Relating new graduate nurse competence to frequency of use

Article Outline

• Summary
• Introduction
• Background
• Aim and hypothesis
• Methods
  • Design
  • Sample
  • Procedure
  • Instrumentation
  • Data analysis methods
• Results
  • Participants
• Discussion
• The relationship of confidence to competence
• Limitations
• Implications and conclusion
• References
• Copyright

Summary 

The healthcare workplace can be a stress-laden environment for new graduates and job performance indicators are an important sign of developing confidence and expertise that will lead to improved patient outcomes. What is not evident from nursing studies is whether new graduate nurse competencies relate to the frequency of their use. This study sought to determine the relationship between perceived nursing competence and self-assessed frequency of use by new graduate nurses.

Three cohorts (n=116) of new graduate nurses undertaking year-long transition to graduate practice programs responded to a questionnaire that utilised the 2001 ANCI competencies and the Nurse Competency Scale and a Visual Analogue scale to self assess their perceived competence and the relative frequency of use for specific competence items.

Results indicate that a relationship exists between perceived competence and frequency of use and that research competency scores are substantially lower than all other categories of competency. Implications for education and practice indicate that assessment of nurse competency for the new graduate nurse should focus on the development of generic nursing competencies rather than current expectation of advanced and workplace specific nurse competencies.

Keywords: New graduate nurse, Competence, Frequency of use

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Introduction 

Competence measuring is becoming an important tool for many aspects of the professional nurse's life. Its use is pervasive from regulatory control bodies through to individual assessment at the workplace level. Competency assessment within nursing is comprehensive and attempts to cover the full range of professional activities. However, not all nurses will have the opportunity to perform or practice all of the diverse range of competence categories. How often a nurse utilises these competence categories may influence their confidence and ability to meet all standards of nurse competence.

Therefore, it follows that the exposure and opportunity to demonstrate competence could increase confidence and ability in that specific competence category. Assessment thus far has tended to focus on a level of overall competence irrespective of whether those competencies are used by the individual being assessed. What is not evident from previous nursing studies is the strength of the relationship of perceived nurse competence to the frequency of their use.

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Background 

New graduate nurses begin their new career armed with a theoretical appreciation and beginners’ knowledge and understanding of what constitutes a competent clinical nurse. However, a lack of confidence and experience may mean that issues such as time management, clinical orientation and self-esteem are more important to the new graduate nurse than aspects of competence such as evidence-based nursing practices (Cowin and Hengstberger-Sims, 2006; Duchscher & Cowin, 2004; Madjar, 1997). This raises the question of whether new graduate nurse competence is substantively different in content and usage to that of the more experienced Registered Nurse (RN) or the RN employed in their current clinical setting for more than 12 months.

The assessment of new graduate nurses provides a good opportunity to explore the relationship between perceived or actual competence and frequency of use. In this situation, the new graduate nurse enters the workforce and is usually allocated into a particular practice setting. This setting may provide opportunities to build confidence and skills in certain competence areas. However, areas of competence for all new graduate nurses may not develop in the same growth pattern as the opportunity or exposure for development maybe limited in particular practice settings.

The Australian Nursing and Midwifery Council, 2000, Australian Nursing and Midwifery Council, 2005 claim that the ANCI National Competency Standards provide a benchmark for the RN but does not distinguish between new graduate nurses and experienced RNs. Studies of competence by Bartlett, Simonite, Wescott, and Taylor (2000) compared qualifications or educational preparation for practice with beginning nurse competency and found that diploma level educational preparation demonstrated lower nurse competency and that preceptorship was an important criteria for improving the competency of new graduate nurses. In a more recent study, Tabari Khomeiran, Yeka, Kiger, and Ahmadi (2006, p. 67) claim that the study of “factors that facilitate the development of competence” could not be found and that this area of nursing research could also focus on what are the barriers to developing competency.

The workplace of the new graduate nurse continues to evolve in complexity. This includes accommodating pressures such as increasing patient acuity, rapidly changing clinical practices (diagnostics and treatment regimes) and an increasingly diverse educational preparation for the health care worker (Heartfield & Gibson, 2005). For example, there has been diversification in the groups who use the title of nurse with a dilution of skill mix and concurrent growth in the number of unregulated health care workers (Crossan & Ferguson, 2005; Heartfield & Gibson, 2005; Holmes, 2006). The potential effect of the diversification of the health care workforce for the new graduate nurse may include finding themselves in a position of leadership at the beginning of their nursing career—a proposition for which they have limited preparation and therefore maybe unable to fulfil those particular competency requirements.

In a study that compared the competence of new graduate nurses and experienced nurses, Lofmark, Smide, and Wikblad (2004) found that experienced but less educated nurses rated new graduate nurse's competence lower than nurses who qualified with a degree in the past 5 years. The authors used a convenience sample of 106 new graduate nurses and 136 experienced nurses to complete a survey that aimed to evaluate their nurse competence and compared their responses. Although there were no significant differences found between new graduate nurses’ self-assessed competence and experienced nurse assessment of the new graduate nurse competence, the areas both groups rated as weakest were those of teaching co-workers, planning and prioritising nursing care. The question that arises from the Lofmark et al. (2004) study is whether these areas of competencies develop more gradually than others such as the ethically oriented competencies and whether the ‘one size fits all’ approach to competency assessment for RNs in Australia is indeed a reasonable and rational method for assessing nurses without concurrent assessment of frequency of use.

Attitudinal self-assessment studies are a popular method for determining professional attributes (Sala, 2003). The use of frequency assessment as an accompaniment is much less common. In a study by Meretoja, Isoaho, and Leino-Kilpi (2004), the authors found a positive relationship between competency and frequency of use. Specifically, Meretoja et al. (2004, p. 128) found that “self-assessed level of competence increased in direct proportion to the self-assessed frequency of using competencies”.

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Aim and hypothesis 

As part of a larger study on competence measures and new graduate nurses, the purpose of this investigation was to test the relationship between perceived competence and self-assessed frequency of use by new graduates using two measures of nursing competence. Moreover, it was hypothesised that new graduate nurse self-reported competency will demonstrate positive relations with frequency of competency use.

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Methods 

Design 

This study utilised a cross-sectional non-experimental survey type method to gather data from three cohorts of new graduate nurses participating in a year long Transition to Graduate Nursing Program in metropolitan public hospitals located within Sydney New South Wales.

Sample 

In New South Wales, Australia, approximately 1200 new graduate nurses participate in transition programs each year. Three sites of moderate to large hospitals located in the metropolitan Sydney area provided access to 150 potential participants. Study participants had previously completed approved and accredited pre-registration Bachelor of Nursing (BN) degrees. The access to participants was facilitated by interested and cooperative program coordinators for their respective new graduate programs. One hundred and sixteen (N=116) new graduate nurses completed the survey between October and December 2005.

Procedure 

Ethical approval was obtained from the prospective participants’ hospital, the respective Area Health Research and Ethics Committees and the University of Western Sydney Research and Ethics Committee prior to approaching any potential participant. Using a purposive sampling design, prospective participants were approached during the last of five educational study days during the last 2 months of their transition program. Prospective participants were provided with a Plain English Statement clearly outlining the aims and potential outcomes of the study, participant rights to anonymity, confidentiality and withdrawal from the study without prejudice together with a summary of their role within the study. Completion of the survey by participants implied consent to participate. A survey package was handed to each participant by a research team member who was also available for any questions prior to leaving the room. Survey completion was anticipated to take approximately 20min. A survey number was allocated to each completed questionnaire and the responses coded and entered into a computer database for subsequent examination and analysis.

Instrumentation 

The survey consisted of three major sections. The background section requested information relating to age, gender and assessment of transitional program. The second and third sections related to perceptions and frequency of use for items in the Australian Nurse Competency Inc. Competency Standards (ANCI) (Australian Nursing and Midwifery Council, 2000) and the Nurse Competency Scale (NCS) (Meretoja et al., 2004; Meretoja & Leino-Kilpi, 2001). The ANCI model of competency (2000 version) consists of 14 elements within the four domains: professional and ethical practice, critical thinking and analysis, management of care and enabling. Within the four domains are a number of specific items that relate to its parent domain (51 items in 14 elements) (Australian Nursing and Midwifery Council, 2000). The psychometric properties of any ANCI model have not been pursued or reported in nursing literature except by Fisher, Marshall, and Kendrick (2005) who report internal consistency for all factors in their study of critical care nurses using a modified version of the 2000 ANCI Standards adopted for Critical Care nurses.

The NCS contains 73 items in seven domains: teaching–coaching, diagnostic functions, managing situations, therapeutic interventions, ensuring quality and work role was specifically designed to empirically assess nurse competency (Meretoja, Eriksson, & Leino-Kilpi, 2002; Meretoja et al., 2004; Meretoja & Leino-Kilpi, 2001). Good internal consistency is reported by Meretoja et al. (2004) for all factors with Cronbach's alpha scores ranging from .79 for helping through to .91 for teaching–coaching and for work role.

A Visual Analog Scale (VAS) (Stomberg & Öman, 2006; Swanton, Iyer, & Reginald, 2006) was utilised for the self-reported assessment of competence. Typically, the VAS ranged from 0 for very low level and 100 for very high level of self-assessed competence. The VAS continues to be a popular measurement scale for assessing attitudes and opinions (Hahn, Needham, Abderhalden, Duxbury, & Halfens, 2006; Mcgilton, Irwin-Robinson, Boscart, & Spanjevic, 2006). A four-point Likert type frequency of use scale was included to elicit responses from participants on their self-reported assessment of competency for both measures. Participants completed their ‘frequency of use’ assessment for each competency item by placing a tick within the tick box of the four-point Likert type scale. The scale ranged from 1 being not applicable, 2 being used very seldom, 3 being used occasionally and 4 being used often.

Data analysis methods 

Statistical analyses consisted of an evaluation of the psychometric properties (internal consistency reliability and factor structure) of the competency responses. The relationship between self-assessed competency scores and frequency of use scores were assessed through a series of analyses of variance at the element and factor level as well as at the domain and total measure score level.

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Results 

Participants 

A total of 116 new graduate nurses from the three sites consented to participate in this study. Nearly half of these (n=46) were aged between 21 and 22 years. However, the mean age of the sample was 28 (median 24). Only 8% (n=9) were male. More than half (55%, n=54) listed Australia as their country of birth. Forty-two percent stated they had no previous experience in nursing.

Table 1, Table 2 provide a summary of the alpha, mean and standard deviations score for each item or factor from the perspective of perceived competence and frequency of use for each competence item or factor as well as the total measures.

Table 1. Subscale alpha, means and standard deviations for ANCI standards at the element or competency unit level and frequency of use (N=116)

Item number	Competency standards			Frequency of use
	α	M	S.D.	α	M	S.D.
Competency unit 1
Functions in accordance with legislation and common law affecting nursing practice	.82	7.24	1.47	.57	3.51	.40
Competency unit 2
Conducts nursing practice in a way that can be ethically justified	.76	7.74	1.31	.61	3.56	.39
Competency unit 3
Protects the rights of individuals and groups in relation to health care	.86	7.89	1.28	.76	3.59	.37
Competency unit 4
Accepts accountability and responsibility for own actions within nursing practice	.70	8.83	1.03	.45	3.78	.31
Competency unit 5
Acts to enhance the professional development of self and others	.72	7.75	1.41	.58	3.37	.45
Competency unit 6
Values research in contributing to developments in nursing and improved standards of care	.77	5.96	2.10	.73	2.71	.62
Competency unit 7
Carries out a comprehensive and accurate nursing assessment of individuals and groups in a variety of settings	.81	5.97	2.29	.75	2.98	.73
Competency unit 8
Formulates a plan of care in collaboration with individuals and groups	.81	6.71	1.99	.73	3.11	.66
Competency unit 9
Implements planned nursing care to achieve identified outcomes within scope of competence	.78	7.55	1.65	.71	3.47	.57
Competency unit 10
Evaluates progress toward expected outcomes and reviews and revises plans in accordance with evaluation data	.65	6.35	2.01	.67	3.00	.71
Competency unit 11
Contributes to the maintenance of an environment which promotes safety, security and personal integrity of individuals and groups	.87	8.28	1.45	.83	3.65	.48
Competency unit 12
Communicates effectively with individuals and groups	.78	8.65	1.29	.48	3.84	.34
Competency unit 13
Manages effectively the nursing care of individuals and groups	.81	6.95	1.91	.68	3.28	.56
Competency unit 14
Collaborates with other members of the health care team	.86	8.25	1.64	.63	3.70	.39
ANCI total	.93	7.88	1.29	.92	3.42	.29

Table 2. Alpha, means and standard deviations scores for NCS at the factor level and for frequency of use (N=116)

It was anticipated that a positive relation would be determined between the level of self-assessed competency and the frequency of use for that competency, unit, domain or factor. This ‘a priori’ prediction was tested through a series of ANOVAs from unit and domain level for the ANCI and at factor level for the NCS.

In the following table (Table 3), an analysis of variance was conducted comparing responses to the ANCI units, domains and total measure to frequency of use. Standardisation of scores allowed for direction of variance to be assessed. The results reveal that in each analysis, competency ratings are significantly related, and consequently, competency self-assessment scores rise with a rise in frequency of use for all elements and domains.

Table 3. Results from analyses of variance for competence and frequency of use at the element and domain level for the ANCI (N=116)

Note: All results p<.001.

As in the assessment of the ANCI measure, the following table report on analyses examining the relation of competency and frequency for the NCS. The results (Table 4) reveal that in each analysis competency ratings rise with frequency of use in each factor and as a total measure.

Table 4. Results from analyses of variance for competence and frequency of use at the factor level for the NCS (N=116)

Based on these results, new graduate nurse self-reported competency demonstrates positive relations with their self-reported frequency of competency use is supported in both competency measures for the population of this study.

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Discussion 

The standards for practice as a registered nurse require that the nurse practice safely and competently. In order to practice nursing competently, a nurse will need to gather both experience and knowledge. The propositions raised by these results are that a lack of experience such as with a new graduate nurse may lead to a temporary lack of competence. Equally, the more experience the new graduate gains, the more competent they may become.

Therefore, a predictor of competence in this study is how often a nurse might use a specific competence. This finding echoes that of Meretoja et al. (2004), where the authors also found competence increased with frequency. However, in post hoc analyses of individual sites, the three sites were assessed in a series of ANOVAs. For the domain of professional and ethical practice in the ANCI model, sites 1 and 2 were non-significant. For the factor of teaching and coaching from the NCS sites 2 and 3 were non-significant. This suggests that there is variation between sites as well as transitional programs and that at the site level frequency of use is not always a predictor of competence. The implications are that at the total sample level significant results from one site may overwhelm non-significant results from other sites, thereby providing an overall interpretation that frequency of use drives higher levels of competence.

Further post hoc analyses reveal that the elements of research and critical thinking self-assessed competency to be the lowest in relation to frequency of use. Most accredited Bachelor of Nursing programs in NWS have a least one unit of study related to research methodology, research application and utilisation in the clinical environment. In addition, critical thinking methods and application are incorporated into many units of study. Programs that have two research units including an introductory research unit and a unit that requires students to conduct simulated research increase the new graduate nurse's ability to utilise nursing research in the clinical setting (Reising, 2003). In addition, Pearson et al. (2006, p. 230), claim, “undertaking research can enhance the nurses’ professional development and assist with gaining credibility among their colleagues”. It is therefore surprising to these authors to find that frequency of use has little impact on self-assessed competency.

It is worth noting here that the lowest mean scores for the ANCI (total mean score of 7.88) were for the research element (Element 6, M=5.96). Similarly, in the NCS those items that related specifically to Nursing Research also revealed lower mean scores than the total mean score (total mean score 5.95) (Item 5, M=5.35; Item 45, M=4.57; Item 53, M=4.95). Hussein Rassool (2005, p. 80) claims that a “lack of awareness and competency in analysing research reports” contribute substantially to the nursing research gap.

It is difficult to determine whether these results are an improvement assisted by an increase in research education at the undergraduate nursing education level or whether self-assessed research competency highlights a lack of confidence and competence in research understanding and application. Unfortunately, no similar studies on nurse competency and research knowledge utilisation were located for comparison. However, Nilsson Kajermo, Nordstrom, Krusebrant, and Bjorvell (1998) state that their research established nurses who had undertaken research methodology and application in their undergraduate nurse education perceived fewer barriers to utilisation. The authors found that time, a lack of nursing colleagues who were research savvy and the inability to incorporate change based on research also increased barriers to nursing research utilisation.

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The relationship of confidence to competence 

Each individual nurse will have some idea of what they believe the standard of their own performance will be according to Crawford and Kiger (1998). The degree to which the individual nurse is able to reflect on their clinical experience and assess their own progress will be influenced by many factors. A central feature of self-assessment is that the assessment is being conducted from the perspective of a beginning registered nurse who is possibly more or less confident about their own abilities or does not know what they need to know in order to be rated as competent.

Experience in nursing is an important and sometimes complex factor to be considered. Many new graduates avail themselves of the opportunity to work as an assistant in nursing (AIN) during their undergraduate degree. Other new nurse graduates may have, for various reasons, taken on employment such as waitressing or customer assistance; therefore, any experience in nursing may alter individual confidence levels. In this context, some new graduate nurses may be further up the ladder in experience, confidence and ability to work in a health environment compared to those new graduate nurses who have no prior nursing experience.

Confidence may also be dependant upon the amount of time spent during undergraduate clinical placements and opportunities for further developing nursing practice clinical skills. Clinical placement time over the duration of the BN undergraduate course may vary between the major universities although there is a recommended minimum requirement to be met by all university programs for accreditation of their programs. In addition, there may be substantial differences between the self-assessment by the new graduate nurse in relation to their perceived competence when compared to an actual assessment of overall competence by an impartial experienced nurse assessor.

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Limitations 

Limitations of the study related to sample size and the tools utilised to measure the construct of nurse competency. The limited number of participants (n=116) may mean that generalisability of findings may be difficult. In addition, the ANCI tool demonstrated areas of weakness with a lack of factor structure at both the element and the domain level. The NCS raises concerns with its high correlation of a number of factors. These issues suggest that results should be read with caution.

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Implications and conclusion 

The results of this section of a larger competency study have important implications for the assessment of competency for performance management. For example, if a new graduate nurse has no experience with a specific competence, how accurate and relevant can a competency assessment be? A review of the literature revealed that as part of the development and ongoing use of the NCS, Meretoja et al. (2004, p. 129) and Meretoja and Leino-Kilpi (2001) compared competency self-assessment to frequency of use finding in both studies that the “self assessed level of competence increased in direct proportion to the self-assessed frequency of using competencies”.

This study has cautiously determined that new graduate nurse competency is related to frequency of use. Therefore, strategies could be directed towards a tailored competency assessment that takes into account those competencies frequently utilised by new graduate nurses or those specific to their current clinical setting. At the very beginning of the nurse's career (i.e. at the undergraduate level), those strategies can focus on developing generic nursing competencies. The strategies might include: (a) an increase in the number of days spent in undergraduate clinical placements and equitable access to placements for all students, (b) the provision of a workload of patients in conjunction with a preceptor to consistently improve issues of time management, competence and confidence with nursing tasks and (c) integrating student clinical decision making with experienced nursing team work.

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