/artikelkatalog/ovrigt/2019-2-14.Pdf. Retrieved from https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/ovrigt/2019-2-14.pdf

Nei, D., Snyder, L. A., & Litwiller, B. J. (2015). Promoting retention of nurses: A meta-analytic examination of causes of nurse turnover. Health Care Management Review, 40(3), 237-253. doi:10.1097/HMR.0000000000000025

Niezen, M. G., & Mathijssen, J. J. (2014). Reframing professional boundaries in healthcare: A systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain. Health Policy, 117(2), 151-169. doi:doi.org/10.1016/j.healthpol.2014.04.016

Nilsson, J., Engström, M., Florin, J., Gardulf, A., & Carlsson, M. (2018). A short version of the nurse professional competence scale for measuring nurses' self-reported competence. Nurse Education Today, 71, 233-239. doi:10.1016/j.nedt.2018.09.028

Nilsson, J., Johansson, E., Egmar, A.-C., Florin, J., Leksell, J., Lepp, M., . . . Wilde-Larsson, B. (2014). Development and validation of a new tool measuring nurses self-reported professional competence—the nurse professional competence (npc) scale. Nurse Education Today, 34(4), 574-580. doi:10.1016/j.nedt.2013.07.016

Nilsson, J., Mischo-Kelling, M., Thiekoetter, A., Deufert, D., Mendes, A. C., Fernandes, A., . . . Lepp, M. (2019a). Nurse professional competence (npc) assessed among newly graduated nurses in higher educational institutions in Europe. Nordic Journal of Nursing Research, 2057158519845321. doi:10.1177/2057158519845321

Nilsson, J., Mischo-Kelling, M., Thiekoetter, A., Deufert, D., Mendes, A. C., Fernandes, A., . . . Lepp, M. (2019b). Nurse professional competence (npc) assessed among newly graduated nurses in higher educational institutions in Europe. Nordic Journal of Nursing Research, 39(3), 159-167. doi:10.1177/2057158519845321

Northern Nurses Federation. (2003). Ethical guidelines for nursing research in the Nordic countries. Vard i Norden, 23(4), 1-19.

Notarnicola, I., Perucci, C., De Jesus Barboa, M.R., Giorgi, F., Stievano, A., Lancia, L,. (2016). Clinical competence in nursing: A concept analysis,. Professioni Infermieristiche, 63(3), 181-188. doi:10.7429/pi.2016.693181

Numminen, O., Laine, T., Isoaho, H., Hupli, M., Leino‐Kilpi, H., & Meretoja, R. (2014). Do educational outcomes correspond with

92

the requirements of nursing practice: Educators' and managers' assessments of novice nurses' professional competence. Scandinavian Journal of Caring Sciences, 28(4), 812-821. doi:10.1111/scs.12115

Numminen, O., Leino-Kilpi, H., Isoaho, H., & Meretoja, R. (2015a). Ethical climate and nurse competence–newly graduated nurses' perceptions. Nursing Ethics, 22(8), 845-859. doi:10.1177/0969733014557137

Numminen, O., Leino-Kilpi, H., Isoaho, H., & Meretoja, R. (2015b). Newly graduated nurses' competence and individual and organizational factors: A multivariate analysis. Journal of Nursing Scholarship, 47(5), 446-457. doi:10.1111/jnu.12153

Numminen, O., Leino-Kilpi, H., Isoaho, H., & Meretoja, R. (2017). Development of nurses' professional competence early in their career: A longitudinal study. The Journal of Continuing Education in Nursing, 48(1), 29-39. doi:10.3928/00220124-20170110-08

Numminen, O., Leino‐Kilpi, H., Isoaho, H., & Meretoja, R. (2016). Newly graduated nurses’ occupational commitment and its associations with professional competence and work‐related factors. Journal of Clinical Nursing, 25(1-2), 117-126. doi:10.1111/jocn.13005

Numminen, O., Ruoppa, E., Leino‐Kilpi, H., Isoaho, H., Hupli, M., & Meretoja, R. (2016). Practice environment and its association with professional competence and work‐related factors: Perception of newly graduated nurses. Journal of Nursing Management, 24(1), E1-E11. doi:10.1111/jonm.12280

OECD. (2020-06-03). Hosptial beds. Retrieved from https://data.Oecd.Org/healtheqt/hospital-beds.Htm.

Page, M., Pool, L., Crick, M., & Leahy, R. (2020). Empowerment of learning and knowledge: Appreciating professional development for registered nurses in aged residential care. Nurse Education in Practice, 43, 102703. doi:10.1016/j.nepr.2020.102703

Pallant, J. (2013). SPSS survival manual. Maidenhead, UK: McGraw-Hill Education

Pasila, K., Elo, S., & Kääriäinen, M. (2017). Newly graduated nurses’ orientation experiences: A systematic review of qualitative studies. International Journal of Nursing Studies, 71, 17-27.

Phillips, C., Kenny, A., Esterman, A., & Smith, C. (2014). A secondary data analysis examining the needs of graduate nurses in their transition to a new role. Nurse Education in Practice, 14(2), 106-111. doi:10.1016/j.nepr.2013.07.007

Pijl-Zieber, E. M., Barton, S., Konkin, J., Awosoga, O., & Caine, V. (2014). Competence and competency-based nursing education:

93

Finding our way through the issues. Nurse Education Today, 34(5), 676-678. doi:10.1016/j.nedt.2013.09.007

Polit, D. F., & Beck, C. T. (2021). Nursing research generating and asessing evidence for nursing practice (11 ed.). Philadelphia, Pa.: Wolters Kluwer.

Rettke, H., Frei, I. A., Horlacher, K., Kleinknecht-Dolf, M., Spichiger, E., & Spirig, R. (2015). Nursing care in the run-up to swiss drg–nurses' experiences with interprofessional collaboration, leadership, work load and job satisfaction. Pflege, 28(3), 133-144. doi:10.1024/1012-5302/a000421

Rizany, I., Hariyati, R. T. S., & Handayani, H. (2018). Factors that affect the development of nurses’ competencies: A systematic review. Enfermeria Clinica, 28, 154-157.

Rudman, A., & Gustavsson, P. (2020). Konsekvenser av utbrändhet i början av sjuksköterskors arbetsliv för karriärutvecklingen. Socialmedicinsk tidskrift, 97(1), 92-101.

Rudman, A., Gustavsson, P., & Hultell, D. (2014). A prospective study of nurses’ intentions to leave the profession during their first five years of practice in sweden. International Journal of Nursing Studies, 51(4), 612-624. doi:10.1016/j.ijnurstu.2013.09.012

Rush, K. L., Adamack, M., Gordon, J., Lilly, M., & Janke, R. (2013). Best practices of formal new graduate nurse transition programs: An integrative review. International Journal of Nursing Studies, 50(3), 345-356. doi:10.1016/j.ijnurstu.2012.06.009

Rush, K. L., Janke, R., Duchscher, J. E., Phillips, R., & Kaur, S. (2019). Best practices of formal new graduate transition programs: An integrative review. International Journal of Nursing Studies, 94, 139-158. doi:10.1016/j.ijnurstu.2019.02.010

Saintsing, D., Gibson, L. M., & Pennington, A. W. (2011). The novice nurse and clinical decision‐making: How to avoid errors. Journal of Nursing Management, 19(3), 354-359. doi:10.1111/j.1365-2834.2011.01248.x

SCB. (2017). Sjuksköterskor utanför yrket [registred nurses working outside healthcare]. Retrieved from https://www.Scb.Se/contentassets/a5ea39c65d9b49748834329da112581f/uf0549_2016a01_br_a40br1703.Pdf. Retrieved from https://www.scb.se/contentassets/a5ea39c65d9b49748834329da112581f/uf0549_2016a01_br_a40br1703.pdf

Schaink, A. K., Kuluski, K., Lyons, R. F., Fortin, M., Jadad, A. R., Upshur, R., & Wodchis, W. P. (2012). A scoping review and thematic classification of patient complexity: Offering a unifying framework. Journal of comorbidity, 2(1), 1-9. doi:10.15256/joc.2012.2.15

SFS 2017:30. Hälso- och sjukvårdslagen [health care act].

94

Shaw, P., Abbott, M., & King, T. S. (2018). Preparation for practice in newly licensed registered nurses: A mixed-methods descriptive survey of preceptors. Journal for Nurses in Professional Development, 34(6), 325-331. doi:10.1097/NND.0000000000000487

Shippee, N. D., Shah, N. D., May, C. R., Mair, F. S., & Montori, V. M. (2012). Cumulative complexity: A functional, patient-centered model of patient complexity can improve research and practice. Journal of Clinical Epidemiology, 65(10), 1041-1051. doi:10.1016/j.jc1inepi.2012.05.005

Smith, S. A. (2012). Nurse competence: A concept analysis. International Journal of Nursing Knowledge, 23(3), 172-182. doi:10.1111/j.2047-3095.2012.01225.x

SSF. (2017). Swedish society of nursing. Kompetensbeskrivning för legitimerad sjuksköterska. [description of competence for registered nurses]. Retrieved from https://www.Swenurse.Se/globalassets/01-svensk-sjukskoterskeforening/publikationer-svensk-sjukskoterskeforening/kompetensbeskrivningar-publikationer/kompetensbeskrivning-legitimerad-sjukskoterska-2017-for-webb.Pdf.

Streiner, D., & Norman, G. (2008). Health measurement scales a practical guide to their development and use (4 ed.). New York: Oxford univeristy press.

Sturm, H., Rieger, M. A., Martus, P., Ueding, E., Wagner, A., Holderried, M., . . . Consortium, W. (2019). Do perceived working conditions and patient safety culture correlate with objective workload and patient outcomes: A cross-sectional explorative study from a german university hospital. PloS One, 14(1), e0209487. doi:10.1371/journal.pone.0209487

Sturmberg, J., & Lanham, H. J. (2014). Understanding health care delivery as a complex system. Journal of Evaluation in Clinical Practice, 20(6), 1005-1009. doi:10.1111/jep.12142

Swedish Higher Education Authority. (2018). Higer education in sweden 2018 status report. Retrieved from https://english.Uka.Se/download/18.7f89790216483fb85588e86/1534509947612/report-2018-06-26-higher-education-in-sweden-2018.Pdf.

Takase, M., Nakayoshi, Y., Yamamoto, M., Teraoka, S., & Imai, T. (2014). Competence development as perceived by degree and non-degree graduates in japan: A longitudinal study. Nurse Education Today, 34(3), 451-456. doi:10.1016/j.nedt.2013.04.017

95

Tavakol, M., & Dennick, R. (2011). Making sense of cronbach's alpha. International Journal of Medical Education, 2(1), 53-55. doi:10.5116/ijme.4dfb.8dfd

Taylor, I., Bing‐Jonsson, P., Wangensteen, S., Finnbakk, E., Sandvik, L., McCormack, B., & Fagerström, L. (2020). The self‐assessment of clinical competence and the need for further training: A cross‐sectional survey of advanced practice nursing students. Journal of Clinical Nursing, 29(3-4), 545-555. doi:10.1111/jocn.15095

ten Hoeve, Y., Kunnen, S., Brouwer, J., & Roodbol, P. F. (2018). The voice of nurses: Novice nurses’ first experiences in a clinical setting. A longitudinal diary study. Journal of Clinical Nursing, 27(7-8), e1612-e1626. doi:10.1111/jocn.14307

Theander, K., Wilde-Larsson, B., Carlsson, M., Florin, J., Gardulf, A., Johansson, E., . . . Nilsson, J. (2016). Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence. Nurse Education Today, 37, 178-183. doi:10.1016/j.nedt.2015.11.012

Theisen, J. L., & Sandau, K. E. (2013). Competency of new graduate nurses: A review of their weaknesses and strategies for success. The Journal of Continuing Education in Nursing, 44(9), 406-414. doi:10.3928/00220124-20130617-38

Treiber, L. A., & Jones, J. H. (2018). After the medication error: Recent nursing graduates' reflections on adequacy of education. Journal of Nursing Education, 57(5), 275-280. doi:10.3928/01484834-20180420-04

Walton, J. A., Lindsay, N., Hales, C., & Rook, H. (2018). Glimpses into the transition world: New graduate nurses' written reflections. Nurse Education Today, 60, 62-66. doi:10.1016/j.nedt.2017.09.022

van Rooyen, D. R., Jordan, P. J., ten Ham-Baloyi, W., & Caka, E. M. (2018). A comprehensive literature review of guidelines facilitating transition of newly graduated nurses to professional nurses. Nurse Education in Practice, 30, 35-41. doi:10.1016/j.nepr.2018.02.010

Wangensteen, S., Finnbakk, E., Adolfsson, A., Kristjansdottir, G., Roodbol, P., Ward, H., & Fagerström, L. (2018). Postgraduate nurses' self-assessment of clinical competence and need for further training. A European cross-sectional survey. Nurse Education Today, 62, 101-106. doi:10.1016/j.nedt.2017.12.020

Wangensteen, S., Johansson, I., & Nordström, G. (2008). The first year as a graduate nurse–an experience of growth and development. Journal of Clinical Nursing, 17(14), 1877-1885. doi:10.1111/j.1365-2702.2007.02229.x

96

Wangensteen, S., Johansson, I. S., Björkström, M. E., & Nordström, G. (2012). Newly graduated nurses' perception of competence and possible predictors: A cross-sectional survey. Journal of Professional Nursing, 28(3), 170-181. doi:10.1016/j.profnurs.2011.11.014

Whitehead, B., Owen, P., Henshaw, L., Beddingham, E., & Simmons, M. (2016). Supporting newly qualified nurse transition: A case study in a uk hospital. Nurse Education Today, 36, 58-63. doi:10.1016/j.nedt.2015.07.008

WHO. (2013). Global health workforce shortage to reach 12.9 million in coming decades. Geneva: World Health Organisation.

WHO. (2015). People-centred and integrated health services: An overview of the evidence: Interim report. Geneva: World Health Organization.

WHO. (2016a). Global strategic directions for strengthening nursing and midwifery. Geneva: World Health Organisation.

WHO. (2016b). Task shifting global recommendation and guidlines. Geneva: World Health Organization.

WHO. (2018a). Nursing and midwifery. Geneva: World Health Organization.

WHO. (2018b). Progress towards the sdgs: A selection of data from world health statistics 2018. Geneva: World Health Organization.

WHO. (2019). Health systems. Geneva: World Health Organization. WHO. (2020a). 2020 triad statement international Council of nurses –

international confederation of midwives – world health organization. Geneva: World Health Organization.

WHO. (2020b). European strategic directions for strengthening nursing and midwifery towards health 2020 goals. Geneva: World Health Organization.

WHO. (2020c). State of the world´s nursing. Investing in education, jobs and leadership. Geneva: World Health Organization.

Wild, D., Grove, A., Martin, M., Eremenco, S., McElroy, S., Verjee-Lorenz, A., & Erikson, P. (2005). Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (pro) measures: Report of the ispor task force for translation and cultural adaptation. Value in Health, 8(2), 94-104. doi:10.1111/j.1524-4733.2005.04054.x

Yanhua, C., & Watson, R. (2011). A review of clinical competence assessment in nursing. Nurse Education Today, 31(8), 832-836. doi:10.1016/j.nedt.2011.05.003

Zhang, Y., Wu, J., Fang, Z., Zhang, Y., & Wong, F. K. Y. (2017). Newly graduated nurses' intention to leave in their first year of practice in shanghai: A longitudinal study. Nursing Outlook, 65(2), 202-211. doi:10.1016/j.outlook.2016.10.007

97

Zieber, M., & Sedgewick, M. (2018). Competence, confidence and knowledge retention in undergraduate nursing students—a mixed method study. Nurse Education Today, 62, 16-21. doi:10.1016/j.nedt.2017.12.008

Zwijsen, S., Nieuwenhuizen, N., Maarsingh, O., Depla, M., & Hertogh, C. (2016). Disentangling the concept of “the complex older patient” in general practice: A qualitative study. BMC Family Practice, 17(1), 64. doi:10.1186/s12875-016-0455-6

98

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.


ISSN 1403-8099

ISBN 978-91-7867-145-8 (pdf)

ISBN 978-91-7867-140-3 (print)

Newly graduated registered nurses’ clinical competence ...kau.diva-portal.org/smash/get/diva2:1460328/FULLTEXT02.pdffessional Nurse Self -Assessment Scale of clinical core competences

Documents