What level of competency do experienced nurses expect from a newly graduated registered nurse? Results of an Australian modified Delphi study

A literature search to locate and review research on competency levels for newly graduated RNs explored a range of databases: the details of which can be seen in Additional file 2.

The papers although not entirely focussed on the new graduates ranged between 2003 and 2014. The main themes will be explored briefly in this section; key themes centred on ‘feeling competent vs feeling incompetent’; ‘skills related to specific client groups’ and ‘what skills are taught and practiced as opposed to what are needed and why’.

In the first theme “feeling competent on graduation” a range of clinical skills or procedures were identified in which new graduates did not ‘feel’ competent to perform (Adair et al. [3]; Dlamini et al. [4]; Liou et al. [5]; Liou and Cheng [6]); both new graduates and senior nursing clinicians supported this perception. This led to the exploration of ‘core’ and ‘advanced’ skills and competency highlighted by Liou et al. [5] however this lacks clarity and requires further research. Students express the need for more practice within their programmes of study, even in the UK where the students spend 2300 h in a variety of settings – they still lack confidence (Bradshaw and Merriman [7], Farrand et al. [8], Ross & Clifford [9], Dolan [10]). Duchscher [11] explored ‘transition shock’; the notion of ‘professional adjustment’ and the ‘feelings of anxiety, insecurity and inadequacy’ which manifest as a lack of competence and/or capability The majority of research focussed on acute tertiary care settings and so has limited value for a comprehensively prepared graduate RN.

In the second theme, “skills related to specific client groups” new graduate skills were identified by a number of authors in order to meet the needs of ‘the most common clinical presentations’. Burns and Poster [12] identified ’10 high risk, high volume’ conditions with nurse executives in order to explore the skills and competencies that new graduates would need to care for this client group. Patterson et al. [13] identified the creation of orientation programmes in emergency nursing for new graduates which centred on ‘classes organized by body system or diagnosis’. and ‘emergency nursing skills were incorporated into the program’. These evaluated well but participants were still concerned about skill acquisition and practice and so competence. Lastly in relating skills development to specific client groups Patterson et al. [14] explored Mental Health Nursing; four main themes were identified and then 14 competencies however these significantly overlapped with the NMBA [15] competencies. There were a number of competencies that were broadly stated but may well be viewed as more ‘specific’ to mental health nursing such as ‘protection from aggression’ and ‘managing unsafe behaviour’.

“What skills are taught and practiced as opposed to what skills are needed and why”: Brown et al. [16] undertook an audit of skills taught in nursing eligibility to practice programmes so that a documentary analysis could be undertaken. From this analysis, and a number of modified Delphi rounds, the thirty skills areas were derived. These thirty skills areas were then circulated to nurses (academics, clinicians and managers n = 495) across Australia to identify whether the skills taught in nursing eligibility to practice programmes were ’necessary’ for a new graduate RN. This work illustrated that there were a great many skills taught but following the modified Delphi rounds the thirty skills areas were identified by respondents as ‘applicable’ and ‘necessary’ for a new graduate RN. Expert nurses involved in the preparation of new graduates were asked what a new RN needed to be competent in practice (Birks et al. [17]). This showed a disparity between what was taught and what was actually needed – again a somewhat acute care focus was noted.

In summary much of the identified literature has a number of foci; firstly there is on the whole a focus on the new graduate in an acute care hospital setting, and secondly self-report was the main means of identifying the new graduates’ competence. There were some variations however Burns and Poster [12] did also include an expert nurse’s assessment of the new graduates’ competence in acute care practice. Patterson et al. [14] considered Mental health practice and Crookes and Brown [1] surveyed a range of clinicians and academics from differing clinical backgrounds. This literature and these strategies provide limited acute care focused evidence regarding the newly graduated RN’s skills set, relatively small numbers were used and self-report provides limited evidence.

The intention of this research, in the light of the literature, was to consider the skill set required of a comprehensively prepared RN through the gaze of experienced registered nurses, clinicians, managers, researchers and academics. Acknowledging the work of Brown et al. [16] in identifying and then verifying with nurses across Australia the thirty skills areas as being ‘necessary’ afforded a high degree of reliability that the skills areas were appropriate for a new graduate RN in Australia.

The competence of new RN graduates, both at the point of joining the workforce on graduation and as they gain experience, is an important dimension of quality and safety. Thus each nursing school and prospective employer has a vested interest in ensuring that the initial skills and competency of the new graduate and the conditions for the transition and the ongoing development of the new graduate RN are optimised.

Unlike in some countries, where there are conjoint and/or national accreditation systems in place (NMC [18]) national accreditation was not introduced in Australia until 2010. Prior to this each state and territory had local accreditation processes in place. This pre-2010 variation within the Australian sectors validation processes probably contributed to a lack of homogeneity in terms of what one might expect of a newly graduating RN.

The sheer geographical size of Australia probably affects local course delivery and expectation of new graduate RN capabilities and competence. Universities are located across states and territories with twenty two metropolitan and seventeen rural or remote; this compounds the variability in the development and the delivery of nursing programmes; and subsequently the competency and skills of the new RN. This when combined with the differing interpretation and application of the NMBA [15] competency statements across eligibility to practice programmes in Australia led to a variation in the competence and skill set of the newly graduating registered nurse. Interestingly this is not solely an Australian phenomenon; Burns and Poster [12] identified, through a discussion with senior nurses and deans and heads of schools in Texas that nurses from different programmes in Texas, USA performed better than others from different schools within the same state. This very fluid space concerning what skills might be taught and assessed; what level of competence was expected and what competency assessment tools were being used prompted the initial, timely ALTC study.

This paper is drawn from a larger project which sought to develop a competency assessment schedule for use in eligibility to practice programmes in Australia Crookes & Brown [1]. The main aim of this paper is to identify the competency level of newly registered nurses in the ‘necessary’ skills areas (Brown et al.) [16] as perceived by experienced RNs.

An inclusive, consensus methodology using a modified Delphi technique was employed to maximise contributions and ownership from the profession. The use of modified Delphi rounds enables experts in their field (in this case experienced nurses and academics) to be engaged in refining the levels of competence expected in a new graduate nurse (Delbecq, Van de Ven & Gustafson [19]). A modified Delphi technique allows each respondent to contribute equally. No respondents are aware of other participant’s responses at the point when they complete the survey – thus minimising any possible power differentials influencing respondent’s rankings; so reducing bias. Any number of iterations or cycles can be used until only a few or no minor changes are suggested by respondents. At the end of each of the modified Delphi rounds there was a section for respondents to make suggestions or to add comments.

The 30 skills areas (Crookes and Brown [1]) utilised were circulated to respondents in the modified Delphi survey to identify the competency levels. The level of competency was measured using Bondy’s [2] modified criteria because of its widespread use in Australian nursing schools (Table 1). Two measures of central tendency were used; “mean” and “mode” in order to give the reader both an ‘average’ view of the data and the highest number of respondents for each of the thirty skills areas. The work is specifically exploring the respondent’s views about whether the new graduate is independent/competent therefore descriptive percentages are used. Numerical values were assigned to the Bondy [2] categories to facilitate this analysis (Table 1); were “independent” was attributed 5 and “dependent” was attributed 1.

This paper reports specifically on the expected competency level of the new graduate at the point of registration. Other aspects of this round and findings of subsequent rounds of the survey are reported elsewhere (Authors own).

An on line survey tool was used (Survey Gizmo) to host the survey and manage the data. The Bondy [2] criteria to be used were identified and were accessible on each page of the online survey to assist the respondents in completing the survey (Table 1). The survey tool comprised of the 30 skills items and open ended questions inviting respondents to add possible missing skills areas or competencies. The presentation of the questions within the survey was rotated in order to avoid respondent fatigue (Oppenheim [20]); this is a recognised technique to reduce such bias. A three week time frame was established so that respondents had sufficient time to complete the survey.

The feedback from the modified Delphi technique was reviewed and then re-presented for verification with the respondents, at this point 100 respondents were randomly invited to review the list of thirty skills areas both in terms of and content and ranking and 89 responded confirming that this ranking was accurate and reflected their expectation.

Following completion of the survey, all data were downloaded as Excel and SPSS files for analysis (Statistical Package for the Social Sciences Version 19). The raw data was reviewed for completeness and missing data. Interestingly there was very little missing data; only a few responses were not answered by some respondent’s time in role and area of practice contained the most missing data. There were no specific items that were consistently missed. Two measures of central tendency were calculated; the mean and mode score for each skill area.

Free text comments were analysed thematically by two independent reviewers. The main findings from this aspect of the survey are reported in a later paper.

Finally the expert panel members (Project Management Group, ANMC-PRG and Chief Nurses Group) were presented with the findings and discussed the analysis and final scores and rankings and agreed the rationale for the final list of skills areas seen in Additional file 1.