Nursing Students' Self-rated Nurse Professional Competence at the End of an International Collaborative Education Program and Follow-up 1 Year Later : Nurse Educator

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Nursing Students' Self-rated Nurse Professional Competence at the End of an International Collaborative Education Program and Follow-up 1 Year Later

Xu, Lijuan PhD, RN; Lou, Yan RN; Willmer, Mikaela PhD; Engström, Maria PhD, RN

Author Information
Nurse Educator ():10.1097/NNE.0000000000001391, March 13, 2023. | DOI: 10.1097/NNE.0000000000001391


Professional competence refers to the complex integration of knowledge, including professional judgment, skills, values, and attitudes.1 It concerns the ability to use knowledge and skills to successfully perform in a professional role. The trait is progressive and develops over time.2 In nursing education, nurses' professional competence is vital for cultivating nurses who can deliver high-quality, safe care.3 Within Chinese nursing education, lecture-based learning is dominant; yet, this approach has limitations regarding assisting nursing students to develop their competence.4 Researchers have shown an increased interest in active learning strategies in nursing education to promote skills, such as problem-solving, critical thinking, and advanced clinical reasoning, within nursing.5–7 These skills are central in higher education and for nurse professional competence (NPC). International collaboration in nursing education, mostly via student exchange, has shown benefits for self-rated NPC.8,9 Although international collaborative programs and student active learning are encouraged, little is known about them. Therefore, this study compared 2 nursing programs at a university in southeastern China: an international collaborative program, which focused on student active learning strategies and nursing research knowledge and skills, and a traditional lecture-based program.


International Collaborative Degree Programs

Different approaches are used to encourage international collaboration within nursing education, such as student exchange, international degree, and international double-degree programs. Knight specifies that “a double degree program awards 2 individual qualifications at equivalent levels upon completion of the collaborative program requirements established by the two partner institutions.”10(p301) Universities may seek international double-degree program collaborations to attract students, increase internationalization, improve their economic situation, and enhance the quality of their student education.11 In China, international collaborative programs have increased; as of 2023, there were 1246 international collaborative education programs at the undergraduate or graduate level, as approved by the Ministry of Education of the People's Republic of China.12

A study of nursing students' general experiences of international collaboration has revealed many perceived benefits8; however, the study focuses on different types of exchange schemes, where students spend part of their study time abroad. The research that has specifically examined international double-degree programs is sparse and has mainly assessed the organizational level, that is, partner universities. There is less research on the students participating in these programs. Hornberger et al13 found that students who had completed a double-degree program in nursing reported both positive experiences about cultural and language competency and challenges related to cultural and pedagogical differences between 2 participating countries. However, there is scant research on the experiences of students taking part in a double-degree program in which they do not spend part of their study time abroad. The international experience for these students consists of being taught by teachers from a different country using different teaching methods from those that they may be used to.

In 2014, an international double-degree program in nursing began as a collaboration between 2 universities in China and Sweden. The host university (in China) wanted their nursing students to receive 2 bachelor's degrees in nursing (one from their home country and one from Sweden) and to improve the quality of the program, so as to enhance the nursing students' NPC. Furthermore, the host university wanted their nursing students to become more skilled in research methodology, more up-to-date with nursing research, better English speakers, and more experienced in patient-centered care. In the international double-degree program, the host university desired a different pedagogy that focused on student active learning, so as to train the students to critically discuss phenomena; independently identify, formulate, and solve problems; and present and discuss problems in dialogues with groups.

Active learning is a form of student-centered learning that engages students through reading, writing, or discussion activities in class, which often involves teamwork. Students learned to build on preexisting knowledge, reinforce their knowledge, and become better thinkers.14 Active learning also motivates students to advance their critical thinking and clinical reasoning skills.14,15 Active learning includes various strategies, such as problem-based learning (PBL) and collaborative learning. A meta-analysis found that PBL enhanced nursing students' critical thinking,16 whereas another systematic review found that it improved their communication skills.17 A systematic review of collaborative learning revealed improvements in nursing students' ability to achieve learning outcomes, including academic performance as well as communication, problem-solving, and critical thinking skills.18 Another review found that collaborative learning improved nursing students' competency, knowledge, and skills performance.7 In China, collaborative learning has been recently used in several courses to improve students' academic performance, self-efficacy, and core nursing competence.19,20 However, in Chinese nursing education, lecture-based learning that focuses on knowledge transfer remains common.21

In sum, the research on nursing students who are enrolled in international exchange programs has shown promising results for nurse competence; however, there is a lack of studies on nursing students who are enrolled in international collaborative education programs. Increased internationalization in education is called for in several countries; yet, little research has explored the outcomes of this initiative. The purpose of this study was to compare students enrolled in a traditional lecture-based program with those enrolled in an international collaborative program at the end of graduation and 1 year later. The specific aims of this study were to (1) compare nursing students' self-rated NPC and general self-efficacy between the 2 programs at the end of graduation and 1 year later, and (2) examine the changes over time in self-rated NPC and general self-efficacy within each group (ie, the traditional lecture-based program and international collaborative program) and between the 2 groups.



This study used a prospective comparative design. Data were obtained from 2 groups of nursing students in their last semester (time 1 [T1]) and 1 year later (T2) when they worked as registered nurses. The students enrolled in the traditional lecture-based program were labeled as the lecture-based learning group (LBL group); those enrolled in the international collaborative program, which included activities to promote students' active learning, were relabeled as the student-active learning group (SAL group). Because this study's aim was to compare nursing students' self-rated NPC, a pre/posttest design was not possible because the approach in the SAL group started from the first day of the education program.

Participants, Setting, and Procedure

All students (N = 294) enrolled in the 2 nursing programs (SAL and LBL groups) at a university in southeastern China were invited to participate. At T1, 209 participants responded (85/124 from the LBL group, 124/170 from the SAL group). At T2, 69 of 85 participants from the LBL group and 68 of 124 from the SAL group responded and had a valid code (student identification number provided by the university) (Figure). Both groups consisted of students who had graduated in 2018 and 2019. To estimate the sample sizes for the 2 groups, this study followed the recommendation of Polit and Beck22 for when no prior research is available: that is, an α value of .05, power of 0.80, and medium effect size of 0.50. Accordingly, 64 participants per group were required. The study was approved by the authors' university ethical review board.

Flowchart of data collection. SAL indicates student active learning; LBL, lecture-based learning.

Data were collected through a survey platform. A link to the online questionnaire was generated and sent through group and personal WeChat messages (a free messaging and calling app available on iOS, Android, and Windows). For the groups that had graduated in 2019 (T1), the participants received paper-based questionnaires from their teachers. When the participants (T1 and T2) were compared with the dropouts from the survey at T2, they demonstrated significantly higher levels for general self-efficacy, total NPC, and all NPC factors than the dropouts (P < .05). Supplemental Digital Content Table 1 (available at: describes the 2 programs.


To measure professional competence, this study used the Nurse Professional Competence Scale Short-Form Chinese version.23 The NPC Scale was developed on the basis of formal nurse competence requirements24 and has been translated into different languages for use in many countries.25–27 The psychometric properties of the original28 and Chinese versions of the scale,23 such as construct validity and internal consistency, are good. The scale includes 6 factors: nursing care (5 items, α in the present study = .86); value-based nursing care (5 items, α= .90); medical and technical care (6 items, α= .82); care pedagogics (5 items, α= .93); documentation and administration of nursing care (8 items, α= .94); and development, leadership, and organization of nursing care (6 items, α= .92). The α value for the NPC total scale was .98. Participant responses are graded on a 7-point scale (1 = very low degree, 7 = very high degree). To obtain the factor scores, the items are summarized, divided by the highest possible score for the factor, and multiplied by 100. Higher scores (maximum 100) indicates greater NPC. Sample items for NPC are shown in Supplemental Digital Content Table 2 (available at:

The 10-item General Self-Efficacy Scale was used to measure self-efficacy,29 which had an α value of .88 in this study. The scale has good psychometric properties.30,31

Data Analysis

Data were analyzed using IBM SPSS Statistics version 26 (Armonk, New York). Chi-square tests, Mann-Whitney U tests, and related-sample Wilcoxon signed-rank tests were used to compare the data between and within the 2 groups. Statistical significance was set at P < .05.


Participant Characteristics

Most participants were female, all participants worked as registered nurses (T2), and their mean age was 23.9 years. There were significant differences in marital status between the 2 groups (see Supplemental Digital Content Table 3, available at:

NPC and General Self-efficacy

At T1, significantly higher values were found for medical and technical care and general self-efficacy in the SAL group than in the LBL group. One year later, significantly higher values for the SAL group were found for total NPC, value-based nursing care, medical and technical care, documentation and administration of nursing care, and the General Self-Efficacy Scale (Table).

Table. - Comparison of NPC and General Self-efficacy Between the LBL and SAL Groups (N = 137)
Factor LBL (n = 69), Mean (SD) SAL (n = 68), Mean (SD) P Value Between Groupsb
Nursing care
T 1 82.9 (11.8) 84.4 (11.0) .467
T 2 88.9 (8.8) 91.1 (8.1) .211
P value within groupsc .003 <.001
Value-based nursing care
T 1 89.2 (10.3) 90.5 (10.1) .268
T 2 89.4 (9.0) 92.0 (8.7) .046
P value within groups .928 .448
Medical and technical care
T 1 85.2 (10.2) 88.0 (10.2) .040
T 2 89.6 (7.1) 92.4 (7.2) .016
P value within groups .011 .010
Care pedagogics
T 1 88.3 (11.4) 89.6 (10.2) .362
T 2 89.6 (6.8) 91.8 (8.4) .039
P value within groups .598 .231
Documentation and administration of nursing care
T 1 87.0 (10.9) 88.7 (9.8) .251
T 2 89.6 (7.6) 92.2 (7.4) .028
P value within groups .146 .023
Development, leadership, and organization of nursing care
T 1 85.8 (10.3) 88.5 (10.2) .053
T 2 87.8 (7.5) 90.4 (8.9) .053
P value within groups .320 .385
NPC total scale
T 1 86.4 (9.5) 88.3 (9.3) .066
T 2 89.2 (6.8) 91.7 (7.4) .012
P value within groups .064 .018
General self-efficacy
T 1 26.0 (4.7) 28.0 (4.5) .016
T 2 28.3 (6.4) 31.0 (6.7) .021
P value within groups .031 .002
Abbreviations: LBL, lecture-based learning; NPC, nurse professional competence; SAL, student active learning; T, time.
aBold P values indicate significance.
bIndependent-samples Mann-Whitney U test.
cRelated sample Wilcoxon signed-rank test.

Regarding the changes over time, both groups reported statistically significant improvements in nursing care, medical and technical care, and general self-efficacy. Participants in the SAL group also reported statistically significant improvements in the NPC factor documentation and administration of nursing care and total NPC (Table). Regarding the changes over time between the 2 groups, the results were not significant for the NPC total scale, factors (P values ranged from .518 to .991), and general self-efficacy (P = .395).


This is the first study to evaluate the effect of an international collaborative nursing program on nurses' professional competence. Both at graduation and 1 year later, the SAL group had higher scores for medical and technical care and general self-efficacy than the LBL group. Furthermore, 1 year after graduation, the SAL group reported higher scores for total NPC, value-based nursing care, documentation and administration of nursing care, and care pedagogics than the LBL group. Moreover, the SAL group reported improvements in total NPC 3 factors of NPC, and general self-efficacy, whereas the LBL group reported improvements in 2 NPC factors and general self-efficacy.

The finding that the SAL group reported higher competence than the LBL group is similar to that of international student exchange studies. For example, Huffman et al32 reveal that international study experience is beneficial for nursing practice knowledge and professional identity, whereas Nilsson et al9 assert that 1 to 4 months abroad can improve students' NPC. In the current study, the SAL group reported higher scores for medical and technical care at graduation, including aspects such as adequately managing drugs, independently administering prescriptions, questioning unclear instructions/prescriptions, displaying judgment during examination and treatment, and handling medical products in accordance with regulations and safety routines. Shin et al15 found that student active learning in nursing education improves students' clinical performance competency and critical thinking skills; active learning strategies have also been associated with students' improvement in pharmacology knowledge.18,33

At the 1-year follow-up, the SAL group reported higher scores for total NPC, value-based nursing care, medical and technical care, and documentation and administration of nursing care. Value-based nursing care was of interest, as the host university wanted the nursing students to become more experienced in patient-centered care. According to Benner, expert nurses' competence is developed over time through a multitude of experiences.34 To develop professional competence, lifelong learning is essential and plays an important role in ensuring that nurses have up-to-date knowledge on providing better patient care.35 In nursing education, active learning has been identified as an essential characteristic to foster nursing students' lifelong learning.36 In the current study, their use of student active learning may be why the students in the SAL group reported higher NPC scores than those in the LBL group 1 year after graduation.

The T2 results are similar to those of an international nursing program study, which reveals that international study experience that includes a didactic course of transcultural nursing and clinical experience improves nursing students' professional role development after graduation.37 However, the current study's results for the changes over time between the 2 groups were not significant. According to Benner's 5 stages of clinical competence (Novice to Expert theory),34 the current study's participants were in the first stage (novice) at T1 and the second stage (advanced beginner) at T2. Thus, a 1-year follow-up may be too short to detect changes in self-rated NPC over time between the 2 programs, as the participants were still considered as beginners. Therefore, using participants with 3 years of experience in clinical practice may have been better for evaluating the programs' long-term effects.

Students in the international collaborative program reported higher levels of general self-efficacy, both at T1 and T2, than those in the LBL group. This may be due to a difference already present at the beginning of the program; that is, the participants enrolled in the international collaborative program had greater general self-efficacy from the start, or it may be a result of the program. This result is similar to other studies that have found that international experience is beneficial to nursing students' personal growth, independence, and self-confidence and enhances their effectiveness and efficiency when working as nurses.32,37 Moreover, student active learning has been found to be beneficial for students' self-efficacy.38 Regarding the students' NPC scores in the current study, both groups (T1) reported higher values than those of nursing students in Sweden.30


The results indicate that an international collaborative program is beneficial for nursing students' self-rated NPC, as they showed higher scores for 4 of the 6 factors of the NPC total scale. The results could inspire other nursing schools in terms of international collaboration and student active learning. Nursing educators should consider student active learning, such as seminars, group work, and oral presentations, and should encourage students to independently search for knowledge and critically evaluate scientific articles and other texts, so as to support their development of skills and abilities related to lifelong learning.


First, the participants were from only one university, thus limiting the generalizability of the results. Second, the response rate was low, indicating the risk of selection bias. Moreover, the participants self-selected the 2 groups when they enrolled in the 2 programs, which may have affected the results. However, when comparing participant characteristics, only marital status showed a statistically significant difference. Third, this study did not examine academic performance or the reasons for selecting the programs. Moreover, this study could not separate the effects of the international collaborative program and the active learning approach. Meanwhile, the study strengths include the prospective design and use of validated scales with α values of more than .70. The study outcome concerned self-reported competence, so the future research could involve objective tests. Following Benner's Novice to Expert theory, the programs' long-term effects could be examined in a follow-up of 3 to 5 years after graduation.


Students in the international collaborative program, which focused on student active learning, rated their competence as higher than those in the LBL group, both in the last semester and 1 year after graduation. However, although they had higher scores for the NPC Scale, T1 (1 factor), and T2 (several factors and total score), and improved in more factors over time, the interaction effect (time × group) for the outcome variables was not significant. Based on the results, this study concludes that the SAL group had higher scores for the NPC values. However, this study cannot conclude that the SAL group improved more than the LBL group over time, that is, from the end of the last semester to 1 year after graduation. This might be because an interaction effect requires more time; that is, student active learning during education and the presumed skills needed for lifelong learning do not make a difference during the first year after graduation as they students are still considered as beginners.


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double degree; international collaborative program; nurse competence; nursing students; self-efficacy

Supplemental Digital Content

© 2023 The Authors. Published by Wolters Kluwer Health, Inc.