Keywords
self-reported clinical practice - graduating nursing students - clinical performance
Introduction
In essence, the nursing profession has considerably been around ancient times. Since
then it has drastically evolved throughout history. Today, nursing is among the most
pivotal profession within the health care industry and are learned in a wide selection
of occupational duties that are utilized within a variety of settings throughout the
world.[1] As among the strong multidisciplinary health care teams, nurses and midwives make
a consequential contribution to delivering on the commitments made within the 2018
Astana Declaration on Primary Health Care, ensuring patient-centered care to the community.
Currently, nurses and midwives account for nearly 50% of the worldwide health workforce
for all countries to succeed in Sustainable Development Goals on health and well-being.
World Health Organization estimates that the globe will need further 9 million nurses
and midwives by the year 2030.[2]
Despite the great need for nursing graduates, there are concerns for their overall
clinical performance before and after joining the clinical areas. Various reports
and studies have concluded that the current system fails to prepare nursing students
for real practical performance in the field, and after graduation also they cannot
perform the procedure in clinical environments as expected.[3] Presently, nursing profession has changed drastically and the focus of health care
is leading into a complex direction that requires a generation of dedicated nursing
professionals.[4]
Today, nursing educational institutions are expected to fabricate nurses which are
clinically practiced ready despite of being a novice to satisfy the growing health
care demands of an aging population and a projected looming nursing shortage.[5] Developed countries like the United States are currently experiencing a serious
shortage of nurses due to the aging nursing workforce and decreased nursing program
enrollments because of the nursing faculty crunch.[6] And presently India alone is facing a shortage of around 2 million nurses.[7] On the other hand, India is one of the top supplies of nurses to the Gulf and the
Organization for Economic Co-operation and Development countries, especially the United
States, Canada, United Kingdom, Ireland, Australia, and New Zealand.[8]
[9]
Consequently, nursing graduates have significantly increased in India as nursing colleges
boomed from just 165 nursing colleges in 2004[10] to 1,667 in 2017.[11] These data indicate that there is a very rapid climb in the number of nurses produced
in India to meet the national and international needs of nurses. However, in that
spot, there is always a challenge to sustain quality with rapid production of quantity.
Further, an acute shortage of nurses necessitates the readiness of nurses to right
away take up the full-fledged role as registered nurses to set the seal on patient
safety and quality of care.[12] Some recent studies conducted in Iran,[13] Australia,[14] and United Arab Emirates[15] showed that nurses are having clinical knowledge shortages and only a few of them
are possessing entry-level competencies and practice-level readiness. And surprisingly,
only a few research studies were done on clinical practice readiness, and in India,
there is less statistical data to understand the nursing student's competencies which
are produced by mass growing nursing institutes in Bengaluru, Karnataka, India. Therefore,
this study was planned to assess the self-reported clinical practice of final year
nursing students at Bengaluru. The findings of this study will help the nurse educator
to see the lacunae or the gap between the theory and clinical practice culture among
nurses and this study will also help the national and international recruiters about
the clinical practice readiness among final year nursing students from Bengaluru.
Objectives of the Study
-
To determine the clinical practice skill readiness among final year nursing students.
-
To explore the factors that show the significant difference with clinical practice
skill readiness level.
Methods
Study Design and Study Population
An institutional-based cross-sectional online survey was undertaken on final year
nursing students studying in B.Sc. Nursing, General Nursing and Midwifery (GNM), and
Post Basic (PB) B.Sc. Nursing at selected private nursing colleges across Bangalore
in the academic year 2019 to 2020. A total of 200 final year nursing students have
participated in the study.
Study Setting
Bangalore (also known as Bengaluru) is the capital of Karnataka state, India. There
are a total number of 124 nursing colleges in Bangalore, of both government and nongovernment
colleges. This survey was undertaken in the academic year 2019/2020 on final year
nursing students at eight nursing institutes which are situated in the northern part
of Bengaluru. As we obtained information from the institute's head, there was a total
of 208 nursing students completing their graduation in the 2019/2020 academic year
in the eight nursing institutes, including B.Sc. Nursing, PB B.Sc. Nursing, and GNM
Nursing.
Sample Size and Sampling Procedures
A total of 200 samples were collected conveniently from eight selected private nursing
colleges in Bangalore. The sample size was estimated using the formula (Z1-∝/2)[2] (p) (q)/d[2]
[16] the expected proportion of a good level of nursing competency is 0.23 (23%),[17] the expected precision of 6%, and at 95% level of confidence, the estimated sample
size was 189 participants, whereas considering 10% nonresponsive rate, total 208 sample
size was considered for the present study. A sampling frame of students studying in
the final year nursing was obtained from selected colleges and the desired sample
was obtained conveniently. However, 8 students did not complete the questionnaire
(96.2% response rate); thus finally, data collected from 200 participants were considered
for analysis. It was an online survey, and all final year students (B.Sc. Nursing,
PB B.Sc. Nursing, and GNM Nursing) who were willing to give informed consent were
included in the study. Participants who did not have access to the Internet and did
not given informed consent were excluded from the study.
Tool for Data Collection and Data Collection Instrument
A self-structured prevalidated and reliable (r = 0.93) instrument, that is, “comprehensive nursing competencies questionnaire (CNCQ),”
was used to assess the clinical practice readiness of final year nursing students.[17] Permission was obtained from Prof. Dr. Suresh K. Sharma, Principal, College of Nursing
(All India Institute of Medical Sciences [AIIMS], Jodhpur, Rajasthan, India) to use
the prevalidated CNCQ tool. The tool consisted of a total of 100 essential nursing
skills items based on the prescribed curriculum for the baccalaureate nursing program
in India, which was divided into two sections, that is, (1) basic nursing skills (52
items) and (2) advanced nursing skills (48 items). Each listed nursing skill practiced
during the nursing program was measured on the six-point rating scale, that is, perform
independently (5), under supervision (4), only assisted (3), only observed (2), only
read (1), and do not know anything (0). The basic nursing skill section included a
total of 52 items (with score range: 0–260) under different categories, that is, admission
and discharge, personal hygiene, medication administration, invasive procedures, wound
care and bandaging, respiratory nursing interventions, elimination, perioperative
nursing, infection control, handling of basic medical equipment, and documentation.
Similarly, the advanced nursing skills section included 48 items (with a score range:
0–240) under different categories, that is, medical and surgical nursing, child health
nursing, obstetrical and gynecological nursing, and mental health nursing.
Pilot Study
Pilot study was conducted on 10% of the sample size of the main study in one of the
nursing colleges which was not included in the main study to check for the clarity
of language, acceptability, validity, and completeness of the questionnaire.
Data Collection Technique
Official permission was obtained from principals of all the eight nursing colleges,
and the data were collected using a Google Form. Then, students were requested to
respond to the questionnaire through online Google Forms, with a consent form appended
to it. The link was sent through e-mails and WhatsApp. The instructions were given
to the students in the Google Form not to use reference material and not to discuss
with their friends to find the correct answer. A standardized and pretested questionnaire
was adapted and we have conveniently selected 8 nursing colleges and conducted a cross-sectional
survey from October 15 to November 15, 2020. The tool was included with five sociodemographic
variables. Under the basic nursing care skills, 11 areas and a total of 52 questions
were asked. Under advanced nursing care skills, four areas, including medical-surgical,
child health, obstetrical and gynecological, and mental health nursing, a total of
48 questions were asked. Then, students were requested to respond to the questionnaire
through Google Form.
Operational Definitions
The two terms frequently used in the present study are operationally defined:
-
Clinical practice readiness: Graduating nurses' level of clinical competency for each selected basic and advanced
nursing skill, based on the scale of performed independently 5, under supervision
4, only assisted 3; only observed 2, only read theoretically 1, to do not know anything
0.
-
Final year nursing students: Final year B.Sc. Nursing, GNM, and PB B.Sc. Nursing students, who are about to complete
their nursing program and do their internship.
Data Quality Control
Quality of data was assured by proper designing and pretesting of the questionnaires
in one of the nursing colleges located other than Bangalore on 10% of the total participants,
to ensure that the questions are clear and can be understood by the respondents, and
further questionnaires were refined based on the results of the pilot study.
Study Variables
-
Dependent/Outcome variable: Self-reported clinical practice readiness.
-
Research variables: Demographic characteristics of study subjects such as age, gender, level of educational
qualification, percentage in a previous university exam, clinical posting duration,
etc.
Data Processing and Analysis
After the data collection, the data were exported from Google Form to Statistical
Package for Social Science (SPSS) version 20.0 for analysis and interpretation. The
descriptive statistics were presented with mean ± standard deviation, frequency, and
percentage. The data were analyzed using an unpaired t-test and a one-way analysis of variance (ANOVA). To compare the demographic variables
with the basic and advanced nursing skills, post hoc multiple comparisons were performed
for significant variables.
Results
A total of 200 nursing students have participated in this study. Out of the study
participants, 167 (83.5%) of them were female and 105 (52.5%) students were in the
age group of 18 to 19 years. One hundred and forty (70%) students were studying Bachelor
of Nursing. Ninety-four (47%) students got 60 to 69% marks in university exams but
108 (54%) of them had clinical experience only for 2 months or less ([Table 1]).
Table 1
Sociodemographic characteristics of final year nursing students from nursing institutions
in Bangalore (n = 200)
Demographic variables
|
Frequency (f)
|
Percentage (%)
|
Age (in years)
|
≤ 21
|
105
|
52.5
|
22
|
77
|
38.5
|
≥ 23
|
18
|
9.0
|
Gender
|
Male
|
33
|
16.5
|
Female
|
167
|
83.5
|
Educational qualification
|
B.Sc. Nursing
|
140
|
70.0
|
PB B.Sc. Nursing
|
49
|
24.5
|
GNM Nursing
|
11
|
5.5
|
Percentage (%) of marks obtained in previous university exam
|
50–59
|
29
|
14.5
|
60–69
|
94
|
47
|
70–79
|
67
|
33.5
|
> 80
|
10
|
5
|
Duration of clinical posting
|
Throughout the year
|
35
|
17.5
|
Half of the year
|
57
|
28.5
|
Only for 2 months or less
|
108
|
54.0
|
Abbreviations: GNM, General Nursing and Midwifery; PB, Post Basic.
[Table 2] depicts the mean competencies score for nursing skills which were divided into two
parts, basic nursing skills and advanced nursing skills. The maximum score for basic
nursing skills is 355 and for advanced nursing skills 145. The findings suggest that
the overall CNCQ mean score of basic nursing skills was reasonably high (39.08 ± 13.27)
compared with advanced nursing care skills (13.03 ± 5.28). Regarding basic nursing
skills, it was found that the mean score of personal hygiene (4.46 ± 1.06) and infection
control and biomedical waste (BMW) management (4.03 ± 1.27) is higher than other basic
nursing skills where the mean competencies score is relatively the same. Further,
under advanced nursing skills, the mean score is relatively the same.
Table 2
Mean competencies score of basic and advanced nursing care skills of the final year
nursing students form nursing institutions in Bangalore (n = 200)
Domains of nursing care skills
|
Nursing care skills score
|
Maximum score
|
Mean ± SD
|
Rank order
|
Basic nursing care skills
|
355
|
39.08 ± 13.27
|
−
|
Personal hygiene
|
74
|
4.46 ± 1.06
|
I
|
Medication administration
|
29
|
3.87 ± 1.06
|
II
|
Admission/discharge
|
34
|
3.02 ± 1.23
|
III
|
Respiratory nursing interventions
|
38
|
3.21 ± 1.20
|
IV
|
Documentation
|
23
|
3.42 ± 1.33
|
V
|
Invasive procedures
|
11
|
3.10 ± 1.25
|
VI
|
Wound care and bandaging
|
36
|
3.91 ± 1.08
|
VII
|
Infection control and BMW
|
50
|
4.03 ± 1.27
|
VIII
|
Elimination
|
22
|
3.31 ± 1.33
|
IX
|
Perioperative nursing
|
12
|
3.12 ± 1.25
|
X
|
Handling basic medical equipment
|
26
|
3.63 ± 1.21
|
XI
|
Advanced nursing care skills
|
145
|
13.03 ± 5.28
|
−
|
Mental health nursing
|
39
|
2.99 ± 1.40
|
1
|
Child health nursing
|
46
|
3.33 ± 1.32
|
2
|
Midwifery
|
35
|
3.03 ± 1.45
|
3
|
Medical surgical nursing
|
25
|
3.68 ± 1.11
|
4
|
Overall nursing care skills
|
500
|
52.11 ± 18.55
|
−
|
Abbreviations: BMW, biomedical waste; SD, standard deviation.
The variables such as age, percentage in previous university exam, clinical posting
duration, and educational qualification were tested using ANOVA test and the variable
gender is tested using unpaired t-test to check the nursing competency score. The results show that there is a higher
CNCQ score and statistically significant (p < 0.05) in overall clinical posting duration in both basic (p < 0.004) and advance (p < 0.001) nursing skills with selected demographic variables. There is also a significant
difference found in the overall level of qualification (p < 0.004) in basic nursing skills. Further, our study did not find any other significant
difference with other demographic variables such as age, gender, and percentage in
previous university exams. The overall significance score found in clinical posting
duration and the level of qualification is important because there is a consistent
amount of clinical posting in a year in different nursing specialty subjects and the
advanced level of qualification among nurses then there is a higher chance for the
students to get improved in different types of clinical skills which ultimately makes
them be a specialized nurse in the coming future ([Table 3]).
Table 3
Comparison of nursing competencies score with selected demographic characteristics
of final year nursing students from nursing institutions in Bangalore (n = 200)
Demographic variables
|
N
|
Basic nursing skill score
|
Advanced nursing skills score
|
Mean ± SD
|
F
-value
|
p
-Value
|
Mean ± SD
|
F
-value
|
p
-Value
|
Age
|
≤ 21 y
|
105
|
3.48 ± 0.86
|
5.68
|
0.40
|
3.30 ± 1.43
|
6.67
|
0.75
|
22 y
|
77
|
3.64 ± 1.04
|
3.42 ± 1.29
|
≥ 23 y
|
18
|
3.72 ± 1.07
|
3.17 ± 1.46
|
Gender
|
Male
|
33
|
3.67 ± 0.99
|
0.70
|
0.48
|
3.48 ± 1.39
|
0.68
|
0.49
|
Female
|
167
|
3.54 ± 0.94
|
3.31 ± 1.37
|
Percentage in previous university exam
|
50–59
|
29
|
3.59 ± 0.86
|
4.84
|
0.42
|
3.66 ± 1.37
|
5.81
|
0.43
|
60–69
|
94
|
3.45 ± 0.99
|
3.21 ± 1.48
|
70–79
|
67
|
3.70 ± 0.96
|
3.40 ± 1.18
|
> 80
|
10
|
3.60 ± 0.69
|
3.10 ± 1.59
|
Clinical posting duration
|
Throughout the year
|
35
|
3.94 ± 0.83
|
1.89
|
0.004[a]
|
3.94 ± 1.13
|
1.09
|
< 0.001[a]
|
Half of the year
|
57
|
3.68 ± 1.00
|
3.61 ± 1.14
|
Only for 2 months
|
108
|
3.37 ± 0.92
|
2.99 ± 1.46
|
Educational qualification
|
B.Sc. Nursing
|
140
|
3.61 ± 0.88
|
1.53
|
0.003[a]
|
3.32 ± 1.29
|
2.13
|
0.153
|
PB B.Sc. Nursing
|
11
|
4.27 ± 0.79
|
4.09 ± 1.04
|
GNM Nursing
|
49
|
3.27 ± 1.09
|
3.20 ± 1.62
|
Demographic variables
|
N
|
Basic nursing skill score
|
Advanced nursing skills score
|
Mean ± SD
|
t
-Value
|
p
-Value
|
Mean ± SD
|
t
-Value
|
p
-Value
|
Gender
|
Male
|
33
|
3.67 ± 0.99
|
0.70
|
0.48
|
3.48 ± 1.39
|
0.68
|
0.49
|
Female
|
167
|
3.54 ± 0 0.94
|
3.31 ± 1.37
|
Abbreviations: GNM, General Nursing and Midwifery; PB, Post Basic; SD, standard deviation.
a
p < 0.001 and 0.004 are statistically significant.
One-way ANOVA was performed to determine the significant difference in the average
basic nursing skills and advance nursing skills across different timings of clinical
posting duration. As the ANOVA test was found statistically significant in overall
clinical posting duration with selected demographic variables, the post hoc test was
done to check the multiple comparisons between basic and advanced nursing care skills
with clinical posting duration. It was observed that in basic nursing care skills,
half of the year clinical posting duration had a significant difference with improved
performance skills (p < 0.005) compared with throughout the year (0.40) and only for 2 months (0.10). It
was also observed that the advanced nursing skills will be greatly improved if the
nursing students get an opportunity to practice in different specialty areas for at
least 2 months (p < 0.013) or half of the year (p < 0.001) ([Table 4]).
Table 4
Pairwise comparison of basic nursing care skills and advanced nursing care skills
with clinical posting duration of final year nursing student from nursing institutions
in Bangalore
Basic nursing care skills
|
Pairwise comparison
|
MD (95% CI of difference)
|
p
-Value
|
Throughout the year
|
0.26 (−0.21, 0.73)
|
0.40
|
Half of the year
|
0.57 (0.14, 1.00)
|
0.005[a]
|
Only for 2 months
|
0.31 (−0.05, 0.67)
|
0.10
|
Advance nursing care skills
|
Pairwise comparison
|
MD (95% CI of difference)
|
p
-Value
|
Throughout the year
|
0.33 (−0.35, 1.00)
|
0.48
|
Half of the year
|
0.95 (0.34, 1.56)
|
0.001[a]
|
Only for 2 months
|
0.62 (0.11, 1.14)
|
0.013[a]
|
Abbreviations: CI, confidence interval; MD, mean difference.
a Significant.
[Table 5] depicts the pairwise comparison of basic nursing care skills with the level of educational
qualification of final year graduating nurses. The result shows that there is a significant
difference between advanced nursing qualification (PB B.Sc.) and improved basic nursing
skills (p < 0.004) compared with B.Sc. Nursing graduating students as they are freshly graduating.
This could be due to the fact that PB B.Sc. Nursing is an advanced nursing course
compared with B.Sc. Nursing where students will learn advanced clinical skills in
the health care sector after completion of their GNM degree. So it is important to
have continuing education with higher nursing degree to improve the basic and specialized
nursing skills in different areas.
Table 5
Pairwise comparison of basic nursing care skills with the level of educational qualification
of final year nursing students from nursing institutions in Bangalore
Pair wise comparison
|
MD (95% CI of difference)
|
p-Value
|
B.Sc. Nursing
|
−0.67 (−1.35, 0.02)
|
0.06
|
GNM Nursing
|
0.34 (−0.02, 0.71)
|
0.07
|
PB B.Sc. Nursing
|
1.01 (0.27, 1.74)
|
0.004[a]
|
Abbreviations: CI, confidence interval; GNM, General Nursing and Midwifery; MD, mean
difference; PB, Post Basic.
a Significant.
[Table 6] depicts the independently practiced basic nursing skills procedures. The basic nursing
skills had been categorized into several subsections like admission and discharge,
infection control and BMW management, documentation, hygiene care, elimination, innovative
procedure, medication administration, oxygenation/respiratory care, wound care and
bandaging, handling basic medical equipment, and preoperative care. The result shows
that under the basic nursing skill (admission and discharge skills) procedures, more
than half 159 (79.5%) and 133 (66.5%) of the students know about vital signs monitoring
and health assessment procedure. The majority 116 (58%) and 87 (43.5%) of the students
know about infection control and BMW management procedure skills. Note that 115 (57.5%)
and 98 (49%) of the participants know about temperature, pulse, and respiration charting
and how to write nurse's notes. Further, majority 175 (87.5%), 122 (61%), and 136
(68%) of the participants were able to perform bed making, oral care, and hair care
procedures. In elimination skills, 57 (28.5%) and 51 (25.5%) of the students were
able to perform bowel wash and enema. Regarding innovative procedure, 78 (39%) and
47 (23.5%) of the participants were able to perform nasogastric (NG) tube feeding
and venous blood sampling procedure. In the skills of medication administration, 124
(62%), 118 (59%), and 115 (57.5%) of the participants were able to perform oral drug
administration, intramuscular injection, and eye, ear, and nasal drop instillation.
Regarding wound care and bandaging skill procedure, 91 (45.5%) and 54 (27%) of the
participants knew how to perform bandaging and surgical wound dressing. It is also
observed that more than 50% of the students, 144 (72%) and 114 (57%), knew how to
handle basic medical equipment like pulse oximeter and electrocardiogram (ECG) recording
followed by 45 (22.5%) of them being able to perform preoperative care for the patients.
Table 6
Percentage of independently practiced basic nursing skills of final year nursing students
from nursing institutions in Bangalore (n = 200)
Admission/Discharge
|
Infection control and BMW
|
Documentation
|
Skills
|
f
|
%
|
Skills
|
F
|
%
|
Skills
|
f
|
%
|
Vitals sign monitoring
|
159
|
79.5
|
BMW management
|
87
|
43.5
|
TPR charting
|
115
|
57.5
|
Health assessment
|
133
|
66.5
|
Nurse's notes
|
98
|
49.0
|
Admission of patient
|
63
|
31.5
|
Use of PPE
|
78
|
39.0
|
Informed consent
|
54
|
27.0
|
Discharge/discharge teaching of patient
|
53
|
26.5
|
Disinfection
|
31
|
15.5
|
Fumigation/fogging
|
116
|
58.0
|
Hygiene care
|
Elimination
|
Innovative procedure
|
Skills
|
f
|
%
|
Skills
|
F
|
%
|
Skills
|
f
|
%
|
Bed making
|
175
|
87.5
|
Catheter care
|
42
|
21.0
|
Venipuncture
|
30
|
15.0
|
Oral care
|
122
|
61.0
|
PBG monitoring
|
37
|
18.5
|
Hair care
|
136
|
68.0
|
Suppositories
|
39
|
19.5
|
Venous blood sampling
|
47
|
23.5
|
Back care
|
121
|
60.5
|
Enema
|
51
|
25.5
|
NG tube feeding
|
78
|
39.0
|
Bed bath
|
105
|
52.5
|
Urinary catheterization
|
19
|
9.5
|
NG tube insertion
|
24
|
12.0
|
Bowel wash
|
57
|
28.5
|
Medication administration
|
Oxygenation/respiratory care
|
Wound care and bandaging
|
Skills
|
f
|
%
|
Skills
|
F
|
%
|
Skills
|
f
|
%
|
IV infusion
|
92
|
46.0
|
Nebulization
|
120
|
60.0
|
Bandaging
|
91
|
45.5
|
Intramuscular injection
|
118
|
59.0
|
Steam inhalation
|
116
|
58.0
|
Surgical wound dressing
|
54
|
27.0
|
IV drugs
|
106
|
53.0
|
O2 administration by simple face mask
|
113
|
56.5
|
Bed sore dressing
|
42
|
21.0
|
Oral drug
|
124
|
62.0
|
O2 administration by nasal prongs
|
61
|
30.5
|
Pin-site care dressing
|
25
|
12.5
|
Subcutaneous injection
|
101
|
50.5
|
Assisted patient with incentive spirometer
|
38
|
19.0
|
Removal of structure and staples
|
47
|
23.5
|
Intradermal injection
|
91
|
45.5
|
O2 administration by partial/nonbreather/venture mask
|
30
|
15.0
|
Burns wound dressing
|
28
|
14.0
|
Eye, ear, nasal drops instillation
|
115
|
57.5
|
Handling basic medical equipment
|
Preoperative care
|
Skills
|
f
|
%
|
Skills
|
f
|
%
|
Pulse oximeter
|
144
|
72.0
|
Preoperative care
|
45
|
22.5
|
Recoding ECG
|
114
|
57.0
|
Postoperative care
|
34
|
17.0
|
Using defibrillator
|
21
|
10.5
|
Intraoperative care
|
17
|
8.5
|
Abbreviations: BMW, biomedical waste; ECG, electrocardiogram; IV, intravenous; NG,
nasogastric; PBG, porphobilinogen; PPE, personal protective equipment; TPR, temperature,
pulse, and respiration.
[Table 7] depicts the independently practiced advanced nursing skills of final year nursing
students. A total of 200 students had participated in the study. Advanced nursing
skills have been categorized into four specialty areas. The result shows that in the
medical and surgical advanced nursing skill, majority 34 (17%), 29 (14.5%), 33 (16.5%),
23 (11.5%), and 20 (10%) of the participants can independently perform blood transfusion,
administration of total parenteral nutrition, gastric lavage, basic life support (BLS),
endotracheal/tracheostomy suctioning, and tracheostomy care procedure. Further, in
child health nursing majority 100 (50%), 85 (42.5%), 65 (32.5%), 64 (32%), and 49
(24.5%) of the participants were able to perform procedures like nebulization, newborn
assessment, intramuscular injection, immunization, care of newborn, and care of newborn
in radiant warmer. In the obstetrics and gynecological advance nursing procedure,
80 (40%), 62 (31%), 60 (30%), and 59 (29.5%) of the participants could independently
perform procedures like assisting the mother with breastfeeding, antenatal examination,
antenatal care, and postnatal examination. Whereas it is observed that 114 (57%),
109 (54.5%), 65 (32.5%), and 63 (31.5%) of the participants were able to perform behavioral
therapy, history collection, MMSE, and process recording procedures in the mental
health advance nursing skill.
Table 7
Percentage of independently practiced advanced nursing skills of final year nursing
students from nursing institutions in Bangalore (n = 200)
Medical and surgical nursing
|
Child health nursing
|
Obstetrical and gynecological nursing
|
Skills
|
f
|
%
|
Skills
|
f
|
%
|
Skills
|
f
|
%
|
Blood transfusion
|
34
|
17.0
|
Nebulization
|
100
|
50.0
|
Perineal care
|
37
|
18.5
|
Endotracheal/tracheostomy suctioning
|
20
|
10.0
|
New born assessment
|
85
|
42.5
|
Assisting the mother with breast feeding
|
80
|
40.0
|
Tracheostomy care
|
20
|
10.0
|
Intramuscular injection
|
65
|
32.5
|
Antenatal care
|
60
|
30.0
|
Care of central venous catheter
|
18
|
9.0
|
Immunization
|
64
|
32.0
|
Postnatal care
|
58
|
29.0
|
Administration of TPN
|
29
|
14.5
|
Care of new born
|
60
|
30.0
|
Antenatal examination
|
62
|
31.0
|
Colostomy care
|
20
|
10.0
|
Care of new born in radiant warmer
|
49
|
24.5
|
Postnatal examination
|
59
|
29.5
|
Arterial blood sampling
|
18
|
9.0
|
IV medication with use of infusion pump
|
35
|
17.5
|
Nonstress test
|
48
|
24.0
|
Care of intercostal chest drainage site
|
15
|
7.5
|
Care of new born under phototherapy
|
57
|
28.5
|
Vaginal examination
|
27
|
13.5
|
Gastrostomy/jejunostomy feeding
|
14
|
7.0
|
Administration of oxygen by oxygen tent
|
29
|
14.5
|
Examination of placenta
|
31
|
15.5
|
Gastric lavage
|
33
|
16.5
|
Administration of oxygen by oxygen hood
|
24
|
12.0
|
Partogram
|
24
|
12.0
|
BLS
|
23
|
11.5
|
Care of new born in incubator
|
21
|
10.5
|
Collection of pap smear
|
8
|
4.0
|
Care of patient on mechanical ventilator
|
15
|
7.5
|
Pediatric vein puncture
|
12
|
6.0
|
Normal vaginal delivery
|
9
|
4.5
|
Care of patient with cardiac catheterization
|
12
|
6.0
|
Neonatal resuscitation
|
9
|
4.5
|
IUCD insertion
|
7
|
3.5
|
|
|
|
Pediatric BLS
|
15
|
7.5
|
Episiotomy and suturing
|
8
|
4.0
|
Mental health nursing
|
Skills
|
f
|
%
|
History collection
|
109
|
54.5
|
Behavioral therapy
|
114
|
57.0
|
Assisting in AT
|
13
|
6.5
|
MMSE
|
65
|
32.5
|
Care patient for ECT
|
24
|
12.0
|
Process recording
|
63
|
31.5
|
Use of restraints
|
47
|
23.5
|
Abbreviations: BLS, basic life support; ECT, electroconvulsive therapy; IUCD, intrauterine
contraceptive device; IV, intravenous; TPN, total parenteral nutrition.
Discussion
Nurses are referred to as the backbone of the health care system. They are the key
to the detection, treatment, and prevention of disease across the world.[18] Nurses and midwives account for nearly 50% of the global health workforce and the
need to fill up these gaps is rising rapidly.[2] Western nations continue to worsen as their population is aging rapidly. So the
nurse's migration is at an all-time high in the 21st century. Currently, India is
facing a shortage of nurses and the nursing colleges are blooming rapidly to take
the chances. And in India, Karnataka has the highest number of nursing colleges, and
most of them are in Bangalore. The four southern states of India have two-thirds of
the nursing institutions in India. And we can see a clear disproportion.[19] As the number of nursing colleges is increasing day by day in Bengaluru, the quality
of nursing care is decreasing simultaneously. Several reports indicated that the compromised
quality of nursing in terms of blooming institutions, shortage of nursing faculty,
less clinical experience among students, poor infrastructure, less salary, and the
institution authority involvement in clinical practice.[19]
[20]
[21] It is important not to produce the nurses like a mass but to produce qualified experienced
nurses who are able to handle any health situation anywhere in the world. The novice
nurses who are going to become registered nurses are expected to have basic knowledge
in nursing skills and should perform the basic and advanced procedures seamlessly
wherever they are.
The purpose of the present study was to assess the self-reported clinical practice
among graduating nurses across Bengaluru. Currently, there were only a few research
data available about the clinical practice readiness among final year graduating nurses
across India as well as in the world. The findings of the present study suggest that
the overall CNCQ mean score of basic nursing skills was reasonably high (39.08 ± 13.27)
compared with advanced nursing care skills (13.03 ± 5.28) which were inconsistent
when we compared with a similar study done in Uttarakhand, India,[17] where the mean competency score of basic nursing skills is 236.5 ± 25.0 and advanced
nursing skills is 148.7 ± 25.6. This discrepancy might be due to the difference in
study settings, characteristics of study participants, sampling techniques used in
the study, and the techniques of data collection in which the current study covers
eight institutions. And also the possible conclusion is that AIIMS Uttarakhand is
one of the premier institutions in our country having senior nursing instructors and
different specialized multispecialty hospitals leading the students to have more exposure.
The difference of results in basic and advanced nursing practice skills among nursing
students could also be due to the nursing curriculum, way of teaching in the different
nursing institutions, public versus private institutions, the experience of faculty
members, and inadequate clinical experience for the students which we should take
into account. But similar results were also seen in other several studies conducted
in India,[22] Iran,[23] Ethiopia,[24] and Zimbabwe[25] which is a cause of concern.
Our research found a significantly high percentage in basic nursing skills compared
with advanced nursing skills. The basic nursing skills result shows that 79.5% was
the highest percentage under admission/discharge skills, 58% under infection control
and BMW management, 57% under documentation, 87.5% under hygiene care, 28.5% under
elimination, 39% under the innovative procedure, 62% under medication administration,
60% under oxygenation/respiratory care, 45% under wound care and bandaging, 72% under
handling basic medical equipment, and 22% under preoperative care. Whereas in advanced
nursing skills 17% was the highest skill percentage under medical and surgical nursing,
50% under child health nursing, 40% under obstetrics and gynecological nursing, and
57% under mental health nursing. This percentage is moderately low when we compare
our study with the study done in Uttarakhand[17] where the result shows that in the basic nursing skills 95.9% was the highest percentage
under admission/discharge skills, 94% under infection control and BMW management,
72.8% under documentation, 94.8% under hygiene care, 83.8% under elimination, 79.8%
under the innovative procedure, 90.2% under medication administration, 95.4% under
oxygenation/respiratory care, 83.2% under wound care and bandaging, 79.2% under handling
basic medical equipment, and 38.1% under preoperative care. Similarly in advanced
nursing skills, 34.1% were under medical and surgical nursing, 62.4% under child health
nursing, 50.3% under obstetrics and gynecological nursing, and 94.2% under mental
health nursing.
This study indicated a significant difference in clinical posting duration with the
improved performance skills (p < 0.005) whereas it was also observed that the advanced nursing skills will be greatly
improved if the nursing students get an opportunity to practice in different specialty
areas for at least 2 months (p < 0.013) or half of the year (p < 0.001).
A study conducted at universities in Northern Ethiopia indicates the overall clinical
practice competency of graduating nursing students shows that only 29% of the participants
were clinically competent and 71% were incompetent.[26] Similarly, another study found that 50% of graduating nurses could not independently
practice some of the basic nursing procedures, while only 10% of them could independently
practice some of the advanced nursing procedures.[17] This is parallel to our study where we found that only 10.5% of the participants
could perform the basic nursing procedures and 20% of them could perform advanced
nursing procedures independently. Whereas 52% of the students could perform the basic
procedures and 37.5% of them could perform advanced procedures while under supervision.
The findings are low when compared with a finding from a study done in Hawassa University,
Hawassa, Ethiopia, which revealed that only 25.2% of the students were clinically
competent.[26] It is also lower than the study done by Debre Birhan Health Science College, Ethiopia[27] and Annals University of Finland[28] where 78.6 and 66.7% of the participants were clinically competent. This discrepancy
might be because of the difference in the study participants in the previous study,
where participants were graduated health professionals, whereas in the present study,
the study participants were graduating nursing students who were lacking work experience.
And possibly one of the other reasons is that most of the private colleges in Bangalore
are having less than 2 months of clinical posting and do not have parent hospitals
because of the increasing number of nursing institutions.
Our study also found that in basic nursing care skills it was found that the mean
score of personal hygiene (4.46 ± 1.06) and infection control and BMW management (4.03 ± 1.27)
is a little higher than the other skills like medication administration (3.87 ± 1.06),
admission/discharge (3.02 ± 1.23), respiratory nursing intervention (3.21 ± 1.20),
documentation (3.42 ± 1.33), invasive procedure (3.10 ± 1.25), wound care and bandaging
(3.91 ± 1.08), infection control and BMW (4.03 ± 1.27), elimination (3.31 ± 1.33),
perioperative nursing (3.12 ± 1.25), and handling basic medical equipment (3.63 ± 1.21),
where most of the mean score is same. Further in advanced nursing care, the result
shows that the mean score of medical and surgical nursing care skills (3.68 ± 1.11)
is more than other departments like mental health nursing (2.99 ± 1.40), child health
nursing (3.33 ± 1.32), and midwifery and obstetrics (3.03 ± 1.45). But the percentage
of independently practicing medical and surgical nursing procedures is less and this
could be due to less exposure of students in different medical and surgical specialty
areas in different hospitals. These results show that the graduating nurses are not
getting enough opportunity to practice advanced nursing procedures in hospitals and
similar findings are also reported in a study done in Korea.[29]
The findings of the study are an eye opener. This shows that 85% of the students cannot
perform basic nursing procedures independently such as informed consent (27%), catheter
care (28.5%), bowel wash (9.5%), NG tube insertion (12%), assisted patients with incentive
spirometer (19%), pin-site care dressing (12.5%), using defibrillator (10.5%), and
intraoperative care (8.5%), but 60% of the students were able to perform most of the
basic nursing procedure such as vital sign monitoring (79.5%), health assessment (66.5%),
BMW management (58%), bed making (87.5%), hair care (68%), back care (60%), oral drug
administration (62%), nebulization (60%), and recording ECG (57%) independently which
is a good finding. But the advanced nursing skills among the students is really surprising
where only 20% of the participants could perform the procedures independently such
as tracheostomy suctioning and care (10%), care of central venous pressure line (9.0%),
arterial blood sampling (9.0%), care of intercostal chest drainage (7.5%), gastrostomy
tube feeding (7.0%), care of the patient in mechanical ventilator (7.5%), care of
the patient in cardiac catheterization (6.0%), pediatrics vein puncture (6.0%), pediatric
BLS (7.5%), intrauterine contraceptive device insertion (3.5%), and care of the patient
for electroconvulsive therapy (12.0%). Further, majority of the students were able
to perform most of the child health nursing, obstetrics and gynecology, and mental
health nursing advanced procedure. This shows that the few graduating nursing students
from India may possess an adequate amount of basic nursing skills but most of them
are lacking while performing advanced procedures.
There is a limited number of similar studies conducted around the world, and in India,
the number is very less. Our study was conducted at Bengaluru, in the state of Karnataka
with only eight nursing colleges which are private institutions. So it is very difficult
to generalize the result with other studies in India and to conclude that nursing
students' skills in India is low. As India is a very big country and there are many
states in India, the result will differ statewise, institution-wise, geographical
areawise, and private and public institution-wise, and there is a higher chance to
get improved nursing competency scores in future studies in different states. In our
study, the percentage of basic nursing skills is a little better than advanced nursing
scores. This could be due to most of the nursing colleges in Bengaluru do not have
parent hospitals, proper clinical facilities, lack demonstration laboratory infrastructure,
and a lack of experienced faculty. Therefore, it is very important for the nursing
teachers to come together to strengthen guiding budding nurses as they are the future
generation who will serve humanity in India and around the world.
Limitations
The study was conducted at eight nursing institutions which lead to a small sample
size and hence the findings of this study cannot be generalized to all nursing college
students in Bengaluru. Also, the study was done using online mode thus the practice
skills of the graduating students could not be assessed in real-time. In addition,
this study is limited to the final year nursing students from private institutions
in Bengaluru and did not make any comparison between private versus public nursing
institutions.
Conclusion and Recommendations
Conclusion and Recommendations
The graduating nurse's overall CNCQ mean score of basic nursing skills was reasonably
high compared with advanced nursing care skills. A significant difference was observed
in overall clinical posting duration in both basic and advanced nursing skills with
selected demographic variables. There is also a significant difference found in the
level of qualification with basic nursing skills. It was observed that basic nursing
care skills with clinical duration time had a significant difference with the improved
performance skills. The authors hope that these findings will support the stakeholders,
teachers, authorities of nursing institutions, and state government to make a significant
decision and to give due attention to enhance the clinical practice among graduating
nurses to improve in both basic and advanced nursing skills if students are exposed
in the clinical area for at least few months. Furthermore, regulatory bodies must
check that nursing institutes have sufficient facilities and processes for adequate
clinical learning experience in basic and advanced nursing skills training.