Competence of newly qualified registered nurses from a nursing college

Correspondence address: Dr Mary Chabeli University o f Johannesburg School o f Nursing PO Box 524 Auckland Park. 2006 South Africa Abstract: Curationis 28(2): 38-50 The South African education and training system, through its policy of outcomesbased education and training, has made competency a national priority. In compliance to this national requirement of producing competent learners, the South African Nursing Council ( 1999 B) require that the beginner professional nurse practitioners and midwives have the necessary knowledge, skills, attitudes and values which will enable them to render efficient professional service. The health care system also demands competent nurse practitioners to ensure quality in health care. In the light of competency being a national priority and a statutory demand, the research question that emerges is, how competent are the newly qualified registered nurses from a specific nursing college in clinical nursing education? A quantitative, non-experim ental contextual design was used to evaluate the competence of newly qualified registered nurses from a specific nursing college. The study was conducted in two phases. The first phase dealt with the development of an instrument together with its manual through the conceptualisation process. The second phase focused on the evaluation of the competency of newly qualified nurses using the instrument based on the steps of the nursing process. A pilot study was conducted to test the feasibility of the items of the instrument. During the evaluation phase, a sample of twenty-six newly qualified nurses was selected by simple random sampling from a target population of thirty-six newly qualified registered nurses. However, six participants withdrew from the study. Data was collected in two general hospitals where the newly qualified registered nurses were working. Observation and questioning were used as data collection techniques in accordance with the developed instrument. Measures were taken to ensure internal validity and reliability of the results. To protect the rights of the participants, the researcher adhered to DENOSA’S (1998:2.2.1) ethical standards of research. A descriptive statistical method of data analysis was used in this study. Findings revealed that newly qualified registered nurses were not competent. The highest score obtained was 51 % and the lowest score was 22% with an average score of 34.05%. The results concerning the implementation of the phases of the nursing process indicated that participants were fairly competent in terms of knowledge, skills, attitudes and values of assessment. Participants had very little knowledge of nursing diagnosis and were not competent on the skills o f diagnosis. Participants lacked basic knowledge, skills, attitudes and values of the nursing process. They lacked critical thinking skills in their approach to providing quality patient care. The recom m endations of the study relate to im proving the system of clinical accompaniment, reviewing the clinical facilities where learners are allocated, reviewing the implementation of the curriculum, the methods of teaching and the quality assurance mechanisms that are in place. Further research is recommended on competence of newly qualified registered nurses at other nursing colleges or similar context.

u itk o m s g e b a s e e rd e o n d e rw y s en o p le id in g , b e v o e g h e id 'n n a sio n a le p rio rite it in o n d e rw y s en o p le id in g gemaak.O nderw orpe aan die nasionale vereistes vir die daarstel van bevoegde le e rd e rs is d ie S u id -A frik a a n s e Verpleegraad van m ening dat die doel van 'n k w a lifik a sie is om b eginnerverpleegpraktisyns en -verloskundeverpleegkundiges, wat die nodige kennis, vaardighede, houding en waardes besit, toe te rus om 'n professionele diens te verrig.
D ie g e s o n d h e id s o rg s is te e m v e re is b e v o e g d e v e rp le e g p ra k tis y n s w at kwaliteit in die gesondheidsorg verseker.In die lig dat bekwaamheid 'n nasionale prioriteit en 'n statutêre vereiste is, is die n a v o rs in g s v ra a g in w a tte r m ate n u u tg e k w a lifis e e rd e g e re g is tre e rd e v erp le e g k u n d ig e s van 'n sp e sifie k e verpleegkollege bevoeg is in kliniese verpleging.
'n Loodsstudie is in die ontwikkelingsfase van die studie onderneem.'n Instrum ent is ook gedurende hierdie fase ontwikkel.In die evalueringsfase is 'n m onster van s e s -e n -tw in tig n u u tg e k w a lifis e e rd e verpleegkundiges willekeurig geselekteer uit 'n doelw itgroep van ses-en-dertig n u u tg e k w a lifis e e rd e g e re g is tre e rd e verpleegkundiges.Ses deelnem ers het egter van die studie onttrek.D ata is by tw ee alg em en e hosp itale ingesamel w aar die nuutgekwalifiseerde geregistreerde verpleegkundiges werksaam was.'n Instrument is gebruik om d a ta te v e rs a m e l. O b s e rv a s ie en v raagstelling is as dataversam elingstegnieke gebruik.Stappe is geneem om interne geldigheid en betroubaarheid van die resultate te verseker.Om die regte van die deelnem ers te beskerm, het navorser getrou gebly aan DENOS A (1998:2.2.1) se etiese standaarde van navorsing.
Beskrywende statistiek is gebruik om die n u m e rie s e d a ta v an d ie s tu d ie te a n a lise e r.D a a r is b e v in d d a t n u u t gekw alifiseerde verpleegkundiges nie bevoegd is nie.Die hoogste telling was 51 % en die laagste 22% met n gemiddeld van 34.05%.Resultate met betrekking tot die implementering van die fases van die verpleegproses toon aan dat deelnemers redelik bevoegd is in term e van die volgende: kennis, vaardighede, houdings en waardes van beraming.Deelnemers het baie min kennis van verpleegdianose en is nie bevoegd in diagnoseringsvaardighede nie.Basiese kennis, vaardighede, h o u d in g s en w a a rd e s van die verpleegproses ontbreek, asook kritiese denkvaardighede in hulle benadering tot die voorsiening van gehaltepasientsorg.
Die aanbevelings van die studie hou verband met die verbetering van kliniese b e g e le id in g , die h e rsie n in g van die kliniese fa silite ite w aar die leerders geallokeer was, 'n hersiening van die implementering van die kurrikulum, die o n d e rrig m e to d e s en die b e sk ik b are kwaliteitversekeringmeganismes.Verdere navorsing rakende bekwaamheid behoort gedoen te word by ander kolleges en in

Introduction
Quality nursing care is a constitutional right of both patients and clients, which must be upheld by com petent nurses.It is unfortunate that this right is often violated by incom petent members o f the nursing profession.This view is also held by Khoza and Ehlers (1998:69) who found that the newly qualified nurses appeared to be lacking in cognitive, affective and psychom otor competencies.Mhlongo and M ashaba (1996:13) also found that as newly qualified nurses took up employment, controversy continued at the grass root level with regard to their competencies.As a result, some nursing service managers were reluctant to place n ew ly q u a lifie d n u rse s in c lin ic s imm ediately after graduating, as these nurses were expected to function more independently than in hospitals, where there was close supervision from more experienced nurses.To alleviate this p ro b le m , G w e le and U ys ( 1 (Profetto-McGrath 2003:569).At qualification level, learners should dem onstrate ability to u tilise critical th in k in g sk ills w hen im plem enting the sc ie n tific nursing process within their scope of practice in the provision of quality nursing care.It th e re fo re b e c am e im p o rta n t th a t competence of newly qualified registered n u rse s fro m a s p e c ific n u rsin g be evaluated.

Research problem and research question
The research studies conducted on the competence of newly qualified registered nurses rev ealed th at they could not provide safe p a tie n t care (K hoza & Ehlers, 1998:69;Mhlongo & Mashaba, 1996:13;Gwele & Uys, 1995:6;Muller, 1998:4;Scheetz, 1989:29).In light of these re se a rc h re p o rts , th e d e m a n d s fo r com petency by the higher education system and the health care system, the following research question was eminent: how competent are the newly qualified registered nurses from a specific nursing college in clinical practice using the nursing process?

Purpose of the study
The purpose of the study was to evaluate the co m p ete n c e o f new ly q u a lifie d registered nurses from a specific nursing college in clinical nursing practice, using the nursing process approach to provide quality nursing care.

Objectives of the study
The objectives o f the study were to: • develop an instrument and a manual through conceptualisation; • evaluate the com petence of newly qualified registered nurses in clinical n u rsin g p ra c tic e u sin g the n u rsin g process approach; and to • describe recommendations based on the findings o f the study on how to improve competency of newly qualified nurses.

Theoretical framework
The study departs from M uller's (1999) theoretical fram ew ork, though other theories supporting M uller's theory were also used, for ex am p le, the nursing process as explained by Ellis and Nowlis (1994:131-192).M uller's theory served as a foundation for the development of the instrument used to evaluate competence of the newly qualified registered nurses.

Definitions of central concepts
• Competence refers to the application of the integration of knowledge, skills, attitudes and values in the context of nursing and midwifery practice (Muller, 1999).Com petence embraces the notion of applied com petence that suggests the integration of foundational, practical and reflexive competence (SAQA,1998).
• A newly qualified registered nurse is a nurse w ho was educated and trained under the South African Nursing Council Regulation 425 o f 22 February 1985 (as a m en d e d ) and q u a lifie d as a nurse (general, psychiatric and com m unity) and m id w ife/acco u ch eu r.T he nurse should have recently com pleted final examinations, i.e. a month before data collection.
• Clinical nursing practice is a dynamic c o n s ta n tly c h a n g in g , re a l-life e n v iro n m e n t in w h ic h th e o re tic a l know ledge is integrated with practice (Chabeli, 2001:348).
• Curriculum process is the curriculum as e x p e rie n c e d by the learn er, and c o n s is ts o f le a rn in g s tra te g ie s and assessment/evaluation methods (Quinn, 1995:297).

Conceptualisation
C onceptualisation o f the key concepts of the study was done.This was done through clarification and defining of key concepts and integrating the research into the existing relevant theory (Mouton, 1998:109).The following key concepts were conceptualised for the purpose of developing the evaluation instrument: com petency; the context within which c lin ic a l n u rsin g p ra c tic e o c c u rs, influenced by the national legislation, local policies and the curriculum process.20844, February, 2000:10;SAQA, 1998:4).
In th is stu d y , fo r c o n s is te n c y and congruency in conducting the research, p a tie n ts s u ffe rin g fro m c o n g e s tiv e cardiac failure were selected as a common m edical c o n d itio n in the hosp ital to evaluate the com petence o f the newly qualified professional nurses using the nursing process.Quinn (1995:80) refers to attitude as an internal state that influences the choice of personal actions made by an individual.Ellis and Knowlis (1994:738) refer to values as "principles or standards o f life th at are h ig h ly p ric e d " , N u rse s are expected to dem onstrate values which show self-respect, empathy, reliability, honesty, justice and respect o f patient's rights.The Batho-Pele principles in the White Paper (1997:16) should be upheld by nurses as these principles form the basis for any quality patient care.M uller (1 9 9 8 :2 3 8 ) fu rth e r state th at nurses should put a high premium on what to believe and do, why they do the activity, how to do it and attach com passion and com m itm ent to what they do.She is also of the opinion that values form the basis of the nurse's perceptions or views on quality nursing.
T h e c lin ic a l e v a lu a tio n in stru m e n t developed from the conceptualisation process included three parts.Part one (24 ite m s) a d d re s s e d th e k n o w le d g e c o m p e te n c e d u rin g th e a sse ssm e n t phase, the knowledge of formulating the nursing diagnosis, the knowledge of how to plan for the identified diagnosis, the knowledge of how to implement the plan, the knowledge o f how to evaluate the effect of the nursing intervention and the knowledge o f the importance of record keeping.Part two (11 items) dealt with the skills of the six parts o f the nursing process and part three (24 items) focused on the a ttitu d e s a n d values of nurses as they executed the six components of the n u rsin g p ro c e ss.T he m anual g iv es detailed inform ation expected from the participants under the sub-components o f th e th re e p a rts (u n p u b lish e d d is s e rta tio n ).T he e v a lu a to r had to a c q u a in t h e r s e lf /h im s e lf on the expectations from the manual before evaluating the student.Having a manual did not force the ev alu ato r to focus strictly to the information, the knowledge and experience o f the evaluator would add value to the evaluation activities.Since clinical evaluation is a complex exercise, two evaluators were used to improve the reliability of the participants' clinical performance (Ewan and White, 1984:216).The ratio scale ranged between 0 and 5, that is, 0 meant that the student is not competent.1 meant that the student dem onstrate very little com petence. 2 represents fairly competent.3 meant that the student is moderately competent.4 meant that the competence of the student is good and 5 m eant that the student d e m o n strate d e x c ellen t co m p eten ce u sin g h ig h e r o rd e r th in k in g in the implementation of the nursing process o f a patient w ith congestive cardiac failure.

The context
The h igher edu catio n system w ithin which the Council on Higher Education (C H E , 2 0 0 2 ), th e S o u th A fric a n Qualification Authority (SAQA, 1995), the South A frica n N ursing C o u n cil (SANC -R425 o f 1985), the H igher Education Quality Committee (HEQC in the Higher Education Act no 101 of 1997) and the nursing college function, has an impact on the concept of competence to provide quality practice in the working world.This impact is depicted by the conceptual map in figure 1.1 The higher education and training system in South Africa is outcomes-based.The u n d e rly in g p rin c ip le o f the h ig h e r e d u c a tio n sy ste m is to p ro d u c e a com petent le a rn e r w ho can provide q u ality se rv ic e in v a rio u s w o rk in g environments.According to the Higher Education Act (Act 101 of 1997:10), the Council on Higher Education, through its permanent committee, namely, the Higher Education Quality Committee (HEQC) and the Education and Training Quality Assurance body (ETQA) which, in this case, is the S o u th A frican N ursing Council (SANC), are responsible for the promotion o f quality assurance in higher education.
These stru c tu re s are resp o n sib le to monitor quality education and training and to evaluate whether the objectives of higher education are being realised.The H EQ C a lso au d its th e q u a lity assurance m echanism s of institutions and a c c re d it h ig h e r e d u c a tio n programmes (CHE, 2002:3).The nursing college cannot be excluded, since it is affiliated to the university and is regarded as an institution o f higher education, with sim ila r e x p e c ta tio n s o f p ro d u c in g com petent nurses who w ill function independently in practice.The nursing college is functioning within the legal and professional boundaries of the country.

The curriculum process
The curriculum process of the college also im pacts on the co m p eten ce o f learners.The curriculum of this specific nursing college is outcomes-based.This is in line w ith the d e m an d s o f the education and training system o f South Africa, as it moves from content-based to o u tc o m e s -b a s e d e d u c a tio n and training.In developing the outcom esbased curriculum , the nursing college followed through the curriculum process by conducting a situational analysis, co n sid e rin g the c ritic a l c ro ss-fie ld outcom es as stated by SAQA (1995), identifying the learning area outcomes and the learning programme outcomes.
The learning outcom es determ ine the specific knowledge, skills, attitudes and values req u ired by the learner.The curriculum goals were set, the assessment of the learning outcomes were made, the teaching and learning a ctiv ities and resources were determined.Facilitative instructional strategies were determined, based on the learning outcomes and the assessm ent o f the learning outcom es were done again to realise statement of learning outcom es which have not been achieved ( Van der Horst & McDonald, 1997:116).
Emphasis was on the development of the culture o f teaching and learning based on the e ffe c tiv e in s tru c tio n a l and classro o m m a n ag em en t co n sid erin g reflection, learner-oriented environment, rules, procedures, self-discipline, teacher and learner work ethics.O f the stated culture, reflection form s the basis on which effective teaching and learning can take place (Van der Horst & McDonald, 1997:84,88).

Research design and method
A q u a n tita tiv e , n o n -e x p e rim e n ta l, contextual research design was used to e v a lu a te th e c o m p e te n c e o f new ly qualified registered nurses trained at a specific nursing college (Polit & Hungler, 1991:24,650).The research design was d iv id e d in to tw o p h a se s, the developm ent phase and the evaluation phase.The purpose o f the development phase was to develop the instrument and the m an u al th ro u g h the p ro c e ss o f conceptualisation.This instrument was used to e v a lu a te the com petence of n ew ly q u a lifie d re g is te re d n u rse s.Recommendations were made.

Population and sampling
A target population of twenty-two newly qualified registered nurses were included in the pilot study to test and modify items o f the instrument.Purposive sampling was done.The inclusion criteria used w ere th a t n u rse s sh o u ld be from a specific nursing college and should be em ployed in g en eral h o sp ita ls.The rese arch er w as a ssisted by a fellow c o lle a g u e w ho had b a c k g ro u n d knowledge on quantitative research.The target population for the main study included all thirty-six newly qualified registered nurses from a specific nursing college.Sim ple random sampling was done to select tw enty-six participants.How ever, six participants voluntarily withdrew from the study leaving the final sample at twenty.

Data collection
O b se rv a tio n an d q u e s tio n in g w ere preferable data collection methods.For the m ain study, the re se a rc h e r was assisted by an experienced expert clinical a c c o m p a n is t w ho w as p u rp o s iv e ly se le c te d fo r d a ta c o lle c tio n .T he researcher and the assistant used the developed instrum ent and its related manual, to evaluate the competence of newly qualified registered nurses.P a tie n ts su ffe rin g fro m c o n g e stiv e cardiac failure, as the m ain m edical diagn osis prev alen t in the hospitals, where participants were employed, were carefully selected for the study.The newly qualified nurses were expected to demonstrate their competence using the nursing process approach to provide qu ality nu rsing care on the selected patients.Patients who were terminally ill were not selected for ethical reasons and also because it would be difficult to obtain subjective data from them.Consent to conduct the research was obtained from the selected patients.
Participants were expected to collect subjective and objective data, prioritise the health needs o f the patient, formulate the nursing diagnosis, plan the nursing in te rv e n tio n and h e a lth p ro m o tio n s tra te g ie s , s ta te h o w th ey w ould im plem ent the plan, how they would e v a lu a te an d re c o rd the fin d in g s.Q uestio ns w ere asked in betw een to determine the depth o f the participant's knowledge, skills and attitudes related to the condition.Participants were given time to prepare the patients, read the patient's record to familiarise themselves with the condition, and prepare the equipm ents they would use to collect data.Each participant was sc o re d a g a in st e a c h and e v e ry competency item on the instrument by th e r e s e a rc h e r an d th e a s s is ta n t independently.A fter evaluating each p a rtic ip a n t, a c o n se n su s score w as reached by the tw o researchers.Data collection from each participant took app rox im ately 45 to 60 m inutes per participant.
The duration o f the entire data collection was two and a half days with breaks in between for tea and lunch.Only twenty participants could be evaluated.The last six participants expressed the view that they did not feel com petent enough to subject them selves to such evaluation.T h ey re q u e s te d to w ith d ra w fro m participating in the research.The request was respected and appreciated by the researcher since they were acting within their rights.

Data analysis
Data from the pilot study was analysed 42 Curationis May 2005 m a n u a lly by th e re s e a rc h e r u sin g p e rc e n ta g e s .D a ta a n a ly s is fo r the e v a lu a tio n p h a se w as d o n e by a statistical consultant.The descriptive analysis of data employed measures such as percentages, bar graphs, tables, boxand-whisker plots.The box-and-whisker plots as indicated in figures 1.3 1.4 and 1.5 shows the characteristics of the data such as the median, outliers, minimum and maximum scores.(Brink, 1996:186).T he la rg e r the sta n d ard deviation, the more spread out the scores are about the mean in a distribution.

Ethical considerations
To protect the rights of the participants, the re search er ad hered to D E N O SA (1 9 9 8 :2 .2.1 ) 's e th ic a l sta n d a rd s o f research.The study was also approved by the research ethics com m ittee of a u n iv e rs ity .In fo rm e d c o n s e n t w as obtained from the Department o f Health, hospital authorities and participants.A nonym ity, priv acy , fa ir treatm en t, protection from harm and discomfort were ascertained.

Measures to ensure validity
To ensure content validity, the constructs measured were derived from literature and M uller (1999)

Research findings
The research findings are presented in the form o f 7 tables, the 3 box-andwhisker plots and 1 figure.
According to the findings o f the pilot study, all six participants who were em ployed within the first six months after completing the course, ranged from fair to good com petence.
H ow ever, the findings o f the main study revealed that, o f the tw e n ty p a r tic ip a n ts w ho participated in the research, only one p a rtic ip a n t sco red 51% , w hich w as the highest score.The low est score obtained by one participant was 22%.The average score was 34.05%.See table

Discussion of findings
The findings of the study revealed that the newly qualified nurses from a specific nursing college were not competent with regard to the management of a patient suffering from congestive cardiac failure using the nursing process as indicated by only one student obtaining 51% and the average perform ance o f 34.05% .The findings revealed that the newly qualified nurses were fairly competent in the assessm ent of patients.This could imply that the participants lacked the knowledge of integrating basic nursing science, hum an b io lo g ica l sciences, chem ical sciences, pharm acology and social sciences.During the assessment phase, it is im portant that the student collect critical information and identify the important cues about the patient and explain why the information is critical, significant or insignificant to a specific patient (Oermann 1998:327).
The withdrawal o f six participants who indicated that they were not competent in executing nursing process, since their kn o w le d g e o f p a th o p h y sio lo g y w as lacking, was also evidential.This poses a serious im plication to the care and safety o f the patient if the products of a b a sic n u rs in g p ro g ra m m e are in c o m p e te n t in th e ir p ra c tic e .T he underlying problem is the inability to use critical thinking in the care of the patient.This was demonstrated by student during the a ss e ss m e n t and p la n n in g phase when they w ere unable to ju stify the reasons for m aking particular decisions, that is, the data on which they based their clinical judgm ent and the assumptions they m ade about the patient.Oermann  Oermann (1998:323), in the same vein, is of the opinion that one way to develop th ese q u e stio n s is w ithin the broad framework of the nursing process.
The findings also demonstrate a theoryp ra c tic e g ap .In e ffe c tiv e c lin ic a l accom panim ent o f students by nurse educators and professional nurses, also contributes to lack of clinical competence o f stu d e n ts.E ffe c tiv e c lin ic a l a c c o m p a n im e n t fa c ilita te s c ritic a l thinking of students.Critical thinking is an important cognitive skill for nurses to develop in order to be able to weigh m ultiple possibilities and to arrive at informed clinical decisions for improved n u rsin g care o f p atie n ts (O erm an n , 1998:322).
The findings o f the study revealed that the newly qualified nurses w ere very little c o m p e te n t in the s k ills o f implementation.This causes concern to th e re s e a rc h e r, b e c a u se n u rsin g is basically a practical skill.According to Reilly and Oermann (1985:1), nursing is a hands-on profession w hich draw s its satisfaction from the clinical practice setting, where specialised skills and the a c c e p ta n c e o f a p a tie n t as an autonomous being must be the norm.
Clinical nursing education, according to Chabeli (2001:150) is a dynamic, multi p u rp o se e n v iro n m e n t in w h ich the theoretical com ponent is integrated into practice.It provides the learner with a m e a n in g fu l, a u th e n tic and hum ane experience.Chabeli further states that, the teacher, as a facilitator should create the en v iro n m e n t th a t w ill p ro m o te the integration of knowledge, skills attitudes and values in order for students to be able to render holistic and comprehensive nursing care to patients using the nursing process as a vehicle.The findings of the study revealed that, new ly qualified nurses from a specific nursing college were unable to use the nursing process, as a v eh icle to re n d e r h o listic and comprehensive care to patients suffering from a congestive cardiac failure.
The implications of the findings were that nurse educators at this specific nursing college need to review their teaching and assessm ent m ethods.D ialectical and d ia lo g ic a l te a c h in g and a ssessm e n t m ethods that w ill stim u late critica l thinking o f students should be used (Gravett, 2001:35;Brookfield, 1987:13;Paul. 1993:333).
The nursing process has been criticised, as b e in g m e c h a n is tic , d e d u c tiv e , reductionistic, method-centred, diseasecentred and following the medical model approach (Lindsey & Hartrick 1996:108).However, the researcher is o f the opinion that if nurses from this college knew how to apply the nursing process effectively to facilitate critical thinking, they would have been in a better position to apply the nursing process on a patient suffering from co ngestive cardiac failure in a

Study limitations
The contextual nature of the study and the participation of 20 participants only, makes the findings not to be generalised to other nursing colleges.The pilot study population (six participants), although from the same college, differed from the evaluation group in term s o f working experience.The pilot study participants had six month working experience, whilst the participants of the main study had one month working experience, as they had just com pleted the programme.
T he p a rtic ip a n ts e q u a te d th e ir participation in the research with the objective sim ulated clinical evaluation e x a m in a tio n (O S C E ) w h ich w as intimidating and brought about tension and stress on students while they were student nurses.This situation could have had a n e g a tiv e in flu e n c e on the perform ance o f the participants.The withdrawal of the six participants who were last on the list, on receiving the feedback from the participants who were finished with the research, stated that they are afraid to be subjected to the same (OSCE) as they did whilst they were students.The situation brought fear to them and the researcher regarded that as a limitation to the study.

Recommendations
In view of the findings o f the study, the following recommendations are made:

Nursing practice
The system of accompaniment of learners to clinical areas should be reviewed.It is through effective clinical accompaniment o f learners that theory and practice can be c o rre la te d , and the p ro b le m s encountered by learners can be identified early and addressed.
The clinical facilities where learners are allocated should also be review ed for availability and accessibility o f human, material and other resources necessary for the facilitation of learning.All human beings learn by and through experience and therefore, availability o f resources in the clinical area can help to enhance experiential learning.
To improve the level of competence in nursing practice, educators should be reflective and critical thinkers themselves in order to be able to facilitate critical thinking of students (M angena 2003:35).
T hey should fo rm u late ill-structured c lin ic a l s c e n a rio s , h o ld c lin ic a l conferences and en gage in problembased learning approach to encourage the students' inquiry m ind using the available resources.They should strive at closing the theory-practice gap (Rolfe, 1996:1).

Nursing education
T he c o lle g e s h o u ld re v ie w the implementation of its curriculum in order to identify reasons as to why clinical learning outcom es were not achieved.
The system o f evaluation/assessm ent, m ethods o f teach in g and the quality assurance systems o f the college should also be reviewed.M ulti-modal methods of teaching and assessm ent to facilitate critical thinking and problem -solving skills should be considered at the college.
Critical thinking enables the learners to a n a ly se , s y n th e s is e and e v a lu a te in fo rm a tio n in d e p en d e n tly .Q u ality assu ran ce m ech an ism s such as peer group ev alu atio n , sta ff d ev elopm ent programmes and m onitoring of college standards of education and training by the u n iv e rsity w h ich the c o lle g e is 9 9 5 :6 ) re c o m m e n d ed th a t n ew ly q u a lifie d registered nurses should undergo a six to tw e lv e m o n th in te rn s h ip .T h is re c o m m e n d a tio n has n o t y et been addressed in South Africa.H ow ev er, the p ro v id e rs o f n u rsin g education have the resp o n sib ility o f p ro d u c in g n u rse s w h o are c ritic a l th in k e rs th ro u g h the c u rric u lu m as determined by the SANC, the Education and Training Quality Assurance body for the nursing profession.Com petency by using critical thinking skills to improve practice is an essential national priority and th e re fo re k n o w le d g e and u n d e rsta n d in g o f n u rsin g s tu d e n t's critical thinking when on practice become important to nurse educators Competency M uller's theoretical framework was used to define and integrate the key concept of competence, which was clarified and conceptualised within the clinical nursing p ra c tic e .M u lle r (1 9 9 9 ) d e fin e s c o m p e te n c e as th e in te g ra tio n o f knowledge, skills, attitudes and values w ith in the c o n te x t o f n u rsin g and midwifery practice.This definition is in line with the SAQA definition o f applied competence which refers to the overarching term for three interconnected kind of competence.The p r a c tic a l c o m p e te n c e is the dem onstrated ability in an authentic context to consider a range of possibilities for action, make considered decisions about which possibility to follow; and perform the chosen action.It is grounded in foundational com petence where the learner dem onstrates an understanding o f the k n o w le d g e and th in k in g that u n d e rp in s th e a c tio n ta k e n , and in te g ra te s it th ro u g h re fle x iv e c o m p e te n c e .T h e le a rn e r, th ro u g h reflexive competence, demonstrates the a b ility to in te g ra te o r c o n n e c t performance and decision-m aking with u n d e rs ta n d in g .T h e le a rn e r a lso d em o n strates the a b ility to adapt to change and unforeseen circum stances and to explain the reasons behind these adaptations (Norm s and Standards for Educators -G overnm ent G azette No. The median is indicated by a thick black vertical line.Bums and Grove (1993:475)   refer to the median as the score at the exact centre o f the ungrouped frequency distribution obtained by rank ordering the scores.The outliers are shown as black thick dots which indicate extreme sc o re s o b ta in e d .B u rn s and G ro v e (1993:476) refer to outliers as subjects w ith extrem e sco res that are w idely separated from the scores o f the rest of the subjects.The minimum and maximum scores are indicated by thin black vertical lines on either side of the box.Figure 1.2 is a bar g ra p h in d ic a tin g th e p e rc e n ta g e d is trib u tio n o f p a r tic ip a n ts in the evaluation phase.Table 1.2 to 1.7 shows the m inim um , m axim um , m ean and standard deviation o f the scores obtained by p a r tic ip a n ts .B u rn s an d G ro v e (1993:772) refer to the mean as the value obtained by sum m ing up all the scores and dividing that total by the num ber of scores being sum m ed.The standard d eviation indicates how values vary about the mean of the distribution

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pilot study was done to test and correct the items on the instrument and to assess the fe a s ib ility o f the study.S im p le random sampling was done to ensure that the sam ple was representative o f the target population.A briefing session on the p u rp o s e an d o b je c tiv e s o f th e research was done.The assistant of the re se a rc h er w as p u rp o siv ely selected because o f her extensive ICU experience and clinical accom panim ent o f student nurses.B oth the re se a rc h er and the assistant used the same instrum ent to e v a lu a te th e c o m p e te n c e o f th e p a rtic ip a n ts .S c o rin g w as d o n e in d ep en d en tly durin g the ev alu atio n p ro c e ss and a c o n se n su s sco re w as reached by both researchers.

Figure
Figure 1.2A bar graph: percentage distribution of participants in the evaluation phase.
Participants were found to be very little c o m p e te n t in the k n o w le d g e o f diagnosis, planning and the skills o f im p le m e n ta tio n .T hey w ere fa irly c o m p e te n t in th e k n o w le d g e o f a s s e s s m e n t, im p le m e n ta tio n and e v a lu a tio n , as w ell as b ein g fa irly competent in the skills of assessment and planning.Their knowledge and skills of recording was found to be moderately competent.The implications o f these findings were that the newly qualified nurses from a specific college were unable to apply the nursing process when caring for patients with congestive cardiac failure, a common condition found in the hospitals.These fin d in g s are su p p o rte d by p rev io u s studies of nursing students on clinical com petence co n d u cte d by L ofm ark,Hannersjo and W ikblad (1999:946).The study revealed that stu d en ts show ed u n c e rta in ty in th e ir k n o w le d g e o f assessm ent of patient's needs, as they either under-estimated or over-estimated p a tie n t's needs and problem s during assessm ent.
(1998:323)  state that when students make clinical judgm ent, they must consider o th e r p o ssib le v iew s o f the clin ical situation, provide reasons behind the a c tio n s th e y to o k .E x p e rt c lin ic a l reasoning depends heavily on relevant knowledge base and strongly connected to the use o f c ritical th in k in g (Paul 1993:473).The evaluator has the responsibility of asking open-ended questions such as why, what if, and what else is possible to assess the critical thinking of students.

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ow ever, the resea rc h fin d in g s are confined to a specific nursing college and can not be generalised to other colleges, p ro v in c ia lly o r n a tio n a lly .F u rth e r 47 Curationis May 2005 research could be done to establish w hether newly qualified nurses from o th e r c o lle g e s e x p e rie n c e sim ila r p roblem s.N urse e d u c a to rs and the clinical practitioners have a responsibility to revisit their teaching and assessment method to facilitate critical thinking of students in clinical nursing education.Critical thinking and reflective learning is the educational learning outcome of all educational program m es nationally and internationally.

CFigure 1 . 3
Figure 1.3The box-and-whisker plots of knowledge of assessment, diagnosis, planning, implementation, evaluation and recording