A STUDY OF CLINICAL PERFORMANCE OF NURSES WHO RECENTLY COMPLETED THE COMPREHENSIVE BASIC NURSING COURSE

A study was conducted to assess clinical performance o f registered nurses who had recently completed the new comprehensive basic nursing course. This regional project was undertaken because o f controversy surrounding clinical competence of the graduates/diplomates o f the new regulation course. Senior qualified nurses gave their views according to L ik e n Scale statem ents and open-ended questions. Findings were that the sample was o f the opinion that clinical performance of the new graduates/diplomates falls short of expectations.


INTRODUCTION
In this study an attempt was made to assess the clin ic al p erform ance o f graduates and diplomates of the recently introduced Basic Nursing Course and to establish if the course prepared them adequately.The course prepares candidates for rendering a service as professional nurses in the general, psychiatric and community health fields as well as in the capacity of midwife.It is a four year course offered as from 1986 by Universities as a degree and by Colleges as a Diploma nursing course.

ORIENTATION
In 1985 the South African Nursing Council passed regulations providing for introduction of the four year course at all nurse training institutions.Such a course would prepare student nurses for registration with the South African Nursing Council (S.A.N.C.) as a nurse (general, psychiatric, community health) and midwife.In this study, this course will be re fe rre d to su b se q u en tly as the "new regulation" course.It replaced and was an improvement on the previous Basic Nursing Courses (hereafter referred to as the "Old regulation" course) whereby a candidate could take up to a minimum of seven years to acquire the same four basic nursing qualifications.
T he la tte r c o u rs e m ade fo r th o ro u g h grounding in practical nursing skills of each nursing speciality but proved to be expensive in the long run, time consuming and involved overlapping and duplication of subject matter.The new course is integrated so as to ensure re la tiv e ly fa s te r p ro d u c tio n o f n u rse practitioners who are competent in the four nursing specialities.It also was streamlined to fit into the tertiary education system of the country and to be in line w ith sim ilar developments in countries like the United Kingdom and Australia.

PRO BLEM STATEMENT
It is estimated that the first graduates and diplomates of the new regulation course started practising as qualified nurses as from 1990.When this Basic Course was introduced there were differences of opinion among registered nurses as to whether such a course would be effective in producing competent nurse practitioners in view of its diminished c lin ic a l le a rn in g ex p erien ce.T his is illustrated by, among others, Armstrong (1987) referring to this course as an "imwanted pregnancy".As the newly qualified nurses ta k e up em p lo y m e n t th e c o n tro v e rs y continues at grassroots level.There are nurses who have reservations about the quality of nursing care rendered by the newly qualified nurses.Against the background of the S ANC scope of practice of the registered nurse and of the terminal course objectives of the new regulation course set by some institutions, the question being asked is :"Do the newly q u a lifie d n u rse s re a lly fa ll s h o rt o f expectations in their clinical performance?"If the negative allegations can be proved to be false then it is time the "ghost" of poor quahty care by these graduates/diplomates is laid to rest.

O BJECTIV ES O F THE STUDY
The goal of this investigation was to ascertain the extent to which products of the new reg u latio n basic course m eet expected com petence in clinical nursing practice w herever they are em ployed.Specific objectives were to:- • the senior/older nurses are familiar enough with the objectives of the new regulation course to make a realistic assessment of the quality of its products.

LITER A TLU E REVIEW
The Historical Background Historically the major problem in nursing world wide is how to provide nursing services in the quantity demanded and quality needed (Creelman, 1969).Quality nursing practice depends upon quality nursing education.
As far back as 1952, the W orld Health Organisation (WHO) working conference on nursing education suggested that the basic need in most countries and especially in developing countries, was for nurses capable of providing total nursing care both in hospital or home and who could integrate preventive an d c u ra tiv e s e rv ic e s in any s e ttin g (Mooneyhan, 1979).Then came the time when emphasis was placed on professional nurses fvmctioning in an expanded or extended role not withstanding that not all nurses had been prepared formally for such functions.
As an attempt to hasten production of nurses w ho could function in m ore th an one speciality, in the 1970s the SANC passed regulations for combined courses such as:- • General nursing and midwifery • General nuning and psychiatry.
Curationis, Vol. 19, No. 4, December 1996 Even in those days older members of the nursing profession had reservations about the clinical competence o f nurses educated and trained through these com bined courses (Mashaba, 1985).

DEFINrnON OF TERM S
Assessment means measurement of an ability to ca rry o u t a sp e cifie d ta sk .It is a g en eralisation m ade on the basis o f an observation of events (Katz and Snow, 1980;Freeman and Byme, 1976;Girot, 1993).
Performance focuses on the total behaviour of a h ealth w orker o r the w hole range o f know ledge, skills and attitudes acquired through training as well as their organisation and integration in practice (Ziv, Ehrenfeld, Kurtzman and Hadani, 1990).In this project performance assessment must be understood to carry the above-stated meaning, that is, measurement of the nurses' ability to behave so as to demonstrate knowledge, skills and attitudes acquired through education and tr a in in g .
A s s e s s m e n t w ill be u se d in te r c h a n g e a b ly w ith e v a lu a tio n and appraisal.

SIM ILA R STUDIES
A s s e s s in g s tu d e n t p e rfo rm a n c e a fte r g ra d u a tio n is an im p o rta n t a s p e c t o f programme evaluation (Howard, Hubelbank an d M o o re , 1 9 8 9 ).
U rd e n (1 9 8 9 ) recommends on-going evaluation at various levels or stages of career development.The first level is soon after graduation on initial clinical placement, when performance should be marginally acceptable.Then comes the level where the graduate has had 2-3 years of clinical experience, at which the graduate should be com petent.A fter 3-5 years experience another evaluation should be done, in which the practitioner should be proficient.
End o f the course assessm ent at which examiners decide to pass or fail the student is good, but according to de Jager (1990) it shows performance only in respect of specific occasions, and it bears little resemblance to the practitioner's performance on daily activities.The initial clinical exposure of a newly e m p lo y e d new g ra d u a te is p e rio d o f ad ju stm e n t and ad ap tatio n (S peedling, Ahmadi and Kuhn-Weissman, 1981).

A P P R O A C H E S T O P E R F O R M A N C E ASSESSMENT
According to literature various approaches have been used.Self-evaluation by the group being studied was used by Speedling et al (1981); Ehrenfeld, Ziv and Bergman (1993); Deane and Campbell (1985); Olsson and Gullberg (1987) and Pierce (1991).An approach which used views of experienced q u a lifie d sisters ab o u t new g rad u ates performances was employed by Girot (1993); Ziv £ U l (1990) and Brasler (1993).
T he foregoing shows that perform ance evaluation of newly qualified nurses is a c o n te m p o ra ry is s u e .
P o s t-g ra d u a te p erfo rm an ce ap p raisal is n ecessary to establish whether or not the nurses are dependable, appropriately educated, ready to respond to patients' demand for nursing and to emergencies (Bassett, 1993).

T H EO R ETICA L FRAM EW ORK
Tyler's model of traditional clinical evaluation w h ich b e g in s w ith o b je c tiv e s o f th e educational programme must be challenged (Malek, 1988).This rational paradigm may be substituted or complemented by responsive evaluation based on perceptions of other stake-holders concerned about graduate p e rfo rm a n c e .R e sp o n siv e e v a lu a tio n constitutes a natural paradigm.Samecky (1990) subscribes to this view and advocates fourth generation evaluation or responsive model, evolved by Guba and Lincoln.In this study the natural paradigm was adopted through seeking opinions of at least one group of stakeholders, ie qualified senior nurses working with the newly qualified nurses.

PERFORM ANCE INDICATORS
Assessment is realistic if the concept to be assessed is operationalised.Narayanasamy (1991) maintains that performance indicators be stipulated to test performance before, during and after acquisition of a nursing degree/diploma.The data collecting instrument focused on the above-mentioned indicators in respect of each variable.

CO LLECTION O F DATA
The setting was the province or region in which the researchers were resident.A cross-sectional descriptive survey was used to collect data.The target population was all experienced qualified nurses currently serving in the health service of this province.The convenience sample was employed in that the research tool was distributed to all those q u a lifie d n u rses w ho w ere w illin g to p articip a te and w ere ac ce ssib le to the researcher and those indirectly accessible through other colleagues.Qualified nurses who were products of the new regulation course were excluded.
A questionnaire was designed, given to two experts to assess face validity and was pilot tested.Although 200 questionnaires were distributed, only 144 were completed and returned, a return rate of 72%.Out of these, 9 were spoiled so eventually 135 questionnaires were processed.

DATA ANALYSIS
Analysis of data was manual in respect of open-ended questions and by computer for the rest of the items.

RESPO N SE S T O L K E R T SC A LE ITE M S
The Likert Scale ratings of never, rarely, sometimes, often and always were given a numerical value of 1 to 5. The maximum possible score was 100 as 20 statements required response; total scores ranged from 35 to 100 with a mean of 73.Responses of Group I (respondents above the mean) and of Group II (respondents below the mean) were examined for significant correlations.
Responses under the variable Nursing Practice are reflected in Figures 1 to 3. It is significant that a rating of "never" was made by a substantial number of respondents in respect of indicators 1 (27.7%),2(17,8%), 7(33,3%) and 8 (20%).By comparison indicator 5 "revising care plans..." appears to be practised better than other activities in view of the fact that 6.7% rated this as getting done "always"; 24.4% said this is done "often" and 28.9% said this is done "sometimes".In summing up the ratings, (Figure 3) Nursing practice as a variable appears to be performed "rarely" according to the majority (38%) of the sample.
According to a m inority (2%) the same activities are practised "always".This does

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8 .In correlating responses of Group I and II the Pearson P.M. Correlation co-efficient was found to be significant; r =942; df = 55; p (-6).In this variable the mean for Group I and II was 34.47 and 23.63 respectively.
f Assessing the quality of Management skills or Ward administration as a variable evoked responses shown in Figures 4,5, and 6.A p p a re n tly m o st m a n ag e m en t a c tiv itie s /in d ic a to r s are p e rfo rm e d predominantly either "sometimes" or "rarely" by the newly qualified nurses.Doing an activ ity "alw ays" was n o n -ex isten t for indicators 4,5 and 6 and was scanty for indicators 1,2 and 3.It is worth noting that a small portion (6.7%) of the sample rated performance of indicators 7 : "evaluation of performance..", 8 : "appropriate corrective action, and 9 : "contributing to efficiency of the unit" as getting done "always".
The summary of ratings for this variable (Figure 6) was such that the majority (37%) of the su b jects reg ard ed the activ ities of Management as getting done predominantly "sometimes".Performing of these skills "always" was endorsed by a minority (3.9).This is equivalent to satisfactory performance by the new nurses.In this variable the Pearson P.M. correlation co-efficient between the two groups was significant Responses for the variable Responsibility can be seen in Figures 7 and 8.The rating of "rarely" was made by many respondents in all indicators.A disturbingly high number of subjects (57.1%) maintained that indicator 2 : "maintenance of confidentiality" is "never" done by the new nurses.One wonders if this is not concomitant with the general lowering of standards in a society that is getting more permissive.Combined ratings of this variable re-affirm that "rarely" or scanty performance of this aspect is predominant, that is, by 35.6% of the sample.Another negative signal is that the rating of "always" was made by a negligible number (2.2%) of the respondents.The Pearson P.M. correlation coefficient between the two groups was r = 79; df = 46; p (-6).Means were 13.93 and 9 for Groups I and II respectively.
Lastly, responses for the variable: teaching are illustrated in Figure 9.More than half (51.8%) of the sample maintained that teaching is done "'sometimes" and 5.2%, (the highest so far) perceive teaching to be done "always".In comparing the performance of this variable with all the previous ones, teaching appears to be done relatively well by the newly qualified nurses.
RESPO  1) and weak points (Table 2) shown by the newly qualified nurses.
The list of strong points is longer than that of weaknesses.This may suggest that although in the Likert Scale items the new nurses were found to range between weak and satisfactory, the respondents cannot put their finger on the ex a ct trouble sp o ts, w hich co n stitu tes weaknesses.

DISCUSSION
Findings of this study show that the qualified experienced nurses in the sample view the performance of newly qualified nurses in a somewhat poor light.It must be borne in mind that the former group of nurses was trained according to the old regulations.The latter group was trained and educated under new regulations and therefore under different circumstances.
The sample indicated that the nursing practice of newly qualified nurses is predominantly poor, though not all o f them .This is disturbing.It would be interesting to find out what the patients who arc recipients of this service have got to say.Management skills were perceived to range from satisfactory to poor.It is possible that some of the newly qualified nurses regard administrative work as more acceptable than slogging at the bedside of the patient.It is a cause for concern that in respect of responsibility newly qualified nurses' performance was regarded as mainly poor; irresponsible nurses can be a hazard to patients.Apparently these nurses are an asset when it comes to teaching.This ftmction was regarded as ranging from satisfactory to good.
It may be concluded that the products of the new regulation course are not as competent as expected by experienced qualified nurses in the sample.The new nurses' performance has a number of strengths as well as a number of  weaknesses which gives problems to the older clinical staff.Collectively, the quality of their clinical performance ranges from satisfactory through poor to never or not at all, with teaching being relatively the best area and responsibility being relatively the poorest area.
In drawing this conclusion it must be borne in mind that the new regulation course is broad, comprehensive and includes four nursing specialities, accomplished within a relatively short span of 4 years.Nursing is as wide as the whole range of human experience.It is not possible in the classroom to teach every contingency obtained in the clinical situation.Therefore, at the end of their course, these candidates are expected to be minimally competent.
The views and opinions of the older qualified nurse cannot be dismissed or taken lightly.However, on the other hand Speedling et al (1981) says the initial clinical exposure of a newly hired, new graduate is a period of adjustment and adaptation.Urden (1989) maintains that there are various levels of career development.The first level is the in itia l c lin ic a l p la c e m e n t w here the performance should be marginally acceptable; then after three years of clinical experience the graduate should be competent; after five years the practitioner should be proficient.Further, Bassett (1993) observes that there may be a shortcoming in the performance of new nurses due to the reduction in the time spent with patients during the form ative months of training.This writer says further that senior or older nurses view the young nurses in the light o f values possessed by themselves.Bassett (1993) therefore is implying that in accepting responses of senior nurses about new nurses' quality of work, room should be made for conservative tendencies, ingrained notions and general resistance to change.

RECOM M ENDATIONS
Due to the limited size of the sample, these findings cannot be generalised to the rest of the target population.Nevertheless this study serves as a prelim inary step and lays a foundation for further studies.It is significant in that it sounds a warning along the lines indicated by de Jager (1990).This writer points out that end o f the course examination is not a perfect indicator of the ability of the nurse to ftinction effectively in an everyday nursing situation.That being the case, good examination results and a high pass rate should n o t m a k e n u rs in g sc h o o l a u th o ritie s com fortable and com plaisant about their graduates.It is therefore, recommended that;-• su p p o rt and c lin ic a l o rie n ta tio n be routinely and actively provided for newly appointed new nurses for the sake of patients • on the job performance assessment of graduates and diplom ates of the new regulation course be institutionalised.
N u rsin g sc h o o l a u th o ritie s sh o u ld r o u tin e ly fo llo w up and assess performance of their graduates in their new jobs, in collaboration with clinical or service authorities • the n ursin g p ro fessio n to seriously consider systematic knowledge and skills d evelo pm en t in clin ic al p ractice as advocated by Urden (1989).This is a model whereby graduates are evaluated on being employed for the first time for performance that is marginally acceptable.About three years later, in a similar setting th e y are e v a lu a te d fo r c o m p e te n t perform ance and five years later, for proficient performance • older nurses be oriented to judge clinical p e rfo rm a n c e o f n u rses o f the new regulation in a realistic and objective manner.

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assess the level of clinical competence of graduates/diplomates of the new regulation basic course • identify problems experienced by clinical p e rs o n n e l in w o rk in g w ith th e se graduates/diplomates • identify strengths in clinical performance of the new regulation course products A SSU M PT IO N S U N D E R L Y IN G T H E STUDY T h is in v e s tig a tio n w as b a s e d on the assumption that:-• one of the best sources of information would be the opinions of senior or older nursing personnel woridng closely with the graduates/diplomates of the new regulation course In operationalising "clinical performance" this concept was reduced to the follow ing constituent variables;-• bedside nursing practice • ward administration • clinical teaching • ethical conduct/responsibility INDICATORS Performance indicators reported on a 5-point Likert Scale of never, rarely, sometimes, often and always, were as foUows:a) Bedside nursing practice indicators:- Figure 1 B arg ra p h s how ing p e rfo rm a n c e ratin g s o f new n u rs e s in respect of s p e c ific in d ic a to rs 1 to 4 under th e v ariab le : N ursing p ra ctic e I Always G o t t e n @ Som etim es S R arely IS Never % OF RESPONDENTS PER RATING

Figure 2 B■
Figure 2 B argraph sh o w in g p e rfo rm a n c e ratin g s of new n u rses in respect of spec ific irK jicators 5 to 8 under the variab le: N u rsin g pra ctic e ■ Always G o t t e n B Som etim es S R arely IS Never % OF RESPONDENTS PER RATING Figure 3 Pie d iag ram show ing the overall perform ance rating of new n u rses in respect of th e variable: Nursing practice Never 18%

Figure 4 B
Figure 4 B argraph sh o w in g p e rfo rm a n c e ratings of new n u rs e s in respect of s p e c ific in d ic a to rs 1 to 5 un der variab le : M anagem en t sl<ills K E Y T O ® Always 0 Often H Som etim es S R arely ! 3 Never IN D IC A T O R S : % OF RESPONDENTS PER RATING 1.A n tic ip atio n of of p o te n tia l w o rk flo w p ro b le m s . 2 .Id e n tific a tio n of a v a ila b le and p o te n tia l re s o u rc e s .3 .Id e n tific a tio n of a ctio n s n e c e ss a ry to acc o m p lis h w o rk tasks.4 .Im p le m e n ta tio n of a p p ro p ria te a c tio n s .5 .D irectio n of a c tiv itie s of d e s ig n a te d stafl.

Figure 5 B
Figure 5 B a rg ra p h s h o w in g p e rfo rm a n c e ratings of new nu rses in re s p e c t of s p e c ific in d ic a to rs 6 to 9 under variab le: M anagem en t skills ■ Always G o tt e n H S o m e tim e s S R a r e ly 1 2 N ever % OF RESPONDENTS PER RATING Figure 6 Pie diag ram sh o w in g th e overall p e rfo rm a n c e rating on n e w nurses in respect of the variable; M anagem en t Skills Never IS.0%

Figure 7 B
Figure 7 B argraph show ing p e iio rm a n c e ratin g s on new nurses in respect of s p e c ific in dicators 1 to 3 under the variab le: R espo nsibility ■ Always g o t t e n S S o m e tim e s ^R a r e ly IS Never % OF RESPONDENTS PER RATING Figure 9 Pie diagram show ing th e overall p e rform ance rating of new nurses in respect of the variab le: Teaching N ever 15.6%

TABLE 2 :
THEMES OF WEAK POINTS IN THE PERFORMANCE OF NEWLY QUAUFIED NURSES: