Advanced practice nursing students’ development of clinical competence – A Norwegian mixed-methods study

Abstract

Advanced practice nursing roles are developing globally and have now been introduced in Norway. The Norwegian government recently regulated master’s education in advanced practice nursing, which encompasses the nurse practitioner role, and established role regulations for graduates. To support a credible and sustainable evolvement of the advanced practice nursing role in Norway, a doctoral study project was designed with the aim of investigating the development of advanced practice nursing students’ clinical competence.

This aim was reached by achieving the objectives of three sub-studies as follows. Sub-study I: (a) to describe and analyse the self-assessment of clinical competence and the need for further training at the beginning of the student’s education, and (b) to analyse the possible predictive variables in students’ self-assessments. Sub-study II: to explore and describe students’ and examiners’ experiences with the Objective Structured Clinical Examination (OSCE). Sub-study III: to analyse the development of students’ self-assessed clinical competence from the beginning of their education to after the completion of their clinical studies. A sequential equal-status mixed methods design was employed for this doctoral study project. For sub-studies I (n = 97) and III (n = 36), data were collected from advanced practice nursing/nurse practitioner students through the Professional Nurse Self-Assessment Scale of clinical core competencies II (PROFFNurse SAS II). For sub-study II, data were collected from focus groups and interviews with nurse practitioner students (n = 15) and examiners (n = 5) after the students had completed their OSCE.

The findings of sub-study I show that at the beginning of their education, the students selfassessed their clinical competence regarding responsibility and cooperation as high but selfassessed their direct clinical practice competence at lower levels. Work experience and previous higher education were not significant predictors of the total score for clinical competence or of the need for further training. The findings in sub-study II show that the students and examiners found the OSCE to be an appropriate method of assessment for advanced clinical competence, although some challenges were experienced regarding the exam form in terms of preparing for the examination, the process for the examination and assessment and demonstrating clinical competence at an advanced level. The findings in substudy III show that the students developed their self-assessed clinical competence for direct clinical practice to the greatest degree. The findings indicate a lack of development regarding clinical leadership in the student’s workplace. Similar to the findings of sub-study I, sub-study III revealed that previous higher education was not a significant predictor of clinical competence. However, somewhat different from sub-study I, the findings of sub-study III indicate that previous work experience in primary health care is a significant, although minor, predictor.

Overall, the findings of this doctoral study project indicate that the students developed direct clinical practice appropriate for an advanced practice nursing role and some aspects of indirect nursing, such as health promotion and disease prevention. Indirect nursing in such areas as clinical leadership, which is essential to leading change in health care services, was found to be lacking on a systemic level. Current regulations in Norway do not include a full scope of practice for the nurse practitioner role, as they exclude such elements as the authority to diagnose, prescribe medications and treat patients, which limits the possibilities for clinical competence development for students in line with international standards.

This doctoral study project is the first study in the Nordic countries to investigate education in advanced practice nursing. The project contributes to advanced practice nursing education by identifying areas of the educational programmes that are in need of improvement, specifically the indirect nursing aspect and, especially, clinical leadership. This project informs further research that uses patient outcomes to measure advanced practice nursing graduates’ impact on patient care to investigate whether advanced practice nurses are safe practitioners. Lastly, this project supports collaboration among education, research and the clinical field to develop new advanced practice nursing models that can facilitate the development of clinical competence that is in line with international standards.