EMPIRICAL STUDIES

doi: 10.1111/j.1471-6712.2011.00939.x

Evidence of clinical competence

Gun-Britt Lejonqvist LNSc, RN (Principle Lecturer, Program Leader)1, Katie Eriksson PhD, RN (Professor and Director of Nursing)2,3 and Riitta Meretoja PhD, RN (Development Manager)3
1

Arcada, University of Applied Sciences, Helsinki, Finland, 2Department of Caring Science, Abo Akademi University, Director of Nursing, Hospital District of Helsinki and Uusimaa, Finland and 3Corporate Headquarters, Hospital District of Helsinki and Uusimaa, Finland

Scand J Caring Sci; 2012; 26; 340348 Evidence of clinical competence This cross-sectional research used a qualitative questionnaire to explore clinical competence in nursing. The aim was to look for evidence of how clinical competence showed itself in practice. In the research, the views from both education and working life are combined to broadly explore and describe clinical competence from the perspective of students, clinical preceptors and teachers. The questions were formulated on how clinical competence is characterised and experienced, what contributes to it and how it is maintained, and on the relation between clinical

competence and evidence-based care. The answers were analysed by inductive content analysis. The results showed that clinical competence in practice is encountering, knowing, performing, maturing and improving. Clinical competence is an ongoing process, rather than a state and manifests itself in an ontological and a contextual dimension. Keywords: evidence, clinical competence, nursing, qualitative content analysis. Submitted 24 May 2011, Accepted 26 September 2011

Few questions have been discussed in nursing education as much as the question of competence, and the concept seems to escape every attempt to dene it (1, 2). Harper dened competence as the ability to perform tasks with desirable outcomes under different circumstances in real variable settings. (3), identied three ways of looking at competence: (i) a behaviouristic or task-oriented way, (ii) generic or pertaining to general attributes crucial to effective performance and (iii) general attributes such as knowledge, skills and attitudes. Some concept analyses have been carried out (46) as a quite new literature review (7) stating that competence is more than mere skills and knowledge, including attitudes, motives, personal insightfulness, interpretive ability, receptivity, maturity and self-assessment. Strange (5) synthesised ve themes in her meta-synthesis describing the process from basic knowledge and skills to going beyond the self-coaching, mentoring and teaching others. Tilley (6) dened competence as the application of skills in all domains of the practice role, while Cassidy (7) spoke about a combination of knowledge, skills and attitudes basic for emotionally intelligent nursing. An integrated holistic approach was

seen as a dynamic process of development, stressing the clinical contextual side and skills, including time management, information techniques and working in teams as motives and attitudes of the learner (8). Benner et al. (9) and Meretoja and Leino-Kilpi (10, 11) added that only a period of consolidation in practice makes nurses develop to the stage of expertise. The use of evidence and clinical competence has a clear connection. Scott & McSherry (12) looked at different existing denitions in literature, and their conclusions suited well the denition by Eriksson (13) as something being clear, obvious, indisputable and visible. Evidence is a combination of scientic knowledge and skills based on clear values and caring ethics (14), meaning doing what is best for the patient. Part of the denition problem could be that clinical competence is still not clear, obvious, indisputable and visible in the clinical context.

Background
A change to a competence-based approach in nursing education can be seen (15), and in Europe, the aim is that education should be transferrable within the European Union (16). Nursing should be grounded in evidence, not tradition (17). Wangensteen (18) showed that students have an ambition to give patient-centred holistic care of high-quality based on evidence, but the development of clinical competence is dependent on interaction with experienced nurses, feeling part of the interdisciplinary

Correspondence to: Gun-Britt Lejonqvist, ARCADA, Jan-Magnus Janssons plats 1, 00550 Helsinki, Finland. E-mail: gun-britt.lejonqvist@arcada.

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Evidence of clinical competence team, condence and taking part in decision-making. Maben et al. (19) found that students are supposed to t in, but with a lack of experience and self-reliance, they feel the responsibilities overwhelming. Ralph et al. (20) listed those aspects in practical training that affect competence development. The positive factors were the reduced theorypractice gap, good mentoring, supportive staff, being treated as a team member and developing self-condence, while the negative factors were poor mentorship, time constraints, poor placements, unfair evaluations and nancial difculties. Dolan (21) showed that students were concerned at achieving an acceptable level of competence in the skills needed for nursing in settings assessing mainly specic skills, not evidence, while Farrand et al. (22) stated that clinical practice should not only teach skills but develop students perception of self-worth and value. Berntsen & Bjork (23) described students need for help in connecting the context of learning and the context of performing, and Clark et al. (24) identied the connection between students self-efcacy and capabilities to perform. Kuiper et al. (25) saw metacognition as improving practical performance, but the belief in being capable, and valuing the skills learned, was the key to performing (25, 26). A preceptor should teach students, but moreover be a role model, which inspires students to develop and to appreciate the value of the nursing practice by transmitting ideals of best practice (27). The preceptors rene the art of nursing by cultivating practical wisdom (28); they offer a supportive environment, learning possibilities and reective communication in complex, unpredictable and continually changing, often busy situations, while also being responsible for the care of the patient, a preceptor supports and evaluates students. Happell (29) pointed out that even if the preceptors were not educators, they created their own sets of teaching skills, preserving and transmitting best practice in the context. Preceptors own views on their clinical competence have been reported in many studies of nurses by Meretoja and Leino-Kilpi (10, 11) and Salonen et al. (30), which reveal they feel most competent in the helping role, managing situations and diagnostic functions. A connection between the use of different competencies and length of work experience correlated positively with self-assessed competence. Rischel et al. (31) again noted that nurses have their own patterns of practice independent of the level of competence and length of experience, and that their competence seems to be situational. An important part of competence development, as the motivation to learn, is played by the learning environment, a good atmosphere at work and an encouraging management style, and the support of a named preceptor (18). The competence of nursing teachers was identied by Hanson and Stenvig (32) as a professional competence

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divided into teaching, nursing and evaluation abilities, and interpersonal relationships, and the need of clinical competence, which was also shown by Rossetti & Fox (33). Griscti et al. (34) again found that there was a variation in the teachers clinical role related to the possibilities they had to spend in practice, and consequently, teachers saw their role more didactic than preparing students for practice. Their study enlightened the need for teachers to adopt a more multifaceted clinical role, but as Maureen et al. (35) pointed out, there is a dilemma in balancing teaching and clinical competencies, even if teachers who are able to practise what they teach are regarded credible, inspirational and understanding. Teachers evaluate their clinical as well as their teaching competence mainly as high (36), and Benner and Sutphen (in (20) identied the characteristics of nursing teachers helping students integrate their intellectual capacities, skill-based clinical practice and ethical dimensions in nursing, as treating students as collaborators, engaging them in professional dialogues and exploring their thinking about ethical issues related to real patient cases.

Material and methods

The aim of this research was to look for evidence of how clinical competence shows itself in clinical practice and how this competence is built and maintained. The theoretical framework was based on Erikssons (13) concept denition on ontological evidence, meaning that the core of nursing, caring, becomes evident in thoughts, words, attitude and actions. Furthermore, evidence refers to the truth as using research and scientic knowledge, the beautiful as being skilful and the good as acting ethically and doing the best for the patients. As a way of triangulating and obtaining a fuller picture, three groups of informants were used, and the aim was approached with the help of following questions that widely explored different aspects of the concept. What characterises a clinically competent nurse? What is experienced as clinical competence in nursing? What contributes to clinical competence? How is clinical competence maintained? What is the relation between clinical competence and evidence-based nursing? In an attempt to reach as many as possible of the chosen informants, a qualitative questionnaire with 12 open questions, derived from the research questions, was distributed in spring 2006 to 3rd-year nursing students, preceptors and teachers. The questionnaire was piloted by a represent from each informant group. The piloting did not lead to any revision of the questions. The answers from all three groups of informants were combined to form the main categories that describe evidence of clinical competence.

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G.-B. Lejonqvist et al. procedures required by the university and by the university hospital were followed. The informants were informed, assured anonymity and condentiality and that their answers in no way would affect future collaboration, or in the case of the students their grades.

Participants and data collection

The contexts for the study were one university of applied sciences, and three wards representing different clinical contexts in a big university hospital setting in Finland, chosen with the help of nursing leaders for the units. All third-year students (N = 35) and all nursing teachers (N = 10) at the university of applied sciences and all the preceptors (N = 58) at the three wards were called to participate in the research. The students all had experience from several practical training placements. The teachers all worked within a nursing degree programme, and before becoming teachers, they had clinical experience as RNs. The preceptors were all RNs and had worked with nursing students for at least 2 years and were engaged as preceptors when answering the questionnaire. The questionnaires to the students were distributed by their teacher, to the preceptors by the nurse manager for the wards and to the teachers by the researcher. All informants had the possibility to discuss with the researcher. A reminder to ll in the questionnaires was sent out after 2 weeks, and the data collection lasted 4 weeks. The questionnaire was completed by 21 students, 21 preceptors and nine teachers, representing a response rate of 49.5%, and even if the responses from the preceptors were only 21, they well represented the different contexts. The data collection comprised 51 completed questionnaires, each consisting of four pages of open-ended questions.

Results
Clinical competence became evident in practice as encountering, knowing, performing, maturing and improving, as shown in Table 1. It was both a stage and an ongoing process, comprising an ontological and contextual dimension. The main categories of encountering, knowing and performing described the core of being clinically competent. Maturing concerned the growth of clinical competence, while improving concerned how clinical competence was rened and maintained. The relation between clinical competence and evidence-based practice could be seen in all categories and is further addressed in the following discussion, together with some implications for nursing education.

Encountering
Encounters with patients and their relatives were seen as a crucial part of clinical competence by all informants. Encountering was characterised by an interpersonal process, sensitivity and close relationships based on good morale. Encountering was described in the material as responsibility, doing good and humility. Responsibility was stressed by all informants as an important part of being competent, which meant being prepared for meeting the patient, having goals and a will to understand the patients needs and desires, as understanding ones limitations. Humility is a personal quality needed in encountering patients and coworkers and is in relation to knowledge and skills. Humility implied a willingness to learn, to listen to others and take advice, to acknowledge any mistakes made, but also to know when one has the required knowledge and skills to act. One student remarked: I know my own competence and understand when to ask for help. Taking into account the wishes of the patient is the ability to create a relation of sharing and trust where reecting upon and understanding the silent language of the patient was apparent. One preceptor wrote: I respect the wishes of the patient, meet severely ill, observe the silent message of the patient.

Data analysis
The data were analysed by qualitative inductive content analysis (37). Each question was coded separately, the unit of meaning being characteristics of clinical competence, experiences of clinical competence, what contributed to and maintained clinical competence, and the relation between evidence and clinical competence. The answers were read through one by one, and the units of meaning according to the research questions were underlined. As the responses were both in Swedish and in Finnish, the condensed expressions were translated directly from Swedish into English and directly from Finnish into English by the researcher, and a check was done by translating them back again into the original language. A native English-speaking teacher after that read through the manuscript and made correction suggestions, which were discussed with the researcher to nd the best corresponding concepts and words (38). The expressions were grouped into subcategories and brought together under main categories. As no big differences occurred in the answers from the three informant groups, a synthesis of all the answers was done. The study followed good ethical conduct, as described in the National Advisory Board on Research Ethics (39). The research was approved by the ethical committees in all research settings, and all ethical

Knowing
Almost all informants mentioned the importance of having the latest knowledge in the care of patients. Knowing

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Evidence of clinical competence

Table 1 The content analysis/evidence of clinical competence

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Condensation Acting ethically The good for the patient Interest Being warm and gentle Listening to the patients wishes Encountering patients with dignity and empathy Acting responsible Knowing limitations and asking for help Prepared for encountering the patient Knowing limitations and asking for help Having theoretical knowledge Using evidence in teaching Evidence as base for actions Finding knowledge Using theory as base for practice Knowing and reading research Up-dating ones knowledge Being aware of need for knowledge Reection Analysing nuances and variations Making decisions about care Thinking critically Knowledge from medicine, nursing and other disciplines Knowing diseases and symptoms Handling varying situations Skills of the hand Courage Good routines Having manual skills Using new technology Technical ability Mastering medical calculation and administration Having experience of care and different patients Working in different places Using common sense Having intuition Seeing what others do Work rotation to get new views on things Trying Rehearsing Doing again and again Keeping up with technological development Observation skills Handling stress Encountering patients Giving total care Understanding the patient as a whole person Flexibility Openness Interest Curiosity Empathy Engagement Thorough Active Motivated

Subcategories Doing good

Main categories/themes Encountering/preserving the dignity of the patient

Responsibility Humility Evident Knowing/using best available knowledge in the care of the individual patient

Current Critically evaluate

Interdisciplinary Condence Performing/condence and experience to give total care to the patient

Experience

Development

Individualisation

Pliant

Maturing/becoming a professional in nursing

Committed

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Table 1 (Continued)

Condensation Honest Firmness Calmness Experience Ability to take responsibility Self-condent Independency Communication skills Humility for the patient Cooperative Adaptive Professional identity Learning from others Working in different places Work rotation Feedback from others Deepen knowledge and skills Formulating goals Professional development Positive attitude learning new things Personal education Know where to nd knowledge Using literature as base for doing Self-studies and reading research Educational days Ability to learn and adopt new things Prepared for practice Look for learning possibilities Participating in research Motivating actions with evidence Working as preceptor and teaching others

Subcategories Condent

Main categories/themes

Connective

Sharing

Improving/developing oneself and the care of the patient

Learning

Teaching

meant being evident and current, being able to evaluate knowledge critically and using interdisciplinary knowledge as the basis for nursing. Knowing was using evidencebased current knowledge, from nursing, medicine and other disciplines, as well as being aware of the need for knowledge and where to nd it. The hospital wards are often highly specialised, making it difcult for new nurses and students to have the knowledge needed there, but possibilities to practise in different contexts and looking for the knowledge required played a major part in experiencing clinical competence. Reading and understanding research is a goal in nursing education today, and research in the eld is extensive. In bringing evidence alive, new coworkers and students could be a real inspiration, as one preceptor wrote: Students bring with them the newest knowledge. Most teachers and preceptors used evidence and based their actions on knowledge, but there were still preceptors who did not see the importance of evidence-based knowledge. One preceptor stated:

Hard to imagine which evidence to use in washing a diarrhea bottom. I cannot combine it (evidence) with practical tasks. Expert practice means making decisions in specic contexts, and research evidence only cannot resolve how to act in each individual situation, but it is important that nursing students and nurses appraise knowledge and skills in their profession, what is of value what is not, because it will affect competent performance (24). Seeing nursing students as part of the team can help develop new models and understanding for evidence-based practice, and is a good method of up-grading theoretical knowledge in practice.

Performing
Performing means having the condence to care. It is supported by experience and development and ultimately being able to give individual care to the patient. Performing therefore comprises mastering skills and procedures,

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Evidence of clinical competence using the latest technology and getting the job done; one supervisor wrote: (The work includes) mastering procedures and nursing programs, dealing with changeable situations. Performing in nursing means caring for various patients in constantly changing situations, and being condent and brave. It requires a form of practical knowledge, learnt by experience often based on intuition and common sense (18). One preceptor stated: Nursing is based on experience, and what older nurses teach the younger, if they feel it works they dont bother about new things. To use common sense is allowed. Even if experience and common sense are important tools in nursing, the use of evidence-based knowledge should be stressed. A demanding profession like nursing cannot be based on common sense and experience or by imitating elderly more experienced nurses (24). Good routines help the new nurse and nursing students to care, but seeing individual demands makes the performance excellent. One student wrote: In meeting the unique patient, (you need to) make use of all evidence-based knowledge, all required experience and design the best possible care for the patient.

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During clinical training I deepen my knowledge about diseases and care in the ward, I develop and strengthen my experience of being professional, develop my collaboration skills, and my communicative skills encountering both patients and relatives.

Improving
As knowledge and technology proceed, so does nursing. A growth is needed in knowledge and skills, and this is manifested as abilities to share, learn and teach. In a learning situation, each person shares his/her knowledge and skill with the others, and both students and teachers can transmit evidence to practise (27). Even if the teachers have many other tasks, their presence in practice is important (34, 35) both for the teachers themselves and for their clinical competence, as well as for the student and the preceptor. One teacher wrote: The teacher is the bridge between theory and practice, he/she should work together with the student and the preceptor. and one student continued: The teacher supports learning.helps to reect, enhances critical thinking.brings theory into practice. Improving while learning includes motivation, willingness, seeking learning opportunities and formulating goals. Taking in new knowledge, research and the growing technology are in line with the thought of life-long learning. Students and teachers acknowledge the need for continuous education mainly as following the latest research. The preceptors saw the need of continuing learning, but there is a strong belief in learning by doing, working and work rotation, even if also education, reading professional journals and following the latest research are mentioned, just as consulting colleagues, asking teachers or nurse students, or as using the net and reading books: (I improve my knowledge by) discussing care with experts, reading professional journals, looking for knowledge on the internet and by reading books. by connections to students and nursing schools. Being up-dated with the newest knowledge requires effort, and in nursing a lack of personnel is a problem that restricts learning opportunities. A critical statement from one student read: Nursing is mainly based on experience and on what more experienced nurses teach the younger, if what they are doing works, they do not care about new things or on what the actions are based. Transmitting the knowledge to students and coworkers, by mentoring, preceptoring and teaching is sharing. Teaching also requires a skill in teaching (34). As Paton (27) pointed out, preceptors are clinically competent but often create their own set of teaching skills without academic involvement. They preserve and transmit ideals of best

Maturing
Maturing means growing in the profession, becoming more competent and reaching the level of prociency (9). It is characterised by being pliant, committed, condent and connective. A competent nurse is pliant, she is exible and open to new experiences and interested in and curious about both patients and knowledge, as well as committed both to the profession and to the patient. One student expressed it as: (I need to) develop and strengthen my feeling of being professional, develop my abilities for teamwork.become more independent, making decisions, taking responsibility, reecting and thinking critically. Condence is based on knowing ones strengths and weaknesses and grows with knowledge and experiences (25) and affects the ability to take responsibility, to act calmly and rmly and depends on the support one gets (27). The possibilities to try, rehearse and plan opportunities to learn are of importance for maturing; one student expressed it as: When my preceptor trusts me and lets me take responsibility for some patients alone, I see that I can manage, and feel more condent. Nursing is teamwork, it requires cooperation and connection with the team members as with the patient (20). To be able to contribute to teamwork, one needs to have ones own clear professional identity and professional knowledge. One student remarked:

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G.-B. Lejonqvist et al. by trying and rehearsing. The ways of performing vary, but the aim is always the same, to give the best possible care to the patient. Maturing means becoming more and more pliant, committed, condent and connective to patients and coworkers. It is a process of personal development, being more and more able through thought, words and actions to make the essence of nursing evident in practice and not getting blinded by the context. Improving implies going beyond oneself (5) as sharing, learning and teaching in relation to both giving and receiving. An integrated ontological clinical competence makes it possible to contribute in multiprofessional teams, to share with and learn from others. Improving brings the condence that helps adopting new things and ideas to develop oneself, the working environment and the care of the patient. Clinical competence can be described rather as a process than a static stage. The foundation is in ontological clinical competence which is time persistent and quite independent of clinical practice, and of which the contextual clinical competence shows different contextually dependent variations. If ontological clinical competence is lacking, contextual competencies are built, applicable only in the contexts where they develop, and thereby affecting the possibilities to adapt to changing situations, because without ontological clinical competence, the meaning of nursing is lost in the change of context. Having ontological competence makes transfers easy because the basic structure enables learning the variations.

practice; they work as role models and teach students to see the context. According to one student, it requires: Knowledge to teach, that she knows what she is talking about and has evidence for what she is saying. In teaching clinical nursing, the preceptorship triad is important, consisting of the teacher, the preceptor and the student, all working together and contributing to growth of clinical competence in all parts.

Discussion
The aim of this research was to explore evidence of clinical competence in practice from the view of nursing students, clinical preceptors and teachers in nursing. The results revealed that clinical competence is seen as encountering, knowing, performing, maturing and improving. Similarities can be seen with earlier research (e.g. (47, 11, 20, 24, 27), but being a synthesis from three different perspectives, these results still contribute to the ongoing discussion. Clinical competence, moreover, showed in the material to be an ontological clinical competence, carrying the inner meaning of nursing and a contextual clinical competence developed in specic contexts. Encountering forms the ethical foundation in clinical competence, describing the relation between the nurse and patient, with the aim of doing good and preserving the dignity of the patient. This being the core of nursing, it forms the ontological clinical competence holding the primary substance of nursing, which becomes visible in thought, words and actions, and constitutes the culture of nursing. It is meaning-bearing and time-resistant and thereby transferable from context to context. An ontological clinical competence requires high moral, knowing, the ability to perform, a personal maturity and the courage to meet severely ill patients in various situations. Knowing is being evident, current, to critically evaluate existing knowledge and to use both nursing as interdisciplinary knowledge in practice for the benet of the patient. Knowing is based on knowledge from caring and nursing science, but develops and becomes more complex and multidisciplinary within a context, so a contextual clinical competence is built. The contextual clinical competence is variations of the ontological and dependent on context, or to quote Eriksson & Lindstrom (40) Our knowledge (and thereby the nursing competence) is always variations of the basic thesis:-to alleviate suffering is the main aim of caring caring is an act of mercy and love. The foundation is the same, the form, the means and the methods vary, as the need arises for more specic knowledge. Performing requires condence, experience, development of ones person, knowledge and skills to be able to give individual care to patients in various situations. Skills are combined with knowledge and the needs and wishes of the patient. The ability to perform develops during practice, and new skills required in specic contexts are gained

Implications for nursing and nursing education

It seems to be important to distinguish between an ontological and a contextual clinical competence in nursing and acknowledge that the ontological clinical competence should be reached during education, holding the foundations to practise common for all nurses. The denition of ontological clinical competence thereby should be operationalised in measurable categories and expressed in learning outcomes, for which this study offers a contribution. A contextual clinical competence can be reached only after experiences, and during education, students start developing contextual clinical competencies, which means students graduating have individual competence proles, depending on their clinical placements during education. The variations in the contextual clinical competencies should be seen as possibilities for the students to deepen their knowledge and skills, to design their own competence proles by goal-directed choices of practical training placements during education, and the possibilities to specialise in areas in line with their interest. Becoming clinically competent is a process where the triad consisting of nursing students, preceptors and

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Evidence of clinical competence teachers (27) should be regarded as a working team developing clinical competence, all parts being teachers and learners in the process, and each deepening their own and each others competence. Formulating aims for learning in clinical practice should consider strengthening the ontological clinical competence alongside developing the students contextual clinical competencies.

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Conict of interest
No conict of interest exists in publishing the paper. No sponsors have been engaged, the material has been gathered, analysed and is now being submitted by the author. Needed permissions for the research have been given from involved organisations and informants.

Ethical approval Author contribution

Katie Eriksson contributed to conception and design, and did the critical revision of the article and supervision. Riitta Meretoja contributed to conception and design, analysis and interpretation, and did the critical revision of the article and supervision. The Ethical Board of Arcada University of Applied Sciences, Helsinki. Hospital District of Helsinki and Uusimaa, Internal Medical Care Units, 40,16.6.2005. Hospital District of Helsinki and Uusimaa, Surgical Care Units, 55,19.8.2005. Hospital District of Helsinki and Uusimaa, Pediatric Care Units, 206, 20.6.2006.

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