an outcome-based evaluation of nursing competency of baccalaureate senior nursing students in taiwan

Nurse Education Today 33 (2013) 1536–1545

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An outcome-based evaluation of nursing competency of baccalaureatesenior nursing students in Taiwan

Suh-Ing Hsieh a, Li-Ling Hsu b,⁎a Department of Nursing, Chang Gung University of Science and Technology, Taiwan, ROCb Graduate Institute of Health Allied Education, National Taipei University of Nursing and Health Sciences, No. 365, Ming-Te Rd., Peitou, Taipei City 11219, Taiwan, ROC

⁎ Corresponding author. Tel.: +886 2 2822 7101x316E-mail addresses: [email protected] (S.-I. Hsieh)

[email protected] (L.-L. Hsu).

0260-6917/$ – see front matter. Crown Copyright © 20http://dx.doi.org/10.1016/j.nedt.2013.01.012

s u m m a r y
a r t i c l e i n f o
Article history:Accepted 14 January 2013

Keyword:Outcome-based nursing competencyBaccalaureate senior nursing studentsLearning factorDemographic factor

Limited literature is available for demographic and learning factors related to performance of baccalaureatenursing students. The study aimed at examining mean differences in nursing competency between the firstweek and the sixth week of a nursing clinical practicum as well as evaluating mean differences in nursingcompetency by demographic and learning factors at the sixth week of a nursing clinical practicum controllingfor baseline scores of nursing competency. A comparative study design was conducted using the competencyinventory for baccalaureate senior nursing students based on learning outcomes. Participants were surveyedat the first week and the sixth week of a nursing practicum with 95% mean response rate. Paired t test wasused to compare within-subjects differences in mean nursing competency. ANCOVA and Kruskal–Wallistest, and Mann–Whitney U test were conducted to compare between-subjects differences in mean nursingcompetency. There are significant mean differences in nursing competency in general clinical skills, lifelonglearning, clinical biomedical science, caring, and critical thinking and reasoning between the 1st week andthe 6th week of nursing practicum. Likewise, type of nursing program, prior schooling, type of nursinglicense, interest in nursing, and extracurricular activity experience were significantly related to mean totalnursing competency. Similarly, demographic attributes (location of school, type of nursing program, priorschooling, type of nursing license, a family member working as a medical practitioner or a nurse, interestin nursing, attributes of preferred workplace after college) and learning factors (extracurricular activityexperience, played an active role in classroom discussions and asked questions, academic class rank, andEnglish grade, clinical biomedical science, nursing science, and nursing practicum) were significantly relatedto six-subscale scores of nursing competency. There are mean differences in nursing competency acrossseveral demographic and learning factors. These factors should be given greater emphasis by nurse educatorsin planning the academic and clinical phases of professional education.

Crown Copyright © 2013 Published by Elsevier Ltd. All rights reserved.

Introduction

Today's educational outcomes in higher education institutionsgenerally focus onwhat is produced (Anema andMcCoy, 2010). Learningoutcomes can serve as a benchmark to measure a success of a universityas a provider of education. In addition, learning outcomes providean opportunity for graduates to acquire the knowledge and skills(Mohayidin et al., 2008). Learning outcomes are commonly expressedin terms of competences or skills and competence (Adam, 2004). Compe-tency focuses on an individual's ability to perform activities related towork, life skills, or learning (Anema and McCoy, 2010). The NationalCouncil of State Boards of Nursing (2005) describes competency asthe ability to apply knowledge and interpersonal, decision making, andpsychomotor skills to nursing practice roles.

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Educating students for nursing practice is challenging. Nurse educa-tors must effectively prepare students for a nursing career in today'shigh-tech health care environment (Klein, 2006). Increasing demandsfor public accountability in all professions require that health professionsschools produce evidence that their graduates have reached at leastminimal standards of competence (Andre, 2000). Health professionalsof the future must (1) provide patient-centered care to diverse popula-tion, (2) work effectively, (3) employ evidence-based practice, (4) applyquality improvement techniques, and (5) utilize informatics in practice.These abilities also serve as a medium through which practice-specificcompetencies may be developed (Jungnickel et al., 2009).

Previous research has examined the nursing competencies in relationto selected variables (Roques, 1999; Lofmark and Wikblad, 2001;Tabari-Khomeiran et al., 2006, 2007; Saeki et al., 2007; Stott, 2007;Rochford et al., 2009), but little involved amore comprehensive approachto identify the most salient contributors to senior nursing students'perceived competency levels. Limited information is available for factorsthat are associated with performance of nursing students. In thispaper, we report an initial–final evaluation of self-perceived nursing

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1537S.-I. Hsieh, L.-L. Hsu / Nurse Education Today 33 (2013) 1536–1545

competency of the senior nursing students in a nursing clinical practicum,and comprehensively explores the factors that have been identified ascorrelating nursing students' nursing competency including personalcharacteristics, learning experience, and course grades.

Literature Review

Competence development for nursing practice begins during under-graduate nursing education programs (Vernon et al., 2011). Assessingthe competence of nursing students is critical to identifying areas forprofessional development and educational needs while ensuring thatcompetencies are put to use for quality care (Marshburn et al., 2009).Lejonqvist et al. (2012) demonstrated that clinical competence in practiceis encountering, knowing, performing, maturing and improving. Clinicalcompetence is an ongoing process, rather than a state andmanifests itselfin an ontological and a contextual dimension. Benner (1984) puts forththe idea that competence is a progressive experience that she calibratesin five distinct stages from Novice to Expert. Nursing students enter anew clinical area as novices; they have little understanding of the contex-tual meaning of the recently learned textbook terms. Understandingnursing students' perceptions of their skills and abilities is important inguiding their orientation during their transition to the professional role(Marshburn et al., 2009). In addition, the identification of factors whichimpact on students' progression, performance and completion is instru-mental in the planning and development of preregistration programs toensure best outcomes for both the institution and the student (Pitt etal., 2012).

Competencies are based upon a behavior theory and its focus onproducing specific desired behaviors (Albanese et al., 2008). Thefundamental premises of behaviorism are that all behavior is learned,and that learning is most influenced through manipulation of theenvironment in which it occurs and the rewards provided to encour-age it (Braungart and Braungart, 2003; Vandeveer and Norton, 2005).Competencies are the subset of outcomes that nursing students need tofunction at the desired level. Competency-based and outcome-basednursing education focus on the result of the educational process, not theprocess itself (Albanese et al., 2008). Outcome-based education refers toa pedagogical model that focuses on student outcomes rather thaninput and was the driving philosophy behind the core competencies(Nelson and Smock, 2005; Nelson et al., 2007). An outcomes-basedapproach to nursing competence shifts the emphasis from what perfor-mances the individual should possess, andwhat a person has been taughtand trained to do, to how that person is expected to perform, now and inthe future (Harrison and Mitchell, 2006).

The Competency Inventory of Nursing Students (CINS) has six factorsand could be a useful instrument for measuring learning outcomes ofnursing students. Ethics and accountability were found to be the mostimportant factors contributing to nursing student's competencies,followed by general clinical skills, lifelong learning, clinical biomedicalscience, caring, and critical thinking and reasoning (Hsu and Hsieh,2012). Ethical competence is a key factor in preventing or reducingmoral distress (Sporrong et al., 2007). Moral behavior and responsibilitytogether are the bases of ethical action. Ethics can be defined as a concernfor doing the right thing and avoiding harm when related to nursing(Paganini and Egry, 2011). The nursing skill competency associatedwith the discipline of nursing are primarily embedded within thestudents' clinical educational experiences (Emerson, 2007). Whenstudents graduate from nursing school, they need to possess a certainlevel of clinical skills to stand a good chance of succeeding in their futurerole as nurses. Competent, lifelong learners generally have the capacity torespond flexibly to changing circumstances (Bath and Smith, 2009), haveaccess to information, use information in the proper place, and attempt tolearn how to learn besides being creative and critical thinkers (Uzunboyluand Hursen, 2011).

Biomedical science is biological sciences which are specificallyinvolved with human health (Arneson, 2011). Nursing students need a

stronger foundation in clinical biomedical sciences to be more effective,competent, independent, and well-rounded health-care providers(Gresty and Cotton, 2003; Kyriacos et al., 2005). Caring is the essentialelement of nursing. Skott and Eriksson (2005) explored the concept ofcaring in the diary of a nurse. It represented three categories of caringincluding verbal communication, physical movement and reflection.Critical thinking is a required outcome measure in the evaluation andaccreditation of baccalaureate and higher degree program (AmericanAssociation of College of Nursing, 1998). Competence is believed tobe related to self-efficacy (Bandura, 1995). Self-efficacy refers to aself-perception of one's ability to perform competently and effectively ina particular task or setting (Bandura, 1989). Confidence is perceived incompetence, skill, or ability and a conception of confidence is similar tothat of self-efficacy (Shrauger and Schohn, 1995). Stajkovic (2006)commented that confidence is an inductive process based on outcomes.In summary, competence requires an up to date knowledge base and ismanifested by demonstrating the ability to achieve desired outcomesthrough the performance of defined skills (LaDuke, 2002).

Methods

Aim

The first aim was to examine mean differences in six-subscale andtotal scores of nursing competency between the first week and the sixthweek of nursing clinical practicum. The second aim was to evaluatemean differences in six-subscale and total scores of nursing competencyat the sixth week of nursing clinical practicum controlling for baselinescores of nursing competency.

Design

A comparative study design was adopted using the competencyinventory for baccalaureate senior nursing students based on learningoutcomes.

Sample and Setting

A convenience sample of baccalaureate nursing students froma university with branches in northern and southern Taiwan wassurveyed. Participants were surveyed at the first week and the sixthweek of nursing practicum. Nursing students were sent to differentvenues of their choosing for nursing practicum.

Instrument

The Competency Inventory of Nursing Students (CINS) was devel-oped to measure learning outcomes of baccalaureate nursing studentsin Taiwan (Hsu and Hsieh, 2012). The CINS was designed based oneight core values (Hsu and Hsieh, 2009; Taiwan Nursing AccreditationCouncil, 2009), literature reviews, and learning outcomes of nursingstudents in Taiwan. The CINS includes three parts: demographicinformation (Table 1), learning experience, and self-rated competencybased on learning outcomes. The third part, competency, is a 7-point(1=no competence to 7=excellent competency) Likert scalecontaining 43 items. The possible total scores ranged from 43 to 301.Higher score represents student's higher competencies. In addition,three overall items assess competence after graduation. Examples aregiven in items such as “I possess nursing competence after college.”“I have confidence in my ability to cope with hospital work aftercollege.” “I can manage clinical stress after college.”

Content validity of the CINS was evaluated by seven experts whospecialized in nursing or medical education, clinical nursing, andhigher education and human resources. The scale-content validityindex (S-CVI) was 0.99 and the item-content validity (I-CVI) rangedfrom 0.83 to 1.00. Construct validity was established using principal

Table 1The characteristics of the sample (n=591).

Variables n (%)

Age in yearsMedian (range) 22 (20–39)Mean (SD) 21.83 (1.02)

SexMale 5 (0.8)Female 586 (99.2)

Nature of previous school attendedPrivate school 504 (85.3)Public school 87 (14.7)

Prior school attendedHigh school 75 (12.7)Nursing vocational school 98 (16.6)Non-nursing vocational school 8 (1.4)2-year AD/ADN 12 (2.0)5-year AD/ADN 396 (67.0)Missing 2 (0.3)

Type of nursing program4-year nursing program 176 (29.8)2-year RN to BSN program 415 (70.2)

Type of hospital as a venue for clinical practicumMedical center 325 (54.3)Regional hospital 23 (3.8)District hospital 251 (41.9)

Nursing licenseNo 87 (14.7)Yes 504 (85.3)Licensed Practical Nurse 90 (15.2)Registered Nurse 16 (2.7)Both 384 (65.0)Missing 14 (2.4)

ReligionNo 304 (51.4)Yes 285 (48.2)Buddhism 76 (12.9)Christianity 37 (6.3)Catholicism 5 (0.8)Taoism 139 (23.5)Other 26 (4.4)Missing 4 (0.7)

A family member working as a medical practitioner or a nurseNo 327 (55.3)Yes 261 (44.2)Father 6 (1.0)Mother 22 (3.7)Siblings 59 (10.0)Relatives 195 (33.0)Missing 3 (0.5)

Attribute of prior workplaceNo 344 (58.2)Yes 246 (41.6)Hospital 32 (5.4)Clinic 70 (11.8)Non-medical institutions 110 (18.6)Others 34 (5.8)Missing 1 (0.2)

Total work experience in yearsMedian (range) 0 (0–15)Mean (SD) 0.62 (1.30)

Interest in nursingVery uninterested 0 (0.0)Uninterested 7 (1.2)Neutral 237 (40.1)Interested 295 (49.9)Very interested 50 (8.5)Missing 2 (0.3)

Plans for life after collegeNo plan 0 (0.0)Plan 591 (100.0)Postgraduate education (nursing-related fields) 17 (2.9)Postgraduate education (non-nursing related fields) 4 (0.7)Nursing-related career 544 (92.0)Postgraduate study abroad 5 (0.8)Non-nursing related career 3 (0.5)Others 16 (2.7)Missing 2 (0.3)

Table 1 (continued)

Variables n (%)

Attribute of preferred workplace after collegeMedical center 466 (78.8)Regional hospital 84 (14.2)District hospital 16 (2.7)Other 23 (3.9)Missing 2 (0.3)

Top three choices of places to work a

Surgical ward 374 (63.3)Intensive care unit 267 (45.2)Medical ward 209 (35.4)Operating room 133 (22.5)

Note.a Multiple choice; AD, associate degree; AND, associate degree of nursing; RN, regis-

tered nurse; BSN, bachelor science in nursing.

1538 S.-I. Hsieh, L.-L. Hsu / Nurse Education Today 33 (2013) 1536–1545

axis factor analysis (PAF) with direct oblimin rotations. Six factorswere identified: ethics and responsibility, general clinical skills,lifelong learning, clinical biomedical science, caring and critical think-ing and reasoning. The CINS could account for 69.84% of the variancein scores of nursing competency. Cronbach's α of the internal consis-tency of the CINS was between 0.91 and 0.98 among six factors. Inaddition, the participants' grades in all mandatory courses wereobtained with their consent.

Data Collection

Six-hundred-and fifty-two questionnaires were distributed to stu-dents by group mails at the 1st week and 6th week of nursing clinicalpracticum during their last semester of enrollment between Marchand June 2011. Six-hundred-and-eighteen questionnaires werereturned (95% mean response rate).

Ethical Considerations

The study was approved by the Institutional Review Board. Consentto participate was implied by voluntary completion and return of thequestionnaire, and participants were informed that they would not bepenalized for failure to participate or for quitting at any stage of thesurvey.

Data Analysis

The data were analyzed using the Statistical Package for the SocialSciences version 17.0 (SPSS Inc., Chicago, IL). Descriptive statisticswere conducted to describe the sample characteristics. A total of eightcases with univariate outliers were dropped from further analyses.Paired t tests were used to analyze mean differences in subscale, totalscores, and three overall scores of competency at the 1st week and6th week of nursing clinical practicum. One-way analyses of covariance(ANCOVA) was used to analyze mean differences in six-subscale andtotal scores of the CINS at the 6th week of nursing clinical practicumby demographics, learning experience, and grades controlling for eachbaseline subscale or total scores and excluding cases analysis byanalysis. Assumptions related to paired t test and ANCOVA werechecked, including normality, univariate and multivariate outliers,equal variance, and homogeneity of regression. Kruskal–Wallis testsand Mann–Whitney U tests were used to analyze baseline subscalescores with significant homogeneity-of-slope assumption via usingchange scores obtained by subtracting scores for the 1st week fromthose for the 6th week. Bonferroni adjustment or Mann–WhitneyU tests were used for post hoc analyses of ANCOVA or Kruskal–Wallistests. A p valueb0.05 was indicated statistically significant.

Fig. 1. Mean scores of the six-subscale CINS at the first week and sixth week of nursingclinical practicum.


Results

Demographics of Participants

A total of 591 nursing students were surveyed as presented inTable 1. Median age of student nurses was 22 years (range=20–39).Almost all participants were female (99.2%). Most of nursing students(85.3%) graduated from private schools and had both licenses of LPNand RN. Two-thirds of nursing students (67.0%) had 5-year associatedegree in non-nursing or associate degree in nursing major. Halfnursing students (54.3%) underwent nursing clinical practicum atmedical centers and less than half nursing students (41.9%) undertooknursing clinical practicum at district hospitals. Less than half studentnurses (41.6%) had worked at different institutions with a median0.62 (range=0–15) years. More than half participants (58.4%) had afamily member working as a medical practitioner or a nurse. Halfmore nursing students (58.4%) were interested in nursing profession.Most nursing students (92%) had made a plan for life after college towork at medical centers (78.8%). Top three choices of places to workfor them to pursue a nursing career after college were surgical ward,intensive care unit, and medical ward.

Mean Differences in Six-subscale and Total Scores of the CINS at the 1stWeek and the 6th Week of Nursing Clinical Practicum

Table 2 and Fig. 1 showed mean differences in six-subscale, totalscores, and three overall scales of the CINS at the 1st week and 6thweek of nursing clinical practicum. Mean scores of six subscale,total scale, and three overall scales at the 6th week of nursing clinicalpracticum are greater than the 1st week of nursing clinical practicum.However, mean scores of general clinical skills (t(588)=6.28, pb0.001,r=0.25), lifelong learning (t(583)=8.56, pb0.001, r=0.33), clinicalbiomedical science (t(575)=10.73, pb0.001, r=0.41), caring(t(585)=4.98, pb0.001, r=0.20), and critical thinking and reason-ing (t(581)=15.45, pb0.001, r=0.54) were statistically significantbetween the 1st week and 6th week of nursing clinical practicumwith an exception of ethics and accountability. Likewise, meantotal scores (t(554)=8.04, pb0.001, r=0.32) and three overallscores (t(587)=5.99, pb0.001, r=0.24) were statistically signifi-cant between two-time period. The effect sizes of all significantsix-subscale, total scale, and three overall scales were between0.20 and 0.54 and these represented small to medium effect sizes.

Mean Differences in sSx-subscale and Total Scores of the CINS at the 6thWeek of Nursing Clinical Practicum Controlling for Baseline Scores

A comparison of six-subscale of the CINS at 6th week of nursingclinical practicum by demographics, learning experience, and gradesusing ANCOVA was shown in Table 3. Only significant resultswere presented in Table 3. Students with high interest in nursingand 80–89.9 English grade had significantly greater ethics and

Table 2Mean differences in six-subscale, total scores, and three overall scores of the CINS at the fir

Time 1 Time 2 Me

Variables Mean (SD)

Ethics and accountability 89.85 (9.31) 90.33 (8.90) 0.4General clinical skills 37.64 (4.36) 38.79 (3.87) 1.1Lifelong learning 33.24 (4.05) 34.75 (3.97) 1.5Clinical biomedical science 24.36 (3.31) 25.92 (2.89) 1.5Caring 34.46 (3.95) 35.32 (3.70) 0.8Critical thinking and reasoning 19.82 (2.72) 21.80 (2.65) 1.9Total scores 239.30 (22.53) 246.78 (22.20) 7.4Three overall scores 15.85 (2.49) 16.49 (2.32) 0.6

Note. ECP, elective clinical practicum; Time 1, the first week of ECP; time 2, the sixth week ofpossess nursing competence after college.”+“I have confidence in my ability to cope with

accountability competency than those with neutral interest in nurs-ing and 70–79.9 English grade. Students with interest in nursing pos-sessed significantly higher general clinical skills than those withneutral interest in nursing. Students with high interest in nursing,≤80 clinical biomedical science grades, and >80 nursing practicumgrades had greater lifelong learning competency than those withneutral interest in nursing, >80 clinical biomedical science grades,and ≤80 nursing practicum grades. There were significant meandifferences in clinical biomedical science competency across previousschooling, type of nursing license, a family member working as amedical practitioner or a nurse, interest in nursing, attributes ofpreferred workplace after college, extracurricular activity experience,played an active role in classroom discussions and asked questions,and grades of English, clinical biomedical science, nursing science,and nursing practicum. Students who had 5-year AD/ADN, withhigh interest in nursing, extracurricular activity experience, andplayed an active role in classroom discussions and asked questionshad greater caring competency compared with those graduatedfrom nursing school, with neutral interest in nursing, no extracurric-ular activity experience, and never played an active role in classroomdiscussions and asked questions. There were significant mean differ-ences in critical thinking and reasoning competency across school lo-cation, type of nursing program, nursing license, interest in nursing,

st week and sixth week of ECP.

an differences Paired t tests Effect size (r)

t value p value (2-tailed)

9 t(579)=1.24 0.215 0.055 t(588)=6.28 b0.001 0.251 t(583)=8.56 b0.001 0.336 t(575)=10.73 b0.001 0.416 t(585)=4.89 b0.001 0.208 t(581)=15.45 b0.001 0.548 t(554)=8.04 b0.001 0.324 t(587)=5.99 b0.001 0.24

ECP; paired t tests excluded cases analysis by analysis; three overall scores=scores of “Ihospital work after college.”+“I can manage clinical stress after college.”

Table 3Mean differences in six-subscale scores of the CINS at 6th week of nursing clinical practicum by demographics, learning experience, and grades using ANCOVA after excluding casesanalysis by analysis.

Dependent variables Independent variables and covariates n (%) Mean (SD) Statistical test PartialEta2

Post hocanalysis

F or χ2 value p value(2-tailed)

Ethics andaccountability

Interest in nursinga Uninterested➁ 6 (1.0) 90.67 (9.46) F(3,573)=4.33 0.005 0.02 ➄>➂d

Neutral➂ 234 (40.5) 87.94(8.81)Interested➃ 288 (49.8) 91.53 (8.66)Very interested➄ 50 (8.7) 94.34 (7.89)

Baseline scores F(1,573)=130.90 b0.001 0.19Grade of Englisha b70 ➀ 68 (11.7) 90.82 (8.05) F(3, 573)=4.19 0.006 0.02 ➂>➁d

70–79.9 ➁ 183 (31.7) 88.17 (9.31)80–89.9 ➂ 238 (41.2) 91.76 (8.55)≥90 ➃ 89 (15.4) 90.71 (8.88)

Baseline scores F(1, 573)=148.51 b0.001 0.21General clinical skills Prior school attendeda High school➀ 75 (12.8) 38.51 (3.97) F(4, 581)=2.63 0.03 0.02 NA

Nursing vocationalschool➁

96 (16.4) 38.77 (4.30)

Non-nursingvocational school➂

8 (1.4) 34.88 (3.04)

2-year AD/ADN➃ 12 (2.0) 37.33 (3.70)5-year AD/ADN➄ 396 (67.5) 39.02 (3.69)

Baseline scores F(1, 581)=121.28 b0.001 0.17Interest in nursinga Uninterested➁ 7 (1.2) 38.14 (3.93) F(3, 582)=6.04 b0.001 0.03 ➃>➂d

Neutral➂ 236 (40.2) 37.64 (3.79)Interested➃ 294 (50.1) 39.48 (3.68)Very interested➄ 50 (8.5) 40.14 (4.04)

Baseline scores F(1, 582)=105.60 b0.001 0.15Lifelong learning Interest in nursinga Uninterested➁ 7 (1.2) 32.43 (3.82) F(3, 577)=7.05 b0.001 0.04 ➃>➂d

Neutral➂ 235 (40.4) 33.55 (3.83) ➄>➂ d

Interested➃ 290 (49.8) 35.34 (3.74)Very interested➄ 50 (8.6) 37.14 (4.00)

Baseline scores F(1, 577)=99.24 b0.001 0.15Grade of clinicalbiomedical sciencea

≤80 ➀ 203 (34.9) 34.99 (3.90) F(1, 578)=4.03 0.045 0.01 NA

>80 ➁ 378 (65.1) 34.64 (4.00)Baseline scores F(1, 578)=135.68 b0.001 0.19Grade of nursingpracticuma

≤80 ➀ 32 (5.5) 33.03 (4.44) F(1, 577)=4.93 0.027 0.01 NA

>80 ➁ 548 (94.5) 34.85 (3.91)Baseline scores F(1, 577)=136.86 b0.001 0.19

Clinicalbiomedical science

Prior school attendeda High school➀ 75 (13.0) 24.99 (2.85) F(4, 569)=4.41 0.002 0.03 ➁>➀d


94 (16.3) 25.97 (3.28) ➁>➃d


8 (1.4) 23.63 (1.69)

2-year AD/ADN➃ 12 (2.1) 24.00 (2.52)5-year AD/ADN➄ 386 (67.1) 26.22 (2.74)

Baseline scores F(1, 569)=83.38 b0.001 0.13Type of nursinglicensea

No➀ 86 (15.3) 24.92 (3.07) F(3, 557)=3.44 0.017 0.02 ➁>➀d

LPN➁ 87 (15.5) 25.85 (3.23)RN➂ 15 (2.7) 26.27 (2.49)LPN & RN➃ 374 (66.5) 26.17 (2.72)

Baseline scores F(1, 557)=83.58 b0.001 0.13A family memberworking as a medicalpractitioner or a nursesa

No 318 (55.5) 25.62 (3.03) F(1, 570)=4.87 0.028 0.01 NA

Yes➀ 255 (44.5) 26.29 (2.67)Baseline scores F(1, 570)=85.89 b0.001 0.13Interest in nursing a Uninterested➁ 7 (1.2) 25.29 (3.55) F(3, 569)=4.46 0.004 0.02 ➃>➂d

Neutral➂ 230 (40.1) 25.15 (2.79) ➄>➂d


Baseline scores F(1, 569)=67.10 b0.001 0.11Attributes of preferredworkplace after college

Medical center➀ 455 (79.3) 25.98 (2.85) F(4, 568)=2.41 0.048 0.02 ➀>➂d

Regional hospital➁ 82 (14.3) 26.09 (3.01) ➁>➂d

District hospital➂ 15 (2.6) 23.40 (2.56)Clinics & long-termcare facilities➃

10 (1.7) 25.80 (4.29)

Multiple choice➄ 12 (2.1) 26.00 (1.65)Baseline scores F(1, 568)=86.93 b0.001 0.13Extracurricular activityexperience

No 62 (10.8) 25.02 (3.50) F(1, 572)=8.11 0.005 0.01 NA

Yes➀ 513 (89.2) 26.04 (2.79)


Unlabelled image

Table 3 (continued)


Post hocanalysis


Baseline scores F(1, 572)=91.44 b0.001 0.14Played an active role inclassroom discussionsand asked questions

Never 8 (1.4) 24.88 (3.04) F(4, 567)=2.67 0.032 0.02 ➃>➁d

Seldom➀ 99 (17.3) 25.67 (2.76)Sometimes➁ 269 (46.9) 25.60 (2.86)Often➂ 151 (26.4) 26.27 (2.88)Always➃ 46 (8.0) 27.39 (2.93)

Baseline scores F(1, 567)=78.96 b0.001 0.12Grade of Englishc ≤80 ➀ 264 (46.0) −2.05 (3.86) Z=−3.01 0.003 −0.13 NA

>80 ➁ 310 (54.0) −1.17 (3.11)Grade of clinicalbiomedical scienceb

b70 ➀ 37 (6.4) −4.14 (3.85) χ2(3)=24.83 b0.001 NA ➀>➂c

➀>➃c

➁>➀c

➁>➂c

➁>➃c

70–79.9 ➁ 161 (28.0) −2.07 (3.94)80–89.9 ➂ 320 (55.8) −1.14 (3.18)≥90 ➃ 56 (9.8) −1.00 (2.68)

Grade of nursing sciencec ≤80 ➀ 196 (34.3) −2.35 (4.19) Z=−3.96 b0.001 −0.17 NA>80 ➁ 376 (65.7) −1.14 (3.02)

Grade of nursing practicuma ≤80 ➀ 32 (5.6) 24.16 (2.49) F(1, 569)=9.35 0.002 0.02 NA>80 ➁ 540 (94.4) 26.02 (2.88)

Baseline scores F(1, 569)=86.39 b0.001 0.13Caring Prior school attendedb High school➀ 75 (12.8) −1.12 (3.56) χ2(4)=12.85 0.012 NA ➁>➄


97 (16.6) −2.24 (4.98)


8 (1.4) 1.13 (5.19)

2-year AD/ADN➃ 12 (2.1) −0.75 (5.05)5-year AD/ADN➄ 392 (67.1) −0.53 (4.09)

Interest in nursinga Uninterested➁ 7 (1.2) 36.29 (5.22) F(3, 579)=7.07 b0.001 0.03 ➃>➂d

Neutral➂ 236 (40.4) 34.30 (3.54) ➄>➂d


Baseline scores F(1, 579)=78.12 b0.001 0.12Extracurricularactivity experiencea

No 62 (10.6) 34.10 (4.28) F(1, 582)=4.43 0.036 0.01 NA

Yes➀ 523 (89.4) 35.46 (3.61)Baseline scores F(1, 582)=94.04 b0.001 0.14Played an active role inclassroom discussionsand asked questions a

Never 8 (1.4) 34.25 (3.77) F(4, 577)=2.82 0.025 0.02 ➃>➀d

Seldom➀ 98 (16.8) 34.52 (3.65)Sometimes➁ 273 (46.8) 35.07 (3.69)Often➂ 156 (26.8) 35.67 (3.65)Always➃ 48 (8.2) 37.27 (3.33)

Baseline scores F(1, 577)=83.81 b0.001 0.13Critical thinkingand reasoning

Location of schoola Southern Taiwan➀ 270 (46.4) 21.90 (2.64) F(1, 579)=4.96 0.026 0.01 NANorthern Taiwan➁ 312 (53.6) 21.72 (2.66)

Baseline scores F(1, 579)=78.2 b0.001 0.12Type of nursing programa 4-year program➀ 173 (29.7) 21.75 (2.86) F(1, 579)=4.57 0.033 0.01 NA

2-year RN to BSNprogram➁

409 (70.3) 21.82 (2.56)

Baseline scores F(1, 579)=78.89 b0.001 0.12Nursing licensec No 87 (14.9) −2.71 (2.74) Z=−2.83 0.005 −1.19 NA

Yes➀ 495 (85.1) −1.85 (3.14)Interest in nursinga Uninterested➁ 7 (1.2) 21.00 (4.08) F(3, 575)=6.09 b0.001 0.03 ➃>➂d

Neutral➂ 231 (39.8) 21.08 (2.51) ➄>➂d


Baseline scores F(1, 575)=55.11 b0.001 0.09Class rank in terms ofacademic performance a

70–79 ➂ 80 (13.7) 22.21 (2.55) F(2, 578)=3.37 0.035 0.01 ➂>➃d

80–89 ➃ 496 (85.2) 21.74 (2.68)≥90 ➄ 6 (1.0) 21.67 (1.03)

Baseline scores F(1, 578)=78.78 b0.001 0.12Grade of clinicalbiomedical science a

b70 ➀ 37 (6.4) 22.68 (2.68) F(3, 575)=3.39 0.018 0.02 ➀>➂d

70–79.9 ➁ 163 (28.1) 21.82 (2.76)80–89.9 ➂ 325 (56.0) 21.72 (2.61)≥90 ➃ 55 (9.5) 21.67 (2.50)

(continued on next page)


Table 3 (continued)


Post hocanalysis


Baseline scores F(1, 575)=78.95 b0.001 0.12Grade of nursing sciencea ≤80 ➀ 199 (34.4) 22.03 (2.63) F(1, 575)=7.73 0.006 0.01 NA

>80 ➁ 379 (65.6) 21.69 (2.66)Baseline scores F(1, 575)=79.09 b0.001 0.12

Note. CINS, competency inventory for nursing students; ECP, elective clinical practicum; AD, associate degree; AND, associate degree in nursing; LPN, licensed practice nurse; RN,registered nurse; BSN, bachelor science in nursing; NA, not applicable.

a ANCOVA.b Kruskal–Wallis test.c Mann–Whitney U test.d Bonferroni for adjusting multiple comparisons.


academic class rank, and grades of clinical biomedical science andnursing science.

A comparison of total scores of the CINS at 6thweek of nursing clinicalpracticum across demographics, learning experience, and grades usingANCOVA was shown in Table 4. Only significant results were presentedin Table 4. There were significant mean differences in total scores ofthe CINS across type of nursing program (F(1,552)=6.62, p=0.01), previ-ous schooling (F(3,548)=3.76, p=0.005), type of nursing license(F(3,536)=2.89, p=0.04), interest in nursing (F(3,548)=5.06, p=0.02),and extracurricular activity experience (F(1,551)=4.24, p=0.04). Posthoc analyses showed that greater total scores were seen in studentswho attended 2-year RN to BSN programs, possessed 5-year AD/ANDqualifications, possessed both LPN and RN licenses, with high interest innursing and extracurricular activity experience than those who attended4-year nursing program, graduated from nursing school, possessed LPNlicense, with neutral interest in nursing, and no extracurricular activityexperience.

Discussion

This study was to compare mean differences in six-subscale andtotal scores of the CINS between the first week and the sixth week ofnursing practicum. Another aim was to compare mean differences insix-subscale and total scores of the CINS at the sixth week of nursingpracticum controlling for baseline scores of the CINS. Results suggestthat themean scores of six subscales, total scale, and three overall scalesat the 6th week of nursing practicum are greater than the 1st week ofnursing practicum. In this study, nursing students are preceptored inthe final semester of their program. In addition, the one-on-one rela-tionship between a student and preceptor is essential in assisting stu-dents' transition to safe and competent practice (Luhanga et al., 2010).Three overall scores in this study represent the participants' nursingcompetence, confidence, and management of clinical stress. This find-ing is consistent with the conclusions of Pongprayun (2002) andStutsky and Laschmger (1995) that preceptorship significantly im-proves nursing students' adaptive learning competencies. Moreover,learning froman experienced and competent nurse exposes the studentto effective clinical practices which directly enhance the student's owndeveloping confidence and competence (Spouse, 2001; Zilembo, 2007).The importance of preceptorship in enhancing positive clinical experi-ences for undergraduates has been widely acknowledged (Charlestonand Happell, 2005). In addition, clinical education must increase self-confidence and promote competency of nursing students (Freiburger,2002). Competence is thought to be related to self-efficacy (Bandura,1995). Stronger self-efficacy beliefs are usually reflected in greaterself-confidence (Lauder et al., 2008). Self-confidence is largely viewed asaffective and cognitive as a consequence of behavior (Cramer et al., 2009).

In this study, the difference in the mean scores of ethics andaccountability was not statistically significant between the 1st weekand 6th week of nursing practicum. Ethical competence as a compo-nent of professional competence is derived from life experience.

Moral behavior and responsibility together are the basis of ethicalaction. Professional ethics determines professional attitudes, valuesand behavior (Paganini and Egry, 2011). Ethical competence canoften be described as tacit knowledge (Sporrong et al., 2007).Therefore, ethics and accountability of a novice nurse may beenhanced by clinical practice and observation of role models.

In this study, students with high interest in nursing had signifi-cantly greater nursing competency (ethics and accountability, generalclinical skills, and lifelong learning competency) than those withneutral interest in nursing. This finding is supported by Plack(2006) who proves that professional identity is fundamental tonursing practice and is an evolving process that occurs throughoutone's career. Jirwe and Rudman (2012) identify three differentmotives for entering the nursing profession: genuine interest, practicalreasons, and default choice, with genuine interest being the strongestone. Shahriari et al. (2012) demonstrate that having a professionalcommitment and conscience is seen as one of the ethical values crucialto the enhancement of patient care. In addition, Worthington et al.(2012) suggest that professional identity has a direct relationshipwith student retention in the nursing program. Therefore, studentswith higher interest in nursing as a profession tend to make betterprogress in improving general clinical skills and lifelong learningcapacities.

Language can affect a student's ability to acquire the neededresources to continue their education (Starr, 2009). Students with80–89.9 English grades had significantly greater ethics and account-ability competency than those with 70–79.9 English grades in thisstudy. The result supports the findings of Whitehead (2006) whichsuggest that improvement in language skills could lead to improve-ment in critical thinking. Ethics play a very important part in thecritical thinking process. Ethical reasoning leads to the formulationof conclusions and the most appropriate, often creative, decisions,options, or alternatives. This study finds no evidence suggesting anegative correlation between the students' command of clinicalbiomedical science and their lifelong learning competency. One possi-ble explanation for this is the conclusion of Minasian-Batmanian et al.(2006) that 70% of students demonstrated an inability to integratebiomedical science knowledge. Lifelong learning is an essentialstrategy for the survival of school learning (Uzunboylu and Hursen,2011). Nursing students who outperformed their peers in theirnursing practicum had greater lifelong learning competency. Thisfinding is supported by the observation of Lofmark et al. (2012) thatlearning outcomes represent not just practical skills, but also abilitiesto work independently and take responsibility.

In this study, there is a strong correlation between the participants'demographic attributes and learning attributes, and their competencein biomedical science. Other studies also showed a significant correla-tion between performances in science based courses and NCLEX-RNor NCLEX-RN examination results (Higgins, 2005; Gilmore, 2008).However, this study showed a negative correlation between compe-tence in clinical biomedical science and competence in several other

Table 4Comparing total scores of the CINS at 6th week of nursing clinical practicum by demographics, and learning experience using ANCOVA after excluding cases analysis by analysis.

Independent variables & covariates n (%) Mean (SD) ANCOVA test Partial Eta2 Post hoc analysis

F value p value (2-tailed)

Type of nursing program 4-Year nursing program➀ 164 (29.5) 245.52 (23.06) F(1, 552)=6.62 0.010 0.01 NA2-Year RN to BSN program➁ 391 (70.5) 247.30 (21.84)

Baseline scores F(1, 552)=212.54 b0.001 0.27Prior school attended High school➀ 74 (13.4) 246.57 (22.85) F(4, 548)=3.76 0.005 0.03 ➄>➁ a

Nursing vocational school➁ 87 (15.7) 246.71 (22.82)Non-nursing vocational school➂ 8 (1.4) 226.00 (18.79)2-Year AD/ADN➃ 12 (2.2) 239.83 (26.00)5-Year AD/ADN➄ 373 (67.3) 247.70 (21.39)

Baseline scores F(1, 548)=207.78 b0.001 0.28Type of nursing license None➀ 85 (15.7) 245.32 (23.76) F(3, 536)=2.89 0.035 0.02 ➃>➁a

LPN➁ 80 (14.8) 245.64 (22.30)RN➂ 15 (2.8) 247.27 (19.02)LPN & RN➃ 361 (66.7) 247.72 (21.41)

Baseline scores F(1, 536)=211.39 b0.001 0.28Interest in nursing Uninterested➁ 6 (1.1) 241.33 (25.93) F(3, 548)=5.06 0.002 0.03 ➃>➂a

Neutral➂ 220 (39.8) 239.12 (21.29) ➄>➂a


Baseline scores F(1, 548)=158.50 b0.001 0.22Extracurricular activity experience No 60 (10.8) 240.08 (26.95) F(1, 551)=4.24 0.040 0.01 NA

Yes➀ 494 (89.2) 247.64 (21.44)Baseline scores F(1, 551)=200.89 b0.001 0.27

Note. CINS, competency inventory for nursing students; AD, associate degree; AND, associate degree in nursing; LPN, licensed practice nurse; RN, registered nurse; BSN, bachelorscience in nursing; NA, not applicable.

a Bonferroni for adjusting multiple comparisons.


subjects (English, clinical biomedical science, nursing science). Therewas no evidence suggesting a negative correlation between theparticipants' competence in biomedical science and their overallacademic performance. One possible explanation for this is discrepancyin theirmetacognitive ability. Metacognitively aware students aremoreknowledgeable about biomedical sciences than their less awarepeers. Furthermore, incompetent individuals displayed a tendency tooverestimate their abilities, while the burden of expertise is the consis-tent tendency to underestimate and criticize one's own performance(Rudy et al., 2001; Lind et al., 2002; Edwards et al., 2003). The resultcontradicted three other studies which affirm the effectiveness of firstsemester GPA as a predictor of academic success (Lin et al., 2003;McCarey et al., 2007; Newton et al., 2007). Salamonson et al. (2008)establish an association between poor English skills and poor academicperformance, pointing out that nearly two-thirds of students failed inbioscience as a result of a poor command of English language. A stronglypositive correlation between extracurricular activity experience andcompetence in clinical biomedical science was identified in this study.This finding is consistent with Pascarella and Terenzini's (2005)conclusion that studentswhomake extracurricular activities an integralpart of their college life stand a better chance of finishing college withgood grades.

Caring is a mode of human existence that brings forth conscience,but also feelings of compassion, competence, confidence, commit-ment, and comportment (Roach, 2002). Swanson (1999) identifiesfive levels of caring from level one (identifying the characteristics ofpersons with capacities for caring) to level five (focusing on positiveand negative consequences of caring). In this study, nursing studentswho have 5-year AD/AND qualifications, high interest in nursing,extracurricular activity experience, and who always played an activerole in classroom discussions and asked questions have greater caringcompetency. Gadamer (1989) makes a similar discovery that thecaring characteristics of persons must be cultivated through individu-al development, through the dialog of the ever-ongoing excursionand return of the human spirit.

There was a significant positive correlation between criticalthinking competency and school location, type of nursing program,nursing license, and interest in nursing, while nursing competencyhad a negative correlation with academic class rank, and grades of

basic science and nursing biomedical science. These findings standin consistence with previous studies regarding the effect of previousexperience in nursing (Hird, 1995), a significant relationship be-tween critical thinking performance and the NCLEX-RN examinationresults (Sayles et al., 2003; Hoffman, 2006), and non existence of re-lationship between critical thinking performance and GPAs of eithernursing courses or science courses (Berger, 1984; Thompson andRebeschi, 1999). However, there are several studies that contradictthis study, including some that present a positive correlation be-tween critical thinking performance and GPAs (Miller, 1992;Facione and Facione, 1997; Stone et al., 2001) and one that demon-strates that critical thinking skills and previous experience in nurs-ing are not correlated (Brigham, 1989).

Post hoc analyses showed that higher total scores were seen instudents who studied 2-year RN to BSN programs, possessed 5-yearAD/AND qualifications, possessed both LPN and RN licenses, withhigh interest in nursing and extracurricular activity experience thanthose who studied 4-year nursing program, graduated from nursingschool, possessed LPN license, with neutral interest in nursing andno extracurricular activity experience. These findings are consistentwith findings drawn from previous studies regarding the effect ofextracurricular activities on university students' academic perfor-mance improvement (Pascarella and Terenzini, 2005; Van Etten etal., 2008; Vermeulen and Schmidt, 2008) and regarding the effect ofnursing practicum experience on nursing competency developmentfor nursing students (Ranse and Grealish, 2007; Ralph et al., 2009).In this study, nursing students who graduated from 5-year technicaldegree nursing education (AD/ADN, which prepare them for a futurecareer in basic nursing care and long-term care settings) demonstrat-ed greater competency than those who graduated from vocationalhigh schools (where training is focused on practical applications ofnursing skills), because the five years of training helped them earntheir RN license and enhance their clinical nursing competences.

Conclusion

Today's healthcare graduates must not only possess the technicalskills necessary to practice but must also be proficient in othercompetencies that impact on their professional practice (Rowe et al.,


2012). A competency-based assessment approach is to meet the de-mand for a complex workforce, so it is essential to identify factorswhich have the greatest impact on student performance. There wereseveral factors that were found to have a significant correlation tosix-subscale and total scores of nursing competency for nursing stu-dents. In this study, demographic attributes (location of school, typeof nursing program, prior schooling, type of nursing license, a familymember working as a medical practitioner or a nurse, interest in nurs-ing, attributes of preferredworkplace after college) and learning factors(extracurricular activity experience, played an active role in classroomdiscussions and asked questions, academic class rank, and grades ofEnglish, clinical biomedical science, nursing science, and nursing practi-cum) are significantly correlated with nursing competency. These fac-tors should be given greater emphasis by nurse educators in planningthe academic and clinical phases of professional education.

Acknowledgment

We would like to thank all the nursing students who participatedin this study and the National Science Council who provided researchfunding for this study.

Funding

This research project was sponsored by the National ScienceCouncilIn Taiwan (NSC-99-2516-S-227-002).

Conflict of Interest

No conflict of interest has been declared by the authors.

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an outcome-based evaluation of nursing competency of baccalaureate senior nursing students in taiwan

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