INTRODUCTION

Education providers in higher education strive to produce graduates well-prepared for their future jobs; however, graduates’ capability in specific working situations may not meet the demand of employers. As a result, preparing graduates to function competently in their work has become a central issue in higher education and professional training (Anema & McCoy, 2009;Martin, 2017). Nursing is no exception to this situation. Despite the efforts of nursing schools in higher education institutions to produce competent graduates, employers express concerns that graduates do not seem prepared for the realities of the workplace and require more education and support before working independently (Berkow, Virkstis, Stewart, & Conway, 2008).

This perceived disconnect between the educational preparation of competent registered nurses and employers’ expectations regarding the competencies of new graduates has become a growing concern regarding the quality of nursing eduction and nursing workforce globally and particularly in Korea where the number of nursing schools has significantly increased due to demand for a larger nursing workforce (Berkow et al., 2008;Ko et al., 2013). To address these concerns, the Korean Accreditation Board of Nursing Education, which is the self-regulation body for nursing education, introduced a competency-based approach to education in 2012 and identified seven core competencies for all registered nurses (Korean Accreditation Board of Nursing Education [KABONE], 2012). A competency- based approach is relatively new in Korean nursing education. The KABONE’s nursing competencies were developed based on registered nurses with two to three years of practice experience (KABONE, 2012). This decision was based on the generally accepted notion that new graduates may need two or three years of experience to demonstrate competencies as a registered nurse. As a result, questions have been raised about whether the KAB ONE’s competencies are appropriate for new graduate nurses and if they require more detail to be effectively applied to nursing education (Ko et al., 2013;Park et al., 2013).

Identifying expected nursing competencies for newly graduated nurses is an important issue across the world. Several countries, such as Australia and the United States of America, have six to twelve months of structured postlicensure programs (known as graduate transition or support programs) designed to support transition of new nurses from the educational environment to professional practice (Levett-Jones & FitzGerald, 2005). However, Korea does not offer this support for new graduate nurses. Korean new graduates are responsible for working independently after a short orientation, which is usually a 6~12 week preceptorship (Sin, Kwon, & Kim, 2014). Importantly, studies of new graduates’ experiences suggest that they feel inadequately prepared for their role as nurses, and insufficiently oriented to their workplace (Sin et al., 2014). Additionlly, there is little known about the nursing competencies of new graduate nurses in the Korean context, which results in difficulty when educating for competency- based practice and assessing competencies (Ko et al., 2013;Park et al., 2013). Thus, there is a need to identify what nursing competencies are required for Korean new graduate nurses at the point of registration in order to bridge the gap between the expectations of education providers and employers, and ultimately ensure delivery of a safe and quality practice.

To explore current evidence for identifying nursing competencies required for new graduates, an international context is important because the globalisation of healthcare is evitable in the contemporary context due to healthcare tourism, immigration, and workforce mobility (Turner, 2018). As global healthcare issues change, for example through emerging infectious diseases and concerns about maternal-newborn health (Edmonson et al., 2017), required nursing competencies also change. Therefore, it is significant to explore the current international context in order to investigate the competencies required for newly graduated nurses. At the same time, specific contexts should also be considered because competencies are holistic entities, relating to the ability of a nurse to practice in a dynamic environment that evolves with society and the system (Yang et al., 2013). In other words, nursing competence should be understood in relation to Korean culture, the healthcare system and the education system. Logically then, the competencies required as a registered nurse in Korea are different from those in other countries. The exploration of required competencies in the Korean context is necessary. It is, therefore, necessary not only to review internationally identified nursing competencies but also to review nursing competencies specifically in the Korean context.

The purpose of this paper is to present an integrative literature review identifying nursing competencies for new nursing graduates, both globally and in the Korean context.

METHODS

The integrative review process follows the five stages described by Whittemore and Knafl (2005): (1) Problem identification, (2) Literature search, (3) Data evaluation, (4) Data analysis and (5) Presentation stage. This framework was chosen not only because this process includes more explicit and systematic methods to enhance rigour, but also because it offers a rigorous approach to providing a holistic understanding of the research topic by combining diverse data sources (Whittemore & Knafl, 2005). The question that guided the review process is: What nursing competencies are expected in newly graduated nurses, both globally and in the Korean context?

1. Literature Search Stage

The primary search method involved the use of computerised databases, and a comprehensive search of the reference lists of the probable literature for a more comprehensive review (Whittemore & Knafl, 2005). The search process was conducted in two separate ways because most Korean nursing literature is written in Korean and published in Korean journals. First, the relevant Korean literature on nursing competencies was searched using Korean keywords including nursing or nurse competency, newly graduated nurses, and graduating students, in the three major Korean electronic databases, which are RISS (Research Information Service System), KISS (Korean Studies Information Service System) and KNbase (Korean Nurs ing Databases). Second, the English international literature databases, PUBMED, CINAHL, SCOPUS, and Web of Science, were searched using terms that included nursing, competency, graduating, and graduated nurses; however, the search terms were varied for different electronic databases with the assistance of an experienced librarian. Grey literature was not primarily included as some researchers claim that the inclusion of grey literature requires an exhaustive investment of time, yet yields very little relevant material (Scott-Findlay & Estabrooks, 2006). However, the grey literature related to the research question was used to source further references by searching the reference lists.

2. Selection Process

The staged method of determining whether the primary studies were eligible for review was followed (Conn et al., 2003). Potentially eligible literature was searched using computerised databases with specific search terms. Inclusion and exclusion criteria were then applied to the research abstracts (Table 1). To enhance rigour, literature was reviewed by two investigators (AH and AC) against the inclusion and exclusion criteria. Finally, eligibility was selected by assessing when information from the research report was determined to be useful in the review (Conn et al., 2003). Figure 1 outlines the process.

3. Data Evaluation Stage

Data evaluation was undertaken using the two steps from the Weight of Evidence Framework (Gough, 2007) to ensure that the selected evidence was of sufficient and appropriate quality and relevance (Gough, 2007;Whittemore & Knafl, 2005). This framework enabled studies to be assessed against more generic criteria for the quality of the study and purpose-specific criteria to assess the relevance of the data (Gough, 2007). The first step involved the assessment of methodological and theoretical rigour and was conducted using the Mixed Method Appraisal Tool (MMAT) version 2011 (Pluye et al., 2011). This tool was developed for the concomitant review of qualitative, quantitative and mixed methods studies (Pluye et al., 2011). The second step of the framework involved evaluating the relevance of the focus of the evidence to the review question on a 2-point scale (high or low). This evaluation was to assess how directly the selected study addressed the focus of the review question or whether it was undertaken in an appropriate context from which results can be generalised to answer the review questions (Gough, 2007;Whittemore & Knafl, 2005). The final eligible studies (n=28) were assessed. The MMAT scores were higher than 75.0 % in the majority of the studies, and only five studies scored 25.0 % - 50.0 % due to small response rates, limited literature reviews, or restricted participants. The data relevance of all selected studies was high; therefore, all selected studies were analysed in the next stage.

4. Data Analysis

The five steps of the data analysis method by Whittemore and Knafl (2005) were utilised: data reduction, data display, data comparison, conclusion drawing, and verification. The data regarding required nursing competencies were extracted from primary sources and categorised. Each primary source was reviewed to verify that the competencies and competency categories derived from primary sources All data were displayed into a matrix table and were iteratively compared by the investigators. To summarise and synthesise the data, a comparison table was drawn up from this analysis and discussed in the results section (Table 2).

RESULTS

Three themes with eleven competency areas were identified in the global and Korean literature (Table 2), which are evidence-based practice, patient-centered care and professional nursing practice. Several competencies are identified in each theme. The first theme of evidence-based practice incorporates the capacity to integrate theory and skills into nursing practice; demonstrate nursing care with contemporary evidence, and deliver care using a systematic approach. The second theme of patient-centred care involves ensuring patient safety, educating the patient and their family, sound interpersonal communication skills, and demonstrating a collaborative approach. In the theme of professional practice, new nurses are expected to practice legal and ethical nursing care, undertake continuing professional development, demonstrate capacity for clinical management, and demonstrate appropriate professional attributes including workplace etiquette. The following discussion outlines these eleven competencies, and also identifies whether they are present in both international and Korean literature.

Theme 1. Delivering Evidence-based Nursing Practice

The first theme was related to evidence-based practice. New graduates are expected to be able to integrate up-todate evidence into the nursing process, and this systematic approach should be flexible enough to meet patients’ changing conditions.

New nurses are expected to be capable of integrating theory and skills into nursing practice. New graduates are expected to possess sufficient theoretical knowledge (n= 15) and practical skills (n=15) to begin practising. Theoretical knowledge includes nursing theory, pathophysiology, pharmacology, natural, social and behavioural science knowledge. New graduate nurses are required to perform core nursing skills and are expected to demonstrate them at a proficient level, rather than just having theoretical knowledge of skills. Furthermore, being able to integrate theory and skills and incorporate them into practice is seen as essential for new graduate nurses, which is mentioned in the fourteen selected studies. The two essential areas in which new graduates should have both theoretical knowledge and practical skills are medication management and effectively responding to emergency situations. The majority of Korean literature have reported that new graduates need to manage an emergency situation while only three international studies have shown that new graduates need to be trained essential emergency procedures. Additionally, other important skills for new graduates were identified in the literature: maintaining infection control measures, providing care by identifying appropriate activities of daily living, caring for a patient in a critical condition, and providing palliative care. When providing nursing care in particular situations, new graduates are expected to understand the purpose of nursing procedures and the principles behind the nursing actions.

Nursing care is expected to be based upon contemporary evidence. Thirteen articles pointed out that new graduates are expected to be able to practise using accurate and contemporary evidence. Research abilities are required for enhancing evidence-based practice including curiosity regarding the issues, basic statistical knowledge, literature search techniques, data collection abilities, examining and investigating findings, and applying the findings into practice (n=20). It is a notable feature in the Korean literature that Korean managers expect new graduates to have a basic research ability while Korean educators’ expectations are more elaborate and extended to having a knowledge of how to conduct research and how to utilise it in practice. Moreover, critical thinking is vital to evidencebased nursing practice. When applied, critical thinking leads to sound, evidence-based practice. Several studies (n=13) also cited that newly graduated nurses required abilities in critical thinking, clinical reasoning, and clinical judgement. For instance, new graduates should be able to execute their decisions based on rationales and clinical knowledge. The literature also highlighted that newly graduated nurses should be equipped with problem-solving skills (n=10) for best practice in the delivery of care.

Evidence-based practice also requires the capacity to deliver care using a systematic approach. Newly graduated nurses are expected to utilise the nursing process in practice effectively. Most of the studies reviewed (n=23) highlighted that nursing graduates need to be able to apply processes of assessment, diagnosis, plan, implement, and evaluation into their practice. First, new graduates are required to conduct a comprehensive health assessment which includes all aspects of the patient, based on their lifespan stage. Second, new graduates are expected to determine a nursing diagnosis and select appropriate care strategies using the collected data. Third, new graduates are expected to develop an individual care plan with multidisciplinary teams for a patient. When planning the individual care, nursing graduates can establish a discharge plan utilising the patient’s community resources for sustainable nursing care which were only mentioned in the international literature outside of Korea. Additionally, new graduates should possess prioritising skills to consider patients’ needs and individual conditions. In addition, new graduates are expected to implement the planned care with monitoring skills so they can respond promptly to small changes. Lastly, evaluation of patients’ outcomes and satisfaction, and evaluation of the nursing process itself was important. This included being able to modify the plan of care if needed.

Theme 2. Delivering Patient-centered Care

The second theme to emerge was related to patient-centred nursing care, which is a widely used concept in the healthcare system (Pelzang, 2010). New graduate nurses are expected to place the patient at the centre of care by protecting patient safety, and involving patients and families in the delivery of nursing care by communicating and coordinating with others.

A key competency is ensuring patient safety. New graduates are expected to deliver nursing care that ensures patients’ physical and psychological safety (n=8). They also should be able to incorporate care that demonstrates respect for a patient’s cultural background, values, and beliefs. Additionally, nursing graduates are required to be aware of their role in patient advocacy and support patients’ rights (n=8). Lastly, they are also expected to participate in quality improvement activities for promoting a therapeutic and safe environment for patients and colleagues (n=13). However, while international studies often mentioned that patients’ culture and values should be respected, only one Korean study highlighted multicultural issues in nursing care. Furthermore, only international studies found that new graduates are expected to report malpractice or violent and threating situation, no Korean literature pointed out this responsibility of newly graduated nurses.

Graduate nurses are expected to be competent in educating the patient and their family. Seventeen studies stated the importance of patient education. Patient and family education includes giving information regarding treatment and test results, verifying whether a patient understood or not, and education involving the multidisciplinary team. Thirteen studies have emphasised that nurses are able to influence patient outcomes and well-being through education.

Sound interpersonal communication skills are expected. Eleven selected articles suggest that new graduates should be competent in communicating with patients and families respectfully and effectively. They are expected to be equipped with active listening and non-verbal communication skills and try to understand what patients want to express. Moreover, nursing graduates need to be able to communicate competently with other professionals (n=10). This implies that they have to possess a sound understanding of medical terminology in order to interpret physicians’ and inter-professional team orders. More importantly, as a new graduate, they are expected to clarify or question any ambiguous orders or instructions. Several articles identify documentation ability as an important skill in order to communicate effectively, and the ability to utilise information technology, such as electronic medical records and computers in nursing practice, is also necessary so that new graduates can utilise medical technology,

New nurses should also be able to implement a collaborative approach. For new graduate nurses, cooperating with patients and families, and other healthcare members in a multidisciplinary team is an essential competency that features in both the global and Korean literature. It is important for new graduates to know what the nursing roles are within the multidisciplinary team and to respect other professions’ cultures and their professional boundaries. Conflict management was also mentioned in the nursing literature. This is not only in a patient-nurse relationship but is also needed whilst working with other nurses and other health professionals. New graduates should be able to manage conflict and debate effectively in the patientnurse relationship as well as when working with other nurses and other health professionals. Korean nurse managers did not mention that new graduates require conflict management skills, but Korean educators think they need this skill.

Theme 3. Demonstrating Professional Nursing Practice

The third theme was professional nursing practice. Not only are newly graduated nurses expected to practise in accordance with legal and ethical responsibilities, but they are also required to continue developing their professional competencies, clinical leadership abilities, and personal attributes.

Being aware of legal standards and responsibilities is necessary for newly graduated nurses. They are expected to practise in accordance with professional standards and be aware of legal boundaries in nursing practice (n=14). There is also an expectation that new graduates have a sound knowledge of international and domestic ethical standards and practise within appropriate ethical frameworks. They have to be aware of ethical issues that might present and the importance of applying ethics in daily practice. Literature suggests that new graduates be able to make good practice decisions in the absence of agency policies and procedures. Furthermore, newly graduated nurses should be knowledgeable of changes in national and global policies and how these policies impact on nursing practice and healthcare system. This is because nurses deliver nursing care with community or society health issues as health professionals. Interestingly, three Korean studies and a Chinese study only suggested that new graduates need to learn English or other languages to communicate with foreign patients as the health care systems become more globalised.

Continual professional development and self-directed learning is a pivotal part of the nurses’ professional development. New graduates are expected to be able to identify their own learning needs and reflect on their practice. Continuing professional development is also important for new graduates, in order to continue to improve professional practice. With this effort, new graduates need to demonstrate a professional attitude, a passion for nursing practice, and demonstrate professional values and responsibility. As a health professional, new graduates should be responsible and accountable for their own actions.

Graduates should also be able to demonstrate competency in clinical management. Sixteen studies suggested that general clinical management ability is required of new graduates. Clinical management is defined as nursing behaviours that provide direction and support to clients and the healthcare team in the delivery of patient care (Chappell & Richards, 2015). New graduates should possess management skills, such as time management, organisational skills, workload management, and resource management. Staff management skills are also suggested for newly graduated nurses in the international literature (n=12). If required, new graduates have to be able to provide teaching to assistant staff or students and to delegate tasks effectively and supervise assistants in the workforce; however, these skills are not mentioned in the Korean literature.

Demonstrating appropriate professional attributes is also important. New graduates need to have personal characteristics that positively influence their attitudes and behaviours in a professional capacity. The most significant attribute required is that new graduates can control their emotions and manage stress. Managers and new graduates frequently reported that graduates should prepare for managing work-related stressors when dealing with unexpected situations.

Workplace manners or etiquette are also required of new graduates. Several Korean studies have found that new graduates required workplace etiquette, politeness and courtesy, and reliability. Only the international literature has suggested that new graduates learn to ask for and accept constructive criticism, be self-reflective and show self-awareness. Some studies have emphasised that seeking assistance if required is an important attribute for new graduates. Additionally, new graduates should have self-belief for improving their level of competencies. Korean nurse managers from the selected literature emphasised that healthy self-esteem is the essential factor to improve competency under stress and new graduates also reported that their competencies increased with experience.

DISCUSSION

The aim of the integrative literature review was to identify nursing competencies required for newly graduated nurses both globally and in the Korean context. This study revealed three main themes including eleven suggested competency areas for newly graduated nurses.

The first theme is related to evidence-based practice, which can be understood as a systematic but flexible approach to nursing practice using a wide range of sources (Nevo & Slonim-Nevo, 2011). This review identified current global efforts within educational institutions to prepare nursing students for evidence-based practice, such as how to find and examine up-to-date information, and how to critically apply it to practice. However, it was also reported that this is still a challenge for newly graduated nurses due to their limitation of the knowledge base, and limited experience of recognising patient values and clinical judgement (Ferguson & Day, 2007;Park, Kim, Kim, An, & Pyo, 2015). It may indicate that a gap still exists between the expectation of graduates and their actual capabilities.

Secondly, patient-centered care is an important competency theme for newly graduated nurses, which was mentioned in almost all of the selected literature. This has become increasingly prominent in recent years due to its positive influence on patients’ satisfaction with care, patients involvement with care, health improvement and creating therapeutic cultures (Pelzang, 2010). Furthermore, the highlighted competencies in this theme are also essential for new graduates because these competencies will frequently be used at the beginning of their practice. For instance, new graduates reported that the most frequently used competencies in their practice were focused on individual needs, supporting patients’ coping strategies, and making decisions concerning patient care in a specific context (Wangensteen, Johansson, Björkström, & Nordström, 2012).

With regards to patient safety, new graduates are required to ensure culturally safe practice. This finding supports that the general identification of cultural safety as an important competency in practice (Jeffreys, 2015;Purnell & Paulanka, 2008). Several countries including Korea currently are experiencing cultural shift with the increase of migrant workers and marriage for migration, which leads to transition to multiculturalism (Purnell & Paulanka, 2008). Therefore, new graduate nurses need to provide nursing care for patients who come from culturally diverse backgrounds. In turn, nursing education and practice may need to provide multicultural educational opportunities for nursing graduates to be prepared for culturally competent practice.

Additionally, patient education was highlighted as an expected competency for newly graduated nurses. This review discovered that new graduates are prepared to deliver patient and family education, encouraging the patients to participate in their nursing care based upon the longterm goal of well-being. This competency is globally known as a core competency for entry-level practice nurses in the selected literature. The international recognition of this competency matches the recent change in the Korean med ical law that registered nurses have a legal responsibility to provide consultation or education for health promotion with patients. Even though patient education and family involvement are the key attributes of patient-centered care (Pelzang, 2010), this study discovered that, while Korean new graduates were able to educate patients without confidence (Park & Kim, 2014). This finding suggests that Korean nursing graduates need more support to improve their competency in delivering patient education during the nursing program, and at the beginning of the practice as registered nurses.

The third competency theme is professional nursing practice. The review found that nursing graduates are expected to practise within their legal and ethical responsibilities as a health professional and possess professional attributes. Nursing education has traditionally emphasised the importance of vocational preparedness (Dolan, 2003). Recently, nursing has tried to achieve professional status beyond the vocational level, so the question has been raised as to whether previously identified competencies reflect the current healthcare system (Cowan et al., 2005). The findings of this review corroborate those of previous studies that society now expects professional and ethical behaviour from registered nurses. Importantly, previous studies found that professionalism has mediating effects between clinical competency and the ability of new graduates to adapt to the field (Kim & Park, 2013), and it also has a negative correlation with turnover intention (Beecroft, Dorey, & Wenten, 2008). Kim and Park (2013) report that new graduates self-assess their level of professionalism with relatively low scores compared with experienced nurses. This finding implies that the preparation of new graduates needs to be improved to support their transition to professional practice.

Certain professional attributes were also discussed as important attributes of the professional practice for new graduates. In the Korean context, professional manners or etiquette, including politeness, courtesy, and reliability, were identified as important indicators for Korean new graduates. In particular, Korean preceptors emphasised that personality is a critical competency for new graduates (Park et al., 2015). Interestingly, only the international literature in this review suggested that new graduates should seek assistance if required and be self-reflective and show self-awareness. These findings may indicate that new graduates are not expected to deliver highest quality of nursing practice, but instead are supposed to be aware of their own competency levels and seek assistance if needed.

The competency of staff management was frequently cited in the international literature, but not in the Korean literature. However, this issue is relevant to the Korean context as ambiguity in the scope of practice and the quality of nursing care by registered nurses and assistant nursing staff was identified as a threat to public health in Korea (Chung, 2015). The result was a significant amendment in nurses’ duties in the Medical Law, which stated that registered nurses have a legal responsibility for supervising assistant staff in nursing. Therefore, the preparation of new graduates who can delegate and supervise assistant staff is an important issue for future research both globally and in the Korean context.

Overall, this review has highlighted that there are many expected competencies for new graduates articulated and identified in the international literature. The three major competency themes and eleven competency areas that are identified could be applied to the Korean context and provide more details on the competencies of newly graduated Korean nurses than the seven KABONE competencies currently in use. Previous studies have reported that the KABONE’s competencies are not of sufficient detail, making them difficult to apply to nursing education (Ko et al., 2013;Park et al., 2013). These findings will inform nursing graduates of the particular learning contexts in which they should be sufficiently prepared before working independently. The present study revealed emerging nursing competencies required for new graduates, such as culturally safe practice, patient and family education and staff management competency. These findings suggest that nursing education and practice have to provide more educational opportunities for nursing graduates to be prepared for competent nursing practice. Moreover, new graduates need to improve their required nursing competency during the nursing program and at the beginning of the nursing practice.

The results could also be used to support future studies on the development of competency assessment tools or the evaluation of the nursing educational preparation in nursing programs and workplace orientations. Studying competencies at this specific level may be beneficial to reduce the gap between the educational preparedness, the employers’ expectations, and the graduates’ achievements. Further research should be undertaken to investigate competency levels in the Korean context, which can provide the benchmark at the point of registration for educators and managers.

CONCLUSION

This integrative literature review was conducted to identify nursing competencies required for new graduates, both globally and in the Korean context. This review has highlighted that global literature identifies many more expected competencies for new graduates than Korean literature. Thus, identifying and applying specific competencies for new graduates in the Korean context will add a level of detail to the current KABONE competencies and enable more effective application of them by educators who are preparing new graduate nurses. While the results of this review can provide valuable information to educational institutions, they can also be used to identify the support needed by graduates when they enter the nursing workforce. Finally, further research should be undertaken on how to collaborate with nursing schools and hospitals to identify opportunities for the educational preparation of a competent new nursing graduate.