In South Africa, it is mandatory for nurses who have qualified as a nurse (general, psychiatric and community) and midwifery, leading to registration in Government Gazette Notice No. R425 of 22 February 1985, to perform 12 months’ compulsory community service after completion of training at a College of Nursing. Community service affords new graduate nurses the opportunity to improve their clinical skills and knowledge while nurturing professional behavioural patterns and critical thinking consistent with the profession.
To explore and describe the experiences of community service nurses (CSNs) regarding clinical competence during their placement in three selected hospitals.
The study setting was North West Province (NWP), South Africa.
This study followed a qualitative, exploratory, descriptive and contextual research design. A cluster sampling technique was used and 17 CSNs participated in the study. Three focus group discussions framed by semi-structured questions were conducted with five to six participants per group. All discussions were recorded using a digital voice recorder and transcribed. Data were analysed using Pienaar’s four steps of qualitative thematic analysis.
Four themes emerged from this study: facilitative experiences, defacilitative experiences, challenges confronted during placement and suggestions to improve clinical competence.
Clinical competence of CSNs could be improved if all the stakeholders, including professional nurses and CSNs themselves, hospital management and the regulatory body, the South African Nursing Council, collaborate. More importantly, this study’s results were used to develop a clinical competence evaluation tool in the NWP, South Africa.
In many countries around the world, new nurses are associated with under-preparedness and a low level of clinical competence, which lead to their inability to provide quality nursing care (Duchscher
In the Republic of South Africa (RSA), it is mandatory for nurses to complete a 12-month community service programme after the successful completion of a 4-year nursing degree or nursing diploma education (R425) before they can be registered as professional nurses (general, psychiatric or community) and midwifery (South African Nursing Council [SANC]
Competence is defined as the constellation of abilities, including knowledge, skills and attitudes across multiple domains of performance in a certain context (Riddle, Beker & Sapp
Community service nurses’ preparedness and readiness to enter the working environment has been questioned for various reasons. This is evident in several studies conducted and reported on the clinical competence of CSNs since the implementation of community service for nurses in 2008 in the RSA. A qualitative study conducted by Shezi (
In a qualitative study conducted by Netshisaulu and Maputle (
This study followed the point of competence development stages by theorist Patricia Benner (
Three selected hospitals formed the research setting for this study in the NWP, South Africa. One was a district level 1 hospital and the other two were regional level 2 hospitals. These hospitals were selected based on the availability of CSNs for focus group discussions (FGDs).
This study utilised a qualitative, exploratory, descriptive and contextual qualitative research design (Creswell
A cluster sampling method was used to select participants for this study. Cluster sampling technique is used when the elements of a population are spread over a wide geographical area (Creswell & Creswell
The FGDs were framed by semi-structured questions to reach an informed understanding of the participants’ lived experiences and to increase the credibility of the findings (Creswell & Creswell
What are your experiences regarding clinical competence during your placement as a CSN?
What suggestions do you have for improving clinical competence of CSNs during placement?
Data were collected through FGDs. Focus group discussion is a research technique used to collect data through group interaction (De Vos et al.
All FDGs were recorded and transcribed. Data from the transcripts were analysed independently by the first and third authors per Pienaar’s four steps of qualitative thematic analysis (Pienaar
Trustworthiness of the results was ensured by following the criteria suggested by Creswell and Creswell (
The scientific committee of the School of Nursing Science (SONS), Faculty of Agriculture, Science and Technology (FAST) Health Science Ethics Committee (HSEC) of the North-West University first approved this study. The North West Department of Health and the three selected hospitals in the NWP, South Africa, also granted ethical clearance for this study. Informed consent was obtained from the CSNs after a thorough explanation of what was expected of them during their voluntary participation in the study. Community service nurses were offered the choice to participate in this study, and they were informed that they could withdraw from participating without being penalised. The study posed minimal risk as CSNs may experience discomfort or emotions when talking about their experiences. The identity of all CSNs was safeguarded by using card numbers as identity codes. Discussion of results was done in such a way that CSNs cannot be identified through of the use of identity codes. Fairness was ensured during participation as all participants were given an opportunity to express their experiences without bias or coercion from the researcher. The study would be of indirect benefit to participants, as their contribution to the developed tool will be of benefit to the future CSNs in the province.
Three FGDs were conducted with CSNs at the three selected hospitals in the NWP. All of these CSNs were allocated to the three selected hospitals for their community service. Two FGDs consisted of six CSNs and one FGD consisted of five CSNs.
Description of the sample for focus group discussions.
Demographic data | Hospital A (District Level 1) | Hospital B (Regional Level 2) | Hospital C (Regional Level 2) |
---|---|---|---|
Age ranges | 22 – 29 = 3 | 26 – 29 = 2 | 23 – 29 = 2 |
30 – 39 = 1 | 30 – 39 = 2 | 30 – 39 = 3 | |
40 – 49 = 2 | 40 – 49 = 1 | 40 – 49 = 1 | |
Gender | 4 females and 2 males | 3 females and 2 males | 4 females and 2 male |
Race | 4 black people and 2 white people | 5 black people | 4 black people and 2 white people |
Qualification obtained | 4 degrees and 2 diplomas | 3 diplomas and 2 degrees | 4 diplomas and 2 degrees |
Province of training | 5 North West and 1 KwaZulu-Natal | 5 North West | 6 North West |
Themes and sub-themes.
Themes | Sub-themes |
---|---|
1. Facilitative experiences of CSNs | Improved clinical competence Effective teamwork among staff members Supportive nursing staff and other health professionals Constructive orientation and supervision |
2. Defacilitative experiences of CSNs | Unrealistic expectations Incompetent to perform basic nursing procedures Undesirable attitudes from some permanently employed staff Lack of interest in specific ward/department (maternity) |
3. Challenges confronted during placement | Shortage of human and material resources Unavailability of a job description or scope of practice Inconsistent rotation and allocation period per ward |
4. Suggestions to improve clinical competence | Sufficient allocation period per ward Need for adequate human and material resources Effective communication including feedback from CSNs |
CSNs, community service nurses.
Facilitative experiences of CSNs emerged as the first theme in this study. Below are the sub-themes with supporting verbatim statements from the participants who are referred to as ‘commserves’. The results are considered and discussed in relation to the literature.
A number of participants mentioned that community service is beneficial to them. To support this finding, one of the participants said:
‘…[
The results of this study concur with those of Govender et al. (
Some of the participants felt that effective teamwork among staff members helped them as CSNs. For example, one of the participants said:
‘I think it depends on people that you are exposed to in the unit cause [
These results contrast with those of Parker et al. (
From this study, it was evident that support received by CSNs from the nursing staff and doctors had a positive impact on their daily practice. This finding is supported by the following quotations: One participant said:
‘Even the assistant nurses, you just go to them and ask them …listen here help me with this or help me with that … I just had to go to the staff nurses and they showed me.’ (FDG2, P5, female, 27 years old)
To support this sub-theme, another participant said:
‘The doctors, in most wards, they are so nice. We’re actually supposed to learn from the sisters, but it’s fine doctors are teaching us.’ (FDG3, P5, female, 23 years old)
The study results concur with other studies conducted outside NWP. These studies include Roziers, Kyriacos and Ramugondo (
With regard to supervision and orientation, the majority of participants mentioned that they received orientation programmes that assisted them in the day-to-day routines of the wards. One of the participants noted:
‘At least they taught me how to do the doctor’s rounds, they orientated me very well, to do other stuff, what is it they expected from a commserve.’ (FDG3, P4, female, 26 years old)
This submission is in contrast with the results of the study by Kruse (
Defacilitative experiences of CSNs were the second theme that emerged from the findings of this study. Participants mentioned some negative experiences during their placement for community service. These experiences were perceived as having a negative impact on their ability to function and perform their tasks as expected by those who are supervising them.
Participants reported that most of their managers and professional nurses displayed some unfair treatment and had unrealistic expectations. This might be attributed to the unavailability of a job description and scope of practice for this group of nurses as mentioned in the existing literature. To support this experience of unrealistic expectations, one of the participants mentioned:
‘I was the only sister, for the whole weekend, for 36 patients. It was expected of me to run the ward. I called the matron and I said to her I can’t do this, I’m a commserve.’ (FDG3, P5, female, 23 years old)
In a different study, Wilkes (
The majority of participants raised concerns regarding their incompetence with basic nursing procedures. Some of the participants said:
‘There’s an intercostal drain, and I don’t even know how to handle this patient with an IC drain.’ (FDG1, P4, female, 33 years old)
‘Sometimes I ask myself what if this patient reacts during blood transfusion, I don’t know what to do, who to call.’ (FDG2, P5, female, 27 years old)
According to Brown and Crookes (
Some participants mentioned that they have experienced instances of negative attitudes from some permanently employed staff members, especially the professional nurses. One participant said:
‘But there’s a bad attitude … coming from the permanent employees who were here before you; they are having this attitude like … they don’t want working with commserves.’ (FDG3, P1, male, 29 years old)
According to Chaiklin (
Some of the participants mentioned that they would prefer to be allocated to departments or wards that are of interest to them to work after completion of their community service. These participants mentioned that being allocated to a ward where one does not have an interest generates a negative attitude and lays blemish on their competence. Some participants said:
‘I’m not competent with maternity. It is just that, I’m not competent with maternity.’ (FDG3, P3, female, 30 years old)
‘I agree with you absolutely because I am so depressed working in maternity.’ (FDG3, P5, female, 23 years old)
In the study by Ross and Clifford (
All participants were faced with challenges that are not new to the specific cohort of CSNs in this study. These challenges were mentioned by participants in several studies conducted at the different provinces of the RSA.
Many of the participants from the three FGDs mentioned shortage of human and material resources as a major challenge influencing negatively on their competence. One participant said:
‘Like you have to do what you have to do with what you have, and doing a dressing without a sterile pack, it’s not correct, but you have to do it because that dressing has to be done.’ (FDG1, P1, female, 22 years old)
These study results replicate those of Thopola, Kgole and Mamogobo (
All participants highlighted the confusion caused by unavailability of a job description or scope of practice. This was perceived as a challenge, as it was difficult for CSNs to know exactly what is expected of them in undertaking their daily duties. One participant mentioned:
‘… And, because you don’t have any scope of practice, but you are a nurse. Whether the scope of practice, whether there’s something written, but you are a nurse.’ (FDG1, P4, female, 33 years old)
The results of this study confirm that of Govender et al. (
Most of the participants in all FGDs displayed feelings of dissatisfaction owing to insufficient allocation period per discipline or inconsistent rotations to different wards or disciplines. This was identified as a disadvantage because this negatively affected the seasoning of clinical competence among participants. Some participants said:
‘So, you are competent now for 6 months in one ward, and now you are PN next year, and I know nothing about theatre. I’m not competent, never got the experience in my commserve.’ (FDG1, P3, female)
Adequate and logical rotation during placement provides opportunities to experience different wards or disciplines. The study conducted by Aggar et al. (
Some participants suggested that several issues should be considered to improve the comprehensive clinical competence of CSNs. Below are the sub-themes and verbatim quotations from participants.
Some participants suggested that the allocation period per ward must be comprehensive enough to allow CSNs exposure to most of the wards during placement. One participant said:
‘So, I think they should at least maybe give two/two for the whole year so that you can get enough experience and then decide at the end of the year where do you want to work.’ (FDG3, P4, female, 26 years old)
These findings concur with those of Ndaba (
Participants also suggested that the provision of adequate human and material resources ought to be considered if the comprehensive objectives of community service should be achieved. One participant said:
‘More staff are needed in the ward so that, if the other sister is busy with the rounds, the other sister must be busy with you on medication, to help you.’ (FDG3, P2, male, 28 years old)
The results of this study supported the recommendation by Thopola et al. (
Participants also suggested that there should be effective communication that includes regular ward meetings and feedback as a strategy to improve clinical competence, which would lead to achieving the objectives of community service. Some participants said:
‘I do think they should get feedback from us before the end of the year, so that they know what we are experiencing so that they can correct such if there are any things that need to be corrected.’ (FDG3, P4, female, 26 years)
These results support the statement from Goodwin-Esola, Deelay and Powell (
This study focussed on only three selected hospitals in the NWP. This means that results of this study cannot be generalised to other hospitals in the province or the country. However, similar studies could be conducted in other hospitals and primary health care settings where CSNs are allocated for their clinical service and in other provinces of the country in order to compare the results from different settings. However, study results could be applied in other provinces.
The study revealed that CSNs have facilitative experiences during their placement. It is recommended that facilities continue to improve on facilitative clinical competence experiences of CSNs by developing and implementing contextual transition programmes to orientate, supervise and support CSNs as well as encouraging peer collaborative learning and effective teamwork among staff members, including the CSNs.
It is necessary for hospitals to develop proper orientation programmes and have mentors for CSNs as definitive strategies to provide support and improve clinical competence. It is also important for Professional Nurses (PNs) to set realistic expectations when they have allocated CSNs in their departments. Rotation or allocation per ward is important as this provides varied exposure for CSNs, with opportunities to experience different wards. Employment of adequate personnel and availability of human and material resources ensure the effectiveness of community service and as such should be integrated in the community service profile for CSNs. It is recommended that there must be a definitive job description and scope of practice for CSNs from the SANC that would inform decisions on delegation of duties for CSNs, thereby preventing the current role confusion and uncertainties with respect to their supervision.
It is recommended that, for the clinical competence of CSNs to improve, CSNs need to be allocated adequate periods of clinical experience in each major clinical setting, with effective communication among all stakeholders. In tandem, hospital management needs to ensure adequate human and material resources. It is also imperative that there is a continuous professional development programme in place for CSNs during their placement to reinforce and refine their clinical competence, particularly in basic nursing procedures.
Clinical competence of CSNs could be improved through effective collaboration among all stakeholders, including the hospital management, professional nurses, CSNs and the SANC. From this study, despite the positive and facilitative experiences, CSNs had defacilitative experiences and challenges that have a negative impact on their development and improvement of clinical competence. Many of the challenges reported by participants are consistent with those reported in the literature. There are various programmes or strategies in place to ensure that the new graduate nurses enter the working environment well prepared and emerge as competent practitioners. However, this study indicates that most of the challenges raised are the result of a shortage of human and material resources that impedes the effectiveness of community service. Suggestions were made in the hope that they would be considered to improve the clinical competence of CSNs. The results of this qualitative study contribute to the body of knowledge regarding clinical competence of CSNs during their placement.
The authors are thankful to North West Department of Health (NWDoH); Hospitals Management and the participants of the study, University of South Africa (UNISA) for granting the 1st author time off, as well as North West University (NWU – Mafikeng campus) and Health and Welfare Sector Education and Training Authority (HWSETA) for funding of the study.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
K.L.M. was responsible for the collection and analysis of data and for drafting the manuscript. L.A.S. was responsible for data analyses and proofreading of the manuscript; A.J.P. made conceptual contributions to the whole manuscript.
This study was funded by the NWU bursary for postgraduate studies and the HWSETA.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.