The Journal of Continuing Education in Nursing

Original Article 

Newly Graduated Swedish Nurses' Inadequacy in Developing Professional Competence

Margareta Widarsson, RN, RM, PhD; Margareta Asp, RNT, PhD; Anna Letterstål, RN, PhD; Marie-Louise S. Källestedt, RN, PhD

Abstract

Background:

The learning process for student and recently graduated nurses during their transition to professional nursing is stressful and challenging. The aim of this study was to describe recent graduates' experiences of developing professional competence in their basic nursing program and during their first year.

Method:

A qualitative descriptive design with an inductive approach based on interviews with 11 nurses, with a qualitative content analysis.

Results:

Recently graduated nurses experience shortages and struggle to develop their professional competence. They find that reflection is a fundamental tool in the process of professional competence development. The competence gap is not between theoretical and practical knowledge, but rather between the university and health care organizations.

Conclusion:

Focusing on the intertwining of theoretical and practical knowledge can bridge the gap between these two organizations and create a foundation for lifelong learning of professional competence. Creating opportunities for reflection is central to the learning process. [J Contin Educ Nurs. 2020;51(2):65–74.]

Abstract

Background:

The learning process for student and recently graduated nurses during their transition to professional nursing is stressful and challenging. The aim of this study was to describe recent graduates' experiences of developing professional competence in their basic nursing program and during their first year.

Method:

A qualitative descriptive design with an inductive approach based on interviews with 11 nurses, with a qualitative content analysis.

Results:

Recently graduated nurses experience shortages and struggle to develop their professional competence. They find that reflection is a fundamental tool in the process of professional competence development. The competence gap is not between theoretical and practical knowledge, but rather between the university and health care organizations.

Conclusion:

Focusing on the intertwining of theoretical and practical knowledge can bridge the gap between these two organizations and create a foundation for lifelong learning of professional competence. Creating opportunities for reflection is central to the learning process. [J Contin Educ Nurs. 2020;51(2):65–74.]

From a global perspective, senior nursing students and newly graduated nurses experience high levels of stress (Blomberg et al., 2014; Blomberg et al. 2016; Elsayes & Obied, 2017; Gardiner & Sheen, 2016; Manninen, Scheja, Henriksson, & Silén, 2013) and psychological distress (Bernhardsdottir, Thome, Skärsäter, & Champion, 2017; Missen, McKenna, & Beauchamp, 2014a) in clinical settings, which affects their health (Elsayes & Obied, 2017; Laschinger et al., 2016). The transition from study to professional nursing is challenging (Doughty, McKillop, Dixon, & Sinnema, 2018; Phillips, Kenny, Esterman, & Smith, 2014). Challenges are associated with overwhelming responsibility (Sterner, Ramstrand, Nyström, Hagiwara, & Palmér, 2018), time management, role adjustment, and the balance between work and private life (Missen et al., 2014a). In Sweden, 20% of RNs have a strong intention to leave the profession 5 years after graduation, which is linked to high levels of stress (Rudman, Gustavsson, & Hultell, 2014). The resulting shortage of nurses is a threat to patient safety (Blomberg & Stier, 2016), which makes it important to focus on new graduates' perspectives in their transition to professional nursing.

Nursing programs take place at university and in collaboration with a health care organization—mainly in the practical part of the program. After graduation, nurses' learning processes continue in the health care organization in clinical introduction programs sometimes conducted in cooperation with a university (Doughty et al., 2018; Henderson, Ossenberg, & Tyler, 2015; Missen et al., 2014a; Missen, McKenna, & Beauchamp, 2016; Pasila, Elo, & Kääriäinen, 2017). These programs have increased nurses' work satisfaction and contributed to their remaining in employment (Missen, McKenna, & Beauchamp, 2014b; Silvestre, Ulrich, Johnson, Spector, & Blegen, 2017). According to Missen et al. (2014b), the introduction programs increase nurses' safety regardless of how they are organized. The programs are established based on the assumption of a disconnection between the university and the health care organization (Freeling & Parker, 2015; Ortiz, 2016; Sterner et al., 2018). The ultimate objectives of nursing programs at universities and the health care organizations should be the same: to provide the prerequisites for student and graduate nurses to develop their professional competences. Mulder (2014) described the roots of the concept of professional competence and stated that the link between competence and professional practice differs according to the definition of competence. In the current study, competence is defined as the capacity of an individual to manage certain situations or complete certain tasks or jobs successfully (Ellström, 1992; Mulder, 2014). This capacity includes competences related to perceptual motor skills, cognitive factors, affective factors, personality traits, and social skills (Ellström & Kock, 2008). An assumption about the concept of competence in this study is that “competence is neither primarily an attribute of an individual, nor an attribute of the job. The focus should be on the interaction between the individual and the job, and on the competence that is actually used by the individual in performing the job. Thus, we can talk about the competence-in-use” (Ellström & Kock, 2008, p. 7). Competence in use is regarded as a dynamic process of learning to mediate between the capacity of the individual and the requirements of the job.

The current study assumes that theoretical and practical knowledge require each other. The two forms of knowledge can be seen as endpoints on the same continuum (Bengtsson, 1993). This approach is consistent with the view of Larsen, Adamsen, Bjerregaard, and Madsen (2002) that the gap between theory and practice is a social construction based on the value placed on different forms of knowledge. Developing the skills to become a nurse means intertwining theoretical and practical knowledge in action (Andersson & Edberg, 2010; Berglund & Ekebergh, 2015). This is an epistemological foundation of evidence-based practice. Nurses are expected to actively apply and implement the best available evidence and proven experience at all stages of the nursing process.

Professional competence development takes place in a care culture. A care culture is a tradition that mediates between people and gives a context for meaning (Rytterström, Unosson, & Arman, 2011). A care culture that stimulates learning and competence development is also important for employees' health and well-being (Elsayes & Obied, 2017; Henderson et al., 2015). Trusting relationships in the team are a prerequisite for the development of professional competence (Della Ratta, 2016).

A professional competence that nurses need to develop to safeguard patients' security is their clinical gaze. Focusing solely on routines does not make care safer. Nurses must also be encouraged to trust their intuition to recognize if anything is normal or abnormal in order to act. A clinical gaze is a complex competence that involves “intuition and the use of a sound, rational, relevant knowledge base in situations that, through experience, are so familiar that the person has learned how to recognize and act on appropriate patterns” (Easen & Wilcockson, 1996, p. 672). It is a competence to intertwine observed patient events with theoretical knowledge using analytical skills, and then to act (Bisholt, 2012).

Prerequisites for nurses' continuing learning need to be studied closely to understand how to support students and nurses to develop their professional competence.

The current study aimed to describe newly graduated nurses' experiences of developing professional competence from a basic nursing program and during the first year after graduation.

Method

Design

The study had a qualitative descriptive design to obtain a deep understanding of nurses' experiences. An inductive approach was chosen to achieve the aim without being limited by theory at the beginning of the analysis. Eleven interviews were performed and analyzed using qualitative content analysis (Graneheim & Lundman, 2004).

Setting

The basic nursing programs in Sweden lead to a Bachelor of Science in nursing, and approximately 25% of a program takes place in clinical settings such as medical wards, surgical wards, and primary care. The onboarding introduction program was established by the health care organization with the aim of developing nurses' competence in leadership and a clinical gaze, as well as integrating national and local guidelines into practice by using reflection to develop critical thinking. The process includes reflection, communication, leadership, and skill training.

Sample

Data were collected from newly graduated nurses enrolled in an introduction program during their first year of employment, held in a county council building in the middle of Sweden. The 1-year introduction program lasted 20 days, and specific department introductions varied between 3 and 12 weeks. All nurses (n = 30) working on medical or surgical wards with at least 40% attendance at the introduction program were included in the study. Information about the study and informed consent was sent by e-mail and a reminder was sent within 14 days.

Eleven nurses were interviewed at the clinical skills centers by the first author (M.W.), who was unknown to all the participants, from February to June 2017, 2 to 5 months after program completion. The plan was to interview in focus groups but due to their working situation some of them declined, resulting in individual or group interviews (Table 1) using a semi-structured interview guide with an opening question on the transition from formal education at the university to full-time practice in the health care organization. This was followed by questions about factors that facilitated or hindered their transition. The guide covered three areas: integrating theory and practice, clinical gaze, and competence in leadership. The interviews lasted 62 to 85 minutes and were audio recorded and transcribed verbatim. The later interviews did not add any further information related to the purpose of this study.

Overview of Participants

Table 1:

Overview of Participants

Data Analysis

The interviews were analyzed using an inductive qualitative content analysis (Graneheim & Lundman, 2004; Graneheim, Lindgren, & Lundman, 2017). The first step was for all authors (M.W., M.A., A.L., M.-L.S.K.) to read the transcribed interviews several times to derive an overview of the content. Content of interest for the study was marked in the text. The text was coded and synthesized into subcategories and categories by the first and fourth authors (M.W., M.-L.S.K.) and then discussed by all authors until consensus was reached and credibility was ensured. Further, a descriptive theme was interpreted, as a unified red thread running through the categories, following Graneheim et al. (2017). To ensure the trustworthiness of the results, the interviews were based on the same interview guide and performed by the same interviewer (M.W.). In addition, appropriate quotations from the interviews were used.

Ethical Considerations

The participants received both verbal and written information explaining that their participation was voluntary and that they were giving informed consent. The study was conducted according to Swedish ethics legislation and followed the principles in the Declaration of Helsinki (World Medical Association, 2014). To maintain confidentiality, names have been anonymized (Table 1).

Results

The findings of this study regarding newly graduated nurses' experiences of developing professional competence during basic nursing program and the first year after graduation highlight one theme—willingness to learn despite their experiences of inadequacy and struggles to develop professional competence. They have an inner motivation to care but are unable to meet various requirements of the university and health care organizations. However, there are also prerequisites for learning embedded in health care settings. This theme was constructed from four categories and eight subcategories (Table 2). The categories and sub-categories are presented under each heading and are highlighted with quotations.

Theme, Categories, and Subcategories Revealed by the Qualitative Content Analysis

Table 2:

Theme, Categories, and Subcategories Revealed by the Qualitative Content Analysis

Individual Learning

On an individual level, the driving force to learn in the nursing profession is nurtured by an interest for and willingness to meet and help the patient. Encounters with patients allow the clinical gaze to develop; this is regarded as a fundamental skill to assess, prioritize, and perform nursing acts.

An Inner Motivation to Develop Competence. The motivation of nurses to educate themselves is described as a willingness to make a difference, to be useful, and to assist people in difficulty and in need of support. Nurses find it meaningful to heal, comfort, and guide patients and their relatives, and this improves their own well-being. This motivation drives the desire to develop the professional competence to become a nurse. Meeting patients and providing direct care are usually felt to be meaningful during their education. Participant D said, “It feels like you are making a difference and doing something important. For me, it feels like I am doing good; I still want to help people.” An inner motivation can create interest in deepening knowledge of the theoretical bases of nursing, as participant A noted, “To educate myself more in what I am interested in…that there is a theory behind what I like to do.” Developing professional competence means personal maturity with the self-knowledge of one's own strengths and limitations. Personal development was described both during education and in working life; participant C said, “I was greatly strengthened [through the school] in self-confidence during these three years.”

Another participant (I) said:

You grow as a human being through everything you have to experience. I see life; I became calmer. You make a difference. I can't think of many jobs that one grows so much as in health care. You get to see so much. I have changed.

Curiosity and willingness to know more also motivates learning and the development of professional competence through daring to take new unexpected steps and switching to new workplaces.

Developing a Clinical Gaze. In individual learning, clinical gaze was described as the most important but most difficult skill to acquire. Assessing the patient's condition and gradual changes based on small signals and nuances was considered to be a skill that required not only time and experience but also the ability to use all the body's senses. According to participant K:

To see more with the eye and the feeling you get…. The clinical gaze means that you not only take it in as you hear but make an assessment directly when you go to a patient, not just when you ask them 'How are you?' But you can actually look at a patient, how he/she seems, how he/she moves, everything…. And you do not need to do checks or blood tests to see that this patient is not well…. You take in the patient's general condition.

To develop a clinical gaze, nurses needed the opportunity to ask colleagues for advice and support. With time and increased experience, the nurses learned to make their own assessments, prioritize the information they received, and thereby develop the clinical gaze. According to participant G:

You know what you want to know and what information to look for. At the beginning, you do not know it when you have no experience. Then everything just comes to you, and you wonder, what can I do with all this information and how should I sift it? And now…I know what I need to know to be able to make an assessment.

The newly graduated nurses were aware that caring science concepts are necessary, but some had difficulty seeing the connection to the development of a clinical gaze. Participant H said:

When we have an education that is not really long, then one can focus more on things that can develop one's clinical gaze. To study almost half a course on suffering and health—yes, rather diffuse concepts, where there is not so much right and wrong on really pretty fuzzy subjects. [The course] did not give much [attention to clinical gaze], wrong priority.

This nurse asked for more knowledge about what is required to develop a clinical gaze in emergency situations.

The Importance of Care Experience in the Development of Professional Competence

Previous nursing experience is considered to be of great importance for learning, and the experienced nursing students helped the less experienced nursing students to develop professional competence because the less experienced felt insecure and unprepared for the care work.

Experience as a Base for Understanding. Meeting patients was described by the nurses as giving inspiration and increasing their understanding of what needed to be learned, both during education and during the first year as a nurse. During education, when they lacked experience, the nursing students had difficulty seeing how theoretical knowledge could be applied in care situations. Their goal was to prepare for the examination. It was difficult to understand connections when they lacked experience. Participant K said:

I had put more energy into the studies and not just hoped to pass the exam. I had put more time into both the practical and theoretical aspects. Now you notice this with making connections; if a patient is dehydrated and this starts to show in their blood pressure…. You go through it pretty well in education. If you don't revise it, then it is something you do for the exam, and then it fades away.

The older students' care and life experience stimulated the younger students' learning. In this way, they gained an increased understanding of learning not only for the examination but for using knowledge in nursing care. Participant K said, “If you have one in your group (an older student with care experience), you fight harder, of course, because there is a higher requirement for the results of the tasks you do together; it is good to have age differences.”

Those with previous experience could concentrate their learning on new things they had not been able to study before education, which made them more secure and expanded their experience. According to participant D:

In the beginning I just wanted to work in actual nursing but gradually I had to let it go, otherwise I would not have been able to deal with the more specific duties of a nurse.

To understand the theoretical and practical aspects of the profession, nurses need to be close to the patient.

Not Feeling Prepared. The nurses felt that the transition from basic nursing program to working life was difficult. There were many new things they were expected to cope with for which they felt unprepared. Knowledge from theory was sometimes difficult to put into practice. According to participant G:

You are not really prepared for what it looks like at work. When you arrive after studying, you have a lot of theoretical knowledge. Then you come out and feel that you can do none of the things you have learned about for three years. There are many new things and much more besides. I thought it would be 3 to 4 months before I started to feel reasonably calm.… It was half a year until I felt safe in myself.

The newly graduated nurses had not expected the profession to involve so many administrative tasks because they did not realize the extent of administration duties during education. The administration tasks competed with nursing care because they wanted to be closer to the patients to lead their nursing care. Participant J said:

It is very administrative; you did not know what to do. I am the one who contacts the hospital pastor, the curator, and the dietician, as well as the one who puts the whole thing together. I didn't understand that before.

The nurses were unprepared for staffing, leadership, or distributing nursing tasks. Their time was considered insufficient for all their tasks. Participant J said, “I really miss being able to go in to the patient and be there.… If I go in, my head is still out there because I have a million things left to do—time and lack of staff. You can't do as good a job as you could.”

In addition, they immediately received more advanced tasks than were practiced during the study period. Participant B said, “You had to do things that others had to work for a year for. Or work a night shift, as we were asked to do a few months after we started working to take care of tracheostomy patients.” Although the newly graduated nurse is aware of their leadership role, they lacked experience and felt unprepared for the task. It was difficult to realize the scope of what it meant to be a leader. Participant I said, “You are the leader without knowing that you have become the leader.” As a leader, the nurse was expected to prioritize tasks and be available to everyone in the team.

The Importance of Care Culture for the Development of Professional Competence

In a care culture that promotes learning, there is understanding from colleagues, responsiveness, and an ability to communicate, all of which create security. Experiencing security was considered a prerequisite for developing the professional competence of nurses. The team members were carriers of the care culture that appeared in communication within the team. For the development of professional competence, there was a need for knowledge about the roles, responsibilities, and competencies of other occupational groups to lead and distribute tasks to nurses and assistant nurses in the team.

The Importance of the Team for Learning. During the study period and the introduction program, support was needed from both supervisors and colleagues for the nurses to feel safe in continuing their learning. Participant H said, “There was a climate in my department so that even if you didn't feel so safe yourself, you were still safe with… strong colleagues who could help.” Sometimes the newly graduated nurses found themselves to be a burden when asking questions, as some colleagues were described as critical. Participant I said, “We get some criticism if you are new and ask… ‘You asked yesterday, and you asked last week, now you are asking again!’” Other colleagues tried to reduce the nurses' high expectations for entering work by encouraging them not to expect too much, but rather to take the time they needed.

Some of the new graduates had a strong need for control, a fear of making mistakes and difficulty distributing and delegating tasks to others. Participant K said, “It is necessary that you dare to abandon the responsibility and trust that it will be good. When you are new, it is unpleasant to have so much responsibility.” Even experienced nurses found it difficult to withdraw so that the new graduates were given the opportunity to take responsibility and develop their knowledge and skills.

As they developed into team leaders, the nurses became familiar with their colleagues in the team, which could mean reduced control needs with confidence in their own and others' skills. As new nurses, they had their own requirements for completing tasks, so they did not need to leave too much to their colleagues. Developing into team leaders and learning to delegate took time and could be difficult and inconvenient:

Participant H said:

I already felt prepared for the patients after a few months in terms of medical knowledge, but for me to feel safe as a leader it took at least half a year. And there is still a lot left to learn.… I must have an overview; I can never get stuck with one patient for too long because then I lose the important overview. I have to delegate tasks. But I have to do some stuff. If there is a seriously ill patient, then I must be with them.

Prior to shifts with only new graduates rostered on, the newly graduated nurses might worry for several days in advance. The nurses expressed a willingness to learn and saw the team as a source of safety and learning in everyday care.

Lack of Opportunity for Reflection in the Team. The nurses described how opportunities for reflection and communication with colleagues strengthened learning. However, reflecting on a regular basis was not described as a natural part of the care culture, even though requests were made for regular reflection sessions at the workplaces. Reflection strengthened the team by confirming and suggesting areas for development because, as participant C noted, “that is when you strengthen yourself.” Reflection needed time, as well as an experienced colleague in the team to provide perspective and be responsible for implementation. Reflection was prioritized on deaths and other traumatic events. One consequence of not having the opportunity to reflect was that new graduates brought their thoughts home, which affected their sleep.

Participant A said:

One has a physical feeling that this day has not been good…as I had today [laughter]. You can't get hold of it and so you have a hard time putting your finger on what it is really about. I realized that I reflect on my own all the time, even at home and maybe late in the evening.… Sometimes it would be good to have someone who led…and was able to ask some questions and lead well.

The nurses need to reflect with the team on their experiences and feelings to obtain guidance.

The Importance of the Organization for the Development of Professional Competence

In university and health care organizations, there are various structures important for the development of professional competence. In these organizations, different aspects of knowledge and learning are emphasized, which affects the learning of students and new graduates.

Different Views on Nurse Competence. The nurses reported that scientific nursing and care was emphasized in basic nursing program, which they then had to work hard to exercise in the health care organization because of different expectations for nurses' competence. The nurses felt that in medical care, medical knowledge and clinical skills were required in order to follow routines. The new graduates primarily followed these health care routines and guidelines, although this did not always correspond with the knowledge they had acquired in education. Participant F said, “Everything you read in school, it's not the same thing we do at work. There is a big difference between what you have read in the book and what we do. ‘No, you will follow the department's routines. It will be so.’” The nurses found that they were unable to follow up and enhance nursing care through evidence and research. They experienced little response from other staff when they referred to unfamiliar nursing science health theorists and the staff did not understand who the theorists were. Participant A said:

We have read about nursing. We are going out now and practicing what we have been reading about for 3 years. I see the whole person and all that. That's what becomes a challenge.… So, you have to fight a little for what we graduated in; I have my own profession, with the caring science bit.… It's more task focused than patient focused. There are rounds, a lot of stuff to do, sampling, faxing and stuff like that. Nursing is my thing.

The objective conflict between expectations of the nurse's competence was described as a burden.

Different Views on the Learning Structure. The support structure that the university provides is seminars, which students find educational because they have the opportunity to share knowledge with each other. On the other hand, in examination seminars, the students feel assessed and then communicate no more than necessary.

Participant K said:

It is very hard to sit in an examination situation; you sit and report and know that what I say now…I will get graded on. Then, you definitely do not get the best conversations; it is a very difficult situation to open your mouth when you know that everything you say will be critically judged. Otherwise, seminars I learn most from are when I have the opportunity to listen to what others…have the opportunity to say what I think. I am forced to be active.

However, the new graduates request control of the competence elements of the education because they state that they could graduate without having undergone an examination on certain basic elements such as taking blood pressure and using peripheral venous catheters. Better coherence between undergraduate education and health care organizations is required because it differs in several respects—for example, in documentation and routines for using sterile and clean methods.

In health care organizations, the introduction program provides a structure for continued learning where nurses have the opportunity to share experiences. Participant A said, “Meet other new graduates. There you can support each other and hear about other workplaces, comparing the pros and cons, and we feel that we have felt the same things; many experience the same things.” Throughout the introduction program, the new graduates experience a deeper understanding and knowledge of various health care interventions through the repetition/rehearsal of various elements. Theoretical elements, but especially practical elements, mature and emerge successively. Participant D said, “At the same time, knowledge grows…when you get practical skills, they are also a kind of knowledge. Then you gain another understanding of the theory and practice together when you experience them in practice.”

To respond to emergency situations, the nurses believe they must learn to prioritize and assess the patient's state of health and the measures required. Scenario training is scarce at school but with the support of repeated scenario training during the introduction program, the professional nurse is developed. Participant B said, “When we got to practice A and E in the team training…[then] it was good to train in the clinical glance in a structured way.”

Another structure for learning in health care organizations is the clinic-specific introduction. This is organized differently for each clinic in terms of both time and organization perspective. The experience of nurses was that the health care organization expected them to be completely equipped. Participant K stated:

We came to a period when there was really no opportunity to be new; there were no staff, so it was enough. At all times, there was the threat that at any time we might not have any [introduction]; then we would have to take on this big responsibility that we knew even experienced nurses do not even want.

For other nurses, on the other hand, the experience was that they received considerable support from supervisors, managers, and others. Participant A said:

You have a mentor at the beginning, in the introductory weeks of training…the manager, also the department head. I thought the support came from everywhere; everyone wanted to support us as much as possible.… It is a pretty big step, to study and come out a nurse.

The nurses asked for structures to allow time for in-depth training, skills training, and reading scientific articles. There are different views on learning structures among the various educational and health care organizations.

Discussion

The main theme of these results is that although the new graduates have a willingness to learn, they experience inadequacy and struggle to develop their professional competence. The results of this study may relate to assumptions about professional competence development (Ellström & Kock, 2008). These assumptions depend on the interaction between the nurses' attributes and competences demanded by their job, as well as the university requirements on the one hand and those of health care environments on the other. The interactions and tensions between different requirements are illustrated in Figure 1.

The interaction between the nurses' attributes, required competences, and requirements of the nursing profession, such as expected qualifications.

Figure 1.

The interaction between the nurses' attributes, required competences, and requirements of the nursing profession, such as expected qualifications.

The arrow in Figure 1 illustrates the nurses' attributes in the development of professional competence. The results show that competence development requires the ability to intertwine theoretical and practical knowledge based on experience and reflection. The nurses express the view that their use of reflection and evidence-based learning are fundamental aspects of the development of an academic nursing professional. The learning process, wherein theoretical and practical knowledge are intertwined, can be regarded as similar in both university and health care settings. Based on these assumptions, it is possible to bridge the disconnections between the two environments for nursing students' and nurses' professional development. The results of the current study enhance understanding of the prerequisites and limitations of intertwining theoretical and practical knowledge in the two settings. For example, the results reveal a tension between the nurses' theoretical knowledge and critical thinking skills on the one hand, and the lack of space and time to use these attributes in structured opportunities for reflection in health care organizations on the other, which may limit their professional competence development and their ability to use their academic competence.

Evidence exists that reflection is a useful tool to help new graduates in their transition to their profession (Walton, Lindsay, Hales, & Rook, 2018), although times for reflection must be regular and routine. Moreover, Della Ratta (2016) and Larsen et al. (2002) reported that learning and orientation in everyday care primarily come from other team members, such as experienced colleagues. The current results show that reflection could strengthen the team by confirming and suggesting areas for development. When team members are carriers of a care culture that promotes learning, there is understanding from colleagues, as well as responsiveness and an ability to communicate and create security. The prerequisites for such a care culture are the ability to ask questions, learn to delegate tasks, and develop leadership skills. Nesley and Brownie (2012) considered that effective and cohesive workplace teams increase productivity and reduce nurse turnover.

The lack of previous experience of working in health care settings before beginning nursing training was described as a limitation in internalizing theory and practice. When health care experience is lacking, nursing students have difficulty in seeing the value of applying theoretical knowledge in everyday clinical situations. Niemeyer (2017) and Andersson and Edberg (2010) emphasized that new graduates have formal education, but too little experience of different clinical situations to internalize their knowledge. This implies that nurses' university education must highlight the relevance of nursing theory and relate it to students' experiences (Berglund & Ekebergh, 2015). In the current study, the newly graduated nurses stated that nursing theory was not requested in the health care setting. To bridge this gap in requirements, there is a need for a common understanding and collaboration between the university health care course and health care settings concerning the importance of theory as a foundation on which to develop professional competence. This view is also supported by our finding that the new graduates described the development of clinical gaze as evolving from experience, as well as depending on the intertwinement of theory and practice.

The university's and health care organizations' requirements for the nursing profession are similar, but they differ regarding their goals and expectations. This difference is evident to graduate nurses with their new colleagues and in other health care professions. In the current study, there are tensions between the health care organizations' requirements for medical skills and routines on the one hand and university requirements to work in an evidence-based way on the other. New graduates primarily follow the everyday routines and guidelines of the clinic, although these are not always consistent with the evidence-based knowledge acquired during their training.

A tension arises between the will to stay close to patients and the expectations of the clinical setting that nurses will administer and perform medical tasks. This is consistent with previous findings that graduate nurses are inadequately prepared for practice (Freeling & Parker, 2015) and that novice RNs describe competency as the ability to meet the requirements of the health care setting (Niemeyer, 2017).

The clinical introduction program offered by the health care organization seems to be important to facilitate the development of newly graduated nurses' competence. The new graduates expressed appreciation of the opportunity to reflect with colleagues during their introduction program. Moreover, they gained a deeper understanding and knowledge of various health care interventions through repetition/rehearsal and skills training in various elements. In addition, Ahlstedt, Eriksson Lindvall, Holmström, and Muntlin Athlin (2019) found that nurses are motivated by learning in their everyday lives when they are taught together with colleagues. New knowledge and learning during daily work, as well as support from colleagues, encourage nurses to remain in work (Ahlstedt et al., 2019).

Interactions and in-depth collaborations between university and health care organizations are needed to expand students' professional learning. This would also affect other professionals in the community of practice, and in turn improve patient outcomes and evidence-based practices (Anderson, Hair, & Todero, 2012; Moran, Hansen, & Schweiss, 2018; Sharpnack, Koppelman, & Fellows, 2014).

Limitations and Strengths

One possible weakness of the current study was the convenience sampling method. The goal was to collect participants from all clinical settings that enrolled nurses in the introduction program. Although medical wards, surgical wards, and primary care were involved, the study could have been more clinically representative if it included participants from other clinics. Although the nurses had agreed to participate and several interview opportunities were offered, some nurses could not attend because of work overload. The consequence of their dropping out was that two interviews had only one participant. The participants in both individual or group interviews generously shared their experiences; thus, we cannot see any difference between the statements made in individual and group interviews, which are rich in content. We believe that our findings may be transferable and useful in other similar settings. As in other qualitative studies, more studies in different locations are needed to reveal the extent to which the results are transferable to other settings.

Conclusion

Newly graduated nurses have an inner motivation for continuous learning, but experience knowledge deficits. They struggle to develop their professional competence due to differences between organizations in their view of knowledge, as well as the structures of the learning environment. Therefore, a structure must be created to support the intertwining of theoretical and practical knowledge for continuous learning. Reflection in different settings is a fundamental tool in this process. Specific supportive structures in health care organizations for professional development, such as regular times for reflection to support critical thinking and evidence-based care, clinical introduction programs, and clinical training centers are also vital. The gap is not between theoretical and practical knowledge but between the university and the health care organizations, and it is due to different views of structures for learning and the value placed on knowledge. This can limit professional competence development. Continuously focusing on the intertwinement of theoretical and practical knowledge can bridge the gap between these two organizations and become the foundation for lifelong learning of professional competence with specific supportive structures for continuous learning. The development of nurses' professional competence needs to be seen in a broader context, both at the structural and organizational levels, than the transition from education to the first year as an RN.

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Overview of Participants

Interview (N = 6)Participants (N = 11)aSex (Female/Male)
1A, B (n = 2)2/0
2C, D, E (n = 3)3/0
3F, G (n = 2)2/0
4H, I (n = 2)1/1
5J (n = 1)1/0
6K (n = 1)1/0

Theme, Categories, and Subcategories Revealed by the Qualitative Content Analysis

ThemeCategorySubcategory
Willingness to Learn Despite Their Experiences of Inadequacy and Struggles to Develop Professional CompetenceIndividual learningAn inner motivation to develop competence Developing a clinical gaze
The importance of care experience in the development of professional competenceExperience as a base for understanding Not feeling prepared
The importance of care culture for the development of professional competenceThe importance of the team for learning Lack of opportunity for reflection in the team
The importance of the organization for the development of professional competenceDifferent views on nurse competence Different views on the learning structure
Authors

Dr. Widarsson is Senior Lecturer, Dr. Asp is Professor, and Dr. Letterstål is Dean of School, School of Health, Care and Social Welfare, Mälardalen University, and Dr. Källestedt is Manager, Clinical Skills Center, Centre for Clinical Research, Uppsala University, Region Västmanland, Västerås, Sweden. Dr. Letterstål is also affiliated with the Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank all the nurses who participated in this study. This study was conducted with support from a Vinnova research grant.

Address correspondence to Margareta Widarsson, RN, RM, PhD, Senior Lecturer, School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23, Västerås, Sweden; e-mail: margareta.widarsson@mdh.se.

Received: March 29, 2019
Accepted: August 06, 2019

10.3928/00220124-20200115-05

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