Nurse Education Today 34 (2014) 421–427

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Exploring the acquisition of entry-to-practice competencies by second-degree nursingstudents during a preceptorship experience

Monique Sedgwick ⁎, Peter Kellett, Ruth Grant KalischuckFaculty of Health Sciences, University of Lethbridge, Lethbridge, AB, Canada

⁎ Corresponding author. Tel.: +1 403 332 5254; fax:E-mail addresses: Monique.sedgwick@uleth.ca (M. Se

(P. Kellett), Kalischuk@uleth.ca (R.G. Kalischuck).

0260-6917/$ – see front matter © 2013 Elsevier Ltd. Allhttp://dx.doi.org/10.1016/j.nedt.2013.04.012

s u m m a r y

a r t i c l e i n f o

Article history:

Accepted 8 April 2013

Keywords:EducationNursingStudentsClinical competencePreceptorshipSecond-degree

Background: Nursing programs across Canada have begun to implement at an unprecedented rate second-degreenursing programs in response to consumer demands and a nursing shortage. While these types of programs areenjoying considerable popularity among prospective students and employers, it is imperative that nursing pro-grams assess their graduates' ability to meet Registered Nursing entry-to-practice competencies (ETCs).Objectives: This study sought to determine if second-degree undergraduate nursing students achieved theentry-to-practice competencies established by the provincial regulatory body for registered nurses of Alberta,Canada.Setting: The study took place in southern Alberta, Canada as the first cohort of second-degree undergraduatenursing students were completing the final practice course for the program.

Design: In this exploratory study, quantitative and qualitative data generation approaches were used. Quantita-tive data were collected using the nursing program's standardized Clinical Evaluation Tool which is mapped tothe 119 ETCs established by the regulatory body. Qualitative data were generated by conducting focus group in-terviews with students, faculty advisors, and preceptors.Participants: A convenience sample consisting of both male and female students (n = 14) submitted theirmid-term and final clinical evaluations for inclusion in the dataset. Thirteen preceptors submitted mid-termand final clinical evaluations. Three students, three faculty advisors, and two preceptors participated in focusgroup interviews.Results: At mid-term, statistically significant differences were noted on 31% of the indicators within the clinicalevaluation tool between students and preceptors with preceptors consistently ranking students higher thanthe students' ratings of their performance. Student and preceptor ratings of students' clinical performancewere more consistent on the final evaluation. However, where there were differences, preceptors rated studentshigher than student ratings. Qualitative data analysis suggests that the concept of competence is complex andmultifaceted and understood differently by students, preceptors, and advisors.Conclusions: The findings of this study suggest that there is ambiguity among second-degree students, preceptorsand faculty advisors surrounding the concept of competence. In order to develop an understanding of compe-tence, nursing program administrators must encourage faculty advisors, preceptors and students to engage ina discussion at the outset of the preceptored practice experience in regard to what ismeant by competence with-in various practice setting. Further, we suggest nursing programs in collaboration with their clinical partners andre-examine their practice evaluation tools to determine the degree to which they are sensitive to the clinicalpractice context.

© 2013 Elsevier Ltd. All rights reserved.

Introduction

Fast-track entry-to-practice nursing programs, including second-degree entry programs, have increased in popularity within Canada.In 2009/10, 52 of 111 Canadian undergraduate nursing programs of-fered one or more entry-to-practice, fast-track programs; an increaseof 67.7% from just two years previously (Canadian Nurses Association,

+1 403 329 2668.dgwick), Peter.kellett@uleth.ca

rights reserved.

and Canadian Association of Schools of Nursing, 2012). The ultimategoal of undergraduate nursing programs including second-degreeprograms is to produce graduates who meet the entry-to-practicecompetencies (ETPCs) in their respective jurisdictions. Respondingto the Alberta (Canada) governments' call to increase the number ofundergraduate nursing graduates, the University of Lethbridge, Facul-ty of Health Sciences developed and subsequently admitted the firstcohort of students to a second-degree program in September 2009.Drawing on data collected during this cohorts' senior preceptoredclinical course in the summer of 2011, we set out to determine ifthese students achieved the ETPCs established by the provincial

422 M. Sedgwick et al. / Nurse Education Today 34 (2014) 421–427

regulatory body, the College and Association of Registered Nurses ofAlberta (CARNA).

Competence is defined by CARNA (2006) as “the ability of a regis-tered nurse to integrate and apply the knowledge, skills, judgmentand interpersonal attributes required to practice safely and ethicallyin a designated role and setting” (p. 17). Competencies define prac-tice expectations of entry-level registered nurses and reflect practicestandards. Hence, competencies are “the specific knowledge, skills,judgment and interpersonal attributes required for a registerednurse to be considered competent” (CARNA, 2006, p. 17).

Literature Review

There is a dearth of literature that discusses second-degree nurs-ing graduates' end of program competence. In fact, the vast majorityof research and literature on accelerated baccalaureate nursing pro-grams originates in the United States where accelerated nursing pro-grams have existed since 1971. A search of the CINAHL database forstudies that addressed the end-of-program competence of second de-gree nursing students generated three relevant studies. In summary,one study assessed the capacity of an accelerated second-degree pro-gram to teach caring (Raines, 2007). In another study (Raines, 2009),at the time of graduation, 58 accelerated students were asked to rankthemselves on seven domains of practice (Benner, 1984). While thestudents ranked themselves as competent on all seven domains, the“three lowest rated domains were: monitoring and ensuring qualityof health care practice, diagnostic and patient monitoring role, and ef-fective management of rapidly changing situations” (pp. 9–10). Alter-nately, the highest ratings were seen in more concrete domains suchas the administration and monitoring of therapeutic interventions. Ina follow-up survey of the same 58 participants at six months follow-ing graduation, ratings in all domains had increased, and the partici-pants perceived that they were better prepared for practice thanthey thought they were when they first completed their program.

In 2010, using a Likert scale, Raines surveyed 22 acceleratedsecond-degree baccalaureate nursing students to determine theirperceived level of competence (1 = not competent, 4 = competent,and 7 = highly competent) at the beginning of their program andagain at the end of their program. At the beginning of the programthe overall mean competency score was 1.87 (SD = 0.73). By theend of their program statistically significant increases in competencyratings were noted on all seven of Benner's (1984) domains of nurs-ing practice (M = 3.84; SD = 0.54). The highest rated domain was“the helping role,” and the lowest rated domain was “effective man-agement of rapidly changing situations” (p. 165). Twenty-two nurseexperts also rated the student participants' nursing practice compe-tency at the end of their program and awarded competency ratingsbetween 4.14 and 5.0 on all seven domains, with “the helping role”rated highest and “monitoring and ensuring quality of health carepractices” rated lowest (p. 166). The nurse expert ratings were signif-icantly higher than the students' own end of program competenceratings on all seven domains. Given that there is limited evidencefrom a program perspective regarding second-degree nursing gradu-ates' ability to meet ETPCs, this study examines student competencefrom the student, preceptor and faculty member perspectives.

Method

In this exploratory study, quantitative and qualitative approacheswere used to generate data. Quantitative data were collected using thenursing program's standardized Clinical Evaluation Tool (CET). Studentsparticipating in the study submitted a copy of their and their preceptors'CET atmid-term and then again when the practice course was complet-ed. Qualitative data were generated through focus-group interviews. Afocus-group interview was conducted with students only, preceptorsonly, and faculty advisors only.

Research Questions

The research question for quantitative component of this studywas “To what degree do preceptor assessments of second-degreestudents' practice performance agree with students' assessments oftheir performance?”

Based on the quantitative data analysis, the research questionsthat guided the qualitative component of this study were:

1. What are second-degree students' perceptions regarding theirability to competently practice as an entry level registered nursein the province of Alberta?

2. What are nurse preceptors' perceptions of second-degree nursingstudents' ability to competently practice as an entry level regis-tered nurse in the province of Alberta?

Since faculty advisors hold the responsibility for the evaluation andfinal grading of students' performance (Myrick and Yonge, 2005), wealso wanted to explore how faculty advisors understand the conceptof competence. The research question for this part of the study was:What are faculty advisors' perceptions of the entry-to-practice compe-tencies exhibited by second-degree student participants?

The Context of the Study

The preceptored practice course is the final practice course studentsundertake in the nursing program. Students complete 350 h in a practicesetting of their choice under the supervision of a registerednurse precep-tor. Students in this study completed their preceptored practice course inacute care or community settings. In all cases, the student-to-preceptorratio was 1:1. Criterion used to select preceptors varies across practicesettings and is determined by the leadership team within each practicesetting.

As part of course and program requirements, all students under-taking clinical practice courses are evaluated utilizing a standardizedclinical evaluation tool (CET). The 62 indicators contained in the CEThave been mapped by the faculty's Evaluation and Curriculum Com-mittees to the 119 CARNA (2006) ETPCs. This contributes to the con-tent validity of the CET within the Alberta context. Although thereliability of the CET has never been formally assessed by the nursingprogram, internal consistency was determined to be favorably basedon the calculation of Cronbach's alphas in the current study (studentsn = 14; preceptors n = 13) for each of the four standards includedin this tool. Standard 1: Professional Responsibility (α = .784). Stan-dard 2: Knowledge-based Practice (α = .919). Standard 3: EthicalPractice (α = .712). Standard 4: Provision of Service to the Public(α = .936).

Each CET indicator is evaluated using a four-point Likert scale: Un-acceptable (U), Inconsistent (1), Competent (C), or Excellent (E). Stu-dents require consistent scores at the competent or excellent level tobe awarded a satisfactory (passing) course grade. Descriptors of be-haviors associated with each level of performance determined bythe nursing program are provided in the CET. In this study, studentand preceptor rankings of the student's performance were examinedto determine the congruence of the ratings within the student–pre-ceptor dyad and the average rankings on each of the CET indicatorsfor both students and preceptors.

Ethical Considerations

Prior to the start of the study, ethical approval from the universityethics committee was received. Student participants were recruited bya graduate student research assistant who presented information aboutthe study at the end of a theory class attended by all second-degree stu-dents. Interested students were contacted later by the research assistantto further discuss study procedures. For example, students could partic-ipate either by submitting their and their preceptors' CETs only or, by

423M. Sedgwick et al. / Nurse Education Today 34 (2014) 421–427

submitting their CETs as well as participating in a focus group interview.Student participation was voluntary. A signed informed consent formwas obtained fromall participants prior to the initiation of the study. Stu-dent participants were aware they could leave the study at any timewithout adverse consequences. Confidentiality of student data wasstrictly maintained: no student identifiers were included in the dataset,code numberswere assigned to all documents, and the research assistantwas responsible for collecting the CETs and entering the data into a sta-tistical package. Data are reported using aggregate findings.

Faculty members facilitating the course and preceptors who werepreceptoring a second-degree student were recruited by the PrincipalInvestigator through in-person and telephone contact. The purpose ofthe study as well as the study procedures were explained at the pointof contact.

All of the participants in each focus group signed a consent formprior to the start of the discussion. The participants were remindedto hold the discussions in strict confidence in accordance with profes-sional registered nursing standards since anonymity could not beguaranteed. Further, since both co-investigators held administrativepositions in the nursing program, to minimize feelings of concern orcensure that the participants might have experienced, focus groupdiscussions were facilitated by the Principal Investigator as she wasnot involved in the delivery of the course nor did she hold an admin-istrative position. Pseudonyms were used in the transcripts and whenreporting the qualitative data. Last, the research assistant signed aconfidentiality agreement prior to the start of the study and all datawere securely locked in the investigators' offices.

The Sample

A convenience sample of five male students and nine female stu-dents (n = 14) representing 46% (14/30) of the students enrolledin the preceptored practice course voluntarily agreed to participatein the study by submitting their and their preceptors' mid-term andfinal CET. Three students completed their preceptored practice coursein an acute care rural facility, one student preceptored in a communi-ty setting and the remaining students completed the course in urbanacute care facilities. One preceptor did not wish to have her final eval-uation of the student included in the study consequently only themid-term CET was included in the dataset.

Focus group interviews were conducted with students only (n =3), preceptors only (n = 2), and faculty advisors only (n = 3). Onepreceptor (male) had extensive experience as a RN (>10 years) aswell as experience preceptoring students. The other preceptor (fe-male) had no experience preceptoring students and had less thanthree years of work experience. All faculty advisors had previous ex-perience teaching the course. Focus group discussions were heldin-person at the university and lasted approximately 90 min. Each in-terview was digitally recorded and transcribed verbatim whilemaintaining participant anonymity. Low participation in focus groupinterviews was attributed to scheduling conflicts for both participantsand the interviewer.

Data Analysis

Quantitative AnalysisAnonymous quantitative data were entered into a Statistical

Package for the Social Sciences (SPSS—Version 21) dataset. Althoughstudents and preceptors were asked to provide a ranking of thestudent's performance based on the four point scale included in theCET, some students and preceptors entered rankings for some ofthe indicators that were between categories. In order to capturethese rankings accurately, these datawere entered into the SPSS datasetutilizing a seven point Likert rating scale for each indicator (1 = Unac-ceptable; 2 = Unacceptable/Inconsistent; 3 = Inconsistent; 4 =

Inconsistent/Competent; 5 = Competent; 6 = Competent/Excellent;7 = Excellent).

Analysis of the distributions for the scores for each indicator onthe CET demonstrated that they were within acceptable limits of nor-mality; therefore, parametric statistics were utilized to analyze thesedata. Means and standard deviations were calculated for each indica-tor on the CET at the mid-term and final evaluations, and were alsocalculated for both the preceptor and student groups. Differences be-tween preceptor and student rankings were tested utilizing indepen-dent t-tests. Appropriate t-statistics are reported based on thepresence or absence of homogeneity of variance.

Qualitative AnalysisThematic data analysis (Boyatzis, 1998) was used throughout the

analysis of the qualitative data. To spot persistent words and phrasesso that underlying patterns could be identified, the transcripts wereread in their entirety and then re-read line by line. Segments andwords were highlighted and grouped into categories. Each categorywas then assessed for how well the data fit into the category andfor completeness. After each interview was independently analyzed,analysis across interviews occurred. This led to the expansion and col-lapse of the categories. The overarching theme of ‘the multifaceted na-ture of competence’ is supported by three categories: fuzzy boundariesof competence, levels of competence, and barriers to the develop-ment of competence.

Trustworthiness of the study was established through confirm-ability, credibility, and transferability (Lincoln and Guba, 1985).Maintaining a decision trail where the researchers' decisions and in-sights were recorded established confirmability. Credibility wasestablished through data triangulation (data sources included afocus group interview with students only, preceptors only, and facul-ty advisors only) and, a peer review where the findings and interpre-tation of the meaning of the findings were extensively discussed withother researchers. Transferability was achieved through thick de-scription; extensive and well articulated quotes are provided by a va-riety of participants.

Results

Quantitative Results

Independent t-tests were used to test for statistically significantdifferences between students' ratings of their own performance oneach of the 62 indicators in the CET and their preceptor's rating oftheir performance on the same indicators. Statistically significant dif-ferences were noted on the mid-term evaluation between studentand preceptor assessments of practice competence on 19 (31%) ofthe CET indicators. These results are presented in Table 1. In allcases of statistically significant differences, preceptors scored the stu-dents' clinical performance higher than the students scored their ownclinical performance.

Student and preceptor ratings of the student's clinical perfor-mance were more consistent on the final evaluation, with significantdifferences noted on only four (6.5%) of the CET indicators (SeeTable 2). Similar to the findings at the mid-term evaluation, precep-tors consistently scored students' practice performance higher thanthe students did themselves in all cases of significant differences.

Qualitative Results: The Multifaceted Nature of Competence

Qualitative data analysis suggests that the concept of competenceis complex and multifaceted. Indeed, analysis suggests that students,preceptors and faculty advisors understand the concept of compe-tence differently. These differences then might account for why stu-dent and preceptor ratings were divergent.

Table 1Perceived entry-to-practice competence in Alberta RN students/preceptors at the mid-term evaluation.

Clinical evaluation tool indicator Rated by Descriptive statistics Test statistic(p-value)

Mean difference(SED)

M SD

Standard 1: Professional Responsibility Student 4.86 .535 t(21.11) = −2.339 − .604Category 1, Coping (a) Preceptor 5.46 .776 (p = .029) (.258)Standard 1: Professional Responsibility Student 5.29 .726 t(21.33) = −2.279 − .791Category 2, Self-awareness (b) Preceptor 6.08 1.038 (p = .033) (.347)Standard 1: Professional Responsibility Student 5.21 .699 t(17.31) = −2.174 − .940Category 4, Initiative (a) Preceptor 6.15 1.405 (p = .044) (.432)Standard 1: Professional Responsibility Student 5.36 .745 t(20.79) = −2.594 − .951Category 4, Initiative (b) Preceptor 6.31 1.109 (p = .017) (.366)Standard 1: Professional Responsibility Student 5.36 .745 t(20.79) = −2.594 − .951Category 4, Initiative (c) Preceptor 6.31 1.109 (p = .017) (.366)Standard 3: Ethical Practice Student 5.43 .852 t(25) = −2.234 − .802Category 1, Client Diversity (a) Preceptor 6.23 1.013 (p = .035) (.359)Standard 3: Ethical Practice Student 5.43 .852 t(25) = −2.234 − .802Category 1, Client Diversity (b) Preceptor 6.23 1.013 (p = .035) (.359)Standard 3: Ethical Practice Student 5.07 1.685 t(25) = −2.145 −1.16Category 1, Advocacy (a) Preceptor 6.23 1.013 (p = .042) (.541)Standard 4: Provision of Service to the Public Student 4.86 .535 t(17.59) = −2.349 − .758Category 1, Client, Family, Agency, or CommunityTeaching and Disseminating (b)

Preceptor 5.62 1.044 (p = .031) (.323)

Standard 4: Provision of Service to the Public Student 5.14 .535 t(16.95) = −2.290 − .780Category 1, Client, Family, Agency, or CommunityTeaching and Disseminating (c)

Preceptor 5.92 1.115 (p = .035) (.341)

Standard 4: Provision of Service to the Public Student 5.29 .611 t(18.04) = −2.433 − .868Category 2, Communication with Health CareTeam Members, Agency Personnel, Instructors and Peers (a)

Preceptor 6.15 1.144 (p = .026) (.357)

Standard 4: Provision of Service to the Public Student 5.07 .829 t(21.78) = −2.798 −1.08Category 2, Communication with Health Care Team Members,Agency Personnel, Instructors and Peers (b)

Preceptor 6.15 1.144 (p = .011) (.387)

Standard 4: Provision of Service to the Public Student 5.21 .579 t(17.79) = −3.175 −1.09Category 2, Communication with Health Care Team Members,Agency Personnel, Instructors and Peers (c)

Preceptor 6.31 1.109 (p = .005) (.344)

Standard 4: Provision of Service to the Public Student 5.14 .535 t(18.18) = −2.277 − .073Category 3, Communication with Clients, Agency, Family,and Significant Others (a)

Preceptor 5.85 .987 (p = .035) (.309)

Standard 4: Provision of Service to the Public Student 5.29 .726 t(21.97) = −2.587 − .868Category 3, Communication with Clients, Agency, Family,and Significant Others (b)

Preceptor 6.15 .987 (p = .017) (.336)

Standard 4: Provision of Service to the Public Student 5.14 .535 t(18.18) = −3.274 −1.01Category 3, Communication with Clients, Agency, Family,and Significant Others (c)

Preceptor 6.15 .987 (p = .004) (.309)

Standard 4: Provision of Service to the Public Student 5.64 .929 t(25) = −2.350 − .819Category 5, Reporting (b) Preceptor 6.46 .877 (p = .027) (.348)Standard 4: Provision of Service to the Public Student 5.07 .267 t(13.77) = −2.280 − .621Category 6, Documentation (b) Preceptor 5.69 .947 (p = .039) (.272)Standard 4: Provision of Service to the Public Student 4.86 .663 t(21.33) = −2.635 − .835Category 6, Documentation (d) Preceptor 5.69 .947 (p = .015) (.317)

Note. M = Mean; SD = Standard Deviation; SED = Standard Error of Difference; Mean calculatedbasedon seven-point Likert scale (1 = Unacceptable, 2 = Unacceptable/Inconsistent,3 = Inconsistent, 4 = Inconsistent/Competent, 5 = Competent, 6 = Competent/Excellent, 7 = Excellent).

424 M. Sedgwick et al. / Nurse Education Today 34 (2014) 421–427

Fuzzy Boundaries of CompetenceWhen students, preceptors, and faculty advisors were asked to de-

scribe the characteristics of competence, therewere considerable varia-tions among the three groups. Student participants viewed competenceas being able to retrieve, understand, and implement hospital/practicesetting policies: “knowing where to get the accurate information to passon” (Bruce, student) and “knowing the procedures and policies insideand out” (Nikki, student). From the students' perspective, engaging inthese behaviors meant that they could provide safe patient care whichthey interpreted as being competent: “Competence speaks of safety tome” (Michelle, student).

Preceptors viewed competence in procedural terms such as hav-ing strong assessment, communication, and psychomotor skills.

“If a student is competent, they're able to have very strong assessmentskills, good interpersonal skills not only with the patients but with thestaff. I think it also means acknowledging your weaknesses; beingable to say ‘I don't know. I need help’” (Johanna, preceptor).

Faculty advisors viewed competence as being able to engage inlearning, critical thinking, and reflective practice including critical anal-ysis of one’s own performance.

“Where I'm coming from is that they're self-reflective, that they'recritical of their own practice, and that they are actually looking toimprove. It's connecting the dots to that level of thinking that they'restarting to critically think about the next steps” (Samantha, facultyadvisor).

Given that the students, preceptors, and faculty advisors in this studydescribed different characteristics of competence, it is perhaps not sur-prising that there seemed to be some fuzzy boundaries surroundingthe concept of competence. For example, while faculty advisors expectedstudents to demonstrate a satisfactory level of performance in all practicestandards at an ETPC level in order to successfully complete thepreceptored clinical course, the qualifying phrase “entry-to-practice,”seemed to challenge this expectation when students undertook a

Table 2Perceived entry-to-practice competence in Alberta RN students/preceptors at the final evaluation.

Clinical evaluation tool indicator Rated by Descriptivestatistics

Test statistic (p-value) Mean difference (SED)

M SD

Standard 1: Professional Responsibility Student 5.71 .914 t(25) = −2.387 − .824Category 1, Coping (b) Preceptor 6.54 .877 (p = .025) (.345)Standard 2: Knowledge-based Practice Student 5.85 .987 t(22.63) = −2.218 − .769Category 6, Evaluation (b) Preceptor 6.62 .768 (p = .037) (.347)Standard 4: Provision of Service to the Public Student 6.29 .994 t(15.15) = −2.303 − .637Category 4, Demonstration of a Caring Attitude (a) Preceptor 6.92 .277 (p = .036) (.277)

Note. M = Mean; SD = Standard Deviation; SED = Standard Error of Difference; Mean calculated based on seven-point Likert scale (1 = Unacceptable, 2 = Unacceptable/Incon-sistent, 3 = Inconsistent, 4 = Inconsistent/Competent, 5 = Competent, 6 = Competent/Excellent, 7 = Excellent).

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preceptored clinical course in ‘specialty clinical areas’ like Emergency orIntensive Care.

“I think sometimes preceptors are considering a level of competencyas being competent in a specialty area like a student should knowwhat the assessment is for a patient with chest pain. To me that's abonus if they know. Students should know the basics and they shouldknow some of the initial assessment pieces but they're not going toknow the whole treatment protocol by the time they're done theirpreceptorship” (Samantha, faculty advisor).

Indeed, because students were placed in settings with varyinglevels of complexity, the notion of competence was elusive. Whatwas meant by competence seemed to differ as the degree of complex-ity within the practice setting increased. As a result, determiningcompetence seemed to become a subjective evaluation.

“You talk about it being a package and saying, well overall they'reokay. What's the tipping point when they're not okay? I think it de-pends on the environment, on the expectations that we have”(Maryanne, faculty advisor).

Levels of CompetenceFocus group participants described the existence of levels of com-

petence. At the beginning of the preceptored clinical course studentsdid not necessarily have to demonstrate an equal degree of compe-tence across all indicators. Indeed, they could display a high level ofcompetence on some indicators while possessing the potential to im-prove in others. “Students can definitely start their preceptorship notbeing fully competent in all of the areas” (David, preceptor).

However, to achieve an ‘overall’ assessment of competent, stu-dents needed to demonstrate improvement in all indicators. “By theend of their program or by the end of their preceptorship, studentsneed to demonstrate an increase in every indicator” (David, preceptor).This belief though, was challenged in situations where students didnot equally improve across the indicators. In this situation it wasless clear if students were competent.

“They're all equally important [referring to the indicators]. I think bythe end of the preceptorship you want the student to be fairly compe-tent…like above average or at least average. Some they're going to beexcelling in and some they're going to be a little behind but you haveto look at the whole picture” (Johanna, preceptor).

Perhaps the most important characteristic that leads to the notionof levels of competence was the recognition by all of the participantsthat competence was not static. Indeed, competence was viewed assomething that continually changes and something that must beworked towards. Achieving competence was a life-long journey.

“I think you have to be a life-long learner and you have to be improvingbecause healthcare is changing so rapidly. You always have to be kind ofreaching that next bar in your practice” (Johanna, preceptor).“I think a

minimal level of competence should be respected because you're go-ing to build it further” (Michelle, student).

Barriers to the Development of CompetenceA number of potential barriers to the development of competence

were identified. The participants believed that some clinical settingswould not provide the right environment to support the students'ability to achieve an acceptable level of competence. Indeed, theyfelt that the program may set students up for failure if there wereno guidelines for student placements. Furthermore, if a setting wastoo complex and had rapidly changing patient needs, students' abilityto develop competence might be impeded.

“They might accomplish a ‘C’ (competent) but there's going to certainthings they're not even allowed to do in an ICU setting. It is very hardto judge because there's a lot of things you can't measure” (Elizabeth,faculty advisor).

While students could demonstrate competence related to the var-ious elements of nursing practice, according to the preceptors, theysometimes had difficulty ‘connecting the dots’ between differentcompetencies, elements of knowledge, and skills to form a clear andcomprehensive picture of the patient's health status and needs. Inother words, they could understand the science of what they weredoing when reduced to its individual parts, but they had trouble ap-plying the art of nursing to deliver competent nursing care as a whole.

“I would think that they have the basic skills. But I guess the issue thatI saw was using it in conjunction with everything else” (David,preceptor).

This study also illuminated other important barriers particular tothe second-degree experience. These study participants passionatelyexplained that it was particularly challenging to build competencewhen there was a different perception between students and precep-tors on the degree of competence exhibited by the student.

“I found at mid-term it was hard because it was written down on pa-per and how he had scored himself and how I had scored him werevery, very different. He thought he had pretty much aced the courseat mid-term. As a student would you ever be excellent in everything?”(Johanna, preceptor).

In fact, these preceptors perceived second-degree students as overlyconfident because of past success in another field which resulted in ten-sions between the student, preceptor, and unit staff.

“These are all students who've had degrees of some kind so they'vereached some level of confidence in what they've done and some suc-cess in what they've done. That brings a positive to continuing on in adifferent degree. They can use that confidence then in their new de-gree. But these second-degree students think that they know every-thing by the time they come into clinical and they don't because it's

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a clinical experience. They can't come in thinking that they can takeknowledge and put it into practice successfully without any kind ofguidance” (David, preceptor).

Discussion/Implications

The concept of competence is multifaceted and complex whichlends itself to being nebulous and open to interpretation (Clark andHolmes, 2007). Indeed, the lack of clear discrimination between theability to apply knowledge and skills in the delivery of complex nursingcare or in the course of making practice decisions (competence), andthe ability to enact certain behaviors, or hold knowledge that underpinscompetent performance (competencies) adds to the confusion. Hence,the difference between achieving competencies and demonstratingcompetence is often discussed as the theory to practice gap. To advanceour understanding of clinical competence, a discussion of the meaningsof the findings and their implications is offered.

Competence as Being Context Dependent

Gonczi (1994) describes three ways of understanding compe-tence: 1) task related skills; 2) pertaining to generic attributes essen-tial for effective performance and; 3) bringing together a range ofgeneral attributes such as knowledge, skills, and attitudes appropriatefor professional practice. These ways of understanding competenceare reflected in how the participants in this study understand compe-tence albeit an emphasis on tasks and attributes in the conceptualiza-tion of competence by the participants speaks primarily to discretecompetencies rather than overall competence. However, because ac-tual work practice is much richer than a sequence of isolated tasks,analysis of discrete tasks using a holistic lens is necessary in orderto evaluate competence (Hager and Gonczi, 1994). In fact, profession-al competence standards should allow for professional discretion thatis, professional behaviors cannot be prescribed in such a way as tosuggest that professionals will act in the same way in a given situa-tion. Ultimately, it may be the interaction between competenciesthat is of greater importance (Messick, 1994). In this study, it maybe the interaction between competencies that resulted in the partici-pants experiencing fuzzy boundaries.

Perhaps equally as important as the lens through which assessingcompetence is understood, is the impact of the context in which com-petence is being assessed. The participants in this study seem to sug-gest that the context in which competence is being assessed isparticularly important. Indeed, some participants suggest that someclinical settings may be too complex resulting in the inability toachieve ‘standardized’ competence. Boud (1995) suggests that qualityclinical assessment is contextually based. Indeed other authors(Levett-Jones et al., 2011) confirm that contemporary clinical envi-ronments influence clinical competence and as such CETs should bepractice-driven, and should motivate student learning and confirmtheir readiness for professional practice. Given that nursing programsand their clinical partners have a responsibility to ensure that gradu-ates are well prepared for the demands they will encounter in thepractice setting, it may be appropriate that CETs be re-examinedwith the aim of determining how sensitive they are to the clinicalpractice context.

Barriers to Competence

Particular challenges were noted in relation to dealing with rapid-ly changing and complex nursing care. In this study, the participantsfelt that some practice settings were not conducive to the develop-ment of competence and recommended that there should be clearguidelines as to when students should be placed in these settingsfor the preceptored practice experience. Since managing complex,

rapidly changing care requires the demonstration of overall compe-tence (Clark and Holmes, 2007), the preceptors identified that stu-dents sometimes had a hard time connecting the dots between thevarious elements to form a clear picture of the patient's status andneeds. Practice settings then must be carefully evaluated and selectedso that they provide second-degree students with the time to consol-idate and integrate the competencies they need to achieve and to re-flect on their actions (Clark and Holmes, 2007).

Developing an Understanding of Competence

The nebulous nature of competence is evident in the differing per-spectives on the concept articulated by the students, preceptors, andfaculty advisors and in the inconsistencies noted between studentand preceptor quantitative ratings of competence in the CETs. Stu-dents focused on knowing and accessing information and policies todirect their practice. Faculty advisors tended to focus on the students'engagement in their ongoing journey as life-long learners. Preceptorsemphasized the ability to “perform all the functions needed” whichspeaks to placing emphasis on procedural knowledge. Similar toRaines (2010), in all cases of statistically significant differences be-tween the student and preceptor ratings of competence using theCET, preceptors consistently rated student competence higher thanthe students themselves. While the reasons for preceptor ratings ofstudent performance are undoubtedly complex (Luhanga et al.,2008), it is possible that conceptual muddiness surrounding the as-sessment of competence contributed to a tendency among preceptorsto overestimate the second-degree students' performance. Alternate-ly, it is possible that these students were underestimating their com-petence due to the feelings of insecurity that frequently plaguestudents as they approach graduation (Clark and Holmes, 2007). In-deed, it is notable that the biggest difference between preceptor andsecond-degree student ratings was noted on the indicator thataddressed student anxiety and coping.

The different understanding of competence between the three keyparties involved in the preceptored practice experience underlines asignificant problem. If students, preceptors, and faculty advisors areevaluating competence from different conceptual perspectives,conflicting assessments of a nursing student's level of competenceare possible. These differences may threaten the integrity of studentperformance evaluations and create a barrier to student success. Cer-tainly, if students are looking for clear direction with regard to theareas they need to work on, lack of clarity is decidedly problematic;therefore, there is a need to clearly articulate the desired competencewithin that particular context at the beginning of the clinical practi-cum so that students, preceptors, and faculty advisors are all workingtowards the same end.

Last, developing an understanding of competence is made evenmore elusive because there seems to be levels of competence thatchange over time suggesting that competence is not only an outcomebut is process as well (Benner, 1984; Clark and Holmes, 2007). Conse-quently, nursing students will not necessarily demonstrate an equaldegree of competence across all standards of practice (Butler, 1978).Indeed, there is evidence to suggest that regardless of educationalpreparation, many nursing program graduates (65% to 76%) fail tomeet the expectations of entry-level clinical judgment ability (DelBueno, 2005). New graduates, staff nurses, and nursing managers allagree that it may take 12–18 months of practicing as a registerednurse to progress from the level of a novice to an advanced beginner(Benner, 1984; Boychuk Duchscher, 2008; Clark and Holmes, 2007;Rafferty and Lindell, 2011; Raines, 2009). Based on the findings ofthis study, a discussion of what is meant by competence as well asthe evaluation process is warranted so that there is congruence be-tween ratings of student performance and the messages that studentsreceive as they strive to achieve competence (Butler et al., 2011).

427M. Sedgwick et al. / Nurse Education Today 34 (2014) 421–427

Limitations

Only 46% (14/30) of the first second-degree cohort agreed to par-ticipate in this study. None of the students who were placed on alearning enhancement plan agreed to participate at the initiation ofthe study. Therefore, study data and findings do not reflect quantita-tive CET data or contextual qualitative data related to students thatexperienced challenges during their final practicum. Second, low par-ticipation in the focus group interviews limited the richness of datathat could be obtained. This study was conducted in one programwith one cohort of second-degree students therefore the findingscannot be generalized to other programs and students. Longitudinaland multijurisdictional studies are needed so that trends might beidentified.

Conclusion

Engaging in assessment of student performance is frequentlyidentified as an ongoing challenge for nurse educators. Assessing stu-dents for clinical competence during clinical preceptored courses ismade even more difficult given that these courses are undertaken ina wide variety of settings with preceptors who may lack knowledgeand experience pertaining to assessment of clinical competence. Ourstatistical analysis revealed that the competence of this first cohortof second-degree graduates is remarkably consistent with publishedassessments of competence for both accelerated second-degree andbasic baccalaureate graduates. However, qualitative data analysissuggests a problematic lack of clarity pertaining to the concept ofcompetence and the influence of the context on this assessment.This study underscores the importance of developing a shared under-standing of competence among students, faculty, and preceptors, andfacilitating clear communication of expectations between the keyplayers in the preceptorship experience. Last, the findings also sug-gest that the clinical evaluation tools used to assess student compe-tence must be practice-driven in order to confirm that graduates arewell prepared to engage in professional practice.

Acknowledgments

This study received funding from the Centre for the Advancementof Excellence in Teaching and Learning (CAETL) Teaching Develop-ment Fund at the University of Lethbridge.

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