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Essential clinical skills for beginning registered nurses
Article
Essential clinical skills for beginning registered nurses Elaine Boxer and Birgit Kluge
A research project investigating the identification of essential clinical skills for registered nurses in their first year of practice was undertaken in a number of Sydney metropolitan hospitals in Australia. Using an adaptation of the Williams & Brammer (1996) study, 206 beginning registered nurses were surveyed to determine the clinical skills they performed frequently in their daily routine, and those they considered essential. One hundred and thirty two questionnaires were returned and the responses were analysed for frequency of clinical skill performance and essential rating. The clinical skills rated as most frequently performed related to universal precautions for infection control, vital sign assessment, management of intravenous therapy, administration of all forms of medication and a wide range of patient hygiene related skills. Many clinical skills rated as essential by these nurses were not rated as performed frequently, which may indicate concern for the need to draw upon less frequently performed skills during emergency situations and thus they rate these skills as essential. This study clearly identified the clinical skills rated as performed frequently by beginning registered nurses and identified those clinical skills deemed essential to beginning nursing practice by novice nurses. A larger sample size would strengthen the reliability of these findings. © 2000 Harcourt Publishers Ltd
Introduction
Elaine Boxer RN, BEd, MN, Senior Lecturer, Birgit Kluge RN, MN, Nurse Educator, School of Nursing, Australian Catholic University, P.O. Box 968, North Sydney NSW 2059, Australia. Tel.: 02 97392359; Fax: 02 97392342; E-mail: e.boxer@mackillop .acu.edu.au (Requests for offprints to E B) Manuscript accepted: 9 September 1999
This study to determine the essential skills required by beginning registered nurses was conducted in the Sydney metropolitan area in public and private hospitals. The purpose of the study was to identify which clinical nursing skills new graduates nurses rated as performed frequently and considered essential in their first year of practice. The study was based on a project undertaken by Williams & Brammer (1996) in Queensland using a slightly modified tool to suit the health care service in NSW. Replication of the Williams & Brammer (1996) study was undertaken to determine whether their findings would be true for new graduate nurses in New South Wales (Burns & Grove 1987). A clear need for the teaching of clinical skills either in a simulated setting or in the clinical field has been described in the literature (Alavi et al. 1991, Gomez & Gomez 1984, Koh 1996, McAdams et al. 1988, Neary 1994, Neighbours et al. 1991,
© 2000 Harcourt Publishers Ltd doi:10.1054/nedt.1999.0415, available online at http://www.idealibrary.com on
Pratt 1989, Reilly & Oermann 1985). These authors identified advantages and disadvantages of both simulated and clinical teaching and proposed ways of ensuring that the most value was gained from the teaching method used. However, there were few recent studies that attempted to identify the essential clinical skills for new graduate nurses which would ensure adequate preparation for their first year of clinical practice. Pelletier (1995) attempted to identify technical skills related to clinical equipment and surveyed new graduate nurses on nine technical skills. This study concluded that there is an increasing use of technological equipment in the clinical area which new graduate nurses need to be able to use confidently. Kieffer (1984) surveyed experienced registered nurses on 154 skills that they considered to be most frequently performed and most important in the clinical area in which they were employed. Consensus on importance and frequency in this study was reached for 25% of
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the skills and included categories such as assessment of vital signs, assisting with mobilizing, elimination, hygiene, sterile technique and asepsis and medication administration. The choice of skills to be included in the undergraduate nursing degree was also studied extensively by Sweeney & Regan (1982) and Reilly & Oermann (1985). Sweeny & Regan (1982) surveyed experienced registered nurses, nurse academics and new graduate nurses to determine whether 291 skills were essential, bonus, graduate or non-nursing. Consensus across the three groups was achieved for 51% of the skills. Reilly & Oermann (1985) developed curriculum implementation guidelines from Sweeny & Regan’s (1982) list of 291 skills. There were two major studies in the Australian context that attempted to identify the skills required for beginning practice and the level of competence needed for these skills (Alavi et al. 1991, Pratt 1989). These studies varied in their methods as Pratt (1989) surveyed new graduates on 154 skills while Alavi et al. (1991) surveyed experienced clinical staff and nurse academics on 84 skills. Both studies provide a list of core skills to be considered for inclusion in undergraduate nursing programs. A more recent study by Madjar et al. (1997) found that beginning registered nurses had expected to be competent in the performance of clinical skills on entry to practice. In the same study, other ward nurses also expected this to be the case. This expectation reinforces the need for identification of the most important clinical skills to be taught in nursing education programs. As the health care system has changed over the last ten years, there is a need to re-examine the clinical skills being taught to undergraduate nursing students for currency and technological relevance.
Methods Unlike the Williams & Brammer (1996) study, which included participants from clinical specialty areas such as mental health, paediatric and maternity settings, this study focussed on acute medical and surgical areas. It was considered that such a sample was representative of the beginning nurse workforce in New South Wales.
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A self-selected purposive sample of 206 beginning registered nurses with clinical experience in acute medical and surgical nursing ranging from 6–12 months was drawn from the cohort of the 1997 New Graduate Nurse Recruitment Consortium. The majority of new graduates in the Sydney metropolitan area are recruited by this Consortium. These new graduates had commenced employment on a Transitional Support Program (TSP) from January 1997 and were employed in either a large metropolitan teaching or smaller community hospital. Following ethical approval at each of six proposed sites (four large metropolitan teaching and two small metropolitan community hospitals) the program coordinators of the TSPs were invited to assist in facilitating this research study. They were informed about the content of the study and the selection criteria for prospective participants. The new graduates were recruited by these coordinators and asked to return the completed questionnaire to a central location nominated by the coordinator, where they were collected by the researchers. The higher than average response rate (64.6%, n = 132) could be explained by the utilization of the network of program coordinators to encourage new graduates to complete the questionnaire. The survey instrument was adapted from the original study, however minimal amendments were made according to clinical relevance for current acute care nursing practice and to allow for differences between the NSW and Queensland health care systems. The changes to the instrument included the addition of basic life support, universal precaution procedures and information technology as clinical skills to be surveyed. The original instrument required a frequency response ranging from A – At least daily to N – Never. This was amended by adding one further category representing ‘More Than Twice Daily’. It was considered that this category would allow participants a more descriptive response. Both the reliability and the validity of the instrument were confirmed in the original study following a pilot study using the questionnaire, and as only minor amendments were made to the instrument for this study it was felt that neither validity nor reliability of the instrument was compromised.
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Essential clinical skills for beginning registered nurses
The questionnaire was divided into part one, demographic data, and part two, identification of clinical skills. In part two, respondents were asked to rate 97 clinical skills in subsets under the following headings: Basic life support Diagnostic skills Patient nutrition Patient activity Medication administration Counselling skills Information technology
Patient assessment skills Hygiene Elimination Respiration Wound management Education Universal precautions
Respondents were asked to indicate how often each skill was performed under the following categories: A = ‘More than once daily’ (2–5 times/day) B = ‘Once daily’ C = ‘3–6 times weekly’ I = ‘Infrequently’ (fortnightly – monthly) N = ‘Never’ In addition, respondents were asked to indicate whether each skill was considered essential to their daily work. Previous studies by Kieffer (1984), Pratt (1989) and Sweeney & Regan (1982) attempted to define ‘essential’ skills as those most important to the client’s welfare or to the nurse’s professional practice. This was indicated in a separate column classified ‘X’. An example of a section of the questionnaire follows in Figure 1.
Results Demographic data The mean age of the sample was 24.6 years with a range of 21–47 years. 93.9% of BRN’s were aged between 21 and 31 years. The remaining 6.1% ranged between the ages of 32 and 47 years. The respondents’ length of clinical experience ranged from 1 month to 18 months, with a mean
of 9 months. One response stated ten years of clinical experience and was not included in the calculation of mean length of experience. The area of clinical experience was varied, ranging from palliative care and rehabilitation to intensive care units and operating rooms, with the majority having gained their experience in acute medical and surgical facilities. Many of the responses indicated employment in combined medical and surgical wards. 10.5% of the sample was obtained from private hospitals and 98.5% from public hospitals.
Frequency of clinical skill performance The relative frequencies of skill performance are expressed as percentages. For the purpose of clarity in reporting it was considered appropriate to combine responses in category A and B 1–5 times or more/day) and also in categories C and I (3–6 times/week to monthly). The category ‘Never’ is reported separately. In all the following tables the category AB (Frequently) is represented by a solid bar, CI (Infrequently) is represented by a clear bar and N (Never) is represented by a shaded bar. The combined relative frequencies for each subset of the clinical skill are reported as percentages and graphed in bar chart format. Basic life support (Fig. 2) had no subsets; it was infrequently rated by 54% of the sample and rated as never performed by 32%. Only 14% rated this skill as performed frequently. Patient assessment skills (Fig. 3) had ten subsets of which vital sign assessment was the most frequently (98%) and developmental assessment was the least frequently rated (42%) skill. Diagnostic skills (Fig. 4) had nine subsets with pulse oximetry being the most frequently rated skill (81%), closely followed by peripheral blood sugar analysis. Arterial blood gas sampling was rated as never performed by 82% of the sample. Basic Life Support 60 50
Patient Assessment Skills
A
B
C
I
N X
1. Airway assessment 2. Respiratory assessment 3. Cardiac assessment
Fig. 1
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Example of a section from the questionnaire.
40
AB CI N
% 30 20 10 0
Fig. 2
Basic life support.
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Patient Assessment Skills
Diagnostic Skills 100
120
80
100 AB
80 % 60 40
AB
% 60
CI
40
N
20
CI N
0
20
1
0 1
2
3
4
5 6 7 Skill Subset
1. Airway assessment 2. Respiratory assessment 3. Cardiac assessment 4. Vital sign assessment 5. Neurological assessment
Fig. 3
8
9
2
3
4
5 6 7 Skill Subset
10
Patient assessment skills.
Fig. 4
9
6. Peripheral blood sugar analysis 7. Venepuncture for pathology 8. Arterial blood gas sampling 9. Microbiology swab
1. Perform 12 lead E.C.G 2. Continuous cardiac monitoring 3. Central venous pressure monitoring 4. Pulse oximetry 5. Peak flow monitoring
6. Glasgow coma scale 7. Abdominal assessment 8. Peripheral vascular assessment 9. Mental state assessment 10. Development assessment
8
Diagnostic skills.
Patient Nutrition 100 Hygiene
80
100 %
80 60 % 40 20
AB
40
CI
20
N
0
1
2
3 Skill Subset
4
1. Full sponge / dependent bath 2. Shower / bath with assistance 3. Oral care
N
Hygiene.
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2
3
4
5
6 7 8 Skill Subset
9
10 11 12
5 4. Grooming 5. Pressure area care
1. Assist / complete patient feeding 2. Insert nasogastric (NG) feeding tube 3. Intermittent / bolus NG feed 5. Maintain feeding pump 6. Manage gastric suction / drainage
Fig. 6
Patient hygiene skills (Fig. 5) had five subsets, all of which were rated as performed frequently. Pressure area care was the most frequently rated of those skills (86%). Patient nutrition (Fig. 6) had 12 subsets, with the most common skills rated being management of intravenous therapy (94%), infusion pumps (78%), assisting with oral feeding (53%) and management of central venous access devices (49%). The skills rated as least performed related to nasogastric feeding and total parenteral nutrition. Elimination skills (Fig. 7) had ten subsets, with management of indwelling urinary catheter being rated the most commonly performed (75%), followed by wound drain management and urine specimen collection. The skills rated as least performed were insertion of urinary catheter for both males (64% never) and females (76% infrequently). Patient activity related skills (Fig. 8) had eight subsets. The most commonly rated skill was assisting with mobilization. The least commonly 330
CI
1
0
Fig. 5
AB
60
7. Insert intravenous (IV) cannula 8. Manage intravenous therapy 9. Manage central venous access devices 11. Manage transfusion of blood / blood products 12. Manage IV-infusion pump
Patient nutrition.
rated skills related to traction management, therapeutic massage and use of lifting devices. Respiration (Fig. 9) was divided into eight subsets, with administration of oxygen (88%) and promotion of breathing and coughing exercises (71%) the most commonly rated. Management of a ventilated patient, tracheostomy and underwater seal drainage were the least frequently rated. Medication administration (Fig. 10) was divided into eight subsets with most of them being rated as frequently performed with the exception of chemotherapy and resuscitation drugs. Wound management (Fig. 11) also had eight subsets. The most frequently rated skills were clean and contaminated wound dressings while the least frequently rated were wound cavity dressing, removal of sutures or clips and drains. A significant percentage (63%) of participants had never managed burns wounds. Counselling skills (Fig. 12) were grouped into six subsets of which the most frequently rated skills © 2000 Harcourt Publishers Ltd
Essential clinical skills for beginning registered nurses
Elimination 80 70 60
Patient Activity
50 % 40 30
AB
100
CI
80
N %
20 10
AB
60
CI
40
N
20
0
1
2
3
4
5
6
7
8
9
0
10
1
Skill Subset 1. Insertion of indwelling urinary catheter Male 2. Insertion of indwelling urinary catheter Female 3. Management of IDC 4. Management of suprapubic catheter 5. Management of bladder irrigation
Fig. 7
6. Management of peritoneal dialysis 7. Management colostomy 8. Wound drain management 9. Specimen collection: urine 10. Specimen collection: other (please specify)
80 %
AB
60
CI
40
N
20 0 1
2
3
4
5
6
7
8
Fig. 9
8
5. Perform therapeutic massage 6. Management of plasters and splints 7. Management of traction set-ups 8. Application of anti-embolic stockings
CI N
2
3
4
5
6
7
8
Skill Subset
5. Administration of O2 6. Management of ventilated patient 7. Management of tracheostomy 8. Management of underwater seal
1. Oral medications 2. Parental medications (SC., IM.) 3. Bolus IV medications 4. Infused IV medications (diluted)
Fig. 10
100 80
AB
60
CI
40
N
20
%
5. Adding meditation to IV flasks 6. Patient controlled analgesia (PCA) 7. Administer medications during resuscitation 8. Administer chemotherapy
Medication administration.
Counselling Skills
80
Wound Management
60
AB
40
CI N
20 0
0
1 1
2
3
4 5 Skill Subset
1. Clean wound management 2. Contaminated wound dressing 3. Wound irrigation 4. Wound cavity dressing
Fig. 11
7
AB
1
Respiration.
%
6
Medication Administration
120 100 80 % 60 40 20 0
Skill Subset 1. Promote breathing/coughing exercise 2. Suction upper airway 3. Postural drainage and percussion 4. Sterile airway suction
4 5 Skill Subset
Patient activity.
Respiration 100
3
1. Assist in mobilization 2. Patient transfer from bed to chair 3. Supervise patient walking with aids 4. Use of lifting machines /devices
Fig. 8
Elimination.
2
6
7
5. Shortening of wound drain 6. Removal of wound drain 7. Removal of clips/sutures 8. Wound management of burns
Wound management.
were assisting patients to make informed choices and acting as patient advocate. The least commonly rated skill was participation in group counselling. Education (Fig. 13) had only three subsets with patient and family education being the most frequently rated skill. Information technology (Fig. 14) had three subsets with telecommunication skills being the © 2000 Harcourt Publishers Ltd
2
8
3 4 Skill Subset
5
6
1. Assisting patient to make informed choices
4. Participate in group counselling
2. Assisting patient’s family to make informed choices
5. Act as patient advocate
3. Support a grieving patient
6. Support a patient in emotional crisis
Fig. 12
Counselling skills.
most frequently rated (79%), and followed closely by the use of computers (71%). Universal precautions (Fig. 15) were divided into six subsets. Hand washing and disposal of sharps and waste were rated at the highest frequency of performance for all clinical skills surveyed (100%). Disposal of cytotoxic waste was rated as infrequently performed (44%). Nurse Education Today (2000) 20, 327–335 331
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Education
80
Information Technology 80
60 %
AB
40
CI
20
N
60
AB
% 40
CI N
20
0 1
2
0
3
1
Skill Subset
3
1. Use of computers 2. Use of other information technology (E-Mail, internet) 3. Use of telecommunication systems (paging, fax, teleconference)
1. Patient education including relevant family 2. Participating in continuing staff education 3. Specific patient education, diabetes
Fig. 13
2 Skill Subset
Education.
Fig. 14
Information technology.
Universal Precautions 120 100 80 % 60 40 20 0
AB CI N
1
2
3
4
5
6
Skill Subset 1. Hand washing 2. Disposal of sharps 3. Disposal of Cytotoxics
Fig. 15
4. Use of protective apparel 5. Disposal of protective apparel 6. Disposal of linen and waste
Universal precautions.
Table 1
332
Most essential clinical skill
%
Least essential clinical skill
Disposal of sharps
92
Arterial blood gas sampling
87
Hand washing
92
Venepuncture for pathology
82
Vital sign measurement
92
Central venous pressure monitoring
77
Oral medication administration
90
Insertion of IV cannula
75
Adding medications to IV flasks
89
Management peritoneal dialysis
75
Parenteral medication administration
89
Administer chemotherapy
74
Pressure area care
89
Developmental assessment
69
Clean wound dressing
88
Use of other information technology
69
Infused IV medications
87
Perform therapeutic massage
68
Manage IV therapy
87
Management of ventilated patient
65
Bolus IV medications
86
Continuous cardiac monitoring
63
Use of protective apparel
85
Management of bladder irrigation
63
Management of IDC
84
Participate in group counselling
63
Peripheral blood sugar analysis
84
Respiratory assessment
84
Airway assessment
84
Disposal of linen & waste
83
Cardiac assessment
83
Full sponge
83
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%
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Essential clinical skills for beginning registered nurses
Clinical skills regarded as essential This component of the questionnaire required respondents to indicate which clinical skills they considered essential for new graduates to be able to perform. The following table summarizes the findings by focusing on the two extremes of skills rated most and least essential.
Discussion The results of the demographic data did not reveal any unexpected findings, with the exception of one participant who claimed ten years of clinical experience. This questionnaire was not included in the interpretation of length of experience.
Frequency of skill performance This study largely confirmed the findings from the original study by Williams & Brammer (1996) with some minor variations. The patient assessment skills category had been amended to differentiate between physical assessment skills and diagnostic skills. The sample in this study rated cardiac and respiratory assessment as more frequently performed than the original study sample, although the wording of the question was slightly different. The original study specifically required a response to ‘auscultation of heart and lung sounds’ whereas this study was worded more generically as ‘cardiac and respiratory assessment’. In the wound management category the removal of clips and sutures was rated as performed more frequently in the original study than in this study (rated infrequently by 72% of this sample). This may be related to the trend in earlier discharge of patients following surgery with continuing wound management in the outpatient setting. Table 2
Relationship between rating of frequency of performance and essential skills
Clinical Skill
Frequency (A&B) %
Essential Rating %
Insertion indwelling urinary catheter (male)
3
52
Insertion indwelling urinary catheter (female)
6
70
Insertion nasogastric tube
8
65
12
61
Management of underwater seal drain
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There were few surprises in the frequency of skills rated as performed by BRNs. Hand washing, disposal of sharps, vital sign assessment, management of intravenous therapy, assisting with mobilisation, and administration oral and all forms of parenteral medications were rated as performed at least once daily or more often by the majority of the respondents. The frequent rating of skills associated with universal precautions is encouraging but needs further investigation to determine the effectiveness of such performance. No attempt was made in this study to determine accuracy or outcome of performance. The whole range of patient hygiene skills was rated frequently by the majority of the respondents as was expected. All the skills most frequently rated could be considered fundamental nursing skills and would be applicable to any clinical area. There were some specialized skills that were rated infrequently performed and were dependent on the clinical area in which the nurse had worked when completing the questionnaire. Some examples of such skills were continuous cardiac monitoring, administration of chemotherapy and management of peritoneal dialysis. In contrast, the patient assessment skills were not rated as performed as frequently as expected, with airway, respiratory and cardiac assessment the only ones rated once a day or more. This is a concern for nursing education programs as the assessment of the patient underlies all nursing care and BRNs would be expected to undertake an assessment of the patient at least once a day at the beginning of each shift. The increasing technological focus of nursing skills is evident in the frequently rated use of computers, pulse oximetry, patient controlled analgesia devices and intravenous infusion pumps. However, patient lifting devices were not
Management of tracheostomy
15
60
Management of colostomy
20
65
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Essential clinical skills for beginning registered nurses
rated as frequently used as expected (44% infrequently and 31% never) given the frequent response for assisting in mobilization (90%). The limited availability of these devices in general medical and surgical wards may have been responsible for the response as these devices are more likely to be used in aged care or disability facilities. An interesting finding in this study is the rating beginning registered nurses gave to skills infrequently performed. The respondents were asked to rate ‘any of the listed clinical skills you consider essential in your daily work.’ Although some skills were not rated as used daily they were still rated as essential to daily work. However, there were some clinical skills that were never performed which were not considered essential e.g. venepuncture was never performed by 83% and rated as essential by only 18% of the sample. Some examples of this finding are illustrated in Table 2. The frequency of performance is represented by the combined categories reported earlier. The study did not seek to ask BRNs why they made such ratings and it is considered a weakness of the study. One possible reason for this finding is that BRNs may feel anxious about the experience of being a novice registered nurse and believe that competency in various clinical skills may better equip them for clinical work. New graduates may also be concerned about the possible need to draw upon less frequently performed skills during emergency situations and thus rate these skills as essential. Alternatively, they may have learnt from clinical experience during their course that clinical skill performance is valued above all other performance in the ward setting. This was supported by Madjar et al. (1997) in the study of new graduates’ expectations of clinical work.
Conclusions The findings of this study reveal those clinical skills rated as performed most frequently by beginning registered nurses, and identified those clinical skills deemed essential to beginning nursing practice by novice nurses. Given the vast range of clinical skills identified as essential, it would be useful to attempt to allocate a priority to these skills for teaching purposes. The minor differences in findings between this study and the original could be related to changes in the
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Nurse Education Today (2000) 20, 327–335
wording of the questionnaire and in the clinical settings from which the sample was recruited. The project supports the definite need for fundamental clinical skills to be taught in undergraduate nursing programs as these were rated as performed most frequently by new graduate nurses. Findings of this study suggest that clinical skills rated infrequently or never performed should be reviewed in relation to their relevance and emphasis in teaching programs. This would allow nursing students more time to gain competence and confidence in the essential clinical skills. However, a larger sample size would improve the reliability of findings from this study. Some tentative conclusions can be drawn from the frequency of rating regarding the importance of each clinical skill, but this would be strengthened by further study with a larger sample size. Due to the number of respondents who rated infrequently performed clinical skills as essential, a second phase to the study is anticipated to further investigate the relevance of all surveyed clinical skills to clinical practice.
References Alavi C, Loh S W, Reilly D 1991 Reality basis for teaching psychomotor skills in a tertiary curriculum. Journal of Advanced Nursing 16: 957–965 Burns N, Grove S 1987 The practice of nursing research conduct, critique and utilisation. WB Saunders Company, Philadelphia Gomez G E, Gomez E A 1984 The teaching of psychomotor skills in nursing. Nurse Educator Winter: 35–39 Kieffer J S 1984 Selecting technical skills to teach for competency. Journal of Nursing Education 5: 198–203 Koh L C 1996 Teaching technical skills to Project 2000 students. Nursing Standard 28: 47–49 Madjar I, McMillan M, Sharkey R, Cadd A 1997 Project to review and examine expectations of beginning registered nurses in the workforce. New South Wales Nurses Registration Board, Sydney MacLeod L P, Farrell P 1994 The need for significant reform: a practice driven approach to curriculum. Journal of Nursing Education 5: 208–214 McAdams C, Rankin EJ, Love B, Patton D 1989 Psychomotor skills laboratories as self-directed learning: a study of nursing students’ perceptions. Journal of Advanced Nursing 14: 788–796 Neary M 1994 Teaching practical skills in colleges. Nursing Standard 8(27): 35–38 Neighbours M, Eldred E, Sullivan M 1991 Nursing skills for competency in the high-tech health care system. Nursing and Health Care 12(2): 92–97 Pelletier D 1995 Diploma-prepared nurses’ use of technological equipment in clinical practice. Journal of Advanced Nursing 21: 6–14
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Essential clinical skills for beginning registered nurses
Pratt R 1989 Sine qua non: the psychomotor skills profile of beginning practitioners in nursing. Unpublished Master of Health Personnel Education, University of New South Wales Reilly D E, Oermann M H 1985 The clinical field its use in nursing education. Appleton-Century-Crofts, Connecticut
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Sweeney M A, Regan P A 1982 Educators, employers and new graduates define essential skills for baccalaureate graduates. The Journal of Nursing Administration. September: 36–42 Williams L, Brammer J 1996. Essential clinical skill preparation for beginning professional nurses. Central Queensland University, Rockhampton
Nurse Education Today (2000) 20, 327–335 335
Essential clinical skills for beginning registered nurses Elaine Boxer and Birgit Kluge
A research project investigating the identification of essential clinical skills for registered nurses in their first year of practice was undertaken in a number of Sydney metropolitan hospitals in Australia. Using an adaptation of the Williams & Brammer (1996) study, 206 beginning registered nurses were surveyed to determine the clinical skills they performed frequently in their daily routine, and those they considered essential. One hundred and thirty two questionnaires were returned and the responses were analysed for frequency of clinical skill performance and essential rating. The clinical skills rated as most frequently performed related to universal precautions for infection control, vital sign assessment, management of intravenous therapy, administration of all forms of medication and a wide range of patient hygiene related skills. Many clinical skills rated as essential by these nurses were not rated as performed frequently, which may indicate concern for the need to draw upon less frequently performed skills during emergency situations and thus they rate these skills as essential. This study clearly identified the clinical skills rated as performed frequently by beginning registered nurses and identified those clinical skills deemed essential to beginning nursing practice by novice nurses. A larger sample size would strengthen the reliability of these findings. © 2000 Harcourt Publishers Ltd
Introduction
Elaine Boxer RN, BEd, MN, Senior Lecturer, Birgit Kluge RN, MN, Nurse Educator, School of Nursing, Australian Catholic University, P.O. Box 968, North Sydney NSW 2059, Australia. Tel.: 02 97392359; Fax: 02 97392342; E-mail: e.boxer@mackillop .acu.edu.au (Requests for offprints to E B) Manuscript accepted: 9 September 1999
This study to determine the essential skills required by beginning registered nurses was conducted in the Sydney metropolitan area in public and private hospitals. The purpose of the study was to identify which clinical nursing skills new graduates nurses rated as performed frequently and considered essential in their first year of practice. The study was based on a project undertaken by Williams & Brammer (1996) in Queensland using a slightly modified tool to suit the health care service in NSW. Replication of the Williams & Brammer (1996) study was undertaken to determine whether their findings would be true for new graduate nurses in New South Wales (Burns & Grove 1987). A clear need for the teaching of clinical skills either in a simulated setting or in the clinical field has been described in the literature (Alavi et al. 1991, Gomez & Gomez 1984, Koh 1996, McAdams et al. 1988, Neary 1994, Neighbours et al. 1991,
© 2000 Harcourt Publishers Ltd doi:10.1054/nedt.1999.0415, available online at http://www.idealibrary.com on
Pratt 1989, Reilly & Oermann 1985). These authors identified advantages and disadvantages of both simulated and clinical teaching and proposed ways of ensuring that the most value was gained from the teaching method used. However, there were few recent studies that attempted to identify the essential clinical skills for new graduate nurses which would ensure adequate preparation for their first year of clinical practice. Pelletier (1995) attempted to identify technical skills related to clinical equipment and surveyed new graduate nurses on nine technical skills. This study concluded that there is an increasing use of technological equipment in the clinical area which new graduate nurses need to be able to use confidently. Kieffer (1984) surveyed experienced registered nurses on 154 skills that they considered to be most frequently performed and most important in the clinical area in which they were employed. Consensus on importance and frequency in this study was reached for 25% of
Nurse Education Today (2000) 20, 327–335 327
Essential clinical skills for beginning registered nurses
the skills and included categories such as assessment of vital signs, assisting with mobilizing, elimination, hygiene, sterile technique and asepsis and medication administration. The choice of skills to be included in the undergraduate nursing degree was also studied extensively by Sweeney & Regan (1982) and Reilly & Oermann (1985). Sweeny & Regan (1982) surveyed experienced registered nurses, nurse academics and new graduate nurses to determine whether 291 skills were essential, bonus, graduate or non-nursing. Consensus across the three groups was achieved for 51% of the skills. Reilly & Oermann (1985) developed curriculum implementation guidelines from Sweeny & Regan’s (1982) list of 291 skills. There were two major studies in the Australian context that attempted to identify the skills required for beginning practice and the level of competence needed for these skills (Alavi et al. 1991, Pratt 1989). These studies varied in their methods as Pratt (1989) surveyed new graduates on 154 skills while Alavi et al. (1991) surveyed experienced clinical staff and nurse academics on 84 skills. Both studies provide a list of core skills to be considered for inclusion in undergraduate nursing programs. A more recent study by Madjar et al. (1997) found that beginning registered nurses had expected to be competent in the performance of clinical skills on entry to practice. In the same study, other ward nurses also expected this to be the case. This expectation reinforces the need for identification of the most important clinical skills to be taught in nursing education programs. As the health care system has changed over the last ten years, there is a need to re-examine the clinical skills being taught to undergraduate nursing students for currency and technological relevance.
Methods Unlike the Williams & Brammer (1996) study, which included participants from clinical specialty areas such as mental health, paediatric and maternity settings, this study focussed on acute medical and surgical areas. It was considered that such a sample was representative of the beginning nurse workforce in New South Wales.
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A self-selected purposive sample of 206 beginning registered nurses with clinical experience in acute medical and surgical nursing ranging from 6–12 months was drawn from the cohort of the 1997 New Graduate Nurse Recruitment Consortium. The majority of new graduates in the Sydney metropolitan area are recruited by this Consortium. These new graduates had commenced employment on a Transitional Support Program (TSP) from January 1997 and were employed in either a large metropolitan teaching or smaller community hospital. Following ethical approval at each of six proposed sites (four large metropolitan teaching and two small metropolitan community hospitals) the program coordinators of the TSPs were invited to assist in facilitating this research study. They were informed about the content of the study and the selection criteria for prospective participants. The new graduates were recruited by these coordinators and asked to return the completed questionnaire to a central location nominated by the coordinator, where they were collected by the researchers. The higher than average response rate (64.6%, n = 132) could be explained by the utilization of the network of program coordinators to encourage new graduates to complete the questionnaire. The survey instrument was adapted from the original study, however minimal amendments were made according to clinical relevance for current acute care nursing practice and to allow for differences between the NSW and Queensland health care systems. The changes to the instrument included the addition of basic life support, universal precaution procedures and information technology as clinical skills to be surveyed. The original instrument required a frequency response ranging from A – At least daily to N – Never. This was amended by adding one further category representing ‘More Than Twice Daily’. It was considered that this category would allow participants a more descriptive response. Both the reliability and the validity of the instrument were confirmed in the original study following a pilot study using the questionnaire, and as only minor amendments were made to the instrument for this study it was felt that neither validity nor reliability of the instrument was compromised.
© 2000 Harcourt Publishers Ltd
Essential clinical skills for beginning registered nurses
The questionnaire was divided into part one, demographic data, and part two, identification of clinical skills. In part two, respondents were asked to rate 97 clinical skills in subsets under the following headings: Basic life support Diagnostic skills Patient nutrition Patient activity Medication administration Counselling skills Information technology
Patient assessment skills Hygiene Elimination Respiration Wound management Education Universal precautions
Respondents were asked to indicate how often each skill was performed under the following categories: A = ‘More than once daily’ (2–5 times/day) B = ‘Once daily’ C = ‘3–6 times weekly’ I = ‘Infrequently’ (fortnightly – monthly) N = ‘Never’ In addition, respondents were asked to indicate whether each skill was considered essential to their daily work. Previous studies by Kieffer (1984), Pratt (1989) and Sweeney & Regan (1982) attempted to define ‘essential’ skills as those most important to the client’s welfare or to the nurse’s professional practice. This was indicated in a separate column classified ‘X’. An example of a section of the questionnaire follows in Figure 1.
Results Demographic data The mean age of the sample was 24.6 years with a range of 21–47 years. 93.9% of BRN’s were aged between 21 and 31 years. The remaining 6.1% ranged between the ages of 32 and 47 years. The respondents’ length of clinical experience ranged from 1 month to 18 months, with a mean
of 9 months. One response stated ten years of clinical experience and was not included in the calculation of mean length of experience. The area of clinical experience was varied, ranging from palliative care and rehabilitation to intensive care units and operating rooms, with the majority having gained their experience in acute medical and surgical facilities. Many of the responses indicated employment in combined medical and surgical wards. 10.5% of the sample was obtained from private hospitals and 98.5% from public hospitals.
Frequency of clinical skill performance The relative frequencies of skill performance are expressed as percentages. For the purpose of clarity in reporting it was considered appropriate to combine responses in category A and B 1–5 times or more/day) and also in categories C and I (3–6 times/week to monthly). The category ‘Never’ is reported separately. In all the following tables the category AB (Frequently) is represented by a solid bar, CI (Infrequently) is represented by a clear bar and N (Never) is represented by a shaded bar. The combined relative frequencies for each subset of the clinical skill are reported as percentages and graphed in bar chart format. Basic life support (Fig. 2) had no subsets; it was infrequently rated by 54% of the sample and rated as never performed by 32%. Only 14% rated this skill as performed frequently. Patient assessment skills (Fig. 3) had ten subsets of which vital sign assessment was the most frequently (98%) and developmental assessment was the least frequently rated (42%) skill. Diagnostic skills (Fig. 4) had nine subsets with pulse oximetry being the most frequently rated skill (81%), closely followed by peripheral blood sugar analysis. Arterial blood gas sampling was rated as never performed by 82% of the sample. Basic Life Support 60 50
Patient Assessment Skills
A
B
C
I
N X
1. Airway assessment 2. Respiratory assessment 3. Cardiac assessment
Fig. 1
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Example of a section from the questionnaire.
40
AB CI N
% 30 20 10 0
Fig. 2
Basic life support.
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Essential clinical skills for beginning registered nurses
Patient Assessment Skills
Diagnostic Skills 100
120
80
100 AB
80 % 60 40
AB
% 60
CI
40
N
20
CI N
0
20
1
0 1
2
3
4
5 6 7 Skill Subset
1. Airway assessment 2. Respiratory assessment 3. Cardiac assessment 4. Vital sign assessment 5. Neurological assessment
Fig. 3
8
9
2
3
4
5 6 7 Skill Subset
10
Patient assessment skills.
Fig. 4
9
6. Peripheral blood sugar analysis 7. Venepuncture for pathology 8. Arterial blood gas sampling 9. Microbiology swab
1. Perform 12 lead E.C.G 2. Continuous cardiac monitoring 3. Central venous pressure monitoring 4. Pulse oximetry 5. Peak flow monitoring
6. Glasgow coma scale 7. Abdominal assessment 8. Peripheral vascular assessment 9. Mental state assessment 10. Development assessment
8
Diagnostic skills.
Patient Nutrition 100 Hygiene
80
100 %
80 60 % 40 20
AB
40
CI
20
N
0
1
2
3 Skill Subset
4
1. Full sponge / dependent bath 2. Shower / bath with assistance 3. Oral care
N
Hygiene.
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2
3
4
5
6 7 8 Skill Subset
9
10 11 12
5 4. Grooming 5. Pressure area care
1. Assist / complete patient feeding 2. Insert nasogastric (NG) feeding tube 3. Intermittent / bolus NG feed 5. Maintain feeding pump 6. Manage gastric suction / drainage
Fig. 6
Patient hygiene skills (Fig. 5) had five subsets, all of which were rated as performed frequently. Pressure area care was the most frequently rated of those skills (86%). Patient nutrition (Fig. 6) had 12 subsets, with the most common skills rated being management of intravenous therapy (94%), infusion pumps (78%), assisting with oral feeding (53%) and management of central venous access devices (49%). The skills rated as least performed related to nasogastric feeding and total parenteral nutrition. Elimination skills (Fig. 7) had ten subsets, with management of indwelling urinary catheter being rated the most commonly performed (75%), followed by wound drain management and urine specimen collection. The skills rated as least performed were insertion of urinary catheter for both males (64% never) and females (76% infrequently). Patient activity related skills (Fig. 8) had eight subsets. The most commonly rated skill was assisting with mobilization. The least commonly 330
CI
1
0
Fig. 5
AB
60
7. Insert intravenous (IV) cannula 8. Manage intravenous therapy 9. Manage central venous access devices 11. Manage transfusion of blood / blood products 12. Manage IV-infusion pump
Patient nutrition.
rated skills related to traction management, therapeutic massage and use of lifting devices. Respiration (Fig. 9) was divided into eight subsets, with administration of oxygen (88%) and promotion of breathing and coughing exercises (71%) the most commonly rated. Management of a ventilated patient, tracheostomy and underwater seal drainage were the least frequently rated. Medication administration (Fig. 10) was divided into eight subsets with most of them being rated as frequently performed with the exception of chemotherapy and resuscitation drugs. Wound management (Fig. 11) also had eight subsets. The most frequently rated skills were clean and contaminated wound dressings while the least frequently rated were wound cavity dressing, removal of sutures or clips and drains. A significant percentage (63%) of participants had never managed burns wounds. Counselling skills (Fig. 12) were grouped into six subsets of which the most frequently rated skills © 2000 Harcourt Publishers Ltd
Essential clinical skills for beginning registered nurses
Elimination 80 70 60
Patient Activity
50 % 40 30
AB
100
CI
80
N %
20 10
AB
60
CI
40
N
20
0
1
2
3
4
5
6
7
8
9
0
10
1
Skill Subset 1. Insertion of indwelling urinary catheter Male 2. Insertion of indwelling urinary catheter Female 3. Management of IDC 4. Management of suprapubic catheter 5. Management of bladder irrigation
Fig. 7
6. Management of peritoneal dialysis 7. Management colostomy 8. Wound drain management 9. Specimen collection: urine 10. Specimen collection: other (please specify)
80 %
AB
60
CI
40
N
20 0 1
2
3
4
5
6
7
8
Fig. 9
8
5. Perform therapeutic massage 6. Management of plasters and splints 7. Management of traction set-ups 8. Application of anti-embolic stockings
CI N
2
3
4
5
6
7
8
Skill Subset
5. Administration of O2 6. Management of ventilated patient 7. Management of tracheostomy 8. Management of underwater seal
1. Oral medications 2. Parental medications (SC., IM.) 3. Bolus IV medications 4. Infused IV medications (diluted)
Fig. 10
100 80
AB
60
CI
40
N
20
%
5. Adding meditation to IV flasks 6. Patient controlled analgesia (PCA) 7. Administer medications during resuscitation 8. Administer chemotherapy
Medication administration.
Counselling Skills
80
Wound Management
60
AB
40
CI N
20 0
0
1 1
2
3
4 5 Skill Subset
1. Clean wound management 2. Contaminated wound dressing 3. Wound irrigation 4. Wound cavity dressing
Fig. 11
7
AB
1
Respiration.
%
6
Medication Administration
120 100 80 % 60 40 20 0
Skill Subset 1. Promote breathing/coughing exercise 2. Suction upper airway 3. Postural drainage and percussion 4. Sterile airway suction
4 5 Skill Subset
Patient activity.
Respiration 100
3
1. Assist in mobilization 2. Patient transfer from bed to chair 3. Supervise patient walking with aids 4. Use of lifting machines /devices
Fig. 8
Elimination.
2
6
7
5. Shortening of wound drain 6. Removal of wound drain 7. Removal of clips/sutures 8. Wound management of burns
Wound management.
were assisting patients to make informed choices and acting as patient advocate. The least commonly rated skill was participation in group counselling. Education (Fig. 13) had only three subsets with patient and family education being the most frequently rated skill. Information technology (Fig. 14) had three subsets with telecommunication skills being the © 2000 Harcourt Publishers Ltd
2
8
3 4 Skill Subset
5
6
1. Assisting patient to make informed choices
4. Participate in group counselling
2. Assisting patient’s family to make informed choices
5. Act as patient advocate
3. Support a grieving patient
6. Support a patient in emotional crisis
Fig. 12
Counselling skills.
most frequently rated (79%), and followed closely by the use of computers (71%). Universal precautions (Fig. 15) were divided into six subsets. Hand washing and disposal of sharps and waste were rated at the highest frequency of performance for all clinical skills surveyed (100%). Disposal of cytotoxic waste was rated as infrequently performed (44%). Nurse Education Today (2000) 20, 327–335 331
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Education
80
Information Technology 80
60 %
AB
40
CI
20
N
60
AB
% 40
CI N
20
0 1
2
0
3
1
Skill Subset
3
1. Use of computers 2. Use of other information technology (E-Mail, internet) 3. Use of telecommunication systems (paging, fax, teleconference)
1. Patient education including relevant family 2. Participating in continuing staff education 3. Specific patient education, diabetes
Fig. 13
2 Skill Subset
Education.
Fig. 14
Information technology.
Universal Precautions 120 100 80 % 60 40 20 0
AB CI N
1
2
3
4
5
6
Skill Subset 1. Hand washing 2. Disposal of sharps 3. Disposal of Cytotoxics
Fig. 15
4. Use of protective apparel 5. Disposal of protective apparel 6. Disposal of linen and waste
Universal precautions.
Table 1
332
Most essential clinical skill
%
Least essential clinical skill
Disposal of sharps
92
Arterial blood gas sampling
87
Hand washing
92
Venepuncture for pathology
82
Vital sign measurement
92
Central venous pressure monitoring
77
Oral medication administration
90
Insertion of IV cannula
75
Adding medications to IV flasks
89
Management peritoneal dialysis
75
Parenteral medication administration
89
Administer chemotherapy
74
Pressure area care
89
Developmental assessment
69
Clean wound dressing
88
Use of other information technology
69
Infused IV medications
87
Perform therapeutic massage
68
Manage IV therapy
87
Management of ventilated patient
65
Bolus IV medications
86
Continuous cardiac monitoring
63
Use of protective apparel
85
Management of bladder irrigation
63
Management of IDC
84
Participate in group counselling
63
Peripheral blood sugar analysis
84
Respiratory assessment
84
Airway assessment
84
Disposal of linen & waste
83
Cardiac assessment
83
Full sponge
83
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%
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Essential clinical skills for beginning registered nurses
Clinical skills regarded as essential This component of the questionnaire required respondents to indicate which clinical skills they considered essential for new graduates to be able to perform. The following table summarizes the findings by focusing on the two extremes of skills rated most and least essential.
Discussion The results of the demographic data did not reveal any unexpected findings, with the exception of one participant who claimed ten years of clinical experience. This questionnaire was not included in the interpretation of length of experience.
Frequency of skill performance This study largely confirmed the findings from the original study by Williams & Brammer (1996) with some minor variations. The patient assessment skills category had been amended to differentiate between physical assessment skills and diagnostic skills. The sample in this study rated cardiac and respiratory assessment as more frequently performed than the original study sample, although the wording of the question was slightly different. The original study specifically required a response to ‘auscultation of heart and lung sounds’ whereas this study was worded more generically as ‘cardiac and respiratory assessment’. In the wound management category the removal of clips and sutures was rated as performed more frequently in the original study than in this study (rated infrequently by 72% of this sample). This may be related to the trend in earlier discharge of patients following surgery with continuing wound management in the outpatient setting. Table 2
Relationship between rating of frequency of performance and essential skills
Clinical Skill
Frequency (A&B) %
Essential Rating %
Insertion indwelling urinary catheter (male)
3
52
Insertion indwelling urinary catheter (female)
6
70
Insertion nasogastric tube
8
65
12
61
Management of underwater seal drain
© 2000 Harcourt Publishers Ltd
There were few surprises in the frequency of skills rated as performed by BRNs. Hand washing, disposal of sharps, vital sign assessment, management of intravenous therapy, assisting with mobilisation, and administration oral and all forms of parenteral medications were rated as performed at least once daily or more often by the majority of the respondents. The frequent rating of skills associated with universal precautions is encouraging but needs further investigation to determine the effectiveness of such performance. No attempt was made in this study to determine accuracy or outcome of performance. The whole range of patient hygiene skills was rated frequently by the majority of the respondents as was expected. All the skills most frequently rated could be considered fundamental nursing skills and would be applicable to any clinical area. There were some specialized skills that were rated infrequently performed and were dependent on the clinical area in which the nurse had worked when completing the questionnaire. Some examples of such skills were continuous cardiac monitoring, administration of chemotherapy and management of peritoneal dialysis. In contrast, the patient assessment skills were not rated as performed as frequently as expected, with airway, respiratory and cardiac assessment the only ones rated once a day or more. This is a concern for nursing education programs as the assessment of the patient underlies all nursing care and BRNs would be expected to undertake an assessment of the patient at least once a day at the beginning of each shift. The increasing technological focus of nursing skills is evident in the frequently rated use of computers, pulse oximetry, patient controlled analgesia devices and intravenous infusion pumps. However, patient lifting devices were not
Management of tracheostomy
15
60
Management of colostomy
20
65
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Essential clinical skills for beginning registered nurses
rated as frequently used as expected (44% infrequently and 31% never) given the frequent response for assisting in mobilization (90%). The limited availability of these devices in general medical and surgical wards may have been responsible for the response as these devices are more likely to be used in aged care or disability facilities. An interesting finding in this study is the rating beginning registered nurses gave to skills infrequently performed. The respondents were asked to rate ‘any of the listed clinical skills you consider essential in your daily work.’ Although some skills were not rated as used daily they were still rated as essential to daily work. However, there were some clinical skills that were never performed which were not considered essential e.g. venepuncture was never performed by 83% and rated as essential by only 18% of the sample. Some examples of this finding are illustrated in Table 2. The frequency of performance is represented by the combined categories reported earlier. The study did not seek to ask BRNs why they made such ratings and it is considered a weakness of the study. One possible reason for this finding is that BRNs may feel anxious about the experience of being a novice registered nurse and believe that competency in various clinical skills may better equip them for clinical work. New graduates may also be concerned about the possible need to draw upon less frequently performed skills during emergency situations and thus rate these skills as essential. Alternatively, they may have learnt from clinical experience during their course that clinical skill performance is valued above all other performance in the ward setting. This was supported by Madjar et al. (1997) in the study of new graduates’ expectations of clinical work.
Conclusions The findings of this study reveal those clinical skills rated as performed most frequently by beginning registered nurses, and identified those clinical skills deemed essential to beginning nursing practice by novice nurses. Given the vast range of clinical skills identified as essential, it would be useful to attempt to allocate a priority to these skills for teaching purposes. The minor differences in findings between this study and the original could be related to changes in the
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wording of the questionnaire and in the clinical settings from which the sample was recruited. The project supports the definite need for fundamental clinical skills to be taught in undergraduate nursing programs as these were rated as performed most frequently by new graduate nurses. Findings of this study suggest that clinical skills rated infrequently or never performed should be reviewed in relation to their relevance and emphasis in teaching programs. This would allow nursing students more time to gain competence and confidence in the essential clinical skills. However, a larger sample size would improve the reliability of findings from this study. Some tentative conclusions can be drawn from the frequency of rating regarding the importance of each clinical skill, but this would be strengthened by further study with a larger sample size. Due to the number of respondents who rated infrequently performed clinical skills as essential, a second phase to the study is anticipated to further investigate the relevance of all surveyed clinical skills to clinical practice.
References Alavi C, Loh S W, Reilly D 1991 Reality basis for teaching psychomotor skills in a tertiary curriculum. Journal of Advanced Nursing 16: 957–965 Burns N, Grove S 1987 The practice of nursing research conduct, critique and utilisation. WB Saunders Company, Philadelphia Gomez G E, Gomez E A 1984 The teaching of psychomotor skills in nursing. Nurse Educator Winter: 35–39 Kieffer J S 1984 Selecting technical skills to teach for competency. Journal of Nursing Education 5: 198–203 Koh L C 1996 Teaching technical skills to Project 2000 students. Nursing Standard 28: 47–49 Madjar I, McMillan M, Sharkey R, Cadd A 1997 Project to review and examine expectations of beginning registered nurses in the workforce. New South Wales Nurses Registration Board, Sydney MacLeod L P, Farrell P 1994 The need for significant reform: a practice driven approach to curriculum. Journal of Nursing Education 5: 208–214 McAdams C, Rankin EJ, Love B, Patton D 1989 Psychomotor skills laboratories as self-directed learning: a study of nursing students’ perceptions. Journal of Advanced Nursing 14: 788–796 Neary M 1994 Teaching practical skills in colleges. Nursing Standard 8(27): 35–38 Neighbours M, Eldred E, Sullivan M 1991 Nursing skills for competency in the high-tech health care system. Nursing and Health Care 12(2): 92–97 Pelletier D 1995 Diploma-prepared nurses’ use of technological equipment in clinical practice. Journal of Advanced Nursing 21: 6–14
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Pratt R 1989 Sine qua non: the psychomotor skills profile of beginning practitioners in nursing. Unpublished Master of Health Personnel Education, University of New South Wales Reilly D E, Oermann M H 1985 The clinical field its use in nursing education. Appleton-Century-Crofts, Connecticut
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Sweeney M A, Regan P A 1982 Educators, employers and new graduates define essential skills for baccalaureate graduates. The Journal of Nursing Administration. September: 36–42 Williams L, Brammer J 1996. Essential clinical skill preparation for beginning professional nurses. Central Queensland University, Rockhampton
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