Abstract
Background
Achieving clinical competency at the end of nursing education is vital to the development of professional standards and the assurance of patient safety. It thus becomes important to define clinical competence. In nurse education and clinical placements, students were assessed regarding their clinical competences.
Objective
The aim of this research was to investigate how clinical knowledge was characterized in the assessment forms used in medical and surgical wards within nurse education.
Methods
The study had a qualitative, descriptive design. The data source consisted of 100 anonymized assessment forms from medical and surgical clinical placements. The analysis was based on Braun and Clarke's reflexive thematic analysis. The article used the Standards for Reporting Qualitative Research (SRQR) checklist.
Results
The analysis resulted in four nursing knowledge areas in clinical competences, related to: medical diagnoses and treatments of the patients, nursing actions, professional attributes and patient safety.
Conclusion
This study underscored the significance of medical treatments and procedures, as well as the understanding of medical diagnoses, as key elements highlighted in the written assessment forms for evaluating nursing students’ clinical competence. This contrasted with previous studies of clinical competence in nursing, which had been more broadly focused on critical thinking, problem-solving and decision-making.
Background
Nurses’ clinical competences are crucial if they are to contribute to safe patient care (Aiken et al., 2017). Nurses are subject to high expectations to develop knowledge and skills to provide up-to-date care for patients in medical and surgical wards. Wu et al. (2016) state that achieving clinical competency at the end of nursing education is vital to the development of professional standards and the assurance of patient safety—it thus becomes important to define clinical competence. In nurse education and clinical placement, the students are assessed regarding their clinical competences. This study examines the assessment forms that describe students’ clinical competence in specialist health services—specifically, the written summaries of the mid-term and final assessments—and provides recommendations for future studies.
Review of Literature
Van Horn and Lewallen (2023) conducted a systematic review concerning clinical evaluation of competence in nurse education. They found a lack of a common definition and evaluation of competence. The concepts of clinical competence were generally described and related to knowledge, attitudes and behaviors, values and ethics. In addition, Lejonqvist et al. (2016) underlined that the evaluation of clinical competence seems to involve an emphasis on skills and performing. Immonen et al. (2019) conducted a systematic review of nurse students’ competence areas in clinical placements and found that assessment tools tend to focus on professional attributes, ethical practices, communication, nursing processes and critical thinking. They concluded that nursing students’ competence is not limited to the procedures but also includes the competences of critical thinking, ethical decision-making and their ability to collaborate.
Huisman-de Waal et al. (2018) conducted an empirical study of students’ perspectives on basic nursing care. Basic nursing care was defined as attending to a person's basic needs, cleanliness and prevention of complications. As a generic skill, basic nursing care is independent of medical condition and health care settings. The study found that basic nursing care is largely invisible, especially in the theoretical part of the education. Basic nursing care can be seen as part of the fundamentals of care, which again are very important in general nurse education. The fundamentals of care framework consist of relational, integrative and contextual dimensions, where the specific domains are the patients’ psychosocial and physical needs, in addition to the caregivers’ actions (Kitson et al., 2013; Voldbjerg et al., 2018, 2020).
With regard to the variety of definitions and perceptions of clinical competence, Willman et al. (2020) conducted a longitudinal empirical study of newly graduated nurses’ self-assessments. The study points to different components of clinical competence, such as ethical decision-making, cooperation and consultation, clinical leadership, professional development, direct clinical practice and critical thinking. The authors underline the ability to think critically as a fundamental aspect of the forming of clinical competence. Despite this, they found that the students rated critical thinking as being of lowest importance in clinical competence. This is supported by the findings of Liou et al. (2020), who conducted an empirical study of hospital nurses and nursing students and measured their performance competence. The authors also highlighted that critical thinking is necessary for the provision of safe and appropriate care.
Liou et al. (2020) defined clinical competence as “the ability to apply critical thinking, problem solving and clinical decision-making skills in patient care” (p. 2654). Kajander-Unkuri et al. (2021) include more specific functions of nursing competence, such as guidance, diagnosing, therapeutic interventions and helping. In addition, Hickey (2010) describes clinical competence as the theoretical and clinical knowledge that is used in practice, combining psychomotor skills and problem-solving to ensure safe patient care (p. 36). Although nursing competence is crucial for patient care, this review of relevant literature reveals that discussions about what clinical competence consists of are quite generally formulated. The theoretical foundation seems unclear, and the definition of the concept of clinical competence lacks a common description.
On an overall level, competence appears to encompass several crucial elements such as critical thinking, problem-solving and decision-making. In an educational context, it is necessary to reflect on what kind of knowledge and skills the students need to achieve. Different areas of clinical competence seem to be emphasized, and the descriptions of competence seem very general. This may contribute to a blurry understanding of competence. Several studies have claimed that there is no common definition of clinical competence (Lewallen & Van Horn, 2019; Ličen & Plazar, 2015; Liou et al., 2020; Van Horn & Lewallen, 2023). A more precise definition of nursing competence might also contribute to improving students’ learning outcomes in clinical placements.
By examining written assessment forms from third-year students’ clinical placements, this study aimed to contribute knowledge about the aspects of nursing knowledge that were emphasized within written assessments. Thus, it sought to nuance the description of clinical competence by analysing the summaries written in the assessment forms.
The study aimed to contribute to a nuanced understanding of clinical competence. Based on the study's aim, the research question is: How is clinical knowledge characterized in the assessment forms used in medical and surgical wards within nurse education?
Methods
Design
The study design was qualitative and descriptive, and included a thematic analysis of the “free texts” included in the assessments, where “free text” was understood as text written in an open format on the assessment forms, constrained to a short description of students’ achievements.
Study Setting, Sampling, and Data Collection
This study was conducted at Oslo Metropolitan University, at the third-year level of the bachelor's program in nursing. The curriculum requires 50% clinical practice, which at this level is concentrated on medical and surgical clinical practice. The learning outcomes for this clinical practice are described in Table 1.
Learning Outcomes.
The data were based solely on assessment forms that contained evaluations of students’ general competence, knowledge and skills in medical and surgical placements. The learning outcomes were evaluated and signed by the clinical supervisor, the university supervisor and the students. The assessment forms included free written text that summarized the student's performance and stated whether the student had passed or failed the clinical placement study. The assessment forms contained 15 learning outcomes, which were based on the national curriculum regulations and developed at the faculty level. These learning outcomes were assessed as either meeting the expected level or being below the expected level. Two of the learning outcomes described required knowledge, with one relating to diseases and medical treatment and the other relating to health legislation, responsibilities, and authorities. Two learning outcomes combined knowledge and actions, whilst the rest related to actions (see Table 1). The assessment forms included comments related to the students’ learning outcomes at the mid-term assessment. In addition, concretization of new learning activities was described at both the mid-term and at the end-of-term assessments. The comments in the summaries and recommendations of new learning activities served as this study's data source.
The study was based on purposive sampling to increase information richness. The inclusion criteria consisted of rich free text, while the exclusion criteria included forms from students who had not passed clinical practice. Additionally, no suitability assessment cases were included in the sample. The study's selection was described as strategic according to Polit and Beck (2017, p. 493). All forms contained both mid-term and final assessments of the students, and the same form was used in both the medical and surgical departments. From a total of 900 forms, 100 forms—50 from a medical department and 50 from a surgical department—were selected to obtain information-rich cases and to ensure both a broad and in-depth study (Patton, 2015).
The specialist health service had clinical placements lasting 8 or 10 weeks during the third year of the bachelor's program in nursing. Standardized assessment forms from the academic year 2017/2018, which were obtained from a state educational institution, were used in the study. The assessment forms were selected based on the inclusion and exclusion criteria and were anonymized by the academic administration by obscuring the names and background data. The data was only available in print format and were not digitalized. The free written text in these hundreds of assessment forms was analysed.
Data Analysis
The analysis was based on Braun and Clarke's (2022) thematic analysis. The purpose of thematic analysis is to identify patterns and themes in qualitative data. The analysis began with an inductive approach to the free text, whereby words and quotes were encoded. In the first phase, all the authors read and re-read the forms individually several times to achieve familiarity with the data. In the second and third phases, the data were organized, and the emerging codes were identified, first individually and then collaboratively. The researchers developed and renewed themes based on how the codes interacted and related to the purpose of the study. The themes were then modified from the previous phases to ensure that the codes accurately encompassed the content of the data (see Table 2). Throughout the analysis process, the researchers reflected on and discussed their engagement in educational research and nurse education. At times, they intentionally distanced themselves from the analysis to gain perspective before reconvening to continue the collaborative coding efforts. This process of reflection and collaboration resulted in the identification of four themes. The codes were subsequently reviewed to ensure alignment with the aim of the study.
Quotes Illustrating the Themes.
All researchers participated in every phase of the analysis. All of them worked at a university, and none had conducted assessments in the clinical placement under study, although two had previously used the assessment form. The three researchers approached the bachelor's program in nursing from different perspectives: one as a leader, one from the master's program in nursing and one from the bachelor's program in nursing.
Ethical Considerations
The study was reviewed in accordance with the Norwegian Centre for Research Data's electronic notification form. The data were assessed as not being subject to notification, as the forms were anonymized and could not be used to identify individuals.
Results
The results were based on the analysis of 100 assessment forms, with 50 originating from medical departments and 50 from surgical departments. Generally, the results indicated minimal differences between those assessment forms related to medical practices and those from surgical practices, except in the descriptions of various medical diagnoses and treatments. The analysis resulted in the construction of four themes, related to: medical diagnoses and treatments of patients, nursing actions, professional attributes and patient safety (see Table 2).
Competence Related to Medical Diagnosis and Treatments of the Patients
The primary emphasis of the assessment forms was on medical diagnosis. Assessment forms from a medical ward mentioned diagnosis, such as “heart failure, infections, thromboses, pulmonary infections,” and “flutter” (assessment form number, medical ward, M3). Additionally, students were encouraged to further study these diagnoses by consulting relevant literature and manuals and following up with patients. In the surgery ward, a similar emphasis on medical diagnoses was found, such as “deepening the knowledge on oesophageal atresia, gastrointestinal diseases and morbus Hirschsprung's disease” (assessment form number, surgical ward, S6). In cancer wards, one student was encouraged to “read the oncological manual related to vulva and ovaria” (S43).
The patient's basic human needs, on the other hand, were only specifically mentioned to a small degree in the assessment forms. The basic needs reported in this study concerned physical needs, such as respiratory needs, circulatory needs, nutrition, rest and activity. In a postoperative ward, one student assessment emphasized that the student ought to study “the postoperative patient regarding respiration, circulation, management of oxygen […] and mobilisation” (S9). Another form stated that the student “was good at mapping pain and rest” (S11). Of all the patient phenomena, pain was the only one that was mentioned. A student in a surgery ward was encouraged “to study pain, different kinds of pains, and pain relief” (S3).
The knowledge related to patients was dominated by medical perspectives, such as comments on diagnoses. The physical basic needs were mentioned to a lesser degree within this theme. Only one patient phenomenon was commented on—the phenomenon of pain.
Competence Related to Nursing Actions
The assessment forms for nursing and medical education place significant emphasis on procedures, in terms of both practice and evaluation. In the summaries of student learning outcomes, the procedures skills are highlighted first. The student “has performed several procedures; peripheral venous catheter, injections […] and observed several advanced medical procedures” (M10). Other comments were related to caring and observing in conjunction with procedures, such as care of a central venous catheter, oral care, care of peg probe and urine catheter, care of stomia, and wound care. Some of the comments mention the standard of the performance—for example, one student “conveys calmness and security while performing the procedures, for example, active listening to the patient” (M25). Some of the students were exposed to quite advanced procedures. One student “has handled medication through central venous catheter and Hickman catheter and receives feedback for demonstrating a good touch” (S39). Even though the performance of procedures requires hygienic knowledge, only one of the hundred forms mentioned that the student had “performed hygiene according to the rules” (M23).
The nursing process was also given attention in the written feedback. Planning, observing, intervening, communicating and documenting medical treatment and nursing care were included in this process and commented on in the forms. According to one form, the student observes and performs interventions […] the student communicates well, educates and guides the patients. The student gets credit for planning nursing actions and also has skills in procedures, such as taking blood tests. She has given an overview of the medication and manages medicines. She reports in journals and makes treatment plans. (M31)
The same was emphasized in a surgery ward, where one student was described as having “studied communication […] and focused on the anamnesis, managing medical treatment and postoperative observations. She has been active in digital documentation” (S10).
Management and leadership were prioritized in the finial clinical placements, and this was reflected in the findings. Prioritizing and planning patient care was given attention, with one form stating that the student “takes responsibility for several patients, following them through the pathway, pre-, per- and post-operation.” She was invited “to be a group leader for the day and to give a report” (S37). The competence of leadership also encourages the student to “facilitate the doctor's round by delegating and making priorities in nursing tasks during the day and participating in meetings” (M2).
Nursing actions contained comments on students’ actions regarding medical treatment, nursing procedures and the nursing process, including observation, planning, decision-making, intervention, evaluation and documentation. This also included health guidance, management and leadership.
Professional Attributes
The ability to cooperate was one of the skills that was most commented upon. This skill encompassed cooperation with patients, next of kin and health care personnel in the ward. In one case, a student was commended for “prioritising interdisciplinary cooperation” (S8), and another described that the student “cooperates in a good way with the patient, [the student is] reliable and has established a good relationship with the patient” (M30).
The student's professionalism was mentioned in several forms, which included specific learning outcomes related to accuracy and reliability. One feedback was that the student was “accurate, secure and independent.” The ability to reflect was also given attention, as the student considered “ethical challenges according to continuing medical treatment and discharge of the patients” (M17). Professional reflections that highlighted the relationship between the abstract diagnosis and the individual patient were given attention, with one student praised for “taking responsibility for different patients, and reflecting professionally on medical diagnoses, the clinical picture of the patients and their symptoms related to clinical observation” (S7).
Personal attributes included collaboration skills, independence, acting with accuracy and reliability, interacting, reflecting and participating in relationships.
Competence Related to Patient Safety
The findings on patient safety were interpreted both as a single theme and as being included in the three themes mentioned above (see, e.g., quotes S11, S10, and M17). Aspects included in the theme of patient safety were documentation of care, quality assurance (e.g., reporting irregularities) and adherence to internal procedures. Governing documents at the institution were collected in an electronic handbook system—the e-book—which was primarily based on research. Regarding this theme, the students’ use of the e-book was most frequently commented on—one student, for example, “used the e-book and studied different procedures” (M30). Some students seemed to have checked on their performance by consulting the ebook.
With regard to reporting irregularities, students were encouraged to notice, report and follow up on any irregularities, such as the student who noted relevant “observations, reported irregularities and followed up the irregularities” (M28).
One of the health care strategies to keep the patients safe was the implementation of evidence-based practice (EBP). EBP was mentioned to a lesser degree in the forms. One student was encouraged “to reflect on evidence-based practice and read relevant research for practice” (S4). Another student was noted to have demonstrated the “use of theory and research in clinical placement” (S27).
Discussion
This study sheds light on the description of clinical knowledge as part of the competence gained from clinical placement in a bachelor's program in nursing. Four key areas of knowledge were identified: medical diagnosis of patients, nursing actions, professional attributes and patient safety. In this discussion, the focus will be on knowledge related to patients and nursing actions, as these two themes were the most prominent in the material. Knowledge related to patients had a major focus on medical diagnoses and, to a lesser degree, on specific nursing themes, such as patient phenomena and the psychosocial part of human needs. Existing research seems to focus more on general nursing competences instead of underlining the medical aspect (see, e.g., Huisman-de Waal et al., 2018; Kajander-Unkuri et al., 2021; Liou et al., 2020).
Although these assessment forms were connected to clinical placements in medical and surgical wards, patient phenomena such as nausea and vomiting were not mentioned, and neither were stress or hope given any attention. Just a few comments on respect and dignity were found in the data. The basic human needs described in the assessment forms were few and mainly related to physical needs. A possible explanation for the focus on medical knowledge and physical human needs might be that the students being evaluated were connected to specialized health care services, where medical treatment was dominant and the patients stayed in the ward for only a short time. However, even during a short hospitalization, patients might have both physical and psychosocial needs that the nurse needs to recognize and address through appropriate interventions.
This focus on medical diagnoses might have weakened the view of the independence of the nursing profession and might have diminished the patient's experience of being cared for. Patient phenomena may have constituted a significant theoretical approach in nursing (Kim, 2010) but they were seemingly not assessed as being important in this study.
Although nursing competence is crucial for patient care, the review of relevant literature revealed that discussions about what clinical competence consisted of were quite generally formulated (Lewallen & Van Horn, 2019; Ličen & Plazar, 2015; Liou et al., 2020). The perspective of medical knowledge, such as medical diagnosis and treatment, might therefore have been blurry or invisible in clinical competence.
The nursing action covered decision-making and problem-solving through the nursing process. This emphasized the focus on skills and performance, which aligns with Lejonqvist et al. (2016) and Hickey's (2010) descriptions of clinical competence. On the other hand, only a few comments highlighted the ability to reflect and think critically, which is consistent with the findings of Liou et al. (2020) and Willman et al. (2020). According to Immonen et al. (2019), clinical competence in nursing can be seen as separated from theoretical reflections. Huisman-de Waal et al. (2018) claimed that nursing students found basic nursing care largely invisible in the theoretical part of their education. If such basic care is in fact absent from nursing programs, care should be taken to integrate or make more explicit the importance of attending to patients’ basic human needs.
The role of nurses in medical treatment might be overlooked or ignored because of the general formulation of clinical competence. The findings of this study showed that clinical competence consisted of knowledge and skills related to medical procedures and medical treatment, such as medication management. Efforts had been made to define the autonomous area of nursing, often in opposition to the medical profession (Beedholm & Frederiksen, 2015). One aspect in the discussion about the medical knowledge in nursing might relate to this history of professionalization in nursing. Justifying the importance of medical knowledge in competence for nursing care might strengthen the link to and cooperation with the medical profession.
Furthermore, the study showed that clinical tasks and skills were predominant in the assessment forms for students’ clinical practice. Nursing procedure skills, such as injections and care of stomia, were given attention, and nursing tasks, such as planning and observation of patients, were emphasized, which is in line with the findings of Lejonqvist et al. (2016). The tasks took precedence in the descriptions of the competence of nurse students. The nursing profession may suffer if the theoretical reflections and critical thinking are ignored. Liou et al. (2020) highlighted that critical thinking is a crucial part of providing safe and appropriate care.
The way in which the system level affected nursing actions was not commented on in the assessment forms. This study showed that the management of a small group of patients received attention, whilst attention to the executive system was absent. Ignoring the system level might reduce autonomy and stamina in the nurse profession. At the society level, a consequence of ignoring this aspect might increase the dropout rate from the profession. On the other hand, the knowledge of patient safety did receive attention, including quality assurance, documentation of care and the need to follow research-based guidelines. The comments in the assessment forms emphasized the importance of reporting any errors or discrepancies, which required a level of critical thinking. The results of this study were largely related to the application of knowledge and skills and, to a lesser degree, to nurses’ competence in judgment. When compared to the International Council of Nurses’ definition of nursing competence (1997), which is described as “a level of performance demonstrating the effective application of knowledge, skills, and judgments” (p. 44), this lack of any mention of judgement skills in our study might have been due to the fact that the assessment forms (see Table 1) did not explicitly include learning outcomes related to judgement skills.
Strengths and Limitations of the Work
This study is based on the ways in which clinical knowledge in nursing competence was commented on in nursing students’ assessment forms. It is therefore important to underline that this study focuses on what was emphasized in written assessments of nursing students’ clinical practice—what actually happened in the assessed situations, as well as how the students’ nursing competences were performed, was not studied. In the free texts, words and phrases were often abbreviated, but in the presentation of the findings, these abbreviations have been printed in full. The assessment forms were handwritten in a colloquial language and, to some degree, written in the form of keywords, which may have caused some misunderstandings in the interpretation of the text. On the other hand, there seemed to be great similarities between the forms, which strengthens the findings in this study.
Three researchers with diverse backgrounds analysed the data in this study, thereby ensuring that different perspectives were considered. Each phase in the analysis process was described. The researchers devoted extensive time to the data to understand its nuances and complexities, based on repeated readings. The results were validated by presenting and discussing them twice with uninvolved researchers in the Education Research Group at the Faculty of Health Sciences. This contributed to strengthening the relevance of the study, its methodological application and the analysis of the data.
The analysis followed the structured approach outlined by Braun and Clarke (2022), which contributed to consistency throughout the phases. The researchers continuously reflected on personal biases and perspectives, especially given their backgrounds in nursing education and research. Through these strategies, the researchers strengthened the robustness and reliability of the thematic analysis, ensuring their findings are well founded and credible.
Implications for Practice
Clearly defining nurses’ clinical competence is essential for both nurse education and the nursing profession. A well-defined definition can help to clarify nurses’ responsibilities and tasks, thereby fostering greater understanding and accountability. Additionally, a precise definition of competence may enhance students’ learning outcomes during clinical placements by providing clearer expectations and objectives for their development.
Conclusion
This study sought to identify how clinical knowledge is characterized in the assessment forms that are used in medical and surgical wards within nurse education. The results highlighted medical treatment and procedures, along with knowledge of medical diagnoses, as being important aspects emphasized in the written assessments of nursing students’ clinical competence. This contrasted with previous studies of clinical competence in nursing, which were more generally formulated and related to critical thinking, problem-solving and decision-making. Attention to patient phenomena seemed to be emphasized to a lesser degree in the assessment forms, and there was hardly any mention of critical thinking. The ability to ensure patient safety appeared to be an important element of clinical competence, based on the written assessments.
Footnotes
Acknowledgments
We want to thank the research group Education Research at OsloMet for constructive and important critique.
Ethical Approval and Consent to Participate
Ethics approval and consent to participate are not applicable to this study. The research was conducted in alignment with the guidelines of the Norwegian Centre for Research Data (NSD) and was deemed not subject to formal reporting requirements. As the study involved the analysis of anonymized written text and the evaluation of assessment forms, it does not involve human participants or personal data that would necessitate ethical approval under the Declaration of Helsinki. The Declaration, primarily designed to safeguard the rights and well-being of individuals in medical research and studies involving human subjects, is therefore not relevant to this research context.
Author Contributions
The project was conceived by Kari Jonsbu Hjerpaasen. All authors made significant contributions to the work's design, as well as data acquisition, analysis, and interpretation. All authors were involved in writing the work and critically revising it for important intellectual content. All parties have agreed on the final version to be published. We have agreed to hold each other accountable for all aspects of the work, including ensuring that any questions about the accuracy or integrity of any part of the work are thoroughly investigated and resolved.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Availability of Data and Materials
The data and materials are available in Norwegian and in paper editions. However, the systematization of the assessment forms is available in the Norwegian edition and can be translated if needed.
Use of AI Software
AI has been used for language improvement in revising this article. The first version of the article underwent professional language editing.