Journal of Nursing Education

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Clinical Nursing Competence of RN-to-BSN Students in a Nursing Concept-Based Curriculum in Taiwan

Jane Lee-Hsieh, MS, RN; Chihui Kao, PhD, RN; Chienlin Kuo, MS, RN; Hung-Fu Tseng, PhD

Abstract

ABSTRACT

This 3-year longitudinal study used a questionnaire to evaluate the clinical nursing competence of RN-to-BSN students in a nursing concept-based curriculum in Taiwan. The research sample consisted of 52 full-time and 69 part-time RN-to-BSN students. A four-dimensional Clinical Nursing Competence Questionnaire was developed to measure student caring, communication/coordination, management/teaching, and professional self-growth competence. Results indicated full-time students' scores on self-evaluations of overall clinical nursing competence significantly increased with each successive evaluation (p < .05). The scores of part-time students fell significantly with successive evaluations, with the exception of professional self-growth competence (p < .01). Instructor evaluations generally showed no significant difference between the two groups. Student self-evaluations were significantly higher than instructor evaluations (p < .05). The results of this study may serve as a reference for nurse educators developing curricula for RN-to-BSN education.

Abstract

ABSTRACT

This 3-year longitudinal study used a questionnaire to evaluate the clinical nursing competence of RN-to-BSN students in a nursing concept-based curriculum in Taiwan. The research sample consisted of 52 full-time and 69 part-time RN-to-BSN students. A four-dimensional Clinical Nursing Competence Questionnaire was developed to measure student caring, communication/coordination, management/teaching, and professional self-growth competence. Results indicated full-time students' scores on self-evaluations of overall clinical nursing competence significantly increased with each successive evaluation (p < .05). The scores of part-time students fell significantly with successive evaluations, with the exception of professional self-growth competence (p < .01). Instructor evaluations generally showed no significant difference between the two groups. Student self-evaluations were significantly higher than instructor evaluations (p < .05). The results of this study may serve as a reference for nurse educators developing curricula for RN-to-BSN education.

During the past few years, Taiwan's colleges have been upgrading to full-fledged universities. In 1994, just 11 universities in Taiwan offered baccalaureate nursing programs, compared to 21 in 2000 (Lee, Chen, & Chen, 2001). Of those 21, 12 are university baccalaureate programs, while the remaining 9 are RNto-BSN programs operated by former vocational colleges that are currently, or have been, upgrading to universities of technology. The latter represent the highest level of the vocational track in Taiwan's educational system.

As a result of this evolution, enhancing the professional competence of certified nurses to enable them to attain university-level competence is now a responsibility of RNto-BSN nursing curricula at the new universities of technology. The authors' school, Fooyin Nursing Medical Junior College, became Fooyin University (FU) in 2002. Fooyin University currently is facing the challenge of developing an RN-to-BSN curriculum.

Taiwan's nursing curriculum has traditionally been oriented around the medical model and divided into five areas (i.e., medical-surgical, obstetric, pediatric, psychiatric, and community nursing), stressing diseases, signs and symptoms, treatment, patient problems, and nursing. Most RN-to-BSN programs in Taiwan still use this model, resulting in a great deal of repetition, as students repeat material in different fields of nursing.

Many authors (Cragg, Plotnikoff, Hugo, & Casey, 2001; Fralic, 1989; Hsu & Lin, 1993; Lawler & Rose, 1987; McHugh, 1991) believe students entering RN-to-BSN nursing programs are different from those entering nursing programs at 4-year colleges. RN-to-BSN nursing students are more mature, more devoted to nursing, and more motivated in their studies. Therefore, recommendations for RN-to-BSN nursing curricula design should be based on reinforcing, strengthening, and filling in gaps in the students' prior education, without repeating previous educational experiences.

The Teaching Protocol of Nursing Concepts (TPNC) is a nursing concept-based curriculum developed at FU by the nursing curriculum committee. Eighty professional nursing concepts covering the physical, psychological, social, and spiritual dimensions were selected in a Delphi study by nurse educators in Taiwan from the 127 originally identified by the North American Nursing Diagnosis Association (NANDA) in 1997. These were incorporated into three core courses and designated Professional Nursing Concepts I, II, and III. Examples of such concepts include "sleep pattern disturbance," "cardiac output decrease," and "hopelessness."

Evaluating clinical nursing competence is an important goal of nurse educators in Taiwan and abroad. Kim (2000) advocated increasing nursing student competence as a way to improve professional nursing competitiveness. Researchers have used a variety of methods to evaluate student nurse performance (Fitzpatrick, While, & Roberts, 1994; Norman, Watson, Murrells, Caiman, & Redfern, 2002). Neary (2000) found that nursing students appreciate the need for assessment of their own clinical competence. The authors' own survey showed that the primary motivation of students enrolling in the RN-to-BSN program was advancing their professional competence. Therefore, this study assessed changes in student clinical nursing competence after implementation of the TPNC, using student self-evaluations and instructor evaluations.

LITERATURE REVIEW

Clinical nursing competence, defined in this study as effective clinical nursing performance or behavior, consists of several integrated components - knowledge, skills, affect, motivation, and self-perception (DeBack & Mentkowski, 1986). It is the outcome of an educational process because clinical nursing competencies are developed through instruction in nursing curricula.

Many authors have defined the dimensions of nursing competencies (Aber & Arathuzik, 1996; Buckenham, 1988; Hsu & Lin, 1993; Schwirian, 1978; Tzeng, Yiin, & Chen 1997). In the most widely cited study, Schwirian (1978) used a Six-D Scale of Nursing Performance to capture nursing performance, evaluating leadership, critical care, teaching/collaboration, planning/evaluation, interpersonal relations/communication, and professional development. Hsu and Lin (1993) surveyed the opinions of nurse educators in Taiwan on the nursing competence of staff nurses. Their version of nursing competence incorporated six dimensions (i.e., caring, communication, selfdevelopment and professional development, management, teaching, and research).

A number of researchers have explored the relationship between the differing educational backgrounds of staff nurses and nursing competence, with various conclusions. Schwirian (1978) found that employer ratings of performance revealed nurses with baccalaureate degrees were rated more highly than those with associate degrees or diplomas. Their planning/evaluation competence was considered superior because they performed more activities such as leadership, patient teaching, communication, and planning. By contrast, nursing staff who graduated from vocational institutions focused more on functional nursing activities. In a survey of the competence of staff nurses currently enrolled in RN-to-BSN programs in Taiwan, Yu and Ku (1998) found that planning/evaluation skills and teaching/collaborating skills were the least well developed among the six major areas studied. Critical/dying care and professional development abilities were comparatively more advanced.

Bassett (1977) found no significant differences between baccalaureate and associate degree graduates in abstract thinking ability and problem-solving skills. Welches, Dixon, and Stanford (1974) found no significant relationship between ratings of staff nurse performance by head nurses and the educational background of staff nurses. McCloskey (1983) compared the job performance of graduates of four types of American educational programs (i.e., practical, associate degree, diploma, baccalaureate degree) and found little direct relationship between the years of nursing education and job performance. However, clinical experience was positively correlated with job competence and nurses' self-confidence. Among the four educational programs McCloskey studied, RN-to-BSN nurses had the highest job effectiveness. Maynard (1996) found that among university nursing students, there were no significant changes in critical thinking ability between the second and fourth years, but significant progress was made between graduation and employment as staff nurses. There was also a positive correlation between the number of years spent as a staff nurse and clinical competence.

Yu and Ma (1993) surveyed 735 new graduates from various vocational high schools, 5-year vocational high schools, 3-year colleges, and university nursing programs using a Scale of Nursing Competence questionnaire to compare their nursing competence. University nursing students scored the highest, followed by the 3-year college students, the 5-year junior college students, and the vocational high school students. However, the 12 variables examined accounted for only 26.7% of the variance. None of the variables examined in the study addressed the issue of nursing curriculum design.

In summary, while some research in this area has failed to find any significant relationship between the educational background of staff nurses and their clinical nursing competence (Bassett, 1977; Maynard, 1996; Welches et al., 1974) or almost no direct influence (McCloskey, 1983), other researchers (DeBack & Mentkowski, 1986; Schwirian, 1978) have found that baccalaureate degree nurses and associate degree or diploma nurses had different professional competencies. Results also indicated that education promotes a broader range of abilities than experience does. In Taiwan, Yu and Ma (1993) and Yu and Ku (1998) found that educational background strongly influences clinical nursing competence but did not explore whether differing curriculum designs had any effect on nursing competence or actual clinical performance.

Figure. Research design diagram.O0 Pretest: Full-time and part-time student self-evaluations.O^sub 1,2,3^ Posttests 1, 2, and 3: Full-time and part-time student self-evaluations and instructor evaluations.O4 Posttest 4 (3 months after employment): Full-time student self-evaluations and supervisor evaluations.X-^sub 1,2,3^ Intervention: Professional nursing concepts I, II, and III.

Figure. Research design diagram.

O0 Pretest: Full-time and part-time student self-evaluations.

O^sub 1,2,3^ Posttests 1, 2, and 3: Full-time and part-time student self-evaluations and instructor evaluations.

O4 Posttest 4 (3 months after employment): Full-time student self-evaluations and supervisor evaluations.

X-^sub 1,2,3^ Intervention: Professional nursing concepts I, II, and III.

Tanner (2001) recently called for increased attention to measurement and evaluation in nursing education research. In particular, she observed that techniques used to develop survey instruments were often inadequately described, categories were too idiosyncratic for meaningful generalization, and program outcomes were often neglected. In this study, the authors attempted to develop a more thoroughly described and outcome-focused instrument.

The purposes of the study were to:

* Develop an instrument for evaluating the clinical nursing competence of RN-to-BSN students.

* Compare student clinical nursing competence before, during, and after implementing a nursing conceptbased curriculum.

* Compare the clinical nursing competence of parttime students to that of full-time students.

* Compare student self-evaluations of their clinical nursing competence to instructor evaluations.

DEFINITIONS OF TERMS

In this study, clinical nursing competence was defined as the patient caring, communication and coordination, management and teaching, and professional self-growth of student nurses in clinical settings. The Clinical Nursing Competence Questionnaire (CNCQ) was developed by the authors to assess the four dimensions of clinical nursing competence:

* Caring competence: behaviors involved in the nursing process from data collection through evaluation of the nursing care of clients.

* Communication/coordination competence: communication and coordination with clients, families, and colleagues in the health care setting.

* Management/teaching competence: infection control, cost management, and the use of teaching principles and methods to provide instruction for individuals and groups.

* Professional self-growth competence: ability to accept constructive criticism, display caring behaviors, share professional knowledge, and follow nursing ethics.

METHOD

Design and Sample

This longitudinal study was conducted during a 3-year period (Figure). Fifty-two of 54 full-time students and 69 of 78 part-time students undergoing the new curriculum agreed to participate in this study. Their demographic characteristics are Usted in Table 1. All students must hold a RN license and have at least 1 year clinical experience before entering the program. Two years of full-time study or 3 years of part-time study is required to finish the program.

Fooyin University is the first school in Taiwan to use a concept-based curriculum. Because RN-to-BSN students already have an KN license, the traditional medical model of instruction would simply repeat content they had already studied. By contrast, the concept-based model shifts nursing education from mastering knowledge and skills for tests to a patient-centered and problem-solving approach more appropriate for experienced nurses returning to school.

The TPNC was implemented during three consecutive semesters. A total of 12 instructors were responsible for teaching nursing concepts and supervising clinical practice. Instructors with backgrounds in medical-surgical nursing taught Professional Nursing Concepts I and supervised clinical practice in the medical-surgical units of the hospital. This instructional arrangement was used for OB/Gyn and pediatric nursing (Professional Nursing Concepts II), and community health and psychiatric nursing (Professional Nursing Concepts III). The authors of this study were not part of the instructor pool.

In the concept-based curriculum used at FU, the instructor introduces a client's health problems and the concepts to which they relate, including the definition and characteristics of the concepts and their physical, pathological, psychological, and psychosocial mechanisms. A nursing care plan and intervention are then discussed, and case studies are used to evaluate the nursing outcome. Students are typically divided into small groups for discussion, simulation, and analysis of nursing priorities. After completing each set of nursing concepts (I, II, and III), students perform clinical practice 3 days per week for 4 weeks.

Instrument

The design of the instrument used in this study was based on the literature and professional nursing competence questionnaires of Girot (1993), Grabbe (1988), Hsu and Lin (1993), Schwirian (1978), and Yu and Ku (1998). A 32-item CNCQ was drafted. Six clinical nursing administrators and four nurse educators evaluated the content validity of the questionnaire items. Four items were eliminated, and the remaining 28 were revised. For the purpose of factor analysis, the questionnaire was then administered to 117 RN-to-BSN students. Fifty-two were full-time students who later participated in the current study (JV = 121), and 65 were part-time students who did not participate in the current study. Factor analysis was conducted by using the principle components method with varimax rotation. Items with factor loading greater than .4 were selected. After elimination of items #1,7,8, 13, 23, and 24, the remaining items were divided into four dimensions based on the results of factor analysis (Table 2). The first dimension was caring competence (items #4, 6, 9, 10, 11, 12, 14, 22), the second dimension was communication and coordination competence (items #2, 3, 5, 15, 16, 17, 18), the third dimension was management and teaching competence (items #19, 20, 21), and the fourth dimension was professional self-growth competence (items #25, 26, 27, 28).

In total, the CNCQ contains 22 items. For the 18 items in the first three dimensions, on a 1 to 5 scale, 5 represents the ability to independently, safely, and accurately complete each nursing activity without advice from instructors and supervisors; handle problems in a minimum of time; apply nursing theories and knowledge accurately; focus on clients while performing activities, and appear confident. Scores of 4, 3, 2, and 1 represent successive reductions in ability to independently perform nursing tasks. For the fourth dimension, the 1 to 5 scale refers to frequency of performance, with 5 representing "all the time" and 1 representing "never." Therefore, the total score possible on all 22 items ranged from 22 to 110. These four factors together explained 60.57% of the variance. The internal reliability was .93 using Cronbach's alpha.

Data Collection Process

The purposes and methods of the study were explained to the students and their instructors prior to the pretest and again before each clinical practice and posttest. In March of 1999, students evaluated their clinical nursing competence by completing a CNCQ before receiving the TPNC. After finishing each section of course work and clinical practice for Professional Nursing Concepts I, II, and III, instructors and students separately evaluated the students' clinical nursing competence. Both full-time and part-time students were taught and evaluated by the same instructors. A fourth posttest was conducted 3 months after the full-time students were employed. The questionnaire was mailed to 42 of the 52 full-time students who were employed within 8 months after graduation and their supervisors. All 42 pairs of questionnaires were returned. The part-time students were not evaluated after graduation because they all had full-time work (in which many held supervisory positions).

Table

TABLE 1Basic Characteristics of Students Receiving Teaching Protocol of Nursing Concepts

TABLE 1

Basic Characteristics of Students Receiving Teaching Protocol of Nursing Concepts

Data Analysis

The Statistical Package for the Social Sciences (SPSS) for Windows, Version 8.0 was used to process the valid questionnaires. Descriptive and inferential statistical analyses were performed, including frequency distribution, mean, standard deviation, chi square, f test, generalized linear model for repeated measurement, and Bonferroni posterior test. Missing values were estimated by the average score of the remainder of the total sample.

RESULTS

The longitudinal design makes it possible to track student progress over time and evaluate the effects of the new curriculum and other factors on clinical nursing competence.

Table

TABLE 2Factor Analysis of Clinical Nursing Competence Questionnaire (N=: 117)

TABLE 2

Factor Analysis of Clinical Nursing Competence Questionnaire (N=: 117)

Student Self-Evaluations of Clinical Nursing Competence

The results of student self evaluations can be found in Table 3. Full-time student self-evaluations generally increased in most dimensions of clinical nursing competence as they went through the TPNC. The highest scores in all dimensions were obtained after the students had been employed for 3 months, with the exception of professional self-growth competence. The sums of all 22 items were 89.17 (pretest), 99.87 (first posttest), 101.77 (second posttest), 98.46 (third posttest), and 103.54 (posttest 3 months after employment). By contrast, scores on parttime student self-evaluations generally decreased. The sums of the scores were 97.46 on the pretest and 99.73, 97.90, and 92.80 on the successive posttests. The score on the third posttest was significantly lower than the scores on the pretest and two prior posttests.

Table

TABLE 3Student Self-Evaluations of Clinical Nursing Competence

TABLE 3

Student Self-Evaluations of Clinical Nursing Competence

A i-test analysis showed that on the pretest, part-time students' scores were significantly higher than full-time students' scores in each dimension and in overall clinical nursing competence ip < .01). However, the situation reversed as the TPNC proceeded. Full-time students scored themselves significantly higher than the part-time students in caring competence, professional self-growth, and overall clinical nursing competence ip < .01) on the second and third posttests. Full-time students also scored higher in management/teaching competence on the second posttest (? < .01).

Instructor/Supervisor Evaluations of Student Clinical Nursing Competence

The results of instructor/supervisor evaluations of student clinical nursing competence are shown in Table 4. Instructor evaluations were performed after clinical practice at the end of each semester. Instructors rated the fulltime students (the sums of the scores were 92.91, 95.87, and 89.28 on each posttest) higher than the part-time students (the sums of the scores were 91.51, 94.25, and 88.45 on each posttest), but the differences were not significant.

Table

TABLE 4Instructor/Supervisor Evaluations of Student Clinical Nursing Competence

TABLE 4

Instructor/Supervisor Evaluations of Student Clinical Nursing Competence

The scores of instructor evaluations of part-time students were generally lowest on the third evaluation in all dimensions, except for professional self-growth, as the curriculum proceeded. The scores of supervisor evaluations of full-time students were generally lower in all dimensions.

DISCUSSION

Clinical Nursing Competence Questionnaire

In contrast to other measurements of nursing competence, the CNCQ does not include leadership, planning/evaluation (Schwirian, 1978; Yu & Ku, 1998), or research competencies (Hsu & Lin, 1993). This is because the questionnaire explores only the behaviors of nursing students, who are not required to perform research or administrative duties as part of their clinical practice. One item, "cost management," was not included as a behavioral item on any of the previous survey instruments the authors examined, although it was frequently mentioned as a concept of crucial importance by the hospital nursing administrators with whom the authors talked. Fiscal management was identified as the weakest area of nursing competence by Diede, McNish, and Coose (2000).

The CNCQ contains 22 items, fewer than the 50 or more items used by other measurement instruments. The lower number of questions reduced the time necessary to complete the questionnaire.

Student Self-Evaluations of Clinical Nursing Competence

The results of the student pretest self-evaluations revealed that length of work experience was an important factor in their clinical nursing competence. In communication/coordination and management/teaching competence, nurses with less than 5 years of work experience tested lower than those with more than 5 years of work experience (data not shown). Similarly, Maynard (1996) found that clinical nursing competence was positively correlated with length of work experience.

Scores from both full-time and part-time student pretest self-evaluations were lowest in professional selfgrowth competence, followed by management/teaching competence. Studies of part-time RN-to-BSN students in Taiwan by Pai, Hsu, and Wang (1999) and Yu and Ku (1998) obtained similar results.

After implementation of the TPNC, the full-time student self-evaluations showed successively increasing scores on most of the posttests. By comparison, scores on part-time student self-evaluations decreased over successive self-evaluations. Differing work experience, motivation, and other factors may explain these results.

Part-time students evaluated themselves higher than full-time students on the pretest self-evaluations simply because they had more work experience and greater selfconfidence. Many already held supervisory positions in their own nursing units. However, as they encountered new concepts and different clinical settings, their selfevaluation scores decreased. Almost all of the part-time students were working as medical-surgical nurses. When placed in psychiatric units or community health settings, they found themselves in unfamiliar environments, and their self-confidence dropped. In addition, because they held status in their full-time jobs, they hesitated to ask questions of younger nurses in the clinical practice units because that would cause them to lose face. For the fulltime students, all material was equally new because they had little work experience. As they mastered new material and new clinical settings, their self-confidence and perceptions of their own competence increased.

Full-time and part-time students also had differing motivations. Part-time students already had jobs and were taking the courses to earn a degree. Some believed they merely needed to pass. Because most of them were already employed as medical-surgical nurses, they sometimes had trouble seeing how new concepts would apply to their work. Lower self-evaluations may also be an ironic outcome of the greater professional experience of the part-time students (i.e., they may have had more realistic views of their own capabilities and performance).

However, because full-time students were studying to obtain employment in a highly competitive local job market, they were strongly motivated to obtain good grades and perform well. Zhang, Luk, Arthur, and Wong (2001) similarly found motivation and attitude to be important factors in effective nursing performance.

Another factor favoring the performance of full-time students was time. Part-time students took night classes after working long hours in clinical settings and had little time and energy to master new material. This problem was also noted by MacDonald (1995) in her study of parttime students in an RN-to-BSN program.

Despite the lower scores they gave themselves, parttime students had a positive response to the new curriculum in interviews. Many of them had friends studying in other schools whose experiences they could compare with their own. Part-time students said FLTs curriculum was less repetitive and more challenging, facilitated professional growth, and enabled them to see clients from another angle. By comparison, FU student nurses reported that their friends had lower levels of satisfaction with the traditional programs at other schools, feeling they were repetitive and not targeted to their professional needs.

In addition, clinical practice for Professional Nursing Concepts III, which produced generally lower scores on all evaluations, occurred in psychiatric or community nursing settings. Both full-time and part-time students had difficulty with clients with psychosocial and mental problems because most students came from medical-surgical backgrounds. Many students felt intimidated by possible violent reactions from psychiatric patients or felt frustrated with dementia patients in in-home settings. Furthermore, while medical-surgical nursing provides student nurses with rapid, positive feedback from successful care, psychiatric and long-term patients did not provide the same boost to students' self-confidence. Finally, Professional Nursing Concepts III did not adequately prepare students for the complexity of psychosocial problems they could encounter in clients and their families in their clinical practice.

Although part-time students' self-evaluations decreased in most dimensions of competence, both groups of students still said, in student-teacher conferences witnessed by the authors, that their professional knowledge and skill had improved. The students even suggested the concept-based curriculum, unique in Taiwan, could be an important selling point in recruiting for FLTs RN-to-BSN program.

Instructor/Supervisor Evaluations of Student Clinical Nursing Competence

Both full-time and part-time students' self-evaluations of their clinical nursing competence were significantly higher than those of their instructors. This is consistent with other studies (e.g., Failla, Maher, & Duffy, 1999). Instructor scores were lower because the instructors saw the students for only limited periods and did not witness certain behaviors, such as sharing reflections on the literature with peers (instructor mean score = 2.58, student mean score = 4.0). In addition, the instructors had higher standards than the students and were more aware of student errors. Because the curriculum was new and often represented a significant departure from what instructors were accustomed to many instructors were insufficiently prepared to evaluate the students.

Generally, there were no significant differences among instructors' evaluations of part-time and full-time students. Because the same instructors taught and evaluated both groups, the progressively lower self-evaluations of part-time students probably reflect their higher expectations for themselves and other emotional factors.

Supervisors and head nurses gave the lowest evaluations of the student nurses. They may have been evaluating the competence of newly graduated nurses against the competence of experienced staff nurses (mean scores < 4.0 in all dimensions). Many of the supervisors rating the new graduates also had associate degrees, rather than baccalaureate degrees, and may have rated the RN-toBSN graduates against expectations of higher standards of preparation. Howell (1978) noted that ratings reflected the educational background of supervisors. Three months after employment was selected as the date of evaluation because that is typically when the trial period for newly hired nurses in Taiwan ends, and new nurses are either let go or given permanent jobs.

LIMITATIONS AND RECOMMENDATIONS

This study used a quasiexperimental design with no control group for ethical reasons (i.e., forming a control group would deny a portion of the students the benefits of the new curriculum). Data collected at a single school from a limited number of students in a new program will probably limit its generalizability. The TPNC was new for the instructors, and they were not completely familiar with its contents or the best teaching strategies for it. The new curriculum was developed by the curriculum committee and imposed on the nursing faculty from above. None of the 12 faculty in study sat on the curriculum committee or participated in the curriculum discussions. In addition to ensuring the effective observer performance (Fitzpatrick et al., 1994), interrater reliability was not established for either the 12 instructors or the 42 supervisors who performed the final evaluation. The education and experience of the nursing instructors and supervisors was not controlled. Student competence may have increased simply as a result of their growing maturity.

The number of hours of classroom instruction was limited, so only 80 professional nursing concepts could be introduced during the three semesters of the curriculum. In addition to expanding the length of the curriculum to accommodate for professional nursing concepts, clinical nursing competency-based evaluation approaches could be incorporated into TPNC for curriculum improvement.

In this study, the full-time and part-time students had markedly different educational goals. Based on these results, the curriculum and teaching strategies should be made more flexible to accommodate the various backgrounds, motivations, and professional needs of part-time and full-time students. Clinical teaching strategies must address the fact that experienced, often senior, nurses are being placed in new clinical situations where they must ask for guidance from junior nurses. For many such nurses in Chinese culture, this presents an unacceptable loss of face.

As the first step in implementing a shift to conceptbased curricula in Taiwan, FU hosted a seminar for Taiwan's nursing programs to introduce the new curriculum and the authors' experiences with it to a wider audience. This exposure had positive results. First, there has been growth in applications from prospective students, while current FU students say they are glad they selected the right school. Second, FU faculty have been invited to other universities to provide workshops on this curriculum. This has enhanced the standing of FtFs program among Taiwan's nursing programs. In recent years, Taiwan's hospitals have been demanding nurses with baccalaureate, rather than associate, degrees. Therefore, demand for RNto-BSN programs will increase in the years to come. The authors see this curriculum as a model for this important transition in nursing education in Taiwan.

CONCLUSION

A clinical nursing competence measurement tool, the CNCQ, was developed for this study. Using this tool, the authors evaluated the effectiveness of a nursing conceptbased curriculum for RN-to-BSN students in Taiwan. The four clinical nursing competencies measured by the CNCQ were caring, communication/coordination, management/teaching, and professional self-growth. Student clinical nursing competence was evaluated over time. The study found that full-time student self-evaluations of their competence showed significant improvement as time passed on all dimensions of competence, except professional self-growth. Self-evaluations of part-time students decreased in all dimensions of competence except professional self-growth. Both groups of students consistently evaluated themselves more highly than their instructors/supervisors did. In addition, both groups of students stated in interviews that they found the program to be of value.

The authors recommend that instructors continuously strengthen their knowledge of nursing concepts and tailor the program to the various needs of part-time and fulltime students. It will be worthwhile in the future to develop two instructional strategies that address these different student populations. The curriculum used in this study provides a model for RN-to-BSN programs applicable to vocational nursing education in many settings.

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TABLE 1

Basic Characteristics of Students Receiving Teaching Protocol of Nursing Concepts

TABLE 2

Factor Analysis of Clinical Nursing Competence Questionnaire (N=: 117)

TABLE 3

Student Self-Evaluations of Clinical Nursing Competence

TABLE 4

Instructor/Supervisor Evaluations of Student Clinical Nursing Competence

10.3928/0148-4834-20031201-05

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