Abstract
BACKGROUND AND AIM:
Considering lack of data on clinical acumen and clinical practice readiness of graduating nurses in India; this cross-sectional survey was undertaken to assess the self-reported clinical practice readiness of graduating nurses from a selected state in India.
MATERIALS AND METHODS:
The survey was conducted at randomly selected public and private nursing institutes in Uttarakahnd, India, during June–July 2017. Total 173 final-year nursing undergraduates were selected through cluster sampling technique and they were asked to report their clinical competencies using a prevalidated and reliable tool, i.e. Comprehensive Nursing Competencies Questionnaire.
RESULTS:
The mean competencies score for basic nursing skills was reasonably high (236.5 ± 25.0). However, it was significantly low for the advanced nursing skills (148.7 ± 25.6) and selected basic nursing tasks such as perioperative care, elimination related interventions, and handling of medical equipment (recoding electrocardiogram and using defibrillator). Graduating nurses with younger age and longer duration of clinical placement had higher mean competency score in basic as well as advanced nursing skills (P < 0.05). Whereas, nurses studying at private nursing institutes had lower mean competency score for advanced nursing skills (P = 0.001).
CONCLUSION:
Clinical practice readiness of graduating nurses for basic nursing skills is good. However, it is seriously poor for the advanced nursing skills. This could be because of lack of sufficient clinical learning material, experienced clinical nursing faculty, and poorly equipped nursing skill labs. Nursing regulatory bodies must regularly monitor and ensure that deficiencies are rectified and nursing faculty remain clinically updated and active to produce clinically competent nurses.
Keywords: Clinical nursing competencies, clinical practice readiness, clinical skills, new graduating nurses, nursing student
Introduction
Today nursing educational institutions are expected to produce nurses which are clinically practice ready inspite being novice to meet the growing healthcare demands of an aging population, and a projected looming nursing shortage.[1] Average life expectancy has doubled since 1990,[2] which has significantly contributed in increased incidence of noncommunicable morbidity and mortality.[3] This phenomenon has led to looming demand of health-care beds and nursing manpower.
However, unfortunately, there is a global shortage of health workers, in particular nurses and midwives, who represent more than 50% of the current shortage in health workers. Further, the WHO estimates that the world will need an additional 9 million nurses and midwives by 2030.[4] Developed countries like USA are facing serious shortage of nurses because of aging nursing workforce and decreased nursing program enrollments because of nursing faculty crunch. According to the American Association of Nurses (ANA), 500,000 seasoned nurses will be retiring by 2022 and it is estimated by the U. S. Bureau of Labor Statistics that 1.1 million new nurses will be required for their replacement and avoid shortage.[5] In addition, presently, India alone is facing shortage of more than 2 million nurses.[6]
On the other hand, India is one of top supplies of nurses to gulf and OECD countries, especially USA, Canada, UK, Ireland, Australia, and New Zealand.[7,8] Consequently, production of graduate nurses has significantly expanded in India from just 165 nursing colleges in 2004[9] to 1667 in 2017.[10] This is evident from data that there is very rapid growth in the number of nurses produced in India to meet the national and international needs of nurses; however, there is always challenge to maintain quality with rapid production of quantity. Further, acute shortage of nurses necessitates the readiness of nurses to immediately take-up the full-fledged role as registered nurse to ensure patient safety and quality of care. In addition, recruiters always need to know the degree of readiness of nurses produced from the countries, which are the major suppliers for the nurses. There are number of studies conducted about clinical readiness of nurses graduated from developed countries. However, there are only few such studies conducted in other countries. Single institute-based studies conducted at Italy[11] and Norway[12] reported good level of nursing competencies among graduating nurses. Contrarily, recent studies conducted at Ohio, USA,[13] Victoria, Australia,[14] and Shiraz, Iran[15] reported that graduating nurses were clinical skill deficit and very few of them were possessing entry-level competencies and practice readiness. Surprisingly, there is no data on the clinical practice readiness of nurses produced by these rapidly mushroomed institutes in India. However, one of the blogger mentioned about scarcity of nursing faculty, inadequate skill development and knowledge and lack of collaboration between nursing services and education departments in India.[16] Therefore, this study was planned to assess the clinical practice readiness of graduating nurses in a selected state of India. The findings of this study will not only guide the nurse educators for transforming nursing curriculum but also inform national and international recruiters about status of practice readiness of nurses in a part of country.
Materials and Methods
Study setting and design
This cross-sectional survey was conducted with an aim to assess the clinical practice readiness of nurses graduating from selected public and private nursing institutes in Uttarakhand. It is a fastest growing state in northern part of India. This state has total 20 nursing institutes recognized by the Indian Nursing Council (public-5 and private-15), which are enrolling students in baccalaureate nursing program. Therefore, considering 40% proportionate sample from public and private institutes, total two public and six private nursing institutes were randomly selected for the present study.
Ethical considerations
Before data collection, ethical approval was obtained from the Institute Ethics Committee of All India Institute of Medical Sciences (AIIMS), Rishikesh (AIIMS/IEC/16/119). Participation was voluntary and participants could withdraw consent at any time. At all times, the research adhered to the National Ethical Guidelines for Biomedical and Health Research of India Council of Medical Research (2017).
Participants
Each of the selected institute enroll about 40–60 students annually in the baccalaureate nursing program; thus, total 382 final-year students studying in baccalaureate nursing program of the selected eight colleges were considered as the study population. The study was conducted in the last months of their final year of baccalaureate nursing program, i.e., June–July 2017.
Sample size was estimated using the formula, (Z1-a/2)2 (p) (q)/d2, [17] with absolute error of 5%, confidence interval 95% and above, and good level of nursing competency (66.9%);[11] the estimated sample size was 168 participants, whereas considering 10% nonresponse rate, total 185 sample size was considered for the present study. A sampling frame of students studying in final year of baccalaureate nursing program was obtained from selected colleges and desired sample was selected using simple random sampling by obtaining 25 participants from each institute. However, 27 students were either absent on day of data collection or did not compete questionnaire (86.5% response rate); thus, finally data collected from 173 participants were considered for analysis [Figure 1].
Figure 1.
Cluster sampling flow chart
Data collection methods and instrument
Self-structured prevalidated and reliable (r = 0.93) instrument, i.e., “Comprehensive Nursing Competencies Questionnaire (CNCQ),” was used to assess the clinical practice readiness of graduating nurses. The tool consisted of total 100 essential nursing skills items based on the prescribed curriculum for the baccalaureate nursing program in India, which was divided into two sections, i.e., (i) basic nursing skills (52 items) and (ii) advanced nursing skills (48 items). Each listed nursing skill practiced during nursing program was measured on six-point rating scale, i.e. perform independently (5), under supervision (4), only assisted (3), only observed (2), only read (1), and don't know anything (0). The basic nursing skill section included total 52 items (with score range: 0–260) under different categories, i.e. admission and discharge, personal hygiene, medication administration, invasive procedures, wound care and bandaging, respiratory nursing interventions, elimination, perioperative nursing, infection control, handling of basic medical equipment, and documentation. Similarly, advanced nursing skills section included 48 items (with score range: 0–240) under different categories, i.e. medical surgical nursing, child health nursing, obstetrical and gynecological nursing, and mental health nursing.
Each participant was handed over the questionnaire in classroom under the supervision of research team and they were asked to first fill sociodemographic data sheet, followed by ranking each nursing skill item based on level of competence they achieved during their nursing program, i.e. perform independently, under supervision, only assisted; only observed, only read theoretically, don't know anything. Participants took about 45–60 min to fill the questionnaire.
Operational definitions
The two terms frequently used in the present study are operationally defined: (i) Clinical practice readiness: Graduating nurses' level of clinical competency for each selected basic and advanced nursing skills, assed on scale of performed independently-5, under supervision-4, only assisted-3; only observed-2, only read theoretically-1, to don't know anything-0). (ii) graduating nurses: Final year baccalaureate nursing students, who were above to compete their nursing program in a month and so.
Statistical analysis
Data were coded and then entered to excel sheets and Statistical Package for Social Sciences (SPSS 21.0) developed by International Businesses Machines Corporation (IBM), New York, USA, was used for statistical analysis. Descriptive and inferential statistics were used for data analysis. Socio-demographic characteristics such as age range, gender, range of percentage of marks obtained in previous academic year and length of clinical experience were presented using frequency and percentage. However, average clinical nursing competency score for basic and advanced nursing skills and their subcategories was analyzed and presented by using mean, standards deviation. Further, independent performance of each selected nursing skill by the participant was presented using percentage distribution. One-way ANOVA or unpaired t-test was used to determine association of basic and advanced clinical nursing competencies score with selected sociodemographic characteristics at 0.05 level of significance.
Results
Sociodemographic characteristics
Majority of participants were females (92.5%) with mean age 21.6 ± 1.1 years. Slightly more than half of participants (55%) scored >70% marks in previous university exams. Further, only 60.7% participants had clinical placement throughout the year [Table 1].
Table 1.
Mean competencies score for nursing skills of participants (n=173)
| Domains of nursing care skills | Nursing care skills score | ||
|---|---|---|---|
| Maximum score | Mean±SD | Rank order | |
| Basic nursing care skills | 260 | 236.5±25.0 | - |
| Personal hygiene | 30 | 29.0±2.9 | I |
| Medication administration | 35 | 33.3±3.2 | II |
| Admission/discharge | 20 | 18.3±2.5 | III |
| Respiratory nursing interventions | 30 | 27.0±4.4 | IV |
| Documentation | 15 | 13.5±2.3 | V |
| Invasive procedures# | 30 | 21.4±2.6 | VI |
| Wound care and bandaging | 30 | 25.1±3.8 | VII |
| Infection control and BMW | 20 | 16.5±2.3 | VIII |
| Elimination | 25 | 20.3±3.5 | IX |
| Perioperative nursing | 15 | 11.7±2.8 | X |
| Handling basic medical equipment | 15 | 10.6±2.7 | XI |
| Advanced nursing care skills | 240 | 148.7±25.6 | - |
| Mental health nursing | 35 | 24.4±11.6 | 1 |
| Child health nursing | 70 | 45.3±6.5 | 2 |
| Midwifery | 70 | 44.0±8.8 | 3 |
| Medical surgical nursing | 65 | 35.0±8.7 | 4 |
| Overall nursing care skills | 500 | 385.2±42.9 | - |
#Invasive procedure: IV cannulation, venous blood sampling, peripheral blood glucose monitoring, NG tube insertion and feeding. SD=Standard deviation, BWM=Biomedical waste management, IV=Intravenous, NG=Nasogastric
Self-reported clinical practice readiness
Overall, CNCQ mean score of basic nursing skills was reasonably high (236.5 ± 25); except some the basic nursing skills. However, overall CNCQ score for the advanced nursing skills was very low (148.7 ± 25.6); further, which was markedly low for the medical surgical nursing skills [Table 1].
It was found that participants with younger age, and who had clinical posting for the longer duration had higher overall CNCQ score for basic and advanced nursing skills (P < 0.05). Further, students from public nursing college had higher overall CNCQ score for advanced nursing skills as compared to their counterparts in private institutes (P < 0.001) [Table 2].
Table 2.
Association of nursing competencies scores with selected demographic characteristics of participants (n=173)
| Demographic variables | n | Basic nursing skills score | Advanced nursing skills score | ||
|---|---|---|---|---|---|
| Mean±SD | P | Mean±SD | P | ||
| Age | |||||
| ≤21 | 81 | 241.32±17.83 | 0.000** | 150.97±23.96 | 0.030* |
| 22 | 65 | 239.51±18.95 | 150.91±25.57 | ||
| ≥23 | 27 | 214.74±33.05 | 136.78±28.14 | ||
| Gender | |||||
| Male | 13 | 240.54±15.33 | 0.514 | 147.00±23.02 | 0.784 |
| Female | 160 | 236.16±23.67 | 148.87±25.88 | ||
| Institution of training | |||||
| Government | 95 | 238.08±22.86 | 0.319 | 154.55±29.85 | 0.001** |
| Private | 78 | 234.55±23.48 | 141.65±16.92 | ||
| Percentage in previous university exam | |||||
| 50-59 | 03 | 218.33±21.45 | 0.055* | 145.00±16.37 | 0.201 |
| 60-69 | 75 | 232.09±26.28 | 145.36±22.96 | ||
| 70-79 | 86 | 240.78±18.71 | 150.27±25.59 | ||
| >80 | 9 | 238.22±27.96 | 163.44±42.87 | ||
| Clinical posting duration | |||||
| Throughout the year | 105 | 254.55±12.75 | 0.000** | 165.97±16.91 | 0.000** |
| Half of the year | 24 | 249.75±14.67 | 151.33±29.47 | ||
| Only for few months | 44 | 210.02±25.69 | 131.95±31.67 | ||
**P<0.01, *P<0.05. SD=Standard deviation
The response of participants about their independent performance of all the identified basic and advanced nursing skills is presented in Tables 3 and 4.
Table 3.
Percentage of participants independently practiced basic nursing skills (n=173)
| Admission/discharge | Infection control and BMW | Documentation | |||
|---|---|---|---|---|---|
| Skills | Percentage | Skills | Percentage | Skills | Percentage |
| Vitals sign monitoring | 95.9 | BMW management | 94.2 | TPR charting | 72.8 |
| Health assessment | 83.8 | Use of PPE | 88.4 | Nurse’s notes | 61.3 |
| Admission of patient | 69.9 | Disinfection | 50.9 | Informed consent | 59.5 |
| Discharge/discharge teaching of patient | 69.4 | Fumigation/fogging | 01.7 | ||
| Hygiene care | Elimination | Innovative procedure | |||
| Skills | Percentage | Skills | Percentage | Skills | Percentage |
| Bed making | 94.8 | Catheter care | 83.8 | Veinipuncture | 76.3 |
| Oral care | 93.6 | Suppositories | 49.7 | PBG monitoring | 79.8 |
| Hair care | 91.3 | Enema | 42.8 | Venous blood sampling | 67.0 |
| Back care | 89.6 | Urinary catheterization | 37.6 | NG tube feeding | 39.9 |
| Bed bath | 84.4 | Bowel wash | 13.3 | NG tube insertion | 5.9 |
| Medication administration | Oxygenation/respiratory care | Wound care and bandaging | |||
| Skills | Percentage | Skills | Percentage | Skills | Percentage |
| IV infusion | 90.2 | Nebulization | 95.4 | Bandaging | 83.2 |
| Intramuscular injection | 87.9 | Steam inhalation | 91.3 | Surgical wound dressing | 55.5 |
| IV drugs | 87.3 | O2 administration by simple face mask | 85.1 | Bed sore dressing | 52.0 |
| Oral drug | 84.4 | O2 administration by nasal prongs | 75.1 | Pin site care dressing | 39.9 |
| Subcutaneous injection | 82.6 | Assisted patient with incentive spirometer | 71.7 | Removal of sutures and staples | 28.3 |
| Intradermal injection | 82.6 | O2 administration by partial/ nonrebreather /venturi mask | 54.3 | Burns wound dressing | 22.5 |
| Eye, ear, nasal drops instillation | 80.9 | ||||
| Preoperative care | Handling basic medical equipment | ||||
| Skills | Percentage | Skills | Percentage | ||
| Preoperative care | 38.1 | Pulse oximeter | 79.2 | ||
| Postoperative care | 32.4 | Recoding ECG | 34.7 | ||
| Intraoperative care | 21.4 | Using defibrillator | 2.9 | ||
ECG=Electrocardiogram, BMW=Bio-medical waste, PPE=Personal protective equipment, TPR=Temperature, pulse and respiration, IV=Intravenous, NG=Nasogastric, PBG=Peripheral blood glucose
Table 4.
Percentage of participants independently practiced advanced nursing skills (n=173)
| Medical surgical nursing | Child health nursing | Obstetrical and gynecological nursing | |||
|---|---|---|---|---|---|
| Skills | Percentage | Skills | Percentage | Skills | Percentage |
| Blood transfusion | 34.1 | Nebulisation | 62.4 | Perineal care | 50.3 |
| Endotracheal/tracheostomy suctioning | 24.3 | New born assessment | 48.5 | Assisting the mother with breast feeding | 47.4 |
| Tracheostomy care | 17.3 | Intramuscular injection | 37.0 | Antenatal care | 42.8 |
| Care of central venous catheter | 15.6 | Immunization | 31.8 | Postnatal care | 39.3 |
| Administration of TPN | 15.6 | Care of new born | 30.6 | Antenatal examination | 37.6 |
| Colostomy care | 15.6 | Care of new-born in radiant warmer | 27.2 | Postnatal examination | 26.0 |
| Arterial blood sampling | 14.4 | IV medication with use of infusion pump | 20.2 | Nonstress test | 20.2 |
| Care of intercostal chest drainage site | 13.9 | care of new born under phototherapy | 19.6 | Vaginal examination | 19.1 |
| Gastrostomy/jejunostomy feeding | 9.8 | Administration of oxygen by oxygen tent | 18.5 | Examination of placenta | 13.3 |
| Gastric lavage | 6.9 | Administration of oxygen by oxygen hood | 16.8 | Partogram | 12.1 |
| BLS | 6.3 | care of new-born in incubator | 13.3 | Collection of pap smear | 9.8 |
| Care of patient on mechanical ventilator | 4.6 | Paediatric vein puncture | 9.8 | Normal vaginal delivery | 4.6 |
| Care of patient with cardiac catheterization | 1.7 | Neonatal resuscitation | 4.6 | IUCD insertion | 3.5 |
| Paediatric BLS | 0.6 | Episiotomy and suturing | 1.1 | ||
| Mental health nursing | |||||
| Skills | Percentage | Skills | Percentage | Skills | Percentage |
| History collection | 94.2 | MMSE | 86.1 | Process recording | 63.0 |
| Behavioural therapy | 12.7 | Care patient for ECT | 11.0 | Use of restraints | 7.5 |
| Assisting in AT | 3.5 | ||||
TPN=Total parental nutrition, IUCD=Intrauterine contraceptive device, ECT=Electroconvulsive therapy, AT=Abrasion therapy, MMSE=Mini-mental status examination, BLS=Basic life support, IV=Intravenous
Discussion
Increasing international and national demand of nurses and growing migration of nurses to developing countries lead to rapid proliferation of nursing institutes offering nursing program especially in private sector.[18] Several reports highlighted the compromised quality of nursing education with this rapid mushrooming such as poor infrastructure, serious teaching staff shortage, inadequate clinical experience for the nursing students.[18,19,20] New graduating nurses are expected to seamlessly integrate into the role of registered nurse in spite being novice and debate about clinical practice readiness of novice nurses remains palpable across globe. Further, it is more important for India being a major supplier for the nurses internationally and there is an acute shortage of nurses nationally.
However, there is no data about the clinical practice readiness of new graduating nurses in India. Therefore, this state-level survey was conducted to assess self-reported clinical practice readiness of new graduating nurses from state Uttarakhand, India. It was found in the present study that there was reasonably high mean clinical competency score for basic nursing skills (236.5 ± 25.0). However, competency score was very low for the advanced nursing skills (148.7 ± 25.6). Recent studies conducted at Ohio, USA,[13] Victoria, Australia,[14] and Shiraz, Iran[15] also reported clinical skill deficit and lack of adequate practice readiness of graduating nurses, where Kavanagh and Szweda[13] reported that only 23% newly graduate demonstrated entry-level competencies and practice readiness and recommended that nursing faculty must maintain clinical currency like medical faculty to strengthen the practice reediness of nursing students. In our study, low practice readiness for advanced nursing skills primarily could be because most of the private nursing institutions do not owe their parent hospitals and place nursing students in small nursing homes for clinical experience, where students do not get enough opportunity to experience and practice advanced nursing skills.
Further, out of basic nursing skills, mean competency score was highest for the personal hygiene related skills, followed by medication administration, admission and discharge, respiratory nursing intervention, documentation, and invasive procedures such as intravenous cannulation, intravenous blood sampling, peripheral blood glucose monitoring etc., However, it was low for some of the basic nursing skills such as ECG reading, use of defibrillator, perioperative care, infection control, wound care and elimination related nursing skills. Similarly, there was low mean score for all the advanced nursing skills which was lowest for medical surgical nursing skills, followed by obstetric and gynecological nursing and child health nursing. This shows that graduating students are not getting enough opportunity to practice advanced nursing skills. Similar findings has been reported by other study from Korea.[21] The reason could be lack of clinical learning material, poor student-patient ratio, lack of tertiary care patient services, and high fidelity nursing skill labs.
Longer duration and intense clinical experience contributes in better clinical practice readiness of nurses.[22] Our study reported that participants, who were placed in clinical experience for longer duration reported higher mean competency score for basic as well as advanced nursing skills (P = 0.001). Nursing students studying at public institutes had higher mean score for advanced nursing skills as compared to their counterparts in private hospital (P = 0.001). However, contradictory findings has been reported by a study from Thailand.[23] More than 88% nursing institutions are private in India[18] and most of these do not owe parent hospital, thus place the students in affiliated small nursing homes, where they do not get enough opportunity to experience and practice advanced nursing skills.
It was a serious finding in the present study that even 50% of graduating nurses could not independently practiced some of the basic nursing procedures such as pressure sore dressing, burns wound dressing, perioperative care, nasogastric tune insertion, NG tube feeding, insertion of suppositories, enema administration, bowel wash, urinary catheterization, removal of sutures, pin site care, fogging, recording electrocardiogram and use of defibrillator. Surprisingly, only few of the participants independently practiced advanced nursing skills in medical surgical nursing, midwifery and child health nursing advanced nursing skills. We astonished to see that not even 10% participants independently practiced some of the advanced nursing skill such as gastrostomy/jejunostomy feeding (9.8%), pediatric venipuncture (9.8%), collection of pap smear (9.8%), gastric gavage (6.9%), basic life support (BLS) (4.6%), neonatal resuscitation (4.6%), pediatric BLS (0.6%), normal vaginal delivery (4.6%), episiotomy (1.1%), care of patient with cardiac catheterization (1.7%). The reason could be less opportunity, and thus low confidence to perform these skills. Woods et al.[24] also reported that overall confidence and clinical preparedness of nursing students was high, however they lacked confidence in venipuncture, assisting in intubation and managing multiple patient assignments. This could be because of lack of opportunity of practice these advanced level of nursing skills or the lack of clinical supervision by nursing faculty.
This clearly shows that graduating nurses from India may be possessing reasonably good level of basic nursing skills but they may be lacking advanced nursing skills especially who are graduating from private nursing institute without a parent teaching hospital. Further, nursing faculty do not maintain clinical practice currency like medical faculty; and students are abandoned in clinical areas to master clinical skills whatever comes-on their way during clinical postings.
Limitations
Despite a rigorous study design, this study still faced some critical limitations. It was a self-reported clinical practice readiness study, so it may have the risk of “reporting bias.” In addition, study had a narrow definition of clinical practice readiness as only level of competencies of selected hundred clinical nursing tasks was assessed in the present study.
Conclusion
Graduating nurses had reasonably good level of clinical practice readiness for the basic nursing skills. However, they lacked the competencies in advanced nursing skills. Therefore, regulatory bodies must check that nursing institutes have sufficient facilities and processes for adequate clinical learning experience in basic and advanced nursing skills. Further, nursing faculty must be clinically updated and regularly practice to ensure planned development and mastery of essential clinical competencies among graduating nurses. A countrywide multi-centric study is recommended to be conducted to understand the contributing factors of poor clinical readiness of nurses in India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We are thankful to principals of nursing institutes for their permission, participants for their participation, and Akansha, Anushka, Babita, Bharti, Chhavi, Ekta and Ekta Tehlan, B. Sc. (Hons) Nursing Batch-2K13 of All India Institute of Medical Sciences for their help in conduction of this research project. A special thanks to Ms. Hemlata for peer-review of the paper before submission for the publication.
References
- 1.El Haddad M, Moxham L, Broadbent M. Graduate nurse practice readiness: A conceptual understanding of an age old debate. Collegian. 2017;24:391–6. [Google Scholar]
- 2.Life Expectancy – Our World in Data. [Last accessed on 2020 Jan 16]. Available from: https://ourworldindataorg/life-expectancy .
- 3.GBD 2016 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390:1151–210. doi: 10.1016/S0140-6736(17)32152-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Nursing and Midwifery. [Last accessed on 2020 Jan 16]. Available from: https://wwwwhoint/news-room/fact-sheets/detail/nursing-and-midwifery .
- 5.Nursing Workforce. [Last accessed on 2020 Jan 16]. Available from: https://wwwnursingworldorg/practice-policy/workforce/
- 6.WHO | Wanted: 2.4 million nurses, and that's just in India. [Last accessed on 2020 Jan 16]. Available from: https://www.who.int/bulletin/volumes/88/5/10-020510/en/
- 7.International Mobility of Nurses from Kerala (India) to the EU: Prospects and Challenges with special reference to the Netherlands and Denmark | IIM Bangalore. [Last accessed on 2020 Jan 16]. Available from: https://wwwiimbacin/node/1797 .
- 8.Brush BL, Sochalski J, Berger AM. Imported care: Recruiting foreign nurses to US health care facilities – Importing nurses is likely to remain a viable and lucrative strategy for plugging holes in the US nurse workforce. Health Affairs. 2004;23:78–87. doi: 10.1377/hlthaff.23.3.78. [DOI] [PubMed] [Google Scholar]
- 9.Khadria B. International nurse recruitment in India. Health Serv Res. 2007;42:1429–36. doi: 10.1111/j.1475-6773.2007.00718.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Indian Nursing Council. Distribution of Nursing Educational Institutions as on 31st M arch 2017. 2017. [Last accessed on 2020 Jan 16]. pp. 1–1. Available from: http://wwwindiannursingcouncilorg/Statisticsasp .
- 11.Notarnicola I, Stievano A, Pulimeno A, Iacorossi L, Petrizzo A, Gambalunga F, et al. Evaluation of the perception of clinical competencies by nursing students in the different clinical settings: An observational study. Ann Ig. 2018;30:200–10. doi: 10.7416/ai.2018.2211. [DOI] [PubMed] [Google Scholar]
- 12.Kajander-Unkuri S, Meretoja R, Katajisto J, Saarikoski M, Salminen L, Suhonen R, et al. Self-assessed level of competence of graduating nursing students and factors related to it. Nurse Educ Today. 2014;34:795–801. doi: 10.1016/j.nedt.2013.08.009. [DOI] [PubMed] [Google Scholar]
- 13.Kavanagh JM, Szweda C. A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses' clinical reasoning. Nurs Educ Perspect. 2017;38:57–62. doi: 10.1097/01.NEP.0000000000000112. [DOI] [PubMed] [Google Scholar]
- 14.Missen K, McKenna L, Beauchamp A. Work readiness of nursing graduates: Current perspectives of graduate nurse program coordinators. Contemp Nurse. 2015;51:27–38. doi: 10.1080/10376178.2015.1095054. [DOI] [PubMed] [Google Scholar]
- 15.Jamshidi N, Molazem Z, Sharif F, Torabizadeh C, Najafi Kalyani M. The challenges of nursing students in the clinical learning environment: A qualitative study. Sci World J. 2016;2016:1846178. doi: 10.1155/2016/1846178. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Challenges to Nursing Education in the Developing World | Evidence-Based Nursing Blog. [Last accessed on 2020 Jan 16]. Available from: https://blogsbmjcom/ebn/2018/03/26/challenges-to-nursing-education-in-the-developing-world/
- 17.Sharma S, Mudgal S, Thakur K, Gaur R. How to calculate sample size for observational and experiential nursing research studies. Natl J Physiol Pharm Pharmacol. 2020;10(1):1–8. [Google Scholar]
- 18.Rao M, Rao KD, Kumar S, Chatterjee M, Sundararaman T. Human resources for health in India.Lancet. 2011 Feb;377(9765):587–98. doi: 10.1016/S0140-6736(10)61888-0. [DOI] [PubMed] [Google Scholar]
- 19.Ministry Of Health And Family Welfare Government Of India. 2005 Report of the National Commission on Macroeconomics and Health Report of the National Commission on Macroeconomics and Health Equitable Development Healthy Future. [Last accessed on 2020 Jan 16]. Available from: wwwmohfwnicin .
- 20.Raha· S, Pelet B, Bhatnagar A. Some priority challenges of the nursing sector in India. Public Heal Found India. 2009;1:1–5. [Google Scholar]
- 21.Ju Son Y, Lee I, Park CS. Study of competence of nursing students in Emergency Nursing Core Skills. J Probl Learn. 2016;3:15–22. [Google Scholar]
- 22.Gemuhay HM, Kalolo A, Mirisho R, Chipwaza B, Nyangena E. Factors affecting performance in clinical practice among preservice diploma nursing students in Northern Tanzania. Nurs Res Pract. 2019;2019:3453085. doi: 10.1155/2019/3453085. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Sawaengdee K, Kantamaturapoj K, Seneerattanaprayul P, Putthasri W, Suphanchaimat R. Self-assessment of nursing competency among final year nursing students in Thailand: A comparison between public and private nursing institutions. Adv Med Educ Pract. 2016;7:475–82. doi: 10.2147/AMEP.S111026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Woods C, West C, Mills J, Park T, Southern J, Usher K. Undergraduate student nurses' self-reported preparedness for practice. Collegian. 2015;22:359–68. doi: 10.1016/j.colegn.2014.05.003. [DOI] [PubMed] [Google Scholar]