Analysis of the evolution of competences in the clinical practice of the nursing degree

Objective: to analyze the student’s progression in the acquisition of specific and transversal competences in relation to the competence dimensions. Method: the cross-sectional descriptive study was carried out in the clinical practice subjects included in the Nursing Degree. We included 323 students and we contemplated the development of competences through an ad-hoc questionnaire with 4 dimensions: delivery and care management, therapeutic communication, professional development and care management. Results: the academic results between the practice of the second and third year showed an improvement in care provision and therapeutic communication skills (Clinical Placements I: 12%-29%; Clinical Placements II: 32%-47%) and worsened in professional development and care management (Clinical Placements I: 44%-38%; Clinical Placements II: 44%-26%). Conclusion: the correlations between these two years were high in all the dimensions analyzed. The evaluation of competence progression in the context of clinical practice in nursing university studies allows us to optimize these practices to the maximum and establish professional profiles with a greater degree of adaptation to the professional future.


Introduction
The Tuning Project establishes the conceptual bases for the creation of what would later be called the European Higher Education Area (EHEA) where there are deep transformations in teaching-learning processes, the role to be played by professors and students, the definition of a credit system, and the quality of academic programs, among others. The EHEA established a unifying system, especially the accreditation of nursing training, allowing the mobility of under and post-graduate students to the different universities (1)(2)(3) .
The EHEA incorporated an important paradigm shift from education directed to knowledge to competency-based learning. These competences tell us the degree of knowledge, know-how and knowhow-to-be within a context of professional practice, a fundamental element to be able to lead the professional activity with optimal levels of quality inside and outside the Spanish State (4)(5) . Therefore, the EHEA appears as a measure to improve the quality of the university system and must be carried out through the establishment of mechanisms and constant processes of evaluation, certification and accreditation of what is done and how it is done (6) .
The reality, both nationally and internationally, in the context of competences in the Degree in Nursing, is the implementation of different educational programs with different structures, levels, durations, certifications, professional and social recognition, and access to studies. This aspect led to the establishment of diverse and heterogeneous educational programs at both European level and in the United States (US) (3)(4)(5) .
A few years after the implementation of the new Royal Decree 1892/2008, the situation has changed and at present the training offers the establishment of more uniform programs in the content of academic programs (7)(8)(9) .
The advantages of learning based on the student's final competences are numerous: greater responsibility in their learning process, the use of active methodology, the design of practical material, the rationalization of resources and greater cohesion in the training curriculum. Competences represent, therefore, the axis par excellence of the teachinglearning process (10)(11)(12) . Following this guideline, the transformation of the studies from Diploma to Degree, during the academic year 2009/2010, forced the incorporation of a set of learning activities and assessment instruments that guarantee the formative curricula of the Degree in Nursing (13) .  (8)(9)(10)14) .
Similarly, there are many organizations that have  (10)(11)(12) . It is worth highlighting those studies that focus on the creation and validation of instruments used to evaluate competence acquisition, such as the Nursing Competency Scale (ECE), the Nurse Competence Scale (NCS) and the Practice Environment Scale-Nursing Work Index (PES-NWI) (15)(16)(17)(18)   of compliance with the objectives set out in each delivery, reflecting at the same time the strategies of each student for inquiry, critical-reflective thinking, rigor and analysis (11,20) .
In the face of this situation there are three major problems: the first refers to the complexity of the competences, the second is related to the difficulty to make evaluations with the different teaching methodologies, and the third refers to the lack of tools that centralize and computerize data to be able to establish in-depth analyzes of the reliability and validity of the instruments used for their measurement (21)(22) .
Several years after the implementation of the Bachelor in Nursing in Spain, we believe it is vital to evaluate competence acquisition within clinical practice subjects, since the existing plurality of agents involved in them and the numerous institutional cultures and professional profiles that participate make it a complex subject to guarantee that all those specific and transversal competences of the degree have been acquired (22)(23)(24) . This complexity can be minimized by establishing instruments that centralize information and rubric systems that unify the criteria and methodological rigor of the different dimensions that make up the learning activities (25)(26)(27)(28) .
The aim was to analyze the student's progression

Results
The ECI students (n = 166) had a mean age of  (Figures 1-2).

Discussion
The findings obtained in respect to the academic results reinforce the evidence consulted, where academic qualifications maintain higher means in the results linked to the clinical practice of both ECI and ECII (29)(30) . This aspect, according to some authors, may be due to the fact that the different agents in charge of evaluating the student find it difficult to penalize low performance in the context of the practice (15)(16)29) .
Other authors consulted establish that the impact of the first contact in the institutional context for the student requires a higher level of adaptation and acceptance, generating a filter that triggers a greater number of failures and dropouts at the beginning of their clinical practice. In our study, the results are similar, and we believe that the reason is the progression and consequently the increase of competence demands between second and third year in the context of the different practice units. Even so, we detected that failure rates are low (ECI 1.36%, ECII 1.25%), meaning that students progressed and passed the different clinical practice subjects, despite their low performance, as confirmed by different authors consulted (30)(31)(32)(33) .
The evidence consulted confirms that students improve in therapeutic communication during the development of clinical practice, and we have not found studies that provide information on a student's evolution in the professional development dimension and care management (26,34) . through different learning activities (11,(19)(20) . making it necessary to reflect on the need to unify the reflective gaze in the practice (23)(24)(25)33) .
According to literature, the importance of the clinical facilitator in the context of clinical practice, as an agent that promotes 'reflection in action', is fundamental to establish cooperative learning and a collaborative approach that fosters integration between the theory and practice of the different agents involved, mainly students (26)(27)(28) .
There are many authors who establish the importance of combining evaluation instruments to unify the triangulation of knowledge, skills and attitudes and thus be able to establish a teaching plan that contemplates not only all the domains of learning, but above all, be able to adapt them to the progression the student makes throughout their degree studies in said triangulation process in their academic training (13) .

Conclusion
The academic results of students in the context of clinical practice maintain high academic means, with a low failure rate in both ECI and ECII. www.eerp.usp.br/rlae