ORIGINAL ARTICLE
Preparedness of final-year Turkish nursing students for work as a professional nurse Perihan G€ uner
Aims and objectives. To determine the preparedness levels of final-year Turkish nursing students starting their careers as professional nurses. Background. The transition from nursing student to professional nurse is challenging. One of the ways to help facilitate this transition is to determine how well students are prepared to start work. There are limited, but conflicting, results on this topic. Design. Mixed-methods study. Methods. Undergraduate nursing students (n = 4490) in their final year of study from 74 Turkish universities were eligible to participate in this study. Of these, 1804 total students participated from 38 randomly selected universities. Data were collected through an investigator-developed questionnaire (n = 1804) and focus group interviews (n = 57). Results. Students felt highly prepared to start work (576%). Those who were older, male, graduates of a vocational high school or already working as a nurse felt most prepared. Students who felt that their education preparation and resources were adequate felt more prepared. Focus group interviews revealed that students felt confident in their knowledge of educational theory, but not in clinical skills. Conclusions. Students may have felt prepared to start work, but insufficient clinical experience probably contributed to a lack of confidence in their skills. The resources of the school, the quality of the education, and the clinical practice environments were considered most important for the students’ perceived preparedness levels. Relevance to clinical practice. An undergraduate education provides the foundation for successful nurse preparation. A good clinical environment along with a high-quality education programme can help give students more confidence in their skills when they join the nursing workforce. Internship or residency programmes may also facilitate this learning. This is extremely important for safe, high-quality patient care.
What does this paper contribute to the wider global clinical community?
• These findings reinforce the glo-
•
•
bal challenge of preparing nursing students to begin work as a professional nurse. The emergence of internships and/or residencies appears to give students the confidence needed to join the nursing workforce. It is incumbent on educational institutions to evaluate the clinical environment of nursing students to ensure that students are exposed to positive experiences and good practice by those who supervise them.
Key words: curriculum, education, nursing student, professional practice, resources Accepted for publication: 21 June 2014
Author: Perihan G€ uner, PhD, RN, Associate Professor of Mental Health Nursing, School of Nursing, Kocß University, Istanbul, Turkey
844
Correspondence: Perihan G€ uner, Associate Professor of Mental Health Nursing, School of Nursing, Kocß University, Guzelbahce sok., No: 20, 34365 Nisantasi, Istanbul, Turkey. Telephone: +90 212 311 26 10. E-mail: [email protected]
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 844–854, doi: 10.1111/jocn.12673
Original article
Preparedness of final-year students
Introduction
Background
Transitioning from being a nursing student to registered nurse can be both exciting and daunting. New graduate nurses can feel hampered by certain anxieties when expected to practise without the security and support provided to them (Carlson et al. 2005, Deasy et al. 2011). Consequently, many factors need to be considered when examining the transition period, such as students’ feelings of preparedness, confidence in clinical skills and need for support (Deasy et al. 2011). The literature shows that new graduate nurses are not sufficiently prepared for professional practice and are a source of concern for educators, hospital administrators and other key stakeholders (Casey et al. 2004). Despite the fact that a wide array of discussion on nurse preparedness exists in the literature, educators, hospital administrators and clinical nurses continue to disagree over how well new graduate nurses are prepared for their jobs (Watt & Pascoe 2013). It is still unclear if students are prepared to fulfil the role and responsibilities of a registered nurse. Moreover, what factors contribute to the perceived preparedness of new graduates and how education and practice can more sufficiently prepare them are part of an ongoing discussion in the literature (Watt & Pascoe 2013). It is necessary for students to prepare for the realities of being a nurse (Doody et al. 2012). Forbes and Hickey (2009) reported that today’s nursing graduates are not prepared to meet the expectations of the current healthcare system and cannot fulfil the competencies expected. Studies on new graduate nurses (Kelly 1998, Thomka 2001, Romyn et al. 2009) found that graduates did not feel prepared for their new role. They leave hospital positions within one year of starting work feeling unprepared (Pellico et al. 2009). Lack of preparedness begins to emerge as a concern by students during the final year of undergraduate study (Newton & McKenna 2007); however, reports of preparedness are conflicting (Heslop et al. 2001, Deasy et al. 2011). The importance of quality and patient safety issues in the healthcare system have increased expectations of nurses and to overcome the challenges faced by the profession and meet the demands linked to changes in healthcare, nurse educators must adapt nursing curricula accordingly (Hegarty et al. 2009, Secomb et al. 2012). Educational institutions must prepare students to have skills in a variety of areas such as making critical decisions and providing care for a wide range of health problems (Petro-Nustas et al. 2001, L€ ofmark & Thorell-Ekstrand 2004).
In a study conducted to determine the extent to which the final-year undergraduate nursing students felt prepared to start work, the results showed that 53% students felt adequately prepared to be registered nurses (Deasy et al. 2011). Areas in which students feel prepared to begin work also vary widely worldwide. These variations may be partially explained by the use of investigator-developed questionnaires focusing on different topics that generate different areas of strengths and weaknesses. Others use open-ended questions resulting in the potential for a wide range of topics. In a study in Australia, students responded ‘well’ to ‘very well prepared’ to communicating with patients, relatives and other health professionals, but ‘unprepared’ to ‘very unprepared’ for caring for groups of patients, patients with complex problems or communicating with physicians (Heslop et al. 2001). In Sweden (Lofmark et al. 2006), students felt most prepared in ethical awareness, communication/interaction with patients, ability to cooperate, preparing for action and working speed, self-knowledge and administering drugs. Based on these studies, it is difficult to determine areas where changes should be considered in nursing programmes and how prepared they felt starting work as a professional nurse. It is observed that these results were obtained by using only a quantitative research method (Heslop et al. 2001, Lofmark et al. 2006, Deasy et al. 2011) and given the limited study of nursing students in Turkey, we sought to obtain more comprehensive and extensive data by using a mixed-method design. The first phase of this study evaluated the perceptions of nursing students regarding educational facilities and the quality of education (G€ uner 2013). The aim of this second phase was to determine the extent to which nursing students felt prepared to begin work, the factors affecting their feelings of preparation and recommendations for preparedness.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 844–854
Methods In Turkey, there are different types of college-level nursing schools: schools of health sciences, schools/colleges of nursing, faculties of health sciences and faculties of nursing. Although the names of schools are different, education at all of these schools is based on the regulations prepared by Turkish Higher Education Council. All undergraduate and graduate levels of education in Turkey are controlled by Turkish Higher Education Council (C ß inar & Altun 2010). According to these regulations, nursing education must be
845
P G€ uner
at least four years or 4600 hours in theoretical coursework and clinical practice. Theoretical classroom education must be at least one-third and clinical practice must be half of the total education. The minimum requirement for admission to nursing education is a high school diploma (Can 2010). Although college education in Turkey has to comply with these criteria, the adequacy and appropriateness of instructors, physical and technological/educational materials and areas of clinical sites for each school may result in some differences in practice. For example, if there is an insufficient number of faculty at a school, nurses might supervise the students during the clinical practice, or an instructor may teach outside his/her specialty area. Under normal conditions, after students practise all nursing skills in school laboratories, they apply these skills at clinical sites with their instructors. The sample consisted of 2268 students selected via a stratified sampling method from among 4490 potential students who were in their final year at the 74 universities throughout Turkey. The final sample consisted of 31 State University Schools of Health Sciences (SHS), seven State University Colleges of Nursing/Faculty of Health Sciences (CON) and one Private University Faculty of Health Sciences (PVT). A total of 1804 students (response rate: 795%) were recruited after having to eliminate 104 due to their refusal to participate and 52 due to incomplete forms. 308 were not contacted because two PVT universities did not give permission for this research and school representatives at one SHS and one CON did not distribute the surveys in a timely manner.
Data collection Data collection consisted of completing questionnaires and focus group interviews. First, the investigator-developed questionnaire (IDQ) was distributed over a four-month period (March–June 2010) by a school representative. Each institution distributed the questionnaires on a day they selected to a class of fourth-year students. The student questionnaires were collected by the university and sent to the principal investigator. Next, after purposive sampling of students was conducted, six focus groups consisting of 8–10 students were formed from randomly selected schools from each region. Interviews were conducted in these focus groups in one of the classes at the schools. The semistructured interviews were driven by five questions:(1) How much do you feel prepared to work as a nurse? (2 & 3) Which areas do you and do you not feel prepared? (4) If you do not feel prepared, what might be the reasons? and (5) What are your recommendations for feeling more
846
prepared? A total of 57 students participated in these focus groups, 38 from four SHSs and 19 from two CONs (the PVT universities did not participate). Group interviews were held once, lasted 60–90 minutes and were taperecorded. The IDQ consisted of 106 questions in two parts, one of which was completed by the students (50 items) and the other by the school administrative representatives (56 items) (G€ uner 2013). The student portion used in this study consisted of 27 questions related to demographic data and 22 assessing adequacy level of preparedness for practice. Lastly, an open-ended question was used to elicit recommendations on how to feel more prepared to begin work.
Data analysis SPSS for Windows (version 20.0, Koc ß University, Turkey) was used for data analysis. Chi-squared test was utilised to determine if a relationship existed between preparedness to practise and select demographic characteristics, school resources, and perceptions on educational adequacy. Because of the small sample size for the PVT university, chi square analysis was only done between the SHS and CON. The limit for statistical significance was set at p < 005. Qualitative data analysis consisted of data coding, theme finding, code and theme arrangement and identification, and evidence interpretation (Hsieh & Shannon 2005). The themes were first identified using content analysis. The starting codes were grouped into significant themes and the data were revised repeatedly until a ‘no further theme exists’ decision was made. The team then gathered and discussed the themes and sub-themes until a consensus was reached and a final decision was made. Lastly, the themes and sub-themes were evaluated by a medical anthropologist who was also an expert in qualitative research.
Ethical considerations Approval for the study was obtained from the Ethical Committees of Kocß University College of Nursing and Hacettepe University and from the Deans and administrators of the universities. Student consent was obtained prior to being provided with the questionnaire.
Results Of 1804 students recruited, two students did not indicate their university affiliation and several did not complete all of the questions. Therefore, the denominator for any question may vary in the Tables. More students from the SHS © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 844–854
Original article
Preparedness of final-year students
(n = 1381) completed the questionnaire than either the CON (n = 383) or PVT (n = 38) university. We elected to look at only those who felt a ‘high’ vs. a ‘low’ level of preparation to begin work as a professional nurse. The majority of students (576%) felt ‘highly prepared’ to begin work (Table 1). PVT students were more likely to indicate feeling prepared (71%) than either the SHS (565%) or CON (607%) students. There was no difference in the level of feeling prepared between SHS and CON (p = ns). Those who were 23 years of age or older indicated feeling more prepared than those under 23 years (p =
Preparedness of final-year Turkish nursing students for work as a professional nurse Perihan G€ uner
Aims and objectives. To determine the preparedness levels of final-year Turkish nursing students starting their careers as professional nurses. Background. The transition from nursing student to professional nurse is challenging. One of the ways to help facilitate this transition is to determine how well students are prepared to start work. There are limited, but conflicting, results on this topic. Design. Mixed-methods study. Methods. Undergraduate nursing students (n = 4490) in their final year of study from 74 Turkish universities were eligible to participate in this study. Of these, 1804 total students participated from 38 randomly selected universities. Data were collected through an investigator-developed questionnaire (n = 1804) and focus group interviews (n = 57). Results. Students felt highly prepared to start work (576%). Those who were older, male, graduates of a vocational high school or already working as a nurse felt most prepared. Students who felt that their education preparation and resources were adequate felt more prepared. Focus group interviews revealed that students felt confident in their knowledge of educational theory, but not in clinical skills. Conclusions. Students may have felt prepared to start work, but insufficient clinical experience probably contributed to a lack of confidence in their skills. The resources of the school, the quality of the education, and the clinical practice environments were considered most important for the students’ perceived preparedness levels. Relevance to clinical practice. An undergraduate education provides the foundation for successful nurse preparation. A good clinical environment along with a high-quality education programme can help give students more confidence in their skills when they join the nursing workforce. Internship or residency programmes may also facilitate this learning. This is extremely important for safe, high-quality patient care.
What does this paper contribute to the wider global clinical community?
• These findings reinforce the glo-
•
•
bal challenge of preparing nursing students to begin work as a professional nurse. The emergence of internships and/or residencies appears to give students the confidence needed to join the nursing workforce. It is incumbent on educational institutions to evaluate the clinical environment of nursing students to ensure that students are exposed to positive experiences and good practice by those who supervise them.
Key words: curriculum, education, nursing student, professional practice, resources Accepted for publication: 21 June 2014
Author: Perihan G€ uner, PhD, RN, Associate Professor of Mental Health Nursing, School of Nursing, Kocß University, Istanbul, Turkey
844
Correspondence: Perihan G€ uner, Associate Professor of Mental Health Nursing, School of Nursing, Kocß University, Guzelbahce sok., No: 20, 34365 Nisantasi, Istanbul, Turkey. Telephone: +90 212 311 26 10. E-mail: [email protected]
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 844–854, doi: 10.1111/jocn.12673
Original article
Preparedness of final-year students
Introduction
Background
Transitioning from being a nursing student to registered nurse can be both exciting and daunting. New graduate nurses can feel hampered by certain anxieties when expected to practise without the security and support provided to them (Carlson et al. 2005, Deasy et al. 2011). Consequently, many factors need to be considered when examining the transition period, such as students’ feelings of preparedness, confidence in clinical skills and need for support (Deasy et al. 2011). The literature shows that new graduate nurses are not sufficiently prepared for professional practice and are a source of concern for educators, hospital administrators and other key stakeholders (Casey et al. 2004). Despite the fact that a wide array of discussion on nurse preparedness exists in the literature, educators, hospital administrators and clinical nurses continue to disagree over how well new graduate nurses are prepared for their jobs (Watt & Pascoe 2013). It is still unclear if students are prepared to fulfil the role and responsibilities of a registered nurse. Moreover, what factors contribute to the perceived preparedness of new graduates and how education and practice can more sufficiently prepare them are part of an ongoing discussion in the literature (Watt & Pascoe 2013). It is necessary for students to prepare for the realities of being a nurse (Doody et al. 2012). Forbes and Hickey (2009) reported that today’s nursing graduates are not prepared to meet the expectations of the current healthcare system and cannot fulfil the competencies expected. Studies on new graduate nurses (Kelly 1998, Thomka 2001, Romyn et al. 2009) found that graduates did not feel prepared for their new role. They leave hospital positions within one year of starting work feeling unprepared (Pellico et al. 2009). Lack of preparedness begins to emerge as a concern by students during the final year of undergraduate study (Newton & McKenna 2007); however, reports of preparedness are conflicting (Heslop et al. 2001, Deasy et al. 2011). The importance of quality and patient safety issues in the healthcare system have increased expectations of nurses and to overcome the challenges faced by the profession and meet the demands linked to changes in healthcare, nurse educators must adapt nursing curricula accordingly (Hegarty et al. 2009, Secomb et al. 2012). Educational institutions must prepare students to have skills in a variety of areas such as making critical decisions and providing care for a wide range of health problems (Petro-Nustas et al. 2001, L€ ofmark & Thorell-Ekstrand 2004).
In a study conducted to determine the extent to which the final-year undergraduate nursing students felt prepared to start work, the results showed that 53% students felt adequately prepared to be registered nurses (Deasy et al. 2011). Areas in which students feel prepared to begin work also vary widely worldwide. These variations may be partially explained by the use of investigator-developed questionnaires focusing on different topics that generate different areas of strengths and weaknesses. Others use open-ended questions resulting in the potential for a wide range of topics. In a study in Australia, students responded ‘well’ to ‘very well prepared’ to communicating with patients, relatives and other health professionals, but ‘unprepared’ to ‘very unprepared’ for caring for groups of patients, patients with complex problems or communicating with physicians (Heslop et al. 2001). In Sweden (Lofmark et al. 2006), students felt most prepared in ethical awareness, communication/interaction with patients, ability to cooperate, preparing for action and working speed, self-knowledge and administering drugs. Based on these studies, it is difficult to determine areas where changes should be considered in nursing programmes and how prepared they felt starting work as a professional nurse. It is observed that these results were obtained by using only a quantitative research method (Heslop et al. 2001, Lofmark et al. 2006, Deasy et al. 2011) and given the limited study of nursing students in Turkey, we sought to obtain more comprehensive and extensive data by using a mixed-method design. The first phase of this study evaluated the perceptions of nursing students regarding educational facilities and the quality of education (G€ uner 2013). The aim of this second phase was to determine the extent to which nursing students felt prepared to begin work, the factors affecting their feelings of preparation and recommendations for preparedness.
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 844–854
Methods In Turkey, there are different types of college-level nursing schools: schools of health sciences, schools/colleges of nursing, faculties of health sciences and faculties of nursing. Although the names of schools are different, education at all of these schools is based on the regulations prepared by Turkish Higher Education Council. All undergraduate and graduate levels of education in Turkey are controlled by Turkish Higher Education Council (C ß inar & Altun 2010). According to these regulations, nursing education must be
845
P G€ uner
at least four years or 4600 hours in theoretical coursework and clinical practice. Theoretical classroom education must be at least one-third and clinical practice must be half of the total education. The minimum requirement for admission to nursing education is a high school diploma (Can 2010). Although college education in Turkey has to comply with these criteria, the adequacy and appropriateness of instructors, physical and technological/educational materials and areas of clinical sites for each school may result in some differences in practice. For example, if there is an insufficient number of faculty at a school, nurses might supervise the students during the clinical practice, or an instructor may teach outside his/her specialty area. Under normal conditions, after students practise all nursing skills in school laboratories, they apply these skills at clinical sites with their instructors. The sample consisted of 2268 students selected via a stratified sampling method from among 4490 potential students who were in their final year at the 74 universities throughout Turkey. The final sample consisted of 31 State University Schools of Health Sciences (SHS), seven State University Colleges of Nursing/Faculty of Health Sciences (CON) and one Private University Faculty of Health Sciences (PVT). A total of 1804 students (response rate: 795%) were recruited after having to eliminate 104 due to their refusal to participate and 52 due to incomplete forms. 308 were not contacted because two PVT universities did not give permission for this research and school representatives at one SHS and one CON did not distribute the surveys in a timely manner.
Data collection Data collection consisted of completing questionnaires and focus group interviews. First, the investigator-developed questionnaire (IDQ) was distributed over a four-month period (March–June 2010) by a school representative. Each institution distributed the questionnaires on a day they selected to a class of fourth-year students. The student questionnaires were collected by the university and sent to the principal investigator. Next, after purposive sampling of students was conducted, six focus groups consisting of 8–10 students were formed from randomly selected schools from each region. Interviews were conducted in these focus groups in one of the classes at the schools. The semistructured interviews were driven by five questions:(1) How much do you feel prepared to work as a nurse? (2 & 3) Which areas do you and do you not feel prepared? (4) If you do not feel prepared, what might be the reasons? and (5) What are your recommendations for feeling more
846
prepared? A total of 57 students participated in these focus groups, 38 from four SHSs and 19 from two CONs (the PVT universities did not participate). Group interviews were held once, lasted 60–90 minutes and were taperecorded. The IDQ consisted of 106 questions in two parts, one of which was completed by the students (50 items) and the other by the school administrative representatives (56 items) (G€ uner 2013). The student portion used in this study consisted of 27 questions related to demographic data and 22 assessing adequacy level of preparedness for practice. Lastly, an open-ended question was used to elicit recommendations on how to feel more prepared to begin work.
Data analysis SPSS for Windows (version 20.0, Koc ß University, Turkey) was used for data analysis. Chi-squared test was utilised to determine if a relationship existed between preparedness to practise and select demographic characteristics, school resources, and perceptions on educational adequacy. Because of the small sample size for the PVT university, chi square analysis was only done between the SHS and CON. The limit for statistical significance was set at p < 005. Qualitative data analysis consisted of data coding, theme finding, code and theme arrangement and identification, and evidence interpretation (Hsieh & Shannon 2005). The themes were first identified using content analysis. The starting codes were grouped into significant themes and the data were revised repeatedly until a ‘no further theme exists’ decision was made. The team then gathered and discussed the themes and sub-themes until a consensus was reached and a final decision was made. Lastly, the themes and sub-themes were evaluated by a medical anthropologist who was also an expert in qualitative research.
Ethical considerations Approval for the study was obtained from the Ethical Committees of Kocß University College of Nursing and Hacettepe University and from the Deans and administrators of the universities. Student consent was obtained prior to being provided with the questionnaire.
Results Of 1804 students recruited, two students did not indicate their university affiliation and several did not complete all of the questions. Therefore, the denominator for any question may vary in the Tables. More students from the SHS © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 844–854
Original article
Preparedness of final-year students
(n = 1381) completed the questionnaire than either the CON (n = 383) or PVT (n = 38) university. We elected to look at only those who felt a ‘high’ vs. a ‘low’ level of preparation to begin work as a professional nurse. The majority of students (576%) felt ‘highly prepared’ to begin work (Table 1). PVT students were more likely to indicate feeling prepared (71%) than either the SHS (565%) or CON (607%) students. There was no difference in the level of feeling prepared between SHS and CON (p = ns). Those who were 23 years of age or older indicated feeling more prepared than those under 23 years (p =
