THE COMPETENCIES OF NEWLY QUALIFIED PSYCHIATRIC NURSES

This research report comprises part of a larger study, which endeavoured to identifjl the competencies of newly qrralified nurses (NQNs) as viewed by senior professional nurses (SPNs) in the clinical units. This report concentrates only on the competencies of the NQNs working in the psychiatric nursing units. SPNs (N=29) from certain health services in the Northern Province (NP) of the RSA, constituted the population for this research. A descriptive survey was used as a research approach to conduct this research. The fieldwork, entailing the distrib~ltion and collection of the questionnaires by a researchec was done during a period of political and labo~lr unrest in this area. Consequently, only certain health services granted permission for this research to be conducted; others rejilsed permission fearing escalations in the unrest which prevailed at the time. The findings revealed that specfic cognitive, affective and psychomotor competencies were expected from the NQNs Lipon entering the psychiatric work setting, as perceived by SPNs. NQNs in the psychiatric clinical units were perceived to be competent in performing numerous, but not all, clinical competencies contained in the qnestionnaire.


INTRODUCTION
The research findings, obtained from the questionnaires completed by the SPNs, are displayed in Tables 1 and 2.
These findings revealed that NQNs in the psychiatric units were viewed by their SPNs to lack competency in HEALTH SA GESONDHEID V01.5 No.3 -2000 performing psychomotor and cognitive activities, but to be competent in performing nursing functions falling within the affective domain.

OVERVIEW OF THE LITERATURE
A review of the literature confirms that psychiatric nurses are expected to be competent in performing the caring and interpersonal relationship nursing activities.
In a study done by Edwards (1995) in England, the users of psychiatric services commented on the competencies and qualities required of mental health nurses.
These included showing respect and heing reassuring, listening skills, explaining and giving information, counselling skills, heing able relate to one as an individual, and to provide touch and comfort.These findings concurred with nursing students' views, who participated in this shidy.Furthermore these students, inter alia, regarded the following to be important in their learning: teaching skills, management, observing and monitoring, counselling, research skills, theory-based practice, and the prescribing of medicines.
A study done by Doorbos (1997) augmented these psychiatric nurses' expectations by suggesting other competencies such as improving spiritual dimensions, that is showing love, forgiveness and hopefulness.Furthermore the nurse as teacher was also highlighted in order to present information about mental illness and the nurse as referral agent was also regarded as heing important so that the nurse will be able to identify the usefulness of support groups and various community resources.
A study done by Monkey-Poole (1995)   (An example of a questionnaire is not included due to the length of this report and because Tables I and 2    The findings revealed that NQNs were perceived by SPNs to be competent in performing affective competencies related to caring and interpersonal relationships and administration and management.These competencies have also been identified as essential in psychiatric units by various other authors (such as Doombos 1997;
Landeen et al. (1 995) found that psychiatric senior nursing students felt inadequate in performing communication skills and in maintaining therapeutic relationships.
NQNs in this study were perceived by the SPNs to be competent in performing administration and management skills.However, admission and discharge poli-  vide teaching opportunities for NQNs and wouM also help them observe the principle of nursing the patient in SPNs regarded most psychomotor competencies to also totality.be non-essential in the psychiatric units.This could imply that the clinical experiences of psychiatric nurses As reflected in Table 3 the SPNs regarded the clinical focus on the psycho-social components with relatively accompaniment of student nurses in the psychiatric units, little attention given to the physical and physiological by clinical preceptors and tutors, as a possible cause imbalances of a patient.Gujbels (1995)

CONCLUSIONS AND RECOMMENDATIONS
The study revealed that NQNs appeared to lack competency to perform important cognitive, psychomotor and affective nursing functions in the psychiatric units.This perception is supported by Benner (1984) who undertook a research study in California, USA, of beginning and expert nurses to determine differences in their clinimica accompanirne Implementation of the R425 curriculum.
as a novice, one who is only just beginning to develop the expertise needed to provide clinical care.Benner asserts that the stages of competency acquisition fall into five broad categories namely: the novice, the advanced beginner, the competent practitioner, the proficient practitioner, and the expert practitioner.Recognito be supported by various studies.Girot (1993) revealed that sisters commented that newly qualified graduates knew nothing and that they actually expected to be "spoon-fed" all the way.Lathlean & Corner (1991) also indicated staff attitudes as a major reason affecting newly registered nurses' competency.Lowane (1990) revealed that sisters' attitudes were a hindrance to student nurses' learning in the clinical settings in the Northern Province.(Adejumo, 1999:240).This study attempted to identify NQNs' competencies expected by SPNs in the psychiatric units in the Northern Province.However, future research would need to determine whether or not these identified competencies are indeed relevant to the people's or communities' health care needs.

LIMITATIONS OF THE RESEARCH PROJECT
Vague and nebu2ozl.sis the beginning of all things, but not their end, and Ifain cvould have yozl remember me as a beginning.
Lfe, and all that lives, is coizceivecl in the mist and not in the crystal.
And who knows but a cq~~trrl is mist in decay?

"
competency" refers to NQNs' cognitive, affective, and psychomotor abilities to perform specific tasks satisfac-The definitions of competency as depicted in the litera-torily as reported by SPNs working in psychiatric units ture, share common concepts such as ability, quality, in the NP.This definition of competency concurs with performance, efficiency and capability.In this report that of Searle & Pera (1992:92) defininy competency as 50 HEALTH SA GESONDHEID Vo1.5 No.3 -2000 "a demonstrated cognitive, affective and/or psychomotor ability required for the performance of specific activities".For the purposes of this report, a NQN is a professional nurse who has fulfilled the requirements of the South African Nursing Council's (SANC's) Regulation no.425 (R425) of 22 February 1985, as amended, and who qualified as a nurse (general, psychiatric and community) and a midwife, with less than one year's clinical experience.NQNs' acts and procedures are determined by the scope of practice of registered nurses as legislated and circum-~cribed by the SANC's Regulation 2598 (R2598) of November 1984, as amended.Since 1983, concerns have been experienced by health professionals that NQNs who completed the comprehensive course (R425) leading to registration as a nurse (general, community and psychiatric) and midwife, were perceived to have inadequate knowledge for rendering psychiatric, midwifery and community health services.Concerned health care professionals, including nurses, doubted whether these comprehensively trained diplomats could handle practical procedures adequately in the clinical nursing units (RHOSA memorandum 4 August 1992).These concerns were often related to the duration of training.The comprehensive (R425) course enabled students to become registered general-, psychiatric-, community health nurses as well as midwives upon successfully completing the four-year course.Prior to the implementation of the R425 course (during 1983), students required three years to become registered general nurses and one year for each of the other three qualifications; thus six-year programmes were condensed to four-year programmes.Upon completion of their training, NQNs are expected to have developed analytic styles, critical, evaluative and creative thinking, and the continuing stimulation of the capacity to interpret scientific data for nursing actions, to draw conclusions and to exercise independent jndgement (SANC, 1992:3).This research endeavoured to identify specific cognitive, psychomotor and affective psychiatric nursing skills which Senior Professional Nurses (SPNs) expected NQNs to possess, and to establish whether or not the SPNs regarded the NQNs as meeting these expectations.(SPNs in this study refer to professional nurses wbo have been promoted to this rank, usually after a minimum of three years' clinical experience, and who are directly involved in the psychiatric clinical settings in which the NQNs were working at the time of collecting the data).Clinical competency demands the acquisition of higher level behaviours in the cognitive, affective and psychomotor domains of learning.Fitzpatrick, White & Roberts (1992) reviewed literature which revealed a range of the nurse's subn~les within the service of nursing.They support the view that competency in psychomotor, cognitive and affective competencies is required for performance within each of these subrules to achieve the delivery of high quality nursing.That is, use of the nursing process, use of research in practice, communication competencies, care management and organisation of workload, and the role of the nurse in health education.Information regarding the competencies of NQNs, as perceived by SPNs, might render valuable contributions towards improving nursing education programmes in the RSA.Such information could provide cuniculum developers with realistic input regarding competencies acquired and competencies showing a deficiency.This should assist in the delineation and refinement of the professional competencies expected for nurses trained in the comprehensive course leading to registration as a nurse (general, psychiatric and community) and midwife.Nurse educators need to investigate the performance of NQNs in order to evaluate whether or not they are preparing nurses who are able to use their education in carrying out their responsibility for providing high quality care.This survey could serve as a platform for future studies with competency-based orientations.
identified the most common skills practised by English psychiatric nurses to include bereavement counselling and general counselling.Gujbels (1995) revealed that psychiatric nurses needed to have a wide range of skills involving problem-solving.This was important for effective referrals to other disciplines.Furthermore, nurses valued interpersonal relationships with patients, but the research findings revealed that this was difficult to achieve adequately due to a lack of continuity of care.Troskie (1993) in the RSA, compared NQNs' problem-solving abilities in the psychiatric, community and midwifery areas.Results indicated that NQNs in the psychiatric hospital were better problem-solvers than the community health nurses and midwives.Landeen, Byme & Brown (1995) revealed that many psychiatric nursing students indicated that they felt inadequately prepared to function in given situations.All psychiatric senior nursing students (n=18) identified communication skills and the maintenance of therapeutic relationships as being critical to working with psychiatric clients.However, they also disclosed feeling very inexperienced in these respects (Landeen et al. 1995).Feely (1997: 1 15-11 6) indicates that effective interpersonal relations do help nurses to identify the appropriate nursing care strategie~ for specific patientslclients.She describes the psychiatric nurse's roles as comprising those of teacher, leader, counsellor, resource person and surrogate.These roles require the mastery of specific competencies.

1 and 2 ,
This reported research endeavoured to determine the competencies of NQNs appointed in the psychiatric clinical units in the NP of the RSA.The purpose of this study was to identify the competencies which SPNs expect of NQNs, and to identify the psychomotor, affective and cognitive competencies displayed by NQNs, as perceived by SPNs.To achieve this, specific questions were formulated: What competencies do SPNs expect NQNs to have upon entering the psychiatric nursing work setting?Which cognitive, psychomotor and affective competencies do NQNs have upon entering the psychiatric work setting, as perceived by SPNs?Which factors, according to the SPNs' perceptions, could contribute towards NQNs' perceived incompetence?HEALTH SA GESONDHEID V01.5 No.3 -2000Research DesignAn exploratory descriptive survey was employed to investigate the competencies of NQNs in the psychiatric units in the Northern Province, as viewed by the SPNs .The study used questionnaires for collecting data.After an extensive literature review about nurses' expected competencies, the items for the questionnaire were selected based on R2598 (the regulation defining the scope of practice of the registered nurse in the RSA).The Construction of the QuestionnaireSection one of the questionnaires requested SPNs to supply general information portraying their profiles in their working situations.Section two comprised ofPart A, attempting to identify which competencies SPNs expected NQNs to have upon entering the work setting and Part B requesting the SPNs to indicate whether or not the NQNs possessed the relevant competencies.Part A used four-point scale requiring SPNs to respond according to the following key, indicating which competencies they expected NQNs to have upon entering the work setting: . 1 essential competency upon entering the work setting . 2 desirable but not essential 3 useful but not essential and not expected from NQNs 4 non-nursing, not considered part of the nurses' competencies.In analysing the completed questionnaires' data, maintaining four categories proved to provide limited information due to the small number of respondents.At the advice of a statistician from the University of South Africa, responses falling within Categories 1 and 2 in Section A of the questionnaire were grouped together to indicate essential competencies, whilst those falling within categories 3 and 4 were accepted to indicate nonessential competencies.In cases where 50 per cent or more of the respondents indicated that a competency was not essential for NQNs by ticking categories 3 or 4 this competency was then accepted to be non-essential, as perceived by the SPNs participating in this survey.Part B attempted to establish whether or not the SPNs perceived the NQNs as having mastered each competency, according to the following four-point scale based on the work of Benner (1984): 1 mastery: able to perform competently and efficiently without supervision 2 competent: able to perform without supervi sion and with reasonable efficiency 3 performance is unsafe, incompetent, and re quires further practice and supervision 4 non-nursing competency: SPN considered this competency as not forming part of the nurse's role.Responses falling within Categories 1 and 2 were grouped together as indicating NQNs' competence in performing these aspects, whilst those falling within Categories 3 and 4 were grouped together as indicating NQNs' incompetence.In cases where 50 per cent or more of the SPNs' responses fell within Categories NQNs were perceived to he competent, whilst NQNs were perceived to be incompetent in those aspects where 50 per cent or more of the SPNs' responses fell within Categories 3 and 4. Section three of the questionnaire consisted of both open and closed-ended questions attempting to identify SPNs' perceptions about NQNs' competency deficiencies, and suggestions for enhancing NQNs' competencies.The Validity and Reliability of the Research Instrument"The validity of an instrument is a determination of the extent to which the instrument actually reflects the abstract concept being examined" (Burns & Grove, 1987:294).The reliability of a research instrument is "... the degree of consistency with which it measures the attribute it is supposed to he measuring ... reliability can be equated with the stability, consistency, or dependability of ameasuring tool"(Polit & Hungler, 1989:242).In preparing the questionnaire for conducting this exploratory survey, it was not possible to test the instru-HEALTH SA GESONDHEID V01.5 No.3 -2000 ment repeatedly because a limited number of SPNs could participate in this sh~dy which pre-tests would have reduced even further.Access to health care services was problematic due to labour unrest, and the researcher was granted permission to visit each institution once only.In order to obtain content validity the questionnaires were completed by clinical psychiatric nurse tutors, not forming part of the survey's population of SPNs in the NP.The clinical psychiatric nurse tutors recommended a few minor changes.These completed questionnaires were analysed by computer, using the SAS programme, in order to establish the feasibility of subjecting the completed questionnaires to computerised statistical analyses.The participating SPNs were guided about the compietion of the questionnaires, reducing the chances of ambiguity or misinterpretations.A researcher delivered the questionnaires at a specific institution and remained there until the completed questionnaires had been returned, being available for any clarifications.
reflect the items contained in the questionnaire).The Distribution of the Questionnaires Questionnaires were delivered and collected by the researcher.SPNs (n=29) working at thirteen hospitals in the Northern Province constituted the population of this study.Scientific sampling techniques were not employed as all subjects participated in the study.Landeen et al. (1995:882) obtained similar negative experiences expressed by psychiatric senior nursing sttidents such as "A few of the staff referred to me as just the student.It could be my knowledge or my innocence that they envy".NQNs upoil entering the psychiatric nursing work setting) in this study.
critical care were perceived by the SPNs to be the central focus of NQNs' incompetence in the psychiatric Table 1 represents the competencies perceived to be essential by SPNs in the psychiatric nursing units (Part A), and the actual competencies of NQNs (Part B), as perceived by the SPNs.All competencies perceived to be essential by at least 50% of the SPNs in part A were accepted as being essential (expected competencies of HEALTH SA GESONDHEID V01.5 N0.3 -2000 units.

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not only expertise in psychological interventions.Edwards (1995) reported that psychiatric student nurses needed to be skilled in a variety of cognitive and psychomotor nursing functions.Patients in the psychiatric clinical units might have cardiac arrests due to adverse reactions to medications, requiring urgent cardio-pulmonary resuscitation; patients might become psychotic due to electrolyte imbalances and might require collection of urine and blood specimens for investigation; patients might need nutritional supplements through naso-gastric tube feeds.SPNs in the psychiatric nursing units could facilitate development of competency by NQNs by influencing NQNs to care for physical illnesses of psychiatric patients in theTABLE 2: THE COMPETENCIES PERCEIVED TO BE cies and practices were areas identified as major con-NON-ESSENTIAL BY SPN'S IN THE PSYCHIATRIC straints requiring improved performance by the NQNs, according to the SPNs' perceptions.NQNs in this study were perceived by SPNs to be incompetent in carrying out admissions and discharges according to the stipulations of the RSA's Mental Health Act, (No I8 of 1973, as amended).Gujbels (1995) also found that psychiatric nurses indicated that administration duties took a priority over therapeutic activities, spending up to 90% of their time in the office.Set sterile trolley for special procedures.
indicated that contributing towards NQNs' incompetencies.This might psychiatric nurses needed to have a wide range of skills, be the case because frequent accompaniment of the students obviates the need for these students to make inde-56 HEALTH SA GESONDHEID V01.5 N0.3 -2000 pendent decisions concerning nursing care interventions.This inability is perceived as incompetence by the SPNs.Further investigations would need to be done to enhance the value of tutors' clinical accompaniment of student nurses in the psychiatric clinical units in the Northern Province.The attitudes of NQNs in the psychiatric units were perceived by the SPNs to be contributing towards NQNs' incompetencies.Fifty-five percent of SPNs commented that their own negative attitudes might have contributed towards the NQNs' incompetencies.The findings seem TABLE 3: SPN'S PERCEPTIONS OF CAUSES WHICH cators and nurse preceptors to enhance the psychiatric nursing competencies of the NQNs in the Northern Province.
This study merely investigated the general views of the SPNs regarding the competencies of NQNs working in psychiatric nursing units in the NP.The actual competencies of the NQNs were neither evaluated by themselves or by the researcher.Future studies could ask the NQNs to evaluate their own competencies and use observers to evaluate the competencies of the NQNs on specific aspectslfunctions.Bi-annual follow-up surveys might he essential to account for changes taking place in both nursing education programmes and in the psychiatric nursing services in the Northern Province and to assist SPNs, nurse edu-tion of these phases could, to some extent, overcome the feelings of inadequacy which are often experienced in the early days after qualifying.It is unrealistic to think that expert practice will be achieved immediately.The findings of the study indicate that NQNs should be provided with in-service education programmes to facilitate their adaptation to the psychiatric nursing units.Such programmes could also enhance the productivity of the NQNs and their sense of job satisfaction.Based on the research findings obtained during this exploratory descriptive survey, future research should investigate: Clinical accompaniment by nurse educators.SPNs' attitudes towards teaching student nurses assigned to their in their units. .Essential competencies as perceived by NQNs upon entering the work setting. .Whether orientation programmes could enhance NQNs' competencies in the psychiatric units.Such information could provide curriculum developers with realistic inputs about the NQNs' expected competencies and perceived competencies upon entering the psychiatric health care services.Such information is HEALTH SA GESONDHEID Vo1.5 No.3 -2000 required to formulate realistic outcomes for students following psychiatric nursing courses.The services of psychiatric nurses, and for psychiatric and mental health nursing are likely to increase on the African continent with the continuation of civil and trans-border armed conflicts escalating throughout the continent

Table 1
numerous, but not all, clinical competencies which were outlined in the questionnaire.Application of stages of the nursing process, clinical judgement, research and