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Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence
YNEDT-03119; No of Pages 6 Nurse Education Today xxx (2015) xxx–xxx
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence Kersti Theander a,⁎, Bodil Wilde-Larsson a,b, Marianne Carlsson c,d, Jan Florin e, Ann Gardulf f,g, Eva Johansson f,g,1, Christina Lindholm h, Gun Nordström a,b, Jan Nilsson a,g a
Faculty of Health, Science, and Technology, Department of Health Sciences, Karlstad University, Karlstad, Sweden Faculty of Public Health, Department of Nursing and Mental Health, Hedmark University College, Hedmark, Norway Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden d Faculty of Health and Occupational Studies, University of Gavle, Gavle, Sweden e School of Education, Health and Social Studies, Dalarna University, Falun, Sweden f The Unit for Clinical Nursing Research and for Clinical Research in Immunotherapy, Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital, Huddinge, Stockholm, Sweden g The Japan Red Cross Institute for Humanitarian Studies, Tokyo, Japan h Sophiahemmet University, Stockholm, Sweden b c
a r t i c l e
i n f o
Article history: Accepted 20 November 2015 Available online xxxx Keywords: Nurse competence Professional nursing Nursing education Nursing curriculum Nursing student NPC scale
s u m m a r y Background: Nursing competence is of significant importance for patient care. Newly graduated nursing students rate their competence as high. However, the impact of different designs of nursing curricula on nursing students' self-reported nursing competence areas is seldom reported. Objectives: To compare newly graduated nursing students' self-reported professional competence before and after the implementation of a new nursing curriculum. The study had a descriptive comparative design. Nursing students, who graduated in 2011, having studied according to an older curriculum, were compared with those who graduated in 2014, after a new nursing curriculum with more focus on person-centered nursing had been implemented. Setting: A higher education nursing program at a Swedish university. Participants: In total, 119 (2011 n = 69, 2014 n = 50) nursing students responded. Methods: Nursing students' self-reported professional competencies were assessed with the Nurse Professional Competence (NPC) scale. Results: There were no significant differences between the two groups of nursing students, who graduated in 2011 and 2014, respectively, with regard to age, sex, education, or work experience. Both groups rated their competencies as very high. Competence in value-based nursing was perceived to be significantly higher after the change in curriculum. The lowest competence, both in 2011 and 2014, was reported in education and supervision of staff and students. Conclusions: Our findings indicate that newly graduated nursing students – both those following the old curriculum and the first batch of students following the new one – perceive that their professional competence is high. Competence in value-based nursing, measured with the NPC scale, was reported higher after the implementation of a new curriculum, reflecting curriculum changes with more focus on person-centered nursing. © 2015 Elsevier Ltd. All rights reserved.
Introduction Healthcare systems require nurses to have the necessary knowledge and skills to deliver safe and high-quality patient care. In healthcare ⁎ Corresponding author at: Faculty of Health, Science, and Technology, Department of Health Sciences, Karlstad University, SE-651 88 Karlstad, Sweden. Tel.: +46 54 7001930. E-mail addresses: [email protected] (K. Theander), [email protected] (B. Wilde-Larsson), [email protected] (M. Carlsson), jfl@du.se (J. Florin), [email protected] (A. Gardulf), [email protected] (E. Johansson), [email protected] (C. Lindholm), [email protected] (G. Nordström), [email protected] (J. Nilsson). 1 Deceased.
today, there is an ongoing shift from patient-centered to person-centered care. A person-centered nursing framework is recognized as being effective in illness management (Dubois et al., 2008; Edvardsson et al., 2008; van Royen et al., 2010; Ekman et al., 2012). Preparing nursing students for person-centered care is a key concern for educators at nursing faculties around the world. Nursing care is constantly changing due to, e.g., increased research-based knowledge and also the organization of healthcare and support of care related to eHealth. Therefore, it is impossible “to teach students everything”; rather, they must be prepared to adapt to new knowledge and in different contexts. Although faculties are striving to develop curricula of the best possible quality, a
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Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
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gap is experienced between nursing theory and clinical reality (Burns and Poster, 2008; Ajani and Moez, 2011). This study will present how nursing students perceive their professional competence before and after changes in the nursing curriculum towards more person-centered nursing. Background Nursing competence General competence is described as “the ability to perform the task with desirable outcomes under the varied circumstances of the real world” (Benner, 1982, p. 304). There is no international consensus on an established definition of nursing competence, but in the USA, it has been proposed that quality and safety competencies for nurses should include: patient-centered care, teamwork and collaboration, evidencebased practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). A literature review performed in 2013 identified eight competencies for nursing students within Europe: professional and ethical values and practice; nursing skills and intervention; communication and interpersonal skills; knowledge and cognitive ability; assessment and improving quality in nursing; professional development; leadership, management and teamwork; and research utilization (Kajander-Unkuri et al., 2013). In Sweden, the National Board of Health and Welfare (2005) has stipulated formal competence requirements for registered nurses that serve as a basis for clinical nurses, as well as for educational purposes. A Nurse Professional Competence (NPC) scale was developed based on national competence requirements (Nilsson et al., 2014), which show many similarities with the US quality and safety competencies for nurses (Cronenwett et al., 2007). The NPC scale assesses the following eight competence areas: nursing care; value-based nursing; medical and technical care; teaching/learning and support; documentation and information technology; legislation in nursing and safety planning; leadership in and development of nursing; and education and supervision of staff and students. Swedish nursing education Swedish nursing education became part of the higher education system in 1977 (Kapborg, 1998), and since 1993 nursing students have followed a three-year curriculum, leading to a professional qualification as well as a Bachelor of Science degree. Guidelines for the design of the curriculum for nursing education are laid down in the Munich Declaration (WHO, 2009) and in national competence requirements (The Swedish National Board of Health and Welfare, 2005), which emphasize holistic and ethical conduct in nursing. The Swedish Higher Education Authority (SFS, 1992) stipulates that nursing education must be a three-year program. Further, the nursing education must consist of equal parts of theoretical and clinical courses, and be rooted in research-based knowledge. Each university must adhere to the national learning goals, but specific local learning goals may be included. This allows for slightly different profiles of nursing curricula between universities/university colleges. Change in the curriculum for nursing education The former curriculum (before 2011) for nursing education at university level was outlined in separate courses based on different disciplines, such as biomedicine, psychology, nursing, and clinical medicine. Nursing students started the first of totally six semesters with biomedicine and continued with separate courses in psychology, nursing, and clinical medicine, i.e., pathology and pharmacology (Fig. 1). It was not until the end of the three-year curriculum that the nursing students could integrate the different knowledge areas, and get a sense of the whole, i.e., what it meant to be a nurse.
The former curriculum consisted of separate learning rather than providing integrated learning. The new nursing curriculum, which was introduced in 2011, was based on Benner et al. (2010) and Iwasiw et al. (2009), and meant a shift from a strategy of teaching to a focus on students' learning. The pedagogical theoretical framework underpinning the new curriculum encompassed theory of variation, transfer, exemplarity, relevance, locus of control, and selfdirectedness (Marton and Booth, 1997). The point of departure was the professional clinical nursing practice where nursing students could focus on patients' experiences and symptoms of illness instead of patients' diseases. In addition, the aim of the new nursing curriculum was to contextualize knowledge by integrating subject matter, theory, and practice. Initially, the needs of healthy human beings are a topic for the course, followed by studies in nursing in relation to patients with specific symptoms and signs of illness, and finally the curriculum focuses on nursing in relation to patients with complex illnesses (Fig. 2). The clinical studies are person-centered, meaning that students follow their assigned patients instead of following the clinical instructor, thus increasing self-directedness, clinical decisionmaking, and preparedness for new situations. Students are expected to deepen their knowledge and reflective ability in clinical seminars where people's experiences are discussed. Reflection skills are further developed by participating in daily reflection sessions with their clinical supervisor, and in groups with specially trained tutors (Sundin-Andersson et al., 2013).
Nursing students' self-reported competence Previous research in relation to nursing students' self-reported competence at graduation is limited. In 2006, Löfmark et al. investigated Swedish nursing students using the Nurse Competence Scale (NCS), which includes the following competence categories: helping role, diagnostic functions, managing situations, work role, teaching/ coaching, therapeutic interventions, and ensuring quality (Meretoja et al., 2004). In the final week of their study, the Swedish nursing students reported that they were “good,” or that they perceived a strong development, in most of the competence categories of the NCS. Competencies in ethical awareness and communication/interaction with patients were scored highest (100%); the lowest score (67.6%) was for information and teaching co-workers and students (Löfmark et al., 2006). In Finland, nursing students assessed their overall competence as “good” at their final clinical placement. The competence was assessed highest regarding the helping role and diagnostics function and lowest in therapeutic interventions and work role (Kajander-Unkuri et al., 2013). In Austria, graduated nurses also rated their overall competence on the NCS as “good” (59.5 [VAS 0100]) during their first year (Hengsberger-Sims et al., 2008). In Norway, newly graduated nurses rated their overall competence as “good” (62.5 [VAS 0-100]) on the NCS. Helping role was rated high, i.e., it was the area in which students perceived they were most competent, and low scores were found in therapeutic interventions and ensuring quality (Wangensteen et al., 2012). However, the study was performed during the first year working as a registered nurse. In summary, studies of newly graduated nursing students indicate that the students rate their competence as good, but the studies differ in terms of areas of competence and measurements used. Unfortunately, none of these studies describe the nursing curriculum followed or make comparisons between ratings before and after the implementation of a new curriculum for nursing education. The aim was to compare newly graduated nursing students' selfreported professional competence before and after the implementation of a new nursing curriculum.
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
K. Theander et al. / Nurse Education Today xxx (2015) xxx–xxx First semester Biomedicine (Level A) Course components: Anantomy and Physiology, 15 ECTS credits Medical Microbiology, 7.5 ECTS credits Pathophysiology, 7.5 ECTS credits
Second semester Psychology (Level A) Course: Health Psychology, 7.5 ECTS credits
Nursing (Level A) Course component: Theoretical and Scientific Foundations in Nursing Research 22.5 ECTS credits (incl. Nursing Research I)
4 weeks of clinical studies
4 weeks of clinical studies Third semester Nursing (Level A) Course component: Clinical Nursing I, 7.5 ECTS credits
3
Clinical Medicine (Level B) Courses: Pathology and Pharmacology I, 6 ECTS credits (incl. Medical Technology) Drug Dosage Calculation 1.5 ECTS credits
Clinical Medicine (Level B) Course: Pathology and Pharmacology II, 7.5 ECTS credits (incl. Medical Technology)
Fourth semester Nursing (Level B) Course: Clinical Nursing II, 15 ECTS credits Clinical Medicine (Level B) Course: Pathology and Pharmacology III, 15 ECTS credits (incl. Medical Technology)
4 weeks of clinical studies 4 weeks of clinical studies Nursing (Level B) Course: Nursing Theories, Diagnostics and Documentation 7,5 ECTS credits 5 weeks of clinical studies
3 weeks of clinical studies
Fifth semester Nursing (Level B) Course: Nursing Research II, 7,5 ECTS credits
Nursing (Level C) Course: Nursing Research III: Degree Project, 15 ECTS credits
The course runs partly parallel to Nursing Research III
20 weeks of clinical studies
Elective Course Course relevant to the study programme, 7.5 ECTS credits
The course runs partly parallel to Nursing Research II
Sixth semester Nursing (Level C) Courses: Clinical Nursing IV, 7.5 ECTS credits Nursing Care Organization and Leadership
Clinical Medicine (Level B) Course: Pathology and Pharmacology IV, 7.5 ECTS credits (incl. Catastrophy Medicine) Can include clinical studies
16 weeks of clinical studies
Fig. 1. Overview of the old study program in nursing 180 ECTS credits.
Methods Design The study has a comparative design. Data derived from two samples of newly graduated nursing students (2011 and 2014) were compared. The group who graduated in 2011 studied according to an older nursing curriculum and those who graduated in 2014 started their studies after the implementation of a new nursing curriculum. Questionnaire Newly graduated nursing students' professional competence was measured with the NPC scale (Nilsson et al., 2014). The scale consists of eight competence areas including 88 items: nursing care (15 items), value-based nursing care (8 items), medical and technical care (10
First semester Nursing from a health perspective, 30 ECTS credits Comprising Clinical Studies 12 ECTS credits incl. Clinical trainee fieldwork 1.5 ECTS credits
Third semester Nursing in relation to symptoms and signs of illness I, 30 ECTS credits Comprising Clinical Studies 20 ECTS credits incl. Clinical field studies 15 ECTS credits
Fifth semester Nursing in relation to complex illness I, 22.5 ECTS credits Comprising Clinical Studies 15 ECTS credits incl. Clinical field studies 9 ECTS credits
Scientific methods in nursing, 7.5 ECTS credits
items), teaching/learning and support (11 items), documentation and information technology (4 items), legislation in nursing and safety planning (9 items), leadership in and development of nursing (26 items), and education and supervision of staff and students (5 items). Respondents were asked to tick a box to indicate their perceived degree of competence. Scores range from 1 = to a very low degree to 4 = to a very high degree. The items of the NPC scale were transformed to a scale from 1 to 100. The NPC scale has been validated with satisfactory psychometrical properties for newly graduated nursing students (Nilsson et al., 2014). In a previous study, the Cronbach's alpha for the different competence areas has varied from 0.75 to 0.94 (Nilsson et al., 2014). In this study, the Cronbach's alpha varied between 0.85 and 0.96. Background questions included data regarding age, sex, previous upper secondary education (classified as natural science, social science, auxiliary nursing, or other programs), university studies prior to nursing education and work experience prior to or during nursing education.
Second semester Fundamentals of Nursing, 30 ECTS credits Comprising Clinical Studies 18 ECTS credits, incl. Clinical trainee fieldwork 6 ECTS credits
Fourth semester Nursing in relation to symptoms and signs of ilness II, 15 ECTS credits Comprising Clinical Studies 10 ECTS credits incl. Clinical field studies 7.5 ECTS credits
Sixth semester Degree thesis in nursing, 15 ECTS credits
Elective course 7.5 ECTS credits Comprising Clinical Studies 5 ECTS credits
Elective course, 7.5 ECTS credits
Nursing in relation to complex illness II, 15 ECTS credits Comprising Clinical Studies 10 ECTS credits incl. Clinical field studies 9 ECTS credits
Fig. 2. Overview of the new study program in nursing 180 ECTS credits.
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
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K. Theander et al. / Nurse Education Today xxx (2015) xxx–xxx
Sample and procedure The nursing students responded to the NPC scale directly prior to their graduation (e.g., during the last week of their education). The head of the nursing program distributed the questionnaire. Of the 69 eligible nursing students in 2011, and 53 nursing students in 2014, a total of 119 filled in the questionnaire (2011 n = 69, 2014 n = 50), giving a response rate of 100% and 94% for 2011 and 2014, respectively. Statistical analyses Descriptive analyses are presented as frequencies and percentage for nominal data and mean and standard deviation for interval data. Differences between the two independent groups were analyzed with the chi-square test for nominal data and independent Student's t-test for interval data. Effect sizes (ES) were calculated to assess the importance of significant mean value differences. According to Cohen (1988), ES = 0.20–0.50 indicates a small difference, ES = 0.51–0.80 indicates a medium difference, and ES N 0.80 indicates a large difference. The level of statistical significance was set to b 0.05. Statistical analyses were performed by using SPSS for Windows, version 20 (SPSS Inc., Chicago, IL, USA). Ethical considerations According to current Swedish legislation on research ethics, it is not necessary to apply for approval from the ethics committee when conducting studies on students using questionnaires where no identifiable data are collected (Ministry of Education and Research, 2003). The principal of the university gave permission to conduct the study. In addition, the newly graduated students were given written information about the study and asked to participate prior to the data collection, and their contributions were based on voluntary participation. By responding to the questionnaire, the students gave their informed consent. The authors of the manuscripts are the owner of the NPC scale. Results There were no significant differences between newly graduated nursing students in 2011 (n = 69) and 2014 (n = 50) with regard to age, sex, previous education, university studies, or work experience prior to nursing education (Table 1). The mean age of the newly graduated nursing students in 2011 and 2014 was 28 and 27 years, respectively, and most of them (94% vs 96%) were women. Most of them had previously taken the three-year science program at upper secondary school level, and 22% vs 18% had taken the three-year auxiliary nursing program. The percentage of newly graduated nursing students who had undertaken university studies prior to nursing education was 30% vs 22%. Comparison of nursing students' self-reported professional competence Prior to their graduation, nursing students reported significantly higher competence in 2014, compared with 2011, in one out of the eight competence areas, i.e., value-based nursing. After the implementation of a new curriculum, there were no significant changes in the other competence areas: nursing care; medical and technical care; teaching/learning and support; documentation and information technology; legislation in nursing and safety planning; leadership and development of nursing; and education and supervision of staff and students. Both groups of newly graduated nursing students reported a very high degree of competence in all areas except for education and supervision of staff and students, which was rated lowest, but nevertheless given the rating “to a relatively high degree” (Table 2).
Table 1 Background characteristics for newly graduated nursing students in 2011 and 2014. Characteristics
Total, n = 119
Age, year mean (SD) 27 (7) Women, n (%) 113 (95) Men, n (%) 6 (5) Previous education at upper secondary school, n (%) 3-year natural science program 16 (13) 3-year social science program 43 (36) 3-year auxiliary nursing program 24 (20) Other programs 35 (29) University studies prior to nursing 32 (29) education, n (%) ECTS credits, mean (SD) 55 (47) Work experience in healthcare prior 74 (62) to nursing education, n (%) - As an auxiliary nurse, n (%) 38 (32) - As an assistant nurse, n (%) 37 (31) - As a personal assistant, n (%) 8 (7) - Other healthcare work (unspecified), 1 (1) n (%) Work experience in healthcare prior to 41 (55) nursing education in months, mean (SD) Working at the same time as studying, 89 (75) n (%)
2011, n = 69
2014, n = 50
p-value
28 (6) 27 (7) 0.508 65 (94) 48 (96) 0.658 4 (6) 2 (4) 0.236 12 (6) 4 (8) 25 (37) 18 (36) 15 (22) 9 (18) 16 (23) 19 (38) 21 (30) 11 (22) 0.306 62 (53) 37 (15) 0.068 47 (68) 27 (54) 0.117 22 (32) 13 (26) 0.676 25 (36) 15 (56) 0.469 6 (9) 2 (7) 0.384 1 (1) 0 (0) 0.635 48 (58) 28 (47) 0.126 48 (72) 41 (82) 0.194
ECTS, European Credit Transfer System.
Discussion The main result after the implementation of a new nursing curriculum for the three-year nursing program at a university in Sweden was that nursing students who had recently graduated from the new program rated their competence in value-based nursing higher than nursing students in the former program had done. The other competence areas were rated as “very high” (mean N 75), and only one competence area, education, and supervision of staff and students, was rated as “relatively high” (mean 69). None of the ratings for competence areas were lower after the implementation of the new nursing curriculum. The results are of interest from both an academic and a clinical perspective. Clinically, it can be seen that it is possible to improve competence areas, even those that are already evaluated as very high, and implement curricula with different profiles. Value-based nursing consists of skills and ability concerned with communication, humanistic values and holistic view, respect for patients' autonomy, integrity, dignity, different values, and beliefs. Acting on patients' and relatives' wishes and needs is also included in this competence area. These competencies are in line with the person-centered framework, which includes working with patients' beliefs and values, engagement, having sympathetic presence, sharing decision-making and providing for physical needs (McCormack and McCance, 2006). Table 2 Comparison of newly graduated nursing students' professional competence areas prior to their graduation in 2011 and 2014. Competence area
2011, n = 69 Mean (SD)
2014, n = 50 Mean (SD)
p-value d
Nursing care Value-based nursing Medical and technical care Teaching/learning and support Documentation and information technology Legislation in nursing and safety planning Leadership and development of nursing Education and supervision of staff and students
84.41 (10.27) 87.89 (9.66) 86.29 (10.04) 80.43 (10.65) 85.60 (12.14)
85.36 (9.27) 93.29 (6.41) 86.14 (9.62) 80.89 (9.86) 84.31 (11.20)
.618 .001 .939 .825 .559
.10 .66 .01 .04 .01
76.78 (12.43) 78.90 (11.05) .383
.18
76.39 (10.87) 78.15 (11.13) .454
.16
68.65 (16.15) 68.56 (14.28) .978
.01
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
K. Theander et al. / Nurse Education Today xxx (2015) xxx–xxx
It could be questioned why the scores for the competence area ‘nursing care’ did not differ after the new curriculum was implemented. A reason for this could be that the clinical care and learning environment are not in line with person-centered nursing, but steps are taken in relation to patient-focused care (Wilde-Larsson et al., 2014). As the care environment has a potential to limit or enhance the use of person-centered care processes (McCormack and McCance, 2006), evaluation of the care or learning environment is of great importance for students' learning. The new curriculum involved a shift from separate courses in different disciplines to integrated courses, and the starting point in the course, nursing from a health perspective, was communication and nursing relations, rather than cells or pathophysiology. During the whole program following the new curriculum, students also continued to have reflection sessions with clinical instructors and participated in a group supervision program with specially trained tutors (SundinAndersson et al., 2013) to support them in their professional role. In accordance with Benner's (1982) stages of clinical competence, it could be hypothesized that if nursing students have high competence in valuebased nursing, holistic understanding and integrated learning, this should improve their decision reasoning in patient care. Also, that participating in daily group reflection sessions will keep the students focused on patients' experiences and translate knowledge into practice that affects the nursing students' proficiency (Benner et al., 2010). However, further research is required in relation to the effects of a curriculum change on proficiency and becoming an expert nurse. From the clinical view, newly graduated nurses must be prepared for future demands and the shift from traditional acute care to caring for patients who have chronic and complex illnesses with multiple symptoms and difficulties (WHO, 2015). They must also be prepared for shortages of resources, and for a shift from secondary care to primary care, as well as from fragmented healthcare to integrated healthcare. Person-centered and integrated care can lead to more efficient and high-quality care (Van Royen et al., 2010; WHO, 2015). The students in this study rated their professional competence in value-based nursing, which is connected with person-centered care, as very high. Furthermore, the competencies required are related to those stipulated by the Swedish National Board of Health and Welfare (2005) and the new demands on professional nurses (Benner et al., 2010). Previous studies indicate that newly graduated nursing students have feelings of anxiety and uncertainty about their professional competence (Clark and Holmes, 2007; Wangensteen et al., 2010). The current study indicates that nursing students might overestimate their competence; other studies have shown indications that professional nurses rate their competence somewhat lower during their first year of practicing (Salonen et al., 2007; Hengsberger-Sims et al., 2008, Wangensteen et al., 2012). However, not surprisingly, frequent use of different competence areas results in increased competence, assessed with the NCS (Meretoja et al., 2004; Hengsberger-Sims et al., 2008; Wangensteen et al., 2012). Therefore, more research on the development of nurses' professional competence and determinants of professional competence during their professional life is of importance. The lowest level of competence in the present study was reported for education and supervision of staff and students. This competence area includes questions about supervision and teaching of co-workers/ staff and students in nursing and development work. Also included are questions concerning the introduction, education, and competence development of co-workers/staff; teams and the care chain; and coteaching of different healthcare professions, in order to provide patients with optimal care within a multidisciplinary approach. These are situations that students are prepared to take part in, in their final course. We do not know whether the students' learning environment included these situations; they might therefore not have had clinical training. Furthermore, these are situations where students need to be certain about their competence before supervising and teaching others. In studies with more experienced nurses, more frequent use of teaching/ coaching has been reported, measured with the NCS in Finland
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(Meretoja et al., 2004; Salonen et al., 2007). It is a challenge to improve this competence area during a nursing program. Nevertheless, competence in teaching/learning and support was evaluated higher. This competence includes teaching and learning situations in relation to patients and relatives.
Method discussion One of the strengths of this study is the use of a validated questionnaire (Nilsson et al., 2014) based on national requirements to assess nursing students' professional competence, prior to their graduation. The current study shows that the NPC scale is sensitive to change in terms of educational interventions. Also, the two groups of nursing students are very similar in characteristics, and this strengthens the prerequisites for comparisons of the two groups. The response rates are high (100% and 94%) but the sample sizes are relatively small (n = 69 and n = 50 respectively), and there is a potential risk of type 2 error (Altman, 1991). The use of a more experimental design using a control and intervention group with data collection before and after intervention could strengthen the study. Nevertheless, significant differences were found between nursing students who graduated in years 2011 and 2014, respectively, with regard to their selfreported professional competence in value-based nursing. The effect size of this difference (d = .66) might be interpreted as being of clinical relevance for nursing practice (Cohen, 1988).
Conclusion Our findings indicate that newly graduated nursing students perceive that their professional competence is high, after the intervention of a new nursing curriculum. Competence in value-based nursing, measured with the NPC scale, was reported higher after the intervention of the new nursing curriculum, indicating curriculum changes with greater focus on person-centered nursing. Education and supervision of staff and students is the competence area with the lowest scores in both samples. In order to develop these skills and improve the curriculum, a seminar on education for staff and/or supervision of students could for example be included during the students' clinical placement in their first semester. Person-centered nursing is recognized as being effective and important for quality of care and patient safety. The development of a new nursing curriculum based on integrated courses instead of separate courses seems promising in terms of producing registered nurses who provide more person-centered care. Further research with larger groups of students is warranted.
Author contribution Study design: Kersti Theander, Jan Nilsson, and Bodil Wilde-Larsson. Data collection: Kersti Theander. Data analyses: Kersti Theander, Jan Nilsson, Bodil Wilde-Larsson. Drafting of manuscript: Kersti Theander, Jan Nilsson, and Bodil Wilde-Larsson. Critical revisions: Marianne Carlsson, Jan Florin, Ann Gardulf, Eva Johansson, Christina Lindholm, and Gun Nordström.
Funding The researchers in this study were supported by local research allocations within their respective universities/university colleges.
Acknowledgments We are grateful to all the students who participated in the study.
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
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Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence Kersti Theander a,⁎, Bodil Wilde-Larsson a,b, Marianne Carlsson c,d, Jan Florin e, Ann Gardulf f,g, Eva Johansson f,g,1, Christina Lindholm h, Gun Nordström a,b, Jan Nilsson a,g a
Faculty of Health, Science, and Technology, Department of Health Sciences, Karlstad University, Karlstad, Sweden Faculty of Public Health, Department of Nursing and Mental Health, Hedmark University College, Hedmark, Norway Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden d Faculty of Health and Occupational Studies, University of Gavle, Gavle, Sweden e School of Education, Health and Social Studies, Dalarna University, Falun, Sweden f The Unit for Clinical Nursing Research and for Clinical Research in Immunotherapy, Division of Clinical Immunology, Department of Laboratory Medicine, Karolinska Institute at Karolinska University Hospital, Huddinge, Stockholm, Sweden g The Japan Red Cross Institute for Humanitarian Studies, Tokyo, Japan h Sophiahemmet University, Stockholm, Sweden b c
a r t i c l e
i n f o
Article history: Accepted 20 November 2015 Available online xxxx Keywords: Nurse competence Professional nursing Nursing education Nursing curriculum Nursing student NPC scale
s u m m a r y Background: Nursing competence is of significant importance for patient care. Newly graduated nursing students rate their competence as high. However, the impact of different designs of nursing curricula on nursing students' self-reported nursing competence areas is seldom reported. Objectives: To compare newly graduated nursing students' self-reported professional competence before and after the implementation of a new nursing curriculum. The study had a descriptive comparative design. Nursing students, who graduated in 2011, having studied according to an older curriculum, were compared with those who graduated in 2014, after a new nursing curriculum with more focus on person-centered nursing had been implemented. Setting: A higher education nursing program at a Swedish university. Participants: In total, 119 (2011 n = 69, 2014 n = 50) nursing students responded. Methods: Nursing students' self-reported professional competencies were assessed with the Nurse Professional Competence (NPC) scale. Results: There were no significant differences between the two groups of nursing students, who graduated in 2011 and 2014, respectively, with regard to age, sex, education, or work experience. Both groups rated their competencies as very high. Competence in value-based nursing was perceived to be significantly higher after the change in curriculum. The lowest competence, both in 2011 and 2014, was reported in education and supervision of staff and students. Conclusions: Our findings indicate that newly graduated nursing students – both those following the old curriculum and the first batch of students following the new one – perceive that their professional competence is high. Competence in value-based nursing, measured with the NPC scale, was reported higher after the implementation of a new curriculum, reflecting curriculum changes with more focus on person-centered nursing. © 2015 Elsevier Ltd. All rights reserved.
Introduction Healthcare systems require nurses to have the necessary knowledge and skills to deliver safe and high-quality patient care. In healthcare ⁎ Corresponding author at: Faculty of Health, Science, and Technology, Department of Health Sciences, Karlstad University, SE-651 88 Karlstad, Sweden. Tel.: +46 54 7001930. E-mail addresses: [email protected] (K. Theander), [email protected] (B. Wilde-Larsson), [email protected] (M. Carlsson), jfl@du.se (J. Florin), [email protected] (A. Gardulf), [email protected] (E. Johansson), [email protected] (C. Lindholm), [email protected] (G. Nordström), [email protected] (J. Nilsson). 1 Deceased.
today, there is an ongoing shift from patient-centered to person-centered care. A person-centered nursing framework is recognized as being effective in illness management (Dubois et al., 2008; Edvardsson et al., 2008; van Royen et al., 2010; Ekman et al., 2012). Preparing nursing students for person-centered care is a key concern for educators at nursing faculties around the world. Nursing care is constantly changing due to, e.g., increased research-based knowledge and also the organization of healthcare and support of care related to eHealth. Therefore, it is impossible “to teach students everything”; rather, they must be prepared to adapt to new knowledge and in different contexts. Although faculties are striving to develop curricula of the best possible quality, a
http://dx.doi.org/10.1016/j.nedt.2015.11.012 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
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gap is experienced between nursing theory and clinical reality (Burns and Poster, 2008; Ajani and Moez, 2011). This study will present how nursing students perceive their professional competence before and after changes in the nursing curriculum towards more person-centered nursing. Background Nursing competence General competence is described as “the ability to perform the task with desirable outcomes under the varied circumstances of the real world” (Benner, 1982, p. 304). There is no international consensus on an established definition of nursing competence, but in the USA, it has been proposed that quality and safety competencies for nurses should include: patient-centered care, teamwork and collaboration, evidencebased practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). A literature review performed in 2013 identified eight competencies for nursing students within Europe: professional and ethical values and practice; nursing skills and intervention; communication and interpersonal skills; knowledge and cognitive ability; assessment and improving quality in nursing; professional development; leadership, management and teamwork; and research utilization (Kajander-Unkuri et al., 2013). In Sweden, the National Board of Health and Welfare (2005) has stipulated formal competence requirements for registered nurses that serve as a basis for clinical nurses, as well as for educational purposes. A Nurse Professional Competence (NPC) scale was developed based on national competence requirements (Nilsson et al., 2014), which show many similarities with the US quality and safety competencies for nurses (Cronenwett et al., 2007). The NPC scale assesses the following eight competence areas: nursing care; value-based nursing; medical and technical care; teaching/learning and support; documentation and information technology; legislation in nursing and safety planning; leadership in and development of nursing; and education and supervision of staff and students. Swedish nursing education Swedish nursing education became part of the higher education system in 1977 (Kapborg, 1998), and since 1993 nursing students have followed a three-year curriculum, leading to a professional qualification as well as a Bachelor of Science degree. Guidelines for the design of the curriculum for nursing education are laid down in the Munich Declaration (WHO, 2009) and in national competence requirements (The Swedish National Board of Health and Welfare, 2005), which emphasize holistic and ethical conduct in nursing. The Swedish Higher Education Authority (SFS, 1992) stipulates that nursing education must be a three-year program. Further, the nursing education must consist of equal parts of theoretical and clinical courses, and be rooted in research-based knowledge. Each university must adhere to the national learning goals, but specific local learning goals may be included. This allows for slightly different profiles of nursing curricula between universities/university colleges. Change in the curriculum for nursing education The former curriculum (before 2011) for nursing education at university level was outlined in separate courses based on different disciplines, such as biomedicine, psychology, nursing, and clinical medicine. Nursing students started the first of totally six semesters with biomedicine and continued with separate courses in psychology, nursing, and clinical medicine, i.e., pathology and pharmacology (Fig. 1). It was not until the end of the three-year curriculum that the nursing students could integrate the different knowledge areas, and get a sense of the whole, i.e., what it meant to be a nurse.
The former curriculum consisted of separate learning rather than providing integrated learning. The new nursing curriculum, which was introduced in 2011, was based on Benner et al. (2010) and Iwasiw et al. (2009), and meant a shift from a strategy of teaching to a focus on students' learning. The pedagogical theoretical framework underpinning the new curriculum encompassed theory of variation, transfer, exemplarity, relevance, locus of control, and selfdirectedness (Marton and Booth, 1997). The point of departure was the professional clinical nursing practice where nursing students could focus on patients' experiences and symptoms of illness instead of patients' diseases. In addition, the aim of the new nursing curriculum was to contextualize knowledge by integrating subject matter, theory, and practice. Initially, the needs of healthy human beings are a topic for the course, followed by studies in nursing in relation to patients with specific symptoms and signs of illness, and finally the curriculum focuses on nursing in relation to patients with complex illnesses (Fig. 2). The clinical studies are person-centered, meaning that students follow their assigned patients instead of following the clinical instructor, thus increasing self-directedness, clinical decisionmaking, and preparedness for new situations. Students are expected to deepen their knowledge and reflective ability in clinical seminars where people's experiences are discussed. Reflection skills are further developed by participating in daily reflection sessions with their clinical supervisor, and in groups with specially trained tutors (Sundin-Andersson et al., 2013).
Nursing students' self-reported competence Previous research in relation to nursing students' self-reported competence at graduation is limited. In 2006, Löfmark et al. investigated Swedish nursing students using the Nurse Competence Scale (NCS), which includes the following competence categories: helping role, diagnostic functions, managing situations, work role, teaching/ coaching, therapeutic interventions, and ensuring quality (Meretoja et al., 2004). In the final week of their study, the Swedish nursing students reported that they were “good,” or that they perceived a strong development, in most of the competence categories of the NCS. Competencies in ethical awareness and communication/interaction with patients were scored highest (100%); the lowest score (67.6%) was for information and teaching co-workers and students (Löfmark et al., 2006). In Finland, nursing students assessed their overall competence as “good” at their final clinical placement. The competence was assessed highest regarding the helping role and diagnostics function and lowest in therapeutic interventions and work role (Kajander-Unkuri et al., 2013). In Austria, graduated nurses also rated their overall competence on the NCS as “good” (59.5 [VAS 0100]) during their first year (Hengsberger-Sims et al., 2008). In Norway, newly graduated nurses rated their overall competence as “good” (62.5 [VAS 0-100]) on the NCS. Helping role was rated high, i.e., it was the area in which students perceived they were most competent, and low scores were found in therapeutic interventions and ensuring quality (Wangensteen et al., 2012). However, the study was performed during the first year working as a registered nurse. In summary, studies of newly graduated nursing students indicate that the students rate their competence as good, but the studies differ in terms of areas of competence and measurements used. Unfortunately, none of these studies describe the nursing curriculum followed or make comparisons between ratings before and after the implementation of a new curriculum for nursing education. The aim was to compare newly graduated nursing students' selfreported professional competence before and after the implementation of a new nursing curriculum.
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
K. Theander et al. / Nurse Education Today xxx (2015) xxx–xxx First semester Biomedicine (Level A) Course components: Anantomy and Physiology, 15 ECTS credits Medical Microbiology, 7.5 ECTS credits Pathophysiology, 7.5 ECTS credits
Second semester Psychology (Level A) Course: Health Psychology, 7.5 ECTS credits
Nursing (Level A) Course component: Theoretical and Scientific Foundations in Nursing Research 22.5 ECTS credits (incl. Nursing Research I)
4 weeks of clinical studies
4 weeks of clinical studies Third semester Nursing (Level A) Course component: Clinical Nursing I, 7.5 ECTS credits
3
Clinical Medicine (Level B) Courses: Pathology and Pharmacology I, 6 ECTS credits (incl. Medical Technology) Drug Dosage Calculation 1.5 ECTS credits
Clinical Medicine (Level B) Course: Pathology and Pharmacology II, 7.5 ECTS credits (incl. Medical Technology)
Fourth semester Nursing (Level B) Course: Clinical Nursing II, 15 ECTS credits Clinical Medicine (Level B) Course: Pathology and Pharmacology III, 15 ECTS credits (incl. Medical Technology)
4 weeks of clinical studies 4 weeks of clinical studies Nursing (Level B) Course: Nursing Theories, Diagnostics and Documentation 7,5 ECTS credits 5 weeks of clinical studies
3 weeks of clinical studies
Fifth semester Nursing (Level B) Course: Nursing Research II, 7,5 ECTS credits
Nursing (Level C) Course: Nursing Research III: Degree Project, 15 ECTS credits
The course runs partly parallel to Nursing Research III
20 weeks of clinical studies
Elective Course Course relevant to the study programme, 7.5 ECTS credits
The course runs partly parallel to Nursing Research II
Sixth semester Nursing (Level C) Courses: Clinical Nursing IV, 7.5 ECTS credits Nursing Care Organization and Leadership
Clinical Medicine (Level B) Course: Pathology and Pharmacology IV, 7.5 ECTS credits (incl. Catastrophy Medicine) Can include clinical studies
16 weeks of clinical studies
Fig. 1. Overview of the old study program in nursing 180 ECTS credits.
Methods Design The study has a comparative design. Data derived from two samples of newly graduated nursing students (2011 and 2014) were compared. The group who graduated in 2011 studied according to an older nursing curriculum and those who graduated in 2014 started their studies after the implementation of a new nursing curriculum. Questionnaire Newly graduated nursing students' professional competence was measured with the NPC scale (Nilsson et al., 2014). The scale consists of eight competence areas including 88 items: nursing care (15 items), value-based nursing care (8 items), medical and technical care (10
First semester Nursing from a health perspective, 30 ECTS credits Comprising Clinical Studies 12 ECTS credits incl. Clinical trainee fieldwork 1.5 ECTS credits
Third semester Nursing in relation to symptoms and signs of illness I, 30 ECTS credits Comprising Clinical Studies 20 ECTS credits incl. Clinical field studies 15 ECTS credits
Fifth semester Nursing in relation to complex illness I, 22.5 ECTS credits Comprising Clinical Studies 15 ECTS credits incl. Clinical field studies 9 ECTS credits
Scientific methods in nursing, 7.5 ECTS credits
items), teaching/learning and support (11 items), documentation and information technology (4 items), legislation in nursing and safety planning (9 items), leadership in and development of nursing (26 items), and education and supervision of staff and students (5 items). Respondents were asked to tick a box to indicate their perceived degree of competence. Scores range from 1 = to a very low degree to 4 = to a very high degree. The items of the NPC scale were transformed to a scale from 1 to 100. The NPC scale has been validated with satisfactory psychometrical properties for newly graduated nursing students (Nilsson et al., 2014). In a previous study, the Cronbach's alpha for the different competence areas has varied from 0.75 to 0.94 (Nilsson et al., 2014). In this study, the Cronbach's alpha varied between 0.85 and 0.96. Background questions included data regarding age, sex, previous upper secondary education (classified as natural science, social science, auxiliary nursing, or other programs), university studies prior to nursing education and work experience prior to or during nursing education.
Second semester Fundamentals of Nursing, 30 ECTS credits Comprising Clinical Studies 18 ECTS credits, incl. Clinical trainee fieldwork 6 ECTS credits
Fourth semester Nursing in relation to symptoms and signs of ilness II, 15 ECTS credits Comprising Clinical Studies 10 ECTS credits incl. Clinical field studies 7.5 ECTS credits
Sixth semester Degree thesis in nursing, 15 ECTS credits
Elective course 7.5 ECTS credits Comprising Clinical Studies 5 ECTS credits
Elective course, 7.5 ECTS credits
Nursing in relation to complex illness II, 15 ECTS credits Comprising Clinical Studies 10 ECTS credits incl. Clinical field studies 9 ECTS credits
Fig. 2. Overview of the new study program in nursing 180 ECTS credits.
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
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K. Theander et al. / Nurse Education Today xxx (2015) xxx–xxx
Sample and procedure The nursing students responded to the NPC scale directly prior to their graduation (e.g., during the last week of their education). The head of the nursing program distributed the questionnaire. Of the 69 eligible nursing students in 2011, and 53 nursing students in 2014, a total of 119 filled in the questionnaire (2011 n = 69, 2014 n = 50), giving a response rate of 100% and 94% for 2011 and 2014, respectively. Statistical analyses Descriptive analyses are presented as frequencies and percentage for nominal data and mean and standard deviation for interval data. Differences between the two independent groups were analyzed with the chi-square test for nominal data and independent Student's t-test for interval data. Effect sizes (ES) were calculated to assess the importance of significant mean value differences. According to Cohen (1988), ES = 0.20–0.50 indicates a small difference, ES = 0.51–0.80 indicates a medium difference, and ES N 0.80 indicates a large difference. The level of statistical significance was set to b 0.05. Statistical analyses were performed by using SPSS for Windows, version 20 (SPSS Inc., Chicago, IL, USA). Ethical considerations According to current Swedish legislation on research ethics, it is not necessary to apply for approval from the ethics committee when conducting studies on students using questionnaires where no identifiable data are collected (Ministry of Education and Research, 2003). The principal of the university gave permission to conduct the study. In addition, the newly graduated students were given written information about the study and asked to participate prior to the data collection, and their contributions were based on voluntary participation. By responding to the questionnaire, the students gave their informed consent. The authors of the manuscripts are the owner of the NPC scale. Results There were no significant differences between newly graduated nursing students in 2011 (n = 69) and 2014 (n = 50) with regard to age, sex, previous education, university studies, or work experience prior to nursing education (Table 1). The mean age of the newly graduated nursing students in 2011 and 2014 was 28 and 27 years, respectively, and most of them (94% vs 96%) were women. Most of them had previously taken the three-year science program at upper secondary school level, and 22% vs 18% had taken the three-year auxiliary nursing program. The percentage of newly graduated nursing students who had undertaken university studies prior to nursing education was 30% vs 22%. Comparison of nursing students' self-reported professional competence Prior to their graduation, nursing students reported significantly higher competence in 2014, compared with 2011, in one out of the eight competence areas, i.e., value-based nursing. After the implementation of a new curriculum, there were no significant changes in the other competence areas: nursing care; medical and technical care; teaching/learning and support; documentation and information technology; legislation in nursing and safety planning; leadership and development of nursing; and education and supervision of staff and students. Both groups of newly graduated nursing students reported a very high degree of competence in all areas except for education and supervision of staff and students, which was rated lowest, but nevertheless given the rating “to a relatively high degree” (Table 2).
Table 1 Background characteristics for newly graduated nursing students in 2011 and 2014. Characteristics
Total, n = 119
Age, year mean (SD) 27 (7) Women, n (%) 113 (95) Men, n (%) 6 (5) Previous education at upper secondary school, n (%) 3-year natural science program 16 (13) 3-year social science program 43 (36) 3-year auxiliary nursing program 24 (20) Other programs 35 (29) University studies prior to nursing 32 (29) education, n (%) ECTS credits, mean (SD) 55 (47) Work experience in healthcare prior 74 (62) to nursing education, n (%) - As an auxiliary nurse, n (%) 38 (32) - As an assistant nurse, n (%) 37 (31) - As a personal assistant, n (%) 8 (7) - Other healthcare work (unspecified), 1 (1) n (%) Work experience in healthcare prior to 41 (55) nursing education in months, mean (SD) Working at the same time as studying, 89 (75) n (%)
2011, n = 69
2014, n = 50
p-value
28 (6) 27 (7) 0.508 65 (94) 48 (96) 0.658 4 (6) 2 (4) 0.236 12 (6) 4 (8) 25 (37) 18 (36) 15 (22) 9 (18) 16 (23) 19 (38) 21 (30) 11 (22) 0.306 62 (53) 37 (15) 0.068 47 (68) 27 (54) 0.117 22 (32) 13 (26) 0.676 25 (36) 15 (56) 0.469 6 (9) 2 (7) 0.384 1 (1) 0 (0) 0.635 48 (58) 28 (47) 0.126 48 (72) 41 (82) 0.194
ECTS, European Credit Transfer System.
Discussion The main result after the implementation of a new nursing curriculum for the three-year nursing program at a university in Sweden was that nursing students who had recently graduated from the new program rated their competence in value-based nursing higher than nursing students in the former program had done. The other competence areas were rated as “very high” (mean N 75), and only one competence area, education, and supervision of staff and students, was rated as “relatively high” (mean 69). None of the ratings for competence areas were lower after the implementation of the new nursing curriculum. The results are of interest from both an academic and a clinical perspective. Clinically, it can be seen that it is possible to improve competence areas, even those that are already evaluated as very high, and implement curricula with different profiles. Value-based nursing consists of skills and ability concerned with communication, humanistic values and holistic view, respect for patients' autonomy, integrity, dignity, different values, and beliefs. Acting on patients' and relatives' wishes and needs is also included in this competence area. These competencies are in line with the person-centered framework, which includes working with patients' beliefs and values, engagement, having sympathetic presence, sharing decision-making and providing for physical needs (McCormack and McCance, 2006). Table 2 Comparison of newly graduated nursing students' professional competence areas prior to their graduation in 2011 and 2014. Competence area
2011, n = 69 Mean (SD)
2014, n = 50 Mean (SD)
p-value d
Nursing care Value-based nursing Medical and technical care Teaching/learning and support Documentation and information technology Legislation in nursing and safety planning Leadership and development of nursing Education and supervision of staff and students
84.41 (10.27) 87.89 (9.66) 86.29 (10.04) 80.43 (10.65) 85.60 (12.14)
85.36 (9.27) 93.29 (6.41) 86.14 (9.62) 80.89 (9.86) 84.31 (11.20)
.618 .001 .939 .825 .559
.10 .66 .01 .04 .01
76.78 (12.43) 78.90 (11.05) .383
.18
76.39 (10.87) 78.15 (11.13) .454
.16
68.65 (16.15) 68.56 (14.28) .978
.01
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
K. Theander et al. / Nurse Education Today xxx (2015) xxx–xxx
It could be questioned why the scores for the competence area ‘nursing care’ did not differ after the new curriculum was implemented. A reason for this could be that the clinical care and learning environment are not in line with person-centered nursing, but steps are taken in relation to patient-focused care (Wilde-Larsson et al., 2014). As the care environment has a potential to limit or enhance the use of person-centered care processes (McCormack and McCance, 2006), evaluation of the care or learning environment is of great importance for students' learning. The new curriculum involved a shift from separate courses in different disciplines to integrated courses, and the starting point in the course, nursing from a health perspective, was communication and nursing relations, rather than cells or pathophysiology. During the whole program following the new curriculum, students also continued to have reflection sessions with clinical instructors and participated in a group supervision program with specially trained tutors (SundinAndersson et al., 2013) to support them in their professional role. In accordance with Benner's (1982) stages of clinical competence, it could be hypothesized that if nursing students have high competence in valuebased nursing, holistic understanding and integrated learning, this should improve their decision reasoning in patient care. Also, that participating in daily group reflection sessions will keep the students focused on patients' experiences and translate knowledge into practice that affects the nursing students' proficiency (Benner et al., 2010). However, further research is required in relation to the effects of a curriculum change on proficiency and becoming an expert nurse. From the clinical view, newly graduated nurses must be prepared for future demands and the shift from traditional acute care to caring for patients who have chronic and complex illnesses with multiple symptoms and difficulties (WHO, 2015). They must also be prepared for shortages of resources, and for a shift from secondary care to primary care, as well as from fragmented healthcare to integrated healthcare. Person-centered and integrated care can lead to more efficient and high-quality care (Van Royen et al., 2010; WHO, 2015). The students in this study rated their professional competence in value-based nursing, which is connected with person-centered care, as very high. Furthermore, the competencies required are related to those stipulated by the Swedish National Board of Health and Welfare (2005) and the new demands on professional nurses (Benner et al., 2010). Previous studies indicate that newly graduated nursing students have feelings of anxiety and uncertainty about their professional competence (Clark and Holmes, 2007; Wangensteen et al., 2010). The current study indicates that nursing students might overestimate their competence; other studies have shown indications that professional nurses rate their competence somewhat lower during their first year of practicing (Salonen et al., 2007; Hengsberger-Sims et al., 2008, Wangensteen et al., 2012). However, not surprisingly, frequent use of different competence areas results in increased competence, assessed with the NCS (Meretoja et al., 2004; Hengsberger-Sims et al., 2008; Wangensteen et al., 2012). Therefore, more research on the development of nurses' professional competence and determinants of professional competence during their professional life is of importance. The lowest level of competence in the present study was reported for education and supervision of staff and students. This competence area includes questions about supervision and teaching of co-workers/ staff and students in nursing and development work. Also included are questions concerning the introduction, education, and competence development of co-workers/staff; teams and the care chain; and coteaching of different healthcare professions, in order to provide patients with optimal care within a multidisciplinary approach. These are situations that students are prepared to take part in, in their final course. We do not know whether the students' learning environment included these situations; they might therefore not have had clinical training. Furthermore, these are situations where students need to be certain about their competence before supervising and teaching others. In studies with more experienced nurses, more frequent use of teaching/ coaching has been reported, measured with the NCS in Finland
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(Meretoja et al., 2004; Salonen et al., 2007). It is a challenge to improve this competence area during a nursing program. Nevertheless, competence in teaching/learning and support was evaluated higher. This competence includes teaching and learning situations in relation to patients and relatives.
Method discussion One of the strengths of this study is the use of a validated questionnaire (Nilsson et al., 2014) based on national requirements to assess nursing students' professional competence, prior to their graduation. The current study shows that the NPC scale is sensitive to change in terms of educational interventions. Also, the two groups of nursing students are very similar in characteristics, and this strengthens the prerequisites for comparisons of the two groups. The response rates are high (100% and 94%) but the sample sizes are relatively small (n = 69 and n = 50 respectively), and there is a potential risk of type 2 error (Altman, 1991). The use of a more experimental design using a control and intervention group with data collection before and after intervention could strengthen the study. Nevertheless, significant differences were found between nursing students who graduated in years 2011 and 2014, respectively, with regard to their selfreported professional competence in value-based nursing. The effect size of this difference (d = .66) might be interpreted as being of clinical relevance for nursing practice (Cohen, 1988).
Conclusion Our findings indicate that newly graduated nursing students perceive that their professional competence is high, after the intervention of a new nursing curriculum. Competence in value-based nursing, measured with the NPC scale, was reported higher after the intervention of the new nursing curriculum, indicating curriculum changes with greater focus on person-centered nursing. Education and supervision of staff and students is the competence area with the lowest scores in both samples. In order to develop these skills and improve the curriculum, a seminar on education for staff and/or supervision of students could for example be included during the students' clinical placement in their first semester. Person-centered nursing is recognized as being effective and important for quality of care and patient safety. The development of a new nursing curriculum based on integrated courses instead of separate courses seems promising in terms of producing registered nurses who provide more person-centered care. Further research with larger groups of students is warranted.
Author contribution Study design: Kersti Theander, Jan Nilsson, and Bodil Wilde-Larsson. Data collection: Kersti Theander. Data analyses: Kersti Theander, Jan Nilsson, Bodil Wilde-Larsson. Drafting of manuscript: Kersti Theander, Jan Nilsson, and Bodil Wilde-Larsson. Critical revisions: Marianne Carlsson, Jan Florin, Ann Gardulf, Eva Johansson, Christina Lindholm, and Gun Nordström.
Funding The researchers in this study were supported by local research allocations within their respective universities/university colleges.
Acknowledgments We are grateful to all the students who participated in the study.
Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012
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Please cite this article as: Theander, K., et al., Adjusting to future demands in healthcare: Curriculum changes and nursing students' self-reported professional competence, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.11.012