Journal of Nursing Education

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Major Article 

The Competence of Nursing Graduates from Problem-Based Programs in South Africa

Leana R. Uys, D Soc Sc; Nomthandazo S. Gwele, PhD; Patricia McInerney, PhD; Lily van Rhyn, D Soc Sc; Thobeka Tanga, PhD

Abstract

Although a significant body of research regarding problem-based learning (PBL) programs has been conducted during the past 2 decades, most of it relates to medical students and their curricula. There has also been very little research in the context of developing countries. In South Africa, most of the students who are admitted into nursing programs are from disadvantaged backgrounds, and it is important to assess the extent to which process-based curricula are appropriate for this group. The purpose of this study was to describe and evaluate the outcomes of PBL programs in nursing schools in South Africa in terms of the actual clinical practice and competence of graduates, and to compare these outcomes with those of graduates from conventional programs. The objectives of the study were to identify the characteristics of practice of graduates from PBL and conventional schools of nursing in South Africa, as described by the graduates and their supervisors, and secondly, to compare the practice characteristics of the two groups.

This was a qualitative evaluation study, descriptive and comparative in nature. In-depth interviews with graduates and their supervisors were conducted, and data were analyzed using Benner’s stages of practice and Crabtree and Miller’s (1994) template analysis style. Most of the graduates chose clinical incidents to describe their stage of practice. The PBL group had a spread of incidents across four stages of practice (novice to proficient), while the control group had a spread of incidents across only three stages of practice (novice to competent). The majority of respondents felt positive about the incidents they had described, although feelings of being scared, angry, and guilty were also identified.

Dr. Uys and Dr. Gwele are Professors, and Dr. McInerney is Senior Lecturer, School of Nursing, University of Natal, Durban; Dr. van Rhyn is Senior Lecturer, University of the Free State, Bloemfontein; and Dr. Tanga is Senior Lecturer, University of Transkei, Umtata, Eastern Cape, South Africa.

The authors acknowledge the financial assistance of the National Research Foundation for this research. The opinions expressed and conclusions made in this article are those of the authors and are not necessarily those of the National Research Foundation.

Address correspondence to Leana R. Uys, D Soc Sc, Professor, School of Nursing, University of Natal, Durban 4041, South Africa; e-mail: uys@nu.ac.za.

Received: January 14, 2003
Accepted: September 24, 2003

Abstract

Although a significant body of research regarding problem-based learning (PBL) programs has been conducted during the past 2 decades, most of it relates to medical students and their curricula. There has also been very little research in the context of developing countries. In South Africa, most of the students who are admitted into nursing programs are from disadvantaged backgrounds, and it is important to assess the extent to which process-based curricula are appropriate for this group. The purpose of this study was to describe and evaluate the outcomes of PBL programs in nursing schools in South Africa in terms of the actual clinical practice and competence of graduates, and to compare these outcomes with those of graduates from conventional programs. The objectives of the study were to identify the characteristics of practice of graduates from PBL and conventional schools of nursing in South Africa, as described by the graduates and their supervisors, and secondly, to compare the practice characteristics of the two groups.

This was a qualitative evaluation study, descriptive and comparative in nature. In-depth interviews with graduates and their supervisors were conducted, and data were analyzed using Benner’s stages of practice and Crabtree and Miller’s (1994) template analysis style. Most of the graduates chose clinical incidents to describe their stage of practice. The PBL group had a spread of incidents across four stages of practice (novice to proficient), while the control group had a spread of incidents across only three stages of practice (novice to competent). The majority of respondents felt positive about the incidents they had described, although feelings of being scared, angry, and guilty were also identified.

Dr. Uys and Dr. Gwele are Professors, and Dr. McInerney is Senior Lecturer, School of Nursing, University of Natal, Durban; Dr. van Rhyn is Senior Lecturer, University of the Free State, Bloemfontein; and Dr. Tanga is Senior Lecturer, University of Transkei, Umtata, Eastern Cape, South Africa.

The authors acknowledge the financial assistance of the National Research Foundation for this research. The opinions expressed and conclusions made in this article are those of the authors and are not necessarily those of the National Research Foundation.

Address correspondence to Leana R. Uys, D Soc Sc, Professor, School of Nursing, University of Natal, Durban 4041, South Africa; e-mail: uys@nu.ac.za.

Received: January 14, 2003
Accepted: September 24, 2003

During the past few years, there has been mounting pressure from the South African Department of Health (1997) on schools of health professional education to embark on problem-based learning (PBL). Although very few, if any, nursing colleges have taken this route yet, four nursing schools at different universities have implemented such programs:

  • University of Natal in 1994.
  • University of the Witwatersrand in 1995.
  • University of Transkei in 1997.
  • University of the Free State in 1997.

Although a significant body of research regarding problem-based learning (PBL) programs has been conducted during the past 2 decades, most of it relates to medical students and their curricula, and very little relates to developing countries (Albanese & Mitchell, 1993; Vernon & Blake, 1993). Research in the developing context is necessary because incoming students in South Africa often come from disadvantaged educational backgrounds, and it is important to assess to what extent process-based curricula are appropriate for this group. In addition, once qualified, South African RNs have very extended roles, with limited supervision and support. For example, South African RNs in primary health clinics are expected to provide comprehensive, primary-level services after only basic nursing education, while in the United States, such services are provided by nurse practitioners with master’s degrees (Anderson, 1994). Because demands on nurses in developing countries are higher after graduation than in other contexts, the education may need to be different. Finally, evaluation studies are necessary if transformation of nursing education is to occur in South Africa, and it is important that such changes be for the better, not just for the sake of change.

Therefore, this study aimed to evaluate the outcomes of the four PBL community-oriented education programs initiated by the South African universities named above in order to facilitate the implementation process in other nursing education institutions.

Purpose

The goal of this research was to describe and evaluate the outcomes of PBL programs in nursing schools in South Africa in terms of the actual clinical practice and competence of graduates, and compare these outcomes with those of graduates from conventional programs. The research objectives were to identify the practice characteristics of graduates from PBL and conventional programs in South Africa, as described by the graduates and their supervisors, and compare the practice characteristics of the two groups.

The specific research questions were:

  • What are the levels or stages of practice of graduates from PBL and conventional programs in South Africa, as described by the graduates and their supervisors?
  • What are the graduates’ feelings about the incidents they describe, and what are the outcomes of the incidents?
  • What function (i.e., clinical, teaching, or management) do respondents address in the incidents they describe?
  • What are the supervisors’ perceptions of PBL graduates?

Definitions of Terms

Problem-based learning is a process-focused type curriculum in which students work in small groups on integrated clinical problems presented in the form of trigger materials on a sequence of patients. Students identify their own learning needs and address these, mainly through self-study, to solve the problems (Barrows, 1986).

In this study, competence is identified as the advanced beginner stage of professional development (Benner, 1984). This means beginners can demonstrate marginally acceptable performance and have coped with enough real situations to note the recurring, meaningful, situational components practitioners use to develop their own guidelines for practice.

Conventional instruction refers to content-based curricula, characterized by large group teaching, primarily through lecture and demonstration, and limited self-directed learning.

Literature Review

Problem-Based Learning

Two definitive literature reviews on the efficacy of PBL were published in 1993, one by Albanese and Mitchell, and the other by Vernon and Blake. Albanese and Mitchell (1993) addressed questions on cost, effectiveness of the integrated approach, adequacy of content covered, dependence on small groups, and time required from faculty. Their references listed 106 studies, and they mentioned that more than 100 additional studies were reviewed but not listed.

All four studies on graduate practice reviewed involved physicians. They involved surveys of practice indicators, such as time spent with patients, referrals, and reimbursement practices. The patterns were different between PBL and conventional graduates, but the direction of the difference was impossible to interpret definitively. Because PBL and community-oriented learning are often used together, this survey also examined the specialty choices of graduates and found there was a pronounced trend toward family medicine in PBL graduates.

Vernon and Blake (1993) conducted a meta-analysis of 22 studies covering 19 different PBL programs, a number of which were nursing programs. Most of the studies referred to process evaluation, not product evaluation. Three studies addressed clinical performance after completion and used performance ratings either in practice settings or of simulated patients. All three of these studies involved medical graduates from the Netherlands, Canada, and the Middle East, and all three showed superior performance by the PBL graduates. The authors pointed out that the measurements were not well conceptualized, and the number of comparisons made was often not indicated (Vernon & Blake, 1993). In addition, the attrition rate was not equal in all groups, making the randomization of the samples less effective.

We found no product outcome studies on nursing students in the literature. Although there are nursing schools in developing countries in South America and the Far East, where PBL approaches have been implemented at least partially, no literature on outcome studies could be found from such schools (McMaster University, School of Nursing, 1996). Therefore, the question about the long-term effects of PBL on nursing practice has not been adequately answered.

Stages of Practice

Benner (1984) described nursing as consisting of five domains: helping, teaching-coaching, diagnostic-monitoring, managing rapidly changing clinical situations, and administering and monitoring treatment regimens. She also identified five levels of practice, ranging from novice to expert, based on the 1977 work of Dreyfus and Dreyfus. For each of these levels, Benner (1984) identified characteristics of practice:

  • Novice. This stage is characterized by rule-governed behavior that is extremely limited and inflexible. Since novice nurses have no experience related to the situations they face, they must be given rules to guide their performance. They are unable to change their behavior according to context.
  • Advanced beginner. Due to their previous experience, these nurses can recognize aspects of the situation that change the rules. Therefore, their performance is more flexible and is marginally acceptable.
  • Competent. Nurses who have performed the job in the same or similar situations for 2 to 3 years can see and plan actions with a view of more long-term objectives. Aspects of the current and future situations are considered, and a plan is based on conscious, abstract, analytic contemplation of the problem.
  • Proficient. These nurses perceive the situation as a whole, and their performance is governed by maxims. Their perception is not thought out but is based on experience of the long-term meaning of the situation.
  • Expert. Expert nurses no longer rely on an analytic principle (i.e., rule, guideline, maxim) to decide on appropriate actions. Their enormous experience base leads to an intuitive grasp of each situation and a targeting of the relevant region of the problem.

These levels were used in this study to classify the practice descriptions obtained from the respondents.

Preregistration Program Evaluation

Greenwood (2000) indicated that, in many countries, the move toward more academic nursing education has led to some uncertainty about whether graduates are competent to practice. In an article on evaluation of continuing professional education programs, Jordan (2000) reviewed the research strategies that can be used and pointed out the difficulties of each. Evaluation by students is the most common strategy, but this can be flawed by copying or conferring. Randomized trials are difficult because multiple sites introduce numerous confounding variables, and single sites lead to contamination and are expensive to implement. Time series models offer a valuable method, but sample losses are difficult to cope with. In addition, data collection methods such as interviews, questionnaires, and observation all have problems. The same can be said about the evaluation of preregistration programs.

Fitzpatrick, While, and Roberts (1996b) developed an observational tool based on the Slater Nursing Competencies Rating Scale and carefully prepared observers to use it. They found an acceptable level of inter-rater reliability could be achieved, with an average of .5 SD of difference between raters on seven subscales, but they also highlighted the difficulties of observational research.

In another study, the same researchers used semi-structured interviews with graduates to explore the influential practice events and key people in the professional socialization of students (Fitzpatrick, While, & Roberts, 1996a). They used the professional socialization process as their theoretical framework, defined as the process by which people selectively acquire, based on their own past experiences and the educational program, the culture of the group they are joining. In this process, role clarification is very important, and this happens through “intentional role instruction, interaction with professional reference groups, role modeling (mainly by practice-based role models, peers, and clinical instructors), and role rehearsal” (Fitzpatrick et al., 1996a, p. 508). Their study confirmed the importance of the educational programs, practice settings, and role models.

Carlisle, Luker, Davies, Stilwell, and Wilson (1999) interviewed 60 nurse managers in individual interviews and focus groups about their perceptions of recently graduated nurses to evaluate their “fitness for purpose.” These managers complained about the levels of what they called “critical” or “core” skills, such as administering injections or drugs. They also found recent graduates’ interpersonal skills and ability to work as part of the health care team to be lacking.

Method

This was a qualitative evaluation study, descriptive and comparative in nature. In-depth interviews with graduates and their supervisors were conducted, and data were analyzed using a template based on the theoretical framework described above.

The population involved the graduates of the four PBL programs identified above (PBL group) and three conventional programs in the same provinces (control group) in the year under consideration. The control group was obtained from three programs who drew students from the same catchment areas, language groups, and population groups, and had the same language of instruction as the PBL programs.

Although authors usually recommend that outcome studies involve graduates 12 months after completion of a program (Clark, Goodwin, Mariani, Marshall, & Moore, 1983; Stufflebeam, 1987), we decided to involve graduates 6 to 9 months after graduation instead. This decision was based on the fact that the services in which graduates may work are so diverse that after a longer period of time it would be difficult to discount the influence of the setting and, hence, ascribe differences to only the programs. In addition, many graduates leave the country after 1 year for overseas experience, which could make it difficult to access a representative sample.

All graduates who could be traced and were in the country were approached by mail to participate in the study, and all graduates who responded positively were included in the sample. All participants who consented by returning the signed agreement were asked to identify the supervisor (i.e., nurse manager) who worked most closely with them. The supervisor was also contacted by mail, with a short proposal attached. If the supervisor consented, the dates and times for the interviews were set. Both the graduate and the supervisor were interviewed once to obtain a description of the graduate’s practice.

The interviews were scheduled for times suitable to both the graduate and supervisor, and were audiotaped, transcribed, and analyzed. To increase the validity of the data, staff from different universities interviewed each other’s students, so graduates were not inhibited by talking to their own lecturers. The interviews used open-ended questions such as:

  • Where are you working? How long have you been working there?
  • Give a detailed description of the most significant incident in your practice during the past month (for graduates). Give a detailed description of the most significant incident you have experienced with regard to this graduate (for supervisors).

Answers were probed further regarding the reasons for their choices, the respondent’s feelings at the time of the incident, and the outcome of the incident. The questions were selected to allow for analysis using the interpretative approach recommended by Benner (1984). She maintained that one cannot interpret a piece of behavior without taking into account the context within which it is found. Therefore, it was essential for data to be collected in a way that allowed the context and the nurse’s intentions and understanding to be analyzed.

Each researcher analyzed the data of one group of students using the template analysis style described by Crabtree and Miller (1994). This meant that the theoretical framework was used as a preliminary template but that we had the freedom to revise categories before interpretation. In addition, the interpretative approach of Benner (1984) was used, so data were not broken down into small pieces and the rich description of actual practice was not lost. Data analysis was performed using the NVivo computer program, version 1.1.

To increase the validity of the coding, the following measures were taken:

  • One researcher coded the first set of data and developed an additional guide for coding, outlining the criteria used to classify levels of practice and problem solving.
  • A second researcher reviewed the coding of the first group of respondents performed by the first researcher.
  • The two researchers who worked together on the first coding then taught all the others the process and helped them use the code book.
  • All five researchers met to discuss the coding before the final coding was entered and the report written.

Results

Sample

A total of 49 graduates were interviewed (40 from PBL programs, and 9 from conventional programs). Of the PBL group, 23 were African, 2 were Indian, and 15 were White. Of the control group, 3 were African, and 6 were White. There was 1 man in the PBL group and 2 in the control group.

In the year in which both groups graduated, the following numbers of students graduated from the PBL programs:

  • University of the Free State = 73 (16 of whom were part of this sample, 22%).
  • University of Natal = 24 (10 of whom were part of this sample, 42%).
  • University of the Witwatersrand = 9 (5 of whom were part of this sample, 56%).
  • University of Transkei = 22 (9 of whom were part of this sample, 41%).

Because this was qualitative research, a specific sample size was not identified. However, the sample did seem to be representative of the population of PBL graduates from the four schools. Although the representation of the sample may have been affected by the fact that graduates volunteered to participate in the study, there is no indication that this affected the results.

The majority of the PBL group were working in provincial services (n = 27, 68%), while only 2 members of the control group worked in this sector (22%). Table 1 summarizes the areas in which the graduates were working. The highest percentage of graduates worked in specialist units (41%), but general and midwifery units were also well represented. A total of 43 supervisors were interviewed.

Work Settings of Graduates (N = 49)

Table 1:

Work Settings of Graduates (N = 49)

Levels of Practice

The levels of practice described in the incidents are summarized in Table 2. All members of the PBL and control groups reported incidents spread across the levels of practice from novice to proficient. Both groups reported incidents at the novice level, and this represented 16% of the incidents described. For some, these incidents were in the clinical area, and for others they were in management. The control group did not report any incidents at the proficient level in the clinical or management areas, but 15% of the incidents described by PBL graduates or their supervisors were at this level.

Number of Incidents by Level of Practice, as Described by Graduates (N = 49) and Supervisors (N = 43)

Table 2:

Number of Incidents by Level of Practice, as Described by Graduates (N = 49) and Supervisors (N = 43)

The graduates often described incidents from two levels of practice. For example, one graduate described one incident at the novice level and another at the advanced beginner level. In addition, graduates and their supervisors often described incidents at different levels. In a group from one of the PBL programs, the supervisors invariably described incidents at a higher level than the graduates did, while the opposite was true in the other groups. For example, one graduate described one incident at the advanced beginner level, while her supervisor described the same incident at the competent level.

Examples of Each Level of Practice

The following are examples of each level of practice, from all groups:

Novice. Incidents classified at the novice level referred to graduates who felt they could not cope with a specific situation or situations in which they saw something going wrong but did very little about it. In some cases, even after the incident, these graduates did not follow up, try to find out why things went wrong, or try to correct the situation. This example is from a graduate from the control group whose description of a significant experience was rated at the novice level of practice:

During the change over [of shifts], at 6:45 in the evening, we found that there was fetal [heartbeat] at that moment, and the mother suddenly became fully dilated. We asked the doctor because we were no longer allowed to deliver the patient if it was a breech presentation. Then we found a doctor who assisted us. We were encouraging the mother to push at that time, but she couldn’t push well.... I thought that the doctor would manage the way I learned when I was still in training, but he didn’t pull the cord; the cord was left inside, and then when he pulled the baby out, then the baby came out dead.

When asked what his role was at the time, the respondent stated that:

At the time, we clamped the cord and cut the cord. We tried to resuscitate the baby, but we failed. Then we came back to the mother, and we told the mother that the baby was not alive, and the mother just cried, and then we tried to reassure her, and we tried to tell her the cause of the death. We told her that she took so long to push the baby out that there was cord around the neck at that time. Then we told the mother that if the cord is around the neck then there’s little chance of the baby to come out alive. I would say, according to my assessment, there was mismanagement.

This graduate’s description of the significant experience is indicative of novice stage of practice in that he not only witnessed “mismanagement” of a breech delivery by a doctor and failed to intervene on behalf of the patient, but continued to blame the patient in his explanation by telling the patient that she took too long to push. In his own words:

Sometimes it becomes difficult to tell the doctor and say, “No doctor, do it like this.” I couldn’t say something about it. I continued encouraging the mother to push. I think it was a doctor’s role to know the management of breech delivery.

Advanced Beginner. The incidents classified at the advanced beginner level do not describe unsafe practice, but instead describe nurses who asked a more experienced colleague to intervene rather than handling the difficult situations themselves. Such nurses participate in interventions, but neither take the lead nor do anything special to help.

In this example, the graduate (from the PBL group) saw something going wrong and brought it to the attention of the doctor, but the doctor did not respond adequately. The nurse remained involved and did her best, but the patient died:

The only case that we had last month is a patient who came in as an emergency case. The indication, she was cesar [sic] for [inaudible] ward, and she was in labor. This lady came with [inaudible], and she was, like, 36 weeks. She came with a high temperature, and you know, the blood pressure was high, high, high; it was, like, 180/120. And, you know, if you talk to anesthetics doctors, “You know, doctor please check on this BP [blood pressure] ‘cause it’s not alright,” he turns like, “OK, you know what [name], this blood pressure has been like this before, and you know, our machines are not all right ‘cause if the patient is shivering [inaudible] become alright, you know, so you have to make the patient cool so as to get the right reading.”

So I thought the patient was stabilized, and she became OK; she was cold, but the blood pressure remained high as we proceeded with the cesarean section. I don’t know if the patient became disoriented. ‘Cause you know we keep on talking to them so as to be sure that the anaesthetic that has been given doesn’t do the wrong thing. So I was talking to this patient, “What baby do you want?” She said, “I don’t know.” “What’s your name?” “I don’t know.” “Where do you stay?” “I don’t know.” What’s the name of the father of the baby?” “I don’t know.” I said to this doctor, “You know what, this patient is getting disoriented, and I don’t know, maybe the spinal, but I’ve never heard of the spinal being [a] cause of disorientation.” So he said, “Anyway let’s carry on ‘cause I think she doesn’t want the baby; maybe that’s the reason why.”

So at the end of this cesarean section, after they’d closed and done everything, and she [the mother] was sent to recovery room, I had a report from the sister [the nurse in charge of the unit] who was working in [the] recovery room, and the patient was bleeding [from her] vagina. We had a doctor there in our duty room, so he went there and checked the patient [inaudible], but the patient continued bleeding, bleeding, bleeding.

So, at that time, the oxygen level in the blood was, like, I can tell you I didn’t get the readings from the book or from the notes, but they said it was, like, 77 or so, but far below the right level of the oxygen. So that patient was transferred to high care after the doctors had got to the [inaudible] the GCS [Glasco Coma Scale] of the patient is not alright; she is getting disoriented. The oxygen saturation is low, BP remains high, but [she was] still bleeding, so they ordered bloods for the patient and transferred her to [the] ICU [intensive care unit], no not ICU, maternity high care; it’s just closer to our theatre.

So as they were transferring this patient to high care, the patient started gasping as if she needs air, so they turned back with the patient, ‘cause in high care, they said they don’t have a bed ready for the patient, so they had to take the patient to our theatre for oxygen and all that [resuscitation]. So the patient was resuscitated and was kept on [a] ventilator and then later was taken to [the] ICU.

So that patient survived for two nights; no, on the second night she passed away, and now we’ve got, like, a blame ‘cause, like, it’s like we didn’t care about the spinal; maybe the spinal went up, instead of doing work at the bottom there, and then they say we were not careful ‘cause we didn’t care about the oxygen level and that the patient was bleeding. But that was sorted out ‘cause they spoke to this anaesthetic doctor, and he said there was no indication that should cause him to suspect the spinal injection to be problematic.

Competent. The following example shows the graduate analyzing the current situation in the light of the past, while at the same time, making plans for the future. She makes her own observations and acts on them with confidence. Other incidents classified at the competent level showed a nurse immediately responding to a patient’s needs, even when it was possible to delegate or refer and a nurse managing difficult situations according to expectations, either on her own or as a team leader. Nurses at this level were willing to bypass unresponsive doctors and assertively confront colleagues if their behavior was unacceptable. These nurses may also be competent in procedures only expected from nurses with specialist training. A PBL graduate working as the only RN in an acute psychiatric unit described the following incident:

Well, we had a difficult patient who was getting very physical with another patient. I managed to actually calm the situation, calm him down and get her out of there and away from the situation. I spoke to them individually, and by the evening, all was calm. But I got the doctor to write some medication up for him just in case he gets agitated again during the night. But I actually managed him [the patient] well enough not to have to resort to giving him medication. You know, just by talking to him and explaining things to him and things like that. He actually managed to calm down without me having to use medication or force.

Proficient. There were a few incidents classified at the proficient level. They reflected a nurse who anticipated a client’s needs based on her own assessment and acted accordingly. Often, these actions were anticipatory and saved time later on in treatment. In one case, the nurse went against a doctor’s direct order and was proven correct. A PBL graduate described the following incident:

Recently in the ward we had, I was on doctors round, and the doctor made a decision to induce a [pregnant] lady. We’d been monitoring her fetal heartbeat every day, and all of her traces hadn’t been the best. They’d been subnormal because she was only about 33 weeks, but her baby had growth retardation, and she [the mother] also had high blood pressure. So we expected the fetal heart rate not to be the best, but we had to put her [the mother] on oxygen and put up a drip before it would actually improve.

The doctor made the decision to start inducing her. And I showed him the traces, and I said, you know, I really don’t think we should waste our time around with induction; her CTGs [cardiotocographs] haven’t been the best, and more than likely, when we do induce our high PIH [pregnancy-induced hypertension] moms, they end up having problems, and we inevitably take them for [cesarean sections]. And he said, “No, go ahead just do a fetal heart trace first, and then we’ll induce,” which I did.

Within an hour or two after inserting the first set of Prostin, I put her [the mother] on to the fetal heart rate machine, and the fetal heart rate started dipping; it had deceleration signs, so I thought, “Oh, here we start with the problems.” So I put her on oxygen, and I put up a drip, and I put her onto lateral, which is all the procedures we have to follow. I managed to phone the doctor, and she wasn’t able to come to the ward at that time. She said just to leave the patient on for 20 more minutes after oxygen and to call her. I actually didn’t even bother doing that. I prepped this patient for [a cesarean section]. I called the intern to take consent, and we got cross match for blood, did the FBC [full blood count], checked her BP because I basically knew from working these types of patients that she was going to end up a cesar.

I phoned the doctor again, and I said she’s OK bring her. So I think that illustrates problem solving where I thought ahead, and I actually just prepped the patient for cesar, and I saved a lot of time. Luckily ,the baby was fine. Because sometimes you know by waiting 20 minutes and then only prepping for cesar and putting the catheter in by that stage the fetal heart rate’s been going for this long, and there’s been a lot of...is not good enough.

Respondents’ Feelings

Respondents were asked about their feelings related to the incidents. The majority felt good about the incidents they had described. This is not surprising, since most of the incidents spoke of mastery, competence, and good performance. In some cases, the respondents’ feelings during the incident were not as positive, since graduates were tense and worried when they had to manage challenging situations. Afterwards, however, they felt satisfied and proud. One PBL graduate stated:

Relief when we got him breathing again. I don’t think there was time to panic at all; it was a more of a step-by-step prioritizing, what you were going to do first and sorting it out. So with each hurdle overcome and, like, first of all the sats [oxygen saturation] being maintained and everything, it was, like, relief that you were actually getting somewhere. You felt like you were doing something of significance.

However, there were exceptions, when an incident led to ambivalent, conflicted feelings or feelings of being scared or angry. This example from a PBL graduate demonstrates ambivalent feelings:

I was very worried about this child.… I felt very helpless.… I did not know whether I must phone the doctor...must I put up the drip...and I was unsure...but I was just happy afterwards that I did what I did.

Another PBL graduate described guilt feelings:

You always feel guilty, specifically because you are new in a ward.

This example from another PBL graduate shows angry or scared feelings:

At that point I felt scared...traumatized with the patient to be resuscitated...dealing with the family...that got to be emotionally…. But I think I felt a bit angry...throwing me into the deep end.… Management should know I am newly qualified.… Can’t someone come and help me from other wards…because I felt at that point I was not safe...competent enough a practitioner...but somehow I was.

Incident Results

Most of the incidents described led to positive outcomes for both the patients and graduates. There was evidence of support from colleagues. In some cases, the nurse’s actions led to the patient’s life being saved or measures being taken to prevent a similar situation in the future. There were no instances of negative results for the patient or of the graduates getting into trouble for their actions. One supervisor of a PBL graduate stated:

...maybe if she [the graduate] hadn’t observed the patient and taken the necessary decision and asked the doctor to come out to see the patient, that patient could have died here at this hospital. After a few days, the patient died at the [name] hospital.

A PBL graduate said:

She [the patient] went to ICU and was intubated...and the very next day the doctor reported that she was better and she was going to be extubated next Monday.

In exploring the reasons why the respondents chose the particular incident as a significant one, different reasons were mentioned. The only negative reason given was from a graduate who was worried about her own performance. This graduate described proficient practice but worked in a private primary health care clinic. Her worry about her performance was related to medico-legal issues. This PBL graduate said:

...suing. My community is a very informed community. They are against antibiotics, against immunization. For me, there is an ethical legal situation. Legally, I’m compelled to vaccinate, whereas my community do not want to have their children vaccinated.

All of the other reasons were positive and included:

  • Two graduates who overcame barriers in the interests of their patients.
  • One graduate who learned something important.
  • One graduate who felt self-fulfilled.
  • Two graduates felt the incident had a significant effect on their thinking.

These quotations from PBL graduates exemplify these reasons:

  • In my line, I think it made me feel a little bit more confident. Now, with someone going through a huge trauma, each time I have to deal with it, it gets easier and easier. I see so many terminal cancer patients here. Every time they walk in, I take a breath and think, “OK, I can deal with it.” I feel stronger each time. It’s the next step.
  • It taught me something about myself. There is a lot to learn, and my feelings made me accept a difficult situation in a better way.
  • It was challenging...and also it gave me a sense of pride that I could actually do something and know that “I’ve actually learned something!”... In the morning when I gave feedback, it was nice, because then you know I had taken control of the situation, and that’s basically what they were teaching you at WITS [University of the Witwatersrand]. Don’t be subordinate, take control and do things. You know, you are just as important as anybody else. Make a difference. It shows the sister [the nurse in charge of the unit] that I can now be responsible and that I can take control in a situation. If she feels the ward is short-staffed, and she wants me to work on my own she knows I can cope.

Functions That Formed the Focus of the Incidents Selected

The majority of incidents chosen by respondents (80%) were related to the clinical role, with 15% related to the management role and only 5% related to the teaching role. When teaching incidents were described, they were usually very positive, and none were classified at the novice level.

Overall, 16% of the incidents related to the clinical role were classified at the novice level, while 25% of the incidents related to the management role fell into this category. Across all three roles, 16% of incidents described were at the novice level, and 16% were at the proficient level.

Supervisors’ Perceptions

It can generally be said that the supervisors were very positive about most PBL graduates. These graduates were repeatedly described as “the best I have ever seen,” “exceptional,” and “very impressive.” Such supervisor perceptions were not as evident for graduates in the control group. Nevertheless, one cannot say there was a difference in the level of practice between graduates from PBL and conventional programs.

Discussion

The findings do not indicate there is a difference in level of practice between graduates from PBL and conventional programs in terms of the lowest level of functioning. Respondents from all programs described incidents at the novice level. However, there was a trend that respondents from PBL programs described more high-level incidents (i.e., proficient). This seems to indicate a tendency toward higher levels of functioning in PBL graduates.

According to Benner (1984), the finding that the incidents described were spread along the continuum of practice levels should be expected, since she asserts that one can only expect competence from a nurse who has done the job in the same or similar situations for 2 to 3 years. For those nurses who have already achieved competence within 8 months of graduation, the clinical experiences they had during their training clearly did much to prepare them for practice, although that exposure is usually characterized by rapid change from situation to situation. For those nurses who had not yet reached the competent level, Benner’s statement holds out the hope that they need more time and that it does not necessarily mean that their training has failed.

When reading the incidents described, it could be said that the novice practitioners seemed to endanger patients, and although this was a small minority of incidents, this issue needs some attention. It would seem from the incidents described that the novice level of practice very often has to do with a lack of confidence in one’s own views or a lack of assertiveness that would make it possible to act on one’s own views.

Incidents at the novice level of practice also appeared when graduates were faced with situations to which they had not been exposed at all during their education, such as those related to the management role or working with specific procedures or equipment. It is important that supervisors explore new graduates’ previous learning when the graduates enter a unit. This would allow further learning needs to be identified early and could prevent low-level practice incidents from occurring.

Another factor that should be kept in mind in this regard is the influence of supervision on the level of practice. It seems that most supervisors expect graduates to come into practice competent. Therefore, the graduates are not expected to need supervision. This is not universally true, as some supervisors said they did not expect any problem solving from novice nurses and expected to be consulted on every problem. Nevertheless, the expectation of competence may influence whether graduates who are not fully competent, ever get to that level. For example, in one case, the graduate did very poorly in the first unit in which she was placed. She finally asked for a transfer and is doing very well in the second unit.

Most of the graduates from all groups described incidents that indicated they practice at a level that is safe for their patients. This is true of all the incidents from all levels of practice. Even at the advanced beginner level, the graduates could identify when they needed help and asked for this assistance. The high levels of competence in all groups and the proficiency demonstrated in the PBL groups indicate the success of the heavy focus on clinical experience during the senior years of the 4-year degree.

During the fourth year, most degree programs allocate students 30 or more hours per week for clinical experience, which is close to the working hours of employed nurses. This experience forms the basis of these graduates’ ability to cope with and manage many contingencies of clinical nursing and the conscious, deliberate planning that characterizes this stage of practice (Benner, 1984).

These results are particularly interesting in that nearly 20% of the graduates were working in midwifery units. There had been allegations that students from the integrated program were not competent midwives. The data in this study do not support this contention. Many of the higher-level incidents described were from this area of practice, and there was no specific reference from supervisors in this area to incompetence.

The positive tone in which the graduates talked about nursing was noteworthy. They talked about learning, enjoying, feeling good, and being proud. This is in stark contrast to other research into the job satisfaction of nurses in South Africa, which showed they were the least satisfied of all health professionals and less satisfied than their counterparts in other parts of the world (Westaway, Wessie, Viljoen, Booysen, & Wolmarans, 1996). It seems to show that, while recent graduates face the challenge of mastering their professional roles, this enhances their self-image and positive feelings.

Teaching and management roles were the focus of very few incidents in all groups, including the control group. Therefore, at this entry level of the profession, the focus seems strongly on clinical practice. This is true of most nursing programs, and thus, the training seems to fit the need. One can expect this focus to shift as nurses becomes more proficient in the clinical role. At this stage, further training in management may be useful. This study does not answer the question of when that should happen.

The general satisfaction of the supervisors with the level of practice at which graduates enter the profession is contrasted to the group interviewed by Carlisle et al. (1999) in the United Kingdom. In that study, it was speculated that the graduates’ lack of practical skills was related to the way in which students are allocated to clinical areas during their clinical experience. They do not work shifts, and they are placed in specific areas for very brief periods (e.g., 2 weeks in a mental health placement). During their senior years, all nursing students in South Africa work shifts for at least 1 month in each setting. This kind of placement appears to support their skill development.

Conclusion

We recommended further research be conducted to examine the timing and manner of the shift of focus from clinical practice to other aspects of the nurse’s role, such as management and teaching, to support these aspects with appropriate continuing education. It is also recommended that supervisors of new graduates explore the graduates’ particular clinical experience to plan for realistic support in new situations.

The research shows that problem-based learning programs probably produce nurses who are at least as able to cope in clinical settings as their peers from conventional programs. Such programs may even produce nurses who demonstrate higher levels of functioning sooner than their peers.

References

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Work Settings of Graduates (N = 49)

GroupWork SettingTotal

Midwifery Units n (%)General Units n (%)Specialist Units n (%)Other n (%)
PBL group
  University of the Free State2 (4)4 (8)9 (18)1 (2)*16 (32)
  University of Natal2 (4)4 (8)4 (8)0 (0)10 (20)
  University of the Witwatersrand0 (0)1 (2)0 (0)4 (8)5 (10)
  University of Transkei4 (8)3 (6)0 (0)2 (4)§9 (18)
Control group1 (2)0 (0)7 (14)1 (2)9 (18)
Total9 (18)12 (24)20 (41)8 (16)49 (100)

Number of Incidents by Level of Practice, as Described by Graduates (N = 49) and Supervisors (N = 43)

GroupLevel of PracticeTotal

NoviceAdvanced BeginnerCompetentProficient




GradSuperGradSuperGradSuperGradSuper
CLINICAL
PBL group
  University of the Free State31410821029
  University of Natal1060355222
  University of the Witwatersrand202000116
  University of Transkei1121221212
Control group1332420015
Subtotal85171317118584
MANAGEMENT
PBL group
  University of the Free State000000000
  University of Natal2110231010
  University of the Witwatersrand000020002
  University of Transkei100000102
Control group000011002
Subtotal3110542016
TEACHING
PBL group
  University of the Free State000000000
  University of Natal001002003
  University of the Witwatersrand000000101
  University of Transkei000000000
Control group000000011
Subtotal001002115
TOTAL11619132217116105

10.3928/01484834-20040801-07

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