(2022) 21:360
Lindfors et al. BMC Nursing
https://doi.org/10.1186/s12912-022-01133-4

Open Access

RESEARCH

New graduate registered nurses’ professional
competence and the impact of preceptors’
education intervention: a quasi‑experimental
longitudinal intervention study
Kirsi Lindfors1*, Mervi Flinkman2, Marja Kaunonen3, Heini Huhtala4 and Eija Paavilainen5

Abstract
Aims and objectives: The aim of this quasi-experimental longitudinal intervention study was to investigate newgraduate nurses’ professional competence development after preceptors’ participation in an education intervention.
Background: New graduate registered nurses are expected to be competent in many areas of nursing. Expectations that are sometimes unrealistic may cause a sense of inadequacy and stress, and this may in turn prevent themfrom fully deploying their competencies. Competence development is related to practice environment, occupational
commitment, empowerment, and work experience. Orientation or transition programs have been designed to ensure
new graduate nurses’ competence, and preceptors and preceptorship could also have significant influence on theircompetence development.
Design: A quasi-experimental longitudinal intervention study.
Methods: The data was collected from October 2015 to November 2017. Participating wards were randomized into
intervention and control groups. The intervention group preceptors had an eight-hour education intervention that
focused on new employees’ orientation, particularly from new graduates’ point of view. Wards in the control group
continued to precept as before. The Nurse Competence Scale was used for new graduates’ self-assessment at baseline and at three-month and nine-month follow-up. This study is reported in accordance with the TREND Statement
Checklist.
Results: The education intervention aimed at preceptors did not have impact on the intervention group NGRNs’
competence development. There were no statistically significant differences between the groups and effect size
remained small.
Conclusions: The preceptors’ education intervention was not effective enough to develop new graduates’ professional competence so that it would have differed from that of the graduates receiving conventional orientation at theuniversity hospital. This study confirmed that competence development is a complex and multidimensional phenomenon and organizations should invest in new graduate registered nurses’ competence development during their early*Correspondence: kirsi.lindfors@tuni.fi
1
Tampere University, The Department of Children and Adolescents, Helsinki
University Hospital, Stenbackinkatu 9, BOX 347, 00290 Helsinki, Finland
Full list of author information is available at the end of the article© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
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Lindfors et al. BMC Nursing(2022) 21:360

Page 2 of 12

career. Preceptors’ education and development of preceptorship and transition programs are an important part ofoverall competence development in complex health care environments.
Trial registration: Retrospectively registered
Keywords: Orientation, New graduate nurse, Professional competence, Intervention study

BackgroundNew graduate registered nurses (hereafter NGRNs) are
expected to be competent in many areas of nursing after
having started to work [1]. The beginning of NGRNs’
career may often be dominated by feelings of fear of making mistakes, harming a patient, the unknown future
after the orientation period, and of being unable to meet
expectations. Despite the feelings of fear, there are also
feelings of achievement and satisfaction [2]. The NGRNs’
transition time has also been described as a process of
becoming, which includes three stages: doing, being, andknowing. Through these stages, a NGRN becomes a professional who can answer questions rather than merely
asking them. At the final stage, NGRNs should havereached a level of comfort and confidence with their role,
responsibilities, and routines [3].
Communication skills, conflict resolution skills, organization, prioritization and time management, criticalthinking skills, clinical decision-making, and stress management are crucial competences for NGRNs but areoften areas that they struggle with, according to literature[1, 4]. Expectations that are sometimes unrealistic may
cause sense of inadequacy and stress, and this may inturn prevent NGRNs from fully deploying their competences [5, 6]. The COVID-19 pandemic has also brought
new challenges to NGRNs by decreasing graduating students’ clinical placements opportunities [7, 8], which may
in turn affect NGRNs’ readiness to enter clinical practiceand increase NGRNs’ feelings of fear, fatigue, and selfdoubt [7, 9].
NGRNs’ competence is built through development ofclinical knowledge and skills. A welcoming and safe clinical environment together with support, guidance andfeedback from colleagues may enhance this development.
[7, 10] Orientation or transition programs have beendeveloped to ensure NGRNs’ competence [11]. Preceptors and preceptorship could also have a significant effecton NGRNs’ competence by supporting development of
their confidence and competence during the transition
period [12–14]. Stability of ward or work shift, perceived
workload, wards’ positive attitude towards continuing
education, and individual factors like the NGRNs themselves and professionals with whom they work with havebeen found to be one way to facilitate NGRNs’ transition
period and give them an opportunity to progressively
develop their competences [6].

NGRNs’ competence should also be seen as part ofquality and patient safety [15]. Confidence, safe practice,and holistic care are factors that are achieved throughnurse competence [16], and it is the moral and ethicalresponsibility of health care organizations to provide safe
patient care by a competent workforce [17]. The morecompetent the graduate, the more confident he or she
is about his or her skills. Awareness of one’s own limitations of knowledge and experience, courage to ask forassistance whenever needed, and awareness of nursing
principles contribute towards safe practice and prevent
doing harm to patients and oneself [16].
Competence has been defined in terms of functional
adequacy, and the capacity to integrate knowledge, skills,
attitudes, and values in specific contextual situations ofpractice. [18] It is a complex, relative, context-dependent,
and variable concept including physical, mental, psychosocial, and social dimensions [19]. The foundation ofcompetence development is laid already during nursing
studies [20]. The level of competence develops alongsideclinical experience [21], and the length of working experience is associated with better professional nurse competence [22]. NGRNs need opportunities and challenges
to progressively develop their competences [5, 23]. The
first years of practice provide nurses with plenty of learning opportunities, and they have the capability to absorb
new knowledge and skills in the early stages of their professional career [21].
After graduation, NGRNs should possess basic knowledge of the nursing profession to act independently andto carry out vocational functions and eventually, to beready for continuous learning. NGRNs’ ability to apply
theory into practice, ethical commitment, critical thinking and problem-solving skills, and ability to work ininterdisciplinary contexts have been considered the mostimportant generic competencies [24]. The study of Brown
and Crookes (2016) showed the complexity of defining
the expected level of NGRNs’ competence at the point ofgraduation [25]. Different clinical work settings requiredifferent competences [26], and NGRNs’ abilities do notalways match the expectations that nurse managers andexperienced colleagues have about NGRNs’ readiness forclinical practice [5, 26].
In studies focusing on NGRNs’ professional competence, the findings highlight that professional competence is related to practice environment, occupational

Lindfors et al. BMC Nursing(2022) 21:360

commitment, and empowerment [27–29], and the findings are usually based on NGRN’s self-assessed competence level [30–33]. The practice environment has
been perceived more positively by NGRNs with higher
competence level, and a positive practice environment,in turn, supported NGRNs’ competence, retention andjob satisfaction [28]. Higher professional competence
was also associated with affective occupational commitment of NGRNs, where they felt proud to be nurses[27]. Higher competence and empowerment seemed tobe related to each other. Higher competence level was
associated with higher moral principles, personal integrity, expertise and future-orientedness [29].
NGRNs’ self-assessed overall competence level varies
in different studies measured by the Nurse Competence
Scale (NCS©) from moderate to good (Visual Analogue
Scale [VAS] mean 40.1–62.5) [34] to very good (VAS
mean 59.5–76.7), depending on time since graduation[35]. NGRNs have assessed themselves as most competent in areas concerning individualized care, patients’
coping strategies and ethical decision-making [30, 31].
They have assessed themselves to be least competent inareas concerning professional development and nursing research [31], collaboration and evaluation of caresituations [30, 32] and patient education and guidanceof family-members and colleagues. [32] In the study of
Lejonqvist and Kajander-Unkuri (2021), self-assessed
professional competence level changed over time, andlow competence levels improved to good level during
six months of practice [35].
Previous studies about NGRNs’ competence havefocused on the practice environment, occupational
commitment, and empowerment and on NGRNs’ perceptions of self-assessed competence level during theirfirst year after graduation [8, 27–33]. Competencerelated intervention studies [36–38] have focused on
more seasoned registered nurses, but studies about
interventions aimed at developing NGRNs’ professional
competence and preceptors’ role in competence development are lacking. Previous studies about preceptors’
training have focused on measuring NGRNs’ retention,
critical thinking skills, and their stress levels [39] andperceived competence of preceptors after their education [40, 41]. The purpose of this study was to examine the development of NGRNs’ competence level after
preceptors had had an eight-hour education entity
about orientation and preceptorship. This study focuseson the impact of the preceptors’ education intervention
on NGRNs’ professional competence by comparing theintervention and control groups’ NGRNs competencedevelopment during the nine-month follow-up period.

Page 3 of 12

Methods
Aim

The aim of this quasi-experimental longitudinal intervention study was to investigate NGRNs’ self-assessed
professional competence development over at ninemonth follow-up period and to compare the NGRNs in
the intervention and control group.
The research questions are:
1. How did NGRNs’ level of competence in terms of
quality of action and frequency of action change during the follow-up period?
2. How did the competence level of the intervention
and control group NGRNs develop during the follow-up period?
3. How did preceptors’ education intervention affectthe intervention group NGRNs’ competence development?
The study hypothesis was that the education givenin the intervention group preceptors would foster
their knowledge about precepting and the orientation
period, and this would in turn enhance NGRNs’ competence level development.
Research design and instrument

This study was part of a larger longitudinal quasiexperimental intervention study which aimed to investigate NGRNs’ professional competence development(primary outcome), their evaluations of received orientation and organizational commitment (secondary
outcomes), and the impact of preceptors’ educationintervention on these outcomes. This paper focusesparticularly on NGRNs’ competence level development
during the nine-month follow-up period after the preceptors’ education intervention to better emphasise on
the phenomenon of NGRNs’ self-assessed competencedevelopment.
A total of 194 nursing wards in one of the five university hospitals in Finland were asked to participate inthis longitudinal quasi-experimental intervention study.
Nearly a third (29.3%; n = 57) of the wards accepted therequest to participate. The wards were randomized bysimple random sampling into intervention group andcontrol group. The nursing wards were divided by ward
type into two categories: inpatient wards and outpatient
clinics. Intensive care units, step-down units, and operation rooms (OR) were combined into a separate, a third
category. The randomisation to intervention and control group was made within these ward categories using
computer-generated randomisation codes and lists. After
randomisation, two of the wards were merged and five ofLindfors et al. BMC Nursing(2022) 21:360

the wards declined to participate. A total of 50 (25.7%)
wards participated in the study [42].
The intervention

The intervention group preceptors (n = 174) were given
an eight-hour face-to-face clinical education session
about new employee orientation, focusing particularly on
NGRNs’ viewpoint. The education intervention included
lectures, discussion moments and exercises. The education intervention was based on Duchscher’s theoryof transition and NGRNs’ first year [3]. Previous study
findings about NGRNs’ professional competence development and preceptors’ role were important part of theeducation intervention [10, 12–16, 18, 27, 28, 31, 32,42]. The content of the education intervention is shownin Table 1. The principal investigator (KL) provided theeducation to the preceptors, and lectures were held in thehospital lecture rooms during preceptors working days.
Nurse managers selected participating preceptors. The
principal investigator (KL) sent preceptors a welcoming
email beforehand with an information leaflet about theupcoming education session. Education group sizes varied from 2 to 17 participants. The first objective was toenhance intervention group preceptors’ knowledge aboutorientation and to give preceptors and wards means toimprove their precepting methods.
This was the first time in this university hospital whenpreceptors were offered a planned education session
about new employees’ orientation. All Finnish nurses are
educated in the universities of applied sciences (3,5 years
and 210 ECTS) and precepting is a normal part of their
daily work of which they don’t have any extra compensations. Preceptors’ education about orientation and
NGRNs’ challenges during their transition period has
not been seen necessary and every registered nurse is
obligated to act as a preceptor. In addition, preceptors
don’t have any official support systems to carry out theirimportant work as preceptors and the second objective was to foster their professional self-confidence as
preceptors.

Page 4 of 12

The study was registered with the ClinicalTrials.gov
identifier NCT04474769 and the TREND Statement
checklist has been followed [43].
The instrument

Many different instruments have been used to measure NGRN’s competence [44]. In this study, the data
was collected by using the NCS instrument by Meretoja. The NCS instrument was developed in Finland bynursing experts. A large pool of competence indicators(n = 1,308) was reduced by deductive content analysis
to a total of 73 items, and the instrument contains two
assessment scales. The NCS was later translated into
many languages, and it has been used in several countries, different practice environments and nurse samples
to study competence levels and the factors associatedwith competence and to evaluate the effects of educationinterventions. The NCS has shown good content validity
and adequate internal consistency [34, 45]. In this study,
the Cronbach’s alpha of each category varied from 0.792
to 0.925, indicating good internal consistency [46].
The NCS consists of seven competence categories:
Helping Role (7 items), Teaching-Coaching (16 items),
Diagnostic Functions (7 items), Managing Situations (8items), Therapeutic Interventions (10 items), Ensuring
Quality (6 items) and Work Role (19 items). The Helping Role category comprises competence areas such assupporting patients’ coping strategies, individualized
and ethical care. The Teaching-Coaching category is
about the education needs of patients and family members, evaluation of education outcomes, and educatingcolleagues. Diagnostic Functions are mainly related toemotional support of patients and their family members whereas Managing Situations is focused on rapidlychanging, life-threating situations. Therapeutic Interventions are focused on critical thinking, ability to utilize research knowledge, ability to assess effectivenessof care and to co-ordinate and organize. Ensuring Quality is about identifying and promoting developmentof patient care areas whereas Work Role is focused on

Table 1 The content of preceptors’ education intervention
Overview of the day’s content, everyone introduced themselves
Preceptor’s role and responsibilities
New graduate nurse’s first year. Also including information about new graduate nurse’s learning needs, different learning styles and exercises about
learning styles, differences between generations
New graduate nurse’s critical thinking abilities and exercises to support development of critical thinking
Assessment and principles of constructive feedback, a structured checklist for orientation assessment discussions with ward manager, preceptee andpreceptor
How to support new graduate nurse? Peer support and another support methods, mentoring
End of the day. Each participant was given materials about lectures and exercises aboveLindfors et al. BMC Nursing(2022) 21:360

acting responsibly and autonomously, taking care of professional development of the nursing ward, and acting as
a valuable team member [45].
In each of these items the competence level is self-rated
by using a visual analogue scale (VAS) from 0 to 100. For
descriptive purposes, the VAS is divided into four parts
to represent the level of competence: VAS score 0–25
means low competence, VAS > 25–50 means quite goodcompetence, VAS > 50–75 means good competence, and
VAS > 75–100 means very good competence [34, 45].
The NCS also contains another scale (frequency ofaction) which measures the frequency of using different
competences (items) in clinical practice on a 4-gradedscale: 0 = not applicable, 1 = used very seldom, 2 = used
occasionally, 3 = used very often in my work. [34, 45].
Data collection

The data was collected by using an electronic questionnaire which included demographic data such as age,gender, ward type, previous qualifications, working experience, and the NCS instrument. The inclusion criteria
were starting work as a registered nurse in his or her first
workplace, upcoming orientation phase, and willingness
to participate. The exclusion criterion was more than one
year from graduation. NGRNs with a previous degree,e.g., licensed practical nurse, were accepted if otherinclusion criteria were met. The study comprised threemeasurement points: at baseline, three and nine months.
The baseline means the moment when the NGRN starts
working in the assigned nursing ward. The three-monthmeasurement point was chosen since by this time, theorientation period is usually over and NGRNs have beenworking independently for some time. The nine-monthmeasurement point was chosen according to Duchscher’s(2008) theory of transition. At nine months, the transition crisis is beginning to ease off, NGRNs are at a relatively stable stage, and they are accepting their role asprofessional nurses [3].
For the control group, data collection started in October 2015. The intervention group’s wards joined in one
by one after their preceptors had been educated. The
data collection lasted until November 2017. Ward managers delivered participating NGRNs’ email addresses tothe researcher. The questionnaires were sent as follows:at the baseline to all participating NGRNs, at the threemonth measurement point to all those NGRNs who had
returned the questionnaire at the baseline, and the ninemonth questionnaire to the NGNRs who had participated at the three-month measurement point.
Data analysis

The sample size calculation was based on the primary
outcome, professional competence, by using the NCS.

Page 5 of 12

The estimated standard deviation was 13. The significance level was set up to 0.05 with statistical power of
80% and difference between groups was set at 6-points.
According to these assumptions, the target sample size
was 75 respondents in each group [47].
The data was analyzed by using IBM SPSS Statistics(27.0) software and the p-value was set at ≤ 0.05. Descriptive statistics as frequencies, mean and standard deviation and percentage values were used to summarize thedata. Mean variables were formed of each competence
category and mean value of the VAS was calculated. A
non-parametric test like Mann–Whitney was used tocompare differences between the groups because part ofthe variables was not normally distributed. Even though
there were variables that were not normally distributed,
the Cohen d was used to determine the impact of theintervention. The frequency of action was analyzed byfrequencies, percentages and by cross-tabulation. The
McNemar test was used to determine the differences infrequency of action categories between baseline and ninemonths. The attrition analysis was conducted by comparing the intervention and control group participants atbaseline, three months, and nine months by using crosstabulation and T-test. The attrition rate was calculated.
Cronbach’s alpha was used to determine the internalconsistency.
Ethical considerations

Ethical approval (98/13/03/03/2012) from the organization’s ethics committee and research permission(24/01/2014) were obtained. Each participating NGRN
was given a cover letter including information about
the purpose and aim of the study for them to make an
independent decision on whether to participate in thisstudy. Answering the electronic questionnaire was seen
as consent to participate in the research [48]. The ward
managers recruited both NGRNs and preceptors to thisstudy. The researcher met every ward manager before thestudy began. At these meetings, voluntary participation
was emphasized. The permit to use the Finnish NCS wasgiven by its developer Riitta Meretoja.

Results
A total of 114 NGNRs’ email addresses were delivered
to the researcher during the follow-up. Three quarters(n = 95, 83%) of the NGNRs participated in the firstmeasurement, 72 (76%) in the second measurement, and61 (85%) in the third measurement. Most of the NGRNs
were aged 20–25 years and they worked in inpatient
wards. Although the participants were NGRNs and had
less than one year from graduation as registered nurses,
the majority had at least one year of work experienceLindfors et al. BMC Nursing(2022) 21:360

Page 6 of 12

Table 2 Participants’ background characteristics at the baseline
Intervention group

Control
group

n

%

n

%

  20–25 years

33

57.9

18

48.6

  26–29 years

14

24.6

9

24.3

  30 years and over

10

17.5

10

27.0

  Female

54

94.7

38

100.0

  Male

3

5.3

0

0

  Inpatient

34

59.6

18

47.4

  Intensive and OR* units

11

19.3

14

36.8

  Outpatient

12

21.1

6

15.8

11

19.3

11

28.9

22

38.6

15

40.5

27

47.4

14

37.8

8

14.0

8

21.6

Age group

GenderWard type

Other professional qualifications
  Licensed practical nurse

Previous working experience in healthcare   < 1 year  1–3 years   > 3 years*

OR Operating rooms

in healthcare. Nearly a quarter (23.2%) had a previous
degree as licensed practical nurses. (Table 2).
The level of NGRNs’ competence during the follow‑up
periodThe NGRNs’ level of competence in all seven categories during the follow-up was either good or very good.
Throughout the follow-up period, NGRNs assessed
themselves as most competent in the Helping Role
category and the least competent in the Therapeutic
Interventions category. During the follow-up, NGRNs’

self-assessed competence level development in each category was statistically significant (p ≤ 0.05). (Table 3).
At item-level analysis, NGRNs assessed themselves
during the follow-up at very good competence level(VAS > 75) on several items. These items related to supporting patient or patient care planning or decisionmaking guided by ethical values (Helping Role), patient
education or maintaining and improving own professional skills (Teaching-Coaching), analyzing patient’s
well-being (Diagnostic Functions), NGRN’s ability toplan own activities flexibly according to clinical situations(Therapeutic Interventions), commitment to organization’s care philosophy (Ensuring Quality), professional
identity or utilizing information technology (Work Role).
Low competence level (VAS score 0–25) at the baseline was reported concerning items related to Work Role
(mentoring new employees or nursing students, acting
as an expert in care teams, guiding staff members andleading situations), Therapeutic Interventions (developing guidelines and clinical paths), Teaching-Coaching(developing orientation programs) and Ensuring Quality(making research and development proposals). However,
the NGRNs’ competence level developed quickly, and at
three-months follow-up, all except one item (Mentoring novices and advanced beginners, VAS mean 23.1, SD27.9) were at quite good competence level (VAS > 25 to50).
The participants were also asked to evaluate the frequency with which they used each competence by using
a 4-graded scale. The frequency of actions used occasionally or very often is seen on the Table 4.
The NGRNs reported using the most frequently competencies in the Helping Role category and Diagnostic
Functions. The least frequently used competencies werein the Therapeutic Intervention category. When comparing the frequency differences between the baseline andnine-month follow-up, statistically significant differences

Table 3 NGRNs’ competence level during the follow-up
Baseline (n = 95)
Competence category

Mean (SD)

3 months (n = 72)αMean (SD)

9 months (n = 61)αMean (SD)αp-value*

Helping role

70.4 (13.9)

0.805

76.8 (12.5)

0.825

76.0 (15.9)

0.869

0.003

Teaching-Coaching

59.6(16.5)

0.925

65.3 (17.8)

0.923

69.8 (15.2)

0.920< 0.001< 0.001

Diagnostic functions

60.6 (17.6)

0.792

65.3 (17.7)

0.848

69.0 (16.4)

0.843

Managing situations

57.7 (19. 9)

0.865

64.7 (18.8)

0.863

67.2 (16.9)

0.876

0.002

Therapeutic interventions

50.4 (21.6)

0.902

59.4 (19.2)

0.908

62.1 (17.8)

0.886< 0.001

Ensuring quality

52.9 (19.9)

0.858

63.9 (17.7)

0.838

64.3 (19.5)

0.805< 0.001

Work role

54.4 (18.7)

0.911

63.2 (15.1)

0.880

67.2 (15.8)

0.882< 0.001

Overall competence level

58.0 (15.5)*

65.5 (14.4)

67.6 (14.3)= Difference between 0 and 9 months, α  Cronbach alpha, p-value ≤ 0.05, SD  Standard deviation, NGRN  New graduate registered nurse< 0.001

Lindfors et al. BMC Nursing(2022) 21:360

Page 7 of 12

Table 4 Frequency of action use as occasionally or very often
Baseline

3 months

9 months

Competence category

n

%

n

%

n

%

p-value*

Helping role

89

93.7

70

97.2

58

95.1

0.500

Teaching-coaching

61

64.2

48

66.6

45

73.8

0.064

Diagnostic functions

71

74.8

51

70.8

49

80.4

0.057

Managing situations

65

68.4

53

73.6

44

72.1

0.035

Therapeutic interventions

47

49.5

38

52.7

36

59.0

0.031

Ensuring quality

61

64.3

49

68.0

49

80.3

0.003

Work role

52

54.8

43

59.8

43

70.5

0.002

*

Difference between baseline and nine-months McNemar, p-value ≤ 0.05, statistically significant values are bolded

were seen in the categories Managing Situations, Therapeutic Interventions, Ensuring Quality and Work Role
(Table 4). An item level analysis revealed that at the items
where NGRNs assessed themselves to be at low competence level (VAS < 25, at the baseline), the frequencyof action was also low. On the items where NGRNs
assessed themselves to be at very good competence level(VAS ≥ 75, at the baseline), the frequency of action washigh.
Competence level development within the intervention
and control groups during the follow‑up period

When analyzing the competence development between
the intervention and control group, only those participants (n = 61; intervention group n = 36 and control
group n = 25) who participated in all three measurements
were included. NGRNs in both groups assessed themselves as most competent in the Helping Role throughout the follow-up period while the lowest competence
was reported in Therapeutic Interventions. NGRNs inboth groups assessed their overall competence level tobe at good level (VAS > 50–75) throughout the follow-up
period. (Table 5).
Comparing competence at the nine-month followup, competence development was statistically significant (p ≤ 0.05) in six categories (Helping Role frommean 69.9 to mean 74.9, Teaching-Coaching from 60.5
to 70.4, Diagnostic Functions from 63.1 to 71.1, Therapeutic Interventions from 54.3 to 60.4, Ensuring Quality
from 55.9 to 65.8, Work Role from 56.6 to 66.5) within
the intervention group. In the control group, competencedevelopment was statistically significant (p ≤ 0.05) in all
categories (Helping Role from 70.6 to 77.6, TeachingCoaching from 55.5 to 68.9, Diagnostic Functions from56.3 to 66.1, Managing Situations from 50.1 to 65.4, Therapeutic Interventions from 43.9 to 64.4, Ensuring Quality from 47.3 to 62.4, Work Role from 51.9 to 68.2). At
item level, the most item level competence development

occurred in the Ensuring Quality category in bothgroups.
When assessing the frequency of action, the mostfrequently used category in both groups was the Helping Role category (Table 6). In the Diagnostic functions,Managing situations and Therapeutic Interventions categories, the intervention group NGRNs’ frequency ofaction was lower than that of the control group, and it
remained lower throughout the follow-up period. On
items related to mentoring student nurses and new colleagues (Work Role), acting as an expert in caring team(Work Role), developing caring processes (Therapeutic
Interventions), making proposals about further development and research (Ensuring Quality) and developing
new nurses’ orientation (Teaching and Coaching), frequency of action remained low throughout the follow-up
period in both groups.
The impact of the intervention

When comparing the competence development between
the intervention and the control group and assessing thepossible impact of the intervention no statistically significant differences could be observed between the groups
in any of the seven competence categories at end of thefollow-up and the effect size (Cohen d) remained small.
When comparing the frequency of action, the control
group’s frequency of action was in general higher in all
but one category throughout the nine-month followup period. There were no statistically significant differences between the groups in frequency of action, either(Table 6).
Discussion

The aim of this quasi-experimental longitudinal intervention study was to investigate NGRNs’ professional
competence development and the impact of preceptors’ education intervention on it. In this study, NGRNs
in both groups showed quite good or good competence

69.9 (14.4)

60.5 (15.7)

63.1 (17.7)

63.4 (20.1)

54.3 (25.6)

55.9 (19.8)

56.6 (20.3)

60.5 (16.5)

Helping role

Teaching-coaching

Diagnostic functions

Managing situations

Therapeutic interventions

Ensuring quality

Work role

Overall competence level54.2 (15.5)

51.9 (18.9)

47.3 (19.4)

43.9 (17.3)

50.13 (21.3)

56.3 (20.7)

55.5 (18.4)

70.6 (15.0)

Mean (SD)p-value

0.180

0.374

0.211
65.7 (16.5)

64.5 (17.0)

65.0 (19.1)

59.3 (22.6)

65.6 (20.2)

0.024
0.196

64.2 (20.4)

64.5 (19.8)

76.6 (13.5)

Mean (SD)

0.195

0.339

0.651

66.4 (14.5)

62.5 (15.6)

62.3 (16.9)

62.1 (15.9)

65.6 (20.7)

66.4 (17.4)

67.6 (17.7)

78.4 (12.0)

Mean (SD)Control groupMann–Whitney, p-value ≤ 0.05, statistically significant values are bolded, *Cohen d at nine-month follow-up, SD Standard deviation

Mean (SD)Competence category

Intervention group

Intervention group

Control group

3 months

Baseline

Table 5 Competence level, quality of actions

0.755

0.727

0.601

0.686

1.000

0.776

0.614

0.633

p-value

67.7 (15.8)

66.5 (18.8)

65.8 (19.3)

60.4 (20.2)

68.5 (18.5)

71.1 (17.4)

70.4 (15.7)

74.9 (16.6)

Mean (SD)Intervention group9 months

67.6 (12.2)

68.2 (10.9)

62.4 (20.0)

64.4 (14.2)

65.4 (14.6)

66.1 (14.7)

68.93 (14.7)

77.5 (14.9)

Mean (SD)Control group

0.937

0.645

0.728

0.438

0.457

0.150

0.821

0.482

p-value

.007

-.102

.172

-.223

.181

.310

.097

-.174

d*

Lindfors et al. BMC Nursing(2022) 21:360
Page 8 of 12

Lindfors et al. BMC Nursing(2022) 21:360

Page 9 of 12

Table 6 Frequency of action, occasionally or very often (%)
Baseline

3 months

Intervention
group

Control
group

Competence category

n

%

n

%

Helping role

35

97.2

22

Teaching-coaching

21

58.3

14

Diagnostic functions

22

61.1

Managing situations

21

Therapeutic interventions

9 months

Intervention
group

ControlgroupIntervention
group

Controlgroupp-value

n

%

n

%

p-value

n

%

n

%

p-value

88.0

0.857

34

94.5

21

56.0

0.987

20

55.5

17

84.0

0.728

34

94.4

24

96.0

0.083

68.0

0.386

26

72.3

19

76.0

21

84.0

0.024

24

66.6

0.278

17

68.0

0.763

26

72.2

23

92.0

58.3

16

64.7

0.640

24

0.068

66.7

17

68.0

0.346

24

66.7

20

80.0

13

36.1

14

56.0

0.145

0.261

17

47.2

15

60.0

0.615

18

50.0

18

72.0

Ensuring quality

18

50.0

18

72.0

0.114

0.112

23

63.9

15

60.0

0.436

26

77.8

21

84.0

Work Role

16

44.4

15

0.155

60.0

0.300

21

58.3

12

48.0

0.264

23

63.9

20

80.0

Overall frequency of actions

20

55.6

19

0.276

76.0

0.169

25

69.4

16

64.0

0.570

28

77.8

22

88.0

0.324

Mann–Whitney, p-value ≤ 0.05, statistically significant values are bolded

level at the baseline, and their competence level improved
during the follow-up period. At nine-month follow-up,
the NGRNs’ self-assessed competence level was to someextent even higher than experienced nurses’ self-assessedcompetence level in previous studies [49–52]. However,there were no statistically significant differences between
the groups and effect size remained small. In the light ofthese findings, the education intervention aimed at preceptors didn’t have impact on the intervention group
NGRNs’ competence development.
The findings of this study revealed that NGRNs evaluated their competence level in the category Helping Role
as good at the baseline, and at nine-month follow-up, thecompetence level was very good. The lowest competenceswere seen in the categories Therapeutic Interventions
and Ensuring Quality. Similar findings can be seen inprevious studies about NGRNs [30, 31, 49] and in studies
concerning experienced registered nurses [49–53]. Even
though Therapeutic Interventions and Ensuring Quality
remained the lowest competence categories throughout
the follow-up period, the competence in these categories
was at good level. The findings of this study suggest that
NGRNs feel themselves the most competent in areas concerning individualized care, ethical decision-making andhelping patients to cope. These competences align withthe competences that are required from graduate nurses
at the point of registration [24] and from this point ofview, it seems that nursing education has been successful.
A similar conclusion was made by Kajander-Unkuri et al.
(2014) in their study about nursing students’ competence
during their final clinical placement [54].
Flexible decision-making, utilizing new knowledge on
patient care, acting as a consultant to other team members and identifying and promoting patient care development initiatives seem to be competence areas where

NGRNs possessed the lowest competences. These findings are quite natural when we know that NGRNs struggle with organization, prioritization, time management
and clinical decision-making and critical thinking skills.
These skills are crucial but difficult to implement at the
beginning of one’s career [1]. Over time, as NGRNs
become familiar with routines and assignments, they can
get a grip on more complex competences [55]. Duchscher (2008) has named the final stage of NGRNs’ transition the “knowing” stage. This stage comprises the lastnine to twelve months of NGRNs’ first year. At this stage,
NGRNs have reached “a relatively stable level of comfort and confidence with their roles, responsibilities, androutines”. (3, p. 447) The statistically significant development of all competence categories can be interpreted asa sign of this kind of development. It is possible that at
the nine-month follow-up, the NGRNs in this study may
have reached a balance between their responsibilities andduties and were able to take possession of different competence areas more broadly. Their journey towards nursing professionals was well on its way.
Professional competence develops alongside working
experience [21, 22] and it requires a versatile and positive
working environment, the ability to utilize theoreticalknowledge, as well as personal motivation and curiosity [6]. In this study, competence level and frequency ofaction were aligned with each other. This was seen whenobserving the findings at both category level and item
level. When the frequency of action was high, the competence level was also high, and vice versa. The findings
are in line with previous studies [30, 31, 45] and indicatethat competence development is dependent on NGRNs’
opportunities to practice their vocational functions andto gain expertise [5, 23]. Interestingly, when comparing NGRNs in the intervention and control group, even

Lindfors et al. BMC Nursing(2022) 21:360

though the control group’s frequency of action remained
higher throughout the follow-up especially in Diagnostic functions, Managing situations and Ensuring quality
categories, their competence level remained alike with
the intervention group’s competence level. This finding
is intriguing, and to some extent, it challenges previous
study results where higher frequency of action predicted
higher competence level [30, 31, 45]. Without additional
knowledge, it is difficult to make further conclusions
about the reasons why competence level and frequencyof action in the control group did not align each other.
This finding may reflect something about NGRNs’ ability
to make self-assessments and their perceived confidence
level. NGRNs do not necessarily know what they are
expected to know even though there are not expected tobe competent or ready for work [26, 30]. NGRNs may feelthe pressure of high expectations and feelings of insecurity [2, 4] and this, in turn, may affect their self-evaluation, making them too critical.
Even though the education intervention didn’t succeed,
the study provided important information about NGRNs’
competence development during their first nine months
when they go through various development stages
adjusting their personal and professional roles [3] andwhen they may feel the most vulnerable. It also provided
insight into NGRNs’ competence areas where they needmore practice and support to become competent professionals. With these results we can develop both transition
to practice programs and support systems to take care of
our newcomers and in the long run, commit them to theorganization as well as the profession.

Conclusions
NGRNs evaluated their overall professional competencelevel as good, and the competence level improved overthe nine-month follow-up period. However, no statistically significant differences could be observed between
the groups in any of the seven competence categories at
end of the follow-up. Although the original objective of
the intervention was not successful, NGRNs’ competencelevel evolved towards more complex competences during
the follow-up period. Ability to utilize research knowledge, ability to assess effectiveness of care, co-ordinate
and organize, delegate, and prioritize are competences
which develop alongside experience, as was seen in thisstudy. NGRNs should practice these competences fromthe very beginning of their nursing career to becomecompetent professional who possess abilities to develop
nursing care. This is vital for nursing and its future. We
should not abandon the thought of preceptors’ education intervention, either. In the complex health careenvironment where organizations struggle with shortageof nurses and the COVID-19 pandemic is diminishing

Page 10 of 12

NGRNs’ readiness for practice, we need different kindsof interventions to develop NGRNs’ professional competence during their transition period. With different
competence development initiatives, such as supportive orientation and preceptors’ education, we can foster NGRNs’ professional identity and commitment tohealthcare.
Limitations

The data collection from one university hospital in Finland made this study geographically limited by reducing
the representativeness of the result. The sample size also
remained small despite the relatively long study period(two years) and the numerous reminders send to ward
managers and participants. Even though the original target sample was not attained, the data collection had to be
stopped after two years. Some of the wards were merging and this would have affected the study significantly.
The follow-up period was relatively long, nine months,
containing three individual measurement points. Questions about professional competence may feel difficult
to answer and the questionnaires were long, and thismay have caused reluctance to participate in the survey.
The small sample size may be the reason why no significant relationships or differences could be indicated. [56]The attrition rate of this follow-up study was moderate,
35.8% (n = 34). Twenty-one participants (36.8%) from theintervention group and thirteen (34.2%) from the control group dropped out during the nine-month followup period. Only one male from the intervention groupremained in study throughout the follow-up period.
There were no differences in age, working experience,ward type or other professional qualifications between
the participants who remained in the study and those
who were lost to attrition. Despite these limitations,the results provide an interesting viewpoint to NGRNs’
first year of practice and their professional competencedevelopment.
Abbreviations
NGRN: New graduate registered nurse; OR: Operating rooms; NCS: Nurse
Competence Scale; VAS: Visual Analogue Scale.
Acknowledgements
The authors would like to thank Anna Vuolteenaho for assistance with professional editing of the language of this manuscript.
Authors’ contributions
KL analysed and interpreted the data with help of HH. KL wrote the manuscript and EP, MK, HH and MF read and revised the manuscript and approved
the final manuscript.
Funding
This research has had funding from the Helsinki University Hospital during
data collection, analysis and interpretation of data.

Lindfors et al. BMC Nursing(2022) 21:360

Availability of data and materials
The datasets generated and/or analysed during the current study are notpublicly available due to a reason that data is a part of unpublished dissertation and data is in Finnish but are available from the corresponding author on
reasonable request.

Declarations
Ethics approval and consent to participate
Ethical approval (98/13/03/03/2012) from the Women, Children and Psychiatric ethics committee and research permission (24/01/2014) were obtained.
Each participating NGRN was given a cover letter including information about
the purpose and aim of the study for them to make an independent decisionon whether to participate in this study. Answering the electronic questionnaire was seen as informed consent to participate in the research. All thesteps/ methods were performed in accordance with the relevant guidelines
and regulations.

Page 11 of 12

11.

12.

13.

14.
15.

Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Tampere University, The Department of Children and Adolescents, Helsinki
University Hospital, Stenbackinkatu 9, BOX 347, 00290 Helsinki, Finland.
2
Department of the Nursing Science, University of Turku, Turku, Finland. 3 Faculty of Social Sciences, Tampere University, Pirkanmaa Hospital District General
Administration, Tampere University, Tampere, Finland. 4 Faculty of Social
Sciences, Tampere University, Tampere, Finland. 5 Faculty of Social Sciences,
Tampere University, Etelä-Pohjanmaa Hospital District, Seinäjoki, Finland.

16.
17.

18.
19.
20.

Received: 23 September 2022 Accepted: 30 November 2022
21.
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