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Senior nurse involvement in project development : how best to utilize the skills of senior nurses in… Riedel, Jane Ada 2009

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SENIOR NURSE INVOLVEMENT IN PROJECT DEVELOPMENT: HOW BEST TO UTILIZE THE SKILLS OF SENIOR NURSES iN THE WORKPLACE  by  Jane Ada Riedel  B.N., University of Calgary, 2004  A THESIS SUBMITTED iN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE  in  The Faculty of Graduate Studies  (Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  April 2009  © Jane Ada Riedel, 2009  ABSTRACT Encouraging senior nurse participation in project development aimed at transferring knowledge from older to younger generations may increase retention of nurses nearing retirement and attract new nurses looking for institutions that offer innovative education and support programs. Senior nurse involvement in project work is not without challenges. Coping with the current nursing shortage and the conflicts of a multi-generational workforce make the design and implementation of senior nurse projects complex. With funding support from the BC Nurses Bargaining Association 12 focus groups were conducted with nurses 55 years of age and older to assess what senior nurses are currently doing and what resources they would need to formalize their project ideas in order to pass on their expertise to others. Participants generated a high level of interest and a number of ideas; such as mentoring programs and strategies to enhance quality and safety in the workplace. Focus group participants also identified current practice facilitators and barriers; such as the need for back-fill to cover time away for project development and implementation. Based on focus group results, this thesis will discuss focus group findings and provide insight on how senior nurses are involved and what potential exists for future development of projects. Senior nurse project work may facilitate the transfer of knowledge from older to younger nurses and increase retention of senior and millennial nurses.  11  TABLE OF CONTENTS Abstract  .  ii  Table of Contents  iii  Acknowledgements  iv  Dedication  V  1 Introduction  1  1.1 1.2 1.3 1.4 1.5  Overview of the Research Problem Research Question Definitions Significance Outline for Thesis  2 Literature Review 2.1 Introduction 2.2 Nursing Shortage 2.2.1 Background 2.2 Role for Senior Nurses 2.2.3 Blending of Experiences 2.3 Mentoring 2.3.1 Defining Mentoring 2.3.2 Informal Mentorship 2.3.3 Mentor and Mentee Pairing 2.3.4 Requirements to Be a Mentor 2.3.5 Structure of a Mentorship Program 2.3.6 Potential Benefits of Mentoring Programs 2.4 Quality Practice Environment 2.4.1 Creating a Quality Practice Environment 2.4.2 Safe Nursing Practice 2.4.3 Competence Development 2.5 Conclusions 3 Research Design and Methods 3.1 3.2 3.3 3.4 3.5 3.6  Research Approach and Rationale Ethical Issues Participants Setting Study Procedures Data Collection  1 4 4 5 6 9 9 10 10 11 13 14 14 15 16 17 18 19 20 20 21 22 23 25 25 25 26 27 28 28 111  3.7 Data Analysis 3.8 Data Transformation 3.9 Measures: Reliability and Validity 4 Results 4.1 Introduction 4.2 Question 1 4.2.1 Working with Peers 4.2.2 Resources 4.2.3 Facilitation of Change 4.3 Question 2 4.3.1 Nursing Work Life 4.3.2 Attitude 4.3.3 Knowledge and Skills 4.3.4 Communication 4.4 Question 3 4.4.1 Working with Peers 4.4.2 Resources 4.4.3 Facilitation of Change 4.5 Question 4 4.5.1 Logistics 4.5.2 Support 4.5.3 Education and Training 4.6 Question 5 4.6.1 Blocks of time 4.6.2 Flexible Scheduling 4.6.3 More Time 4.6.4 Less Time 4.7 Question 6 4.7.1 Logistics 4.7.2 Support 4.7.3 Education and Training 4.8 Conclusion 5 Discussion 5.1 Introduction 5.2 The Changing Face of Nursing 5.2.1 Hospital-based Nursing Education 5.2.2 University-based Nursing Education 5.2.3 Recruiting New Nurses 5.3 Generational Gap and Workplace Conflict 5.3.1 Generational Gap 5.3.2 Organizational Commitment 5.3.3 Disunity Among Nurses  .29 31 32 37 37 37 37 40 41 43 43 46 48 49 51 51 53 54 55 56 57 58 59 59 60 60 61 61 61 63 64 65 66 66 66 66 68 69 71 71 73 74 iv  5.3.4 The Role of Senior Nurses in Closing the Generational Gap 5.4 Mentoring 5.4.1 Focus Group Responses 5.4.2 Orienting aNew Nurse 5.4.3 Senior Nurses as Mentors 5.4.4 Support for Mentor and Mentee 5.4.5 Time to Mentor 5.4.6 Finding a Mentorship Fit 5.4.7 Positives of Mentorship 5.5 Project Resources 5.5.1 Time 5.5.2 Manager Support 5.5.3 Support of Peers 5.6 Innovation and Change 5.6.1 Senior Nurse Involvement in Change 5.6.2 Adapting Other Ideas 5.6.3 Finding Innovative Ideas 5.6.4 Senior Nurses as Early Adopters 5.7 Study Limitations 5.7.1 Number of Participants 5.7.2 Focus Group Questions 5.7.3 Focus Group Method 5.7.4 Presence of Managers 5.7.5 Data Collection and Analysis 5.7.6 Responses of Senior Nurses 5.8 Recommendations 5.9 Conclusion  76 79 79 80 81 83 84 84 85 87 87 88 88 89 89 90 91 93 94 94 95 95 96 97 98 99 101  References  103  Appendices Appendix A—Educator Pathway Project Appendix B—Recruitment Poster Appendix C—Focus Group Questions Appendix D—Consent Form Appendix E—Data Charts Appendix F—Ethics Approval  115 115 116 117 118 121 124  v  ACKNOWLEDGEMENTS To those involved in the Educator Pathway Project, including those project partners directly involved in my thesis; University of British Columbia, Vancouver Coastal Health, Fraser Health, and the BC Nurse’s Union, who have made it possible for senior nurses to become increasingly involved in nursing education at all levels. I would like to thank the British Columbia Nurses Union for recognizing the importance of input from frontline senior nurses and for providing financial support for this project. Special thanks to the senior nurses who took part in the focus groups as part of this study. These nurses were generous with both their time and their willingness to share their expertise. Without their participation, this study would not have been possible. I would like to take this opportunity to thank my entire thesis committee; Maura MacPhee, Alison Phinney, Linda Frost, and Patricia Wejr, whose input and ideas were both thoughtful and inspiring. Special acknowledgement needs to be given to my thesis committee chair, Maura MacPhee, who showed enthusiasm and understanding as she guided me through the process of writing a thesis. Maura took the time to answer my endless questions, gave critical feedback, and helped me to be able to think outside the box. I would also like to acknowledge Michael Davis, a consultant on my thesis, who conducted the focus groups with me and assisted greatly with the analysis of the data. I would also like to acknowledge my family who have been endlessly supportive through this degree both financially and emotionally. A special thanks to be my cats for their companionship and devotion. A great deal of gratitude to my husband for always believing in me and for giving me nothing but support and encouragement in everything I do.  vi  To nurses who have inspired my passion and vision through leadership, intelligence, and a commitment to excellence everyday.  vii  1 INTRODUCTION 1.1 Overview of the Research Problem In Canada the nursing workforce has increased in size by approximately two percent a year over the last five years due to efforts of most provinces to increase nursing seats in colleges and universities (Canadian Institute for Health Information, 2008). Despite this increase in the workforce, there is a critical shortage of nurses to fill the demands of Canadians for healthcare. Canada’s population is aging. In 2006, 13.7% of the total population was over the age of 65—this is up from only 7.7% of the population in 1966 (Statistics Canada, 2007). This rapidly growing age group is in need of services from healthcare at a rate that the system is not currently prepared to handle. Canada’s nursing workforce is also aging. The current average age of a nurse is 45.7 years, and is increasing (Canadian Institute for Health Information, 2008). In 2007 it was documented that nurses who are considered part of the baby boomer generation, which are those aged 43-61, now make up 54% of the total nursing workforce (Canadian Institute for Health Information, 2008). The large cohort of the current nursing workforce that is approaching retirement age will place further stress on the healthcare system (Cyr, 2005). The tremendous stress associated with working in today’s healthcare system along with the physical demands leave many nurses wanting to retire at the first available option (Cyr, 2005) Senior nursing staff often is not given the acknowledgement or flexibility that may be necessary to keep them from retiring before they need to (Cyr, 2005). Having experienced nurses retire later could have enormous benefits to the healthcare system and finding ways to keep this group interested and motivated to work has become a focus in the literature in  1  recent years (Cyr, 2005). Although retaining senior nurses in the workforce for longer periods of time may be perceived as a simple cure for the nursing shortage, several studies have shown that strategies aimed at retaining nurses beyond initial retirement age have proven to be largely ineffective (Buerhaus, 2002; Cohen, 2006; Cooper, 2003). Therefore alternative strategies that are aimed at utilizing this population for the benefit of the next generation of nurses are highly sought after. By offering senior nurses the opportunity to share their experiences, the transfer of skills and knowledge may be possible in order to increase the competency of newer nurses and lessen the gap between those who are novice and experienced (Butler & Felts, 2006). The Educator Pathway Project (EPP) is a collaborative pilot project between the University of British Columbia (UBC), the University of Victoria (UVic), Vancouver Coastal Health Authority (VCHA), Fraser Health Authority (FHA), the Nurse’s Bargaining Association (NBA), and government agencies including Human Resources and Social Development Canada (HRSDC), the British Columbia Ministry of Health, and British Columbia Ministry of Advanced Education (Appendix A). One of its purposes is designed to develop nurses’ knowledge and competency to become educators. The shortage of nurses expands to all areas of the profession including a need for more nurse educators (Buerhaus, Staiger, & Auerbach, 2000). Inside of this larger umbrella project, the need arose to identif’ means to utilize skills that already exist inside of organizations. It was noted during this process that other provinces, such as Ontario had successes in utilizing senior nursing staff for project work including mentoring (Bournes, 2006). The Senior Nurse Mentor Steering Committee that was formed to oversee this part of the EPP felt that many senior nurses already mentor on  2  an informal basis and that some may wish to have formal time to devote to this important role. It was the recognized commitment by senior nurses to mentorship along with the literature about Ontario’s success that helped the steering committee to select the title of Senior Nurse Mentor project for this program. It was also acknowledged by the Senior Nurse Mentor Steering Committee that other senior nurses may not want to fill a mentoring role but could create projects that would benefit their workplaces, such as developing resource materials. The Steering Committee recognized that gaining an understanding of how senior nurses view their roles in their workplaces, especially in reference to their ability to influence learning, was a necessary part of the larger Senior Nurse Mentor Project and formed the basis of the research question in this study. By creating an environment for senior staff nurses to contribute under the Senior Nurse Mentor Project, it was identified that it may be possible to have this group of nurses share the knowledge and skills they have accumulated over the years here in British Columbia. This project was supported by the above mentioned partners and by the British Columbia Nurses Union (BCNU). The Senior Nurse Mentor Project will provide 216 supernunmiery hours, hours to work where the senior nurse is not counted in the baseline number of nurses needed for patient assignments for that shift, for senior nurses to work on projects that have approval from a steering committee comprised of members from the EPP collaboration. Providing project time to senior nurses showcases the value identified by nursing leadership of the contributions of senior nurses and the valuable role senior nurses are able to play in improving the healthcare system.  3  1.2 Research Question From the information that would be gathered during the focus groups, an understanding of how senior nurses could be involved in projects that would affect their workplaces directly was desired. In particular, the ability of senior nurses to influence they way in which nurses were able to obtain education in the workplace. This led to the formation of the research question: How do senior registered nurses perceive their potential role in contributing to the learning environment of their workplace? 1.3 Definitions The following definitions are provided for key concepts within this thesis. These defmitions are taken primarily from the nursing education literature. Competence: For the purpose of this thesis competence will be defmed as a specific set of skills that require knowledge and judgment that are performed as part of a nurse’s role. In other words the nurse must be able to complete these skills after determining they are appropriate in order to care for the patients (Tabari Khomeiran, Yekta, Kiger, & Ahmadi, 2006). Generational Gap: There is a wide range of ages working in nursing today. There are many different generations employed together that may not think, act, or believe in the same things, and these presumed differences are thought to constitute a generational gap (Clausing, Kurtz, Prendeville & Walt, 2003). Mentee: This term refers to a new nurse who is paired with a senior nurse in order to gain experience and knowledge with support (Milner & Bossers, 2004). Mentor: The most commonly used defmitions in the nursing literature refers to a mentor as an experienced nurse who has agreed to work with a newer nurse in order to pass on  4  knowledge, skills, and attitudes (Yonge, Billay, Myrick & Luhanga, 2007; Bryson, 2005; Dyer, 2008). There are many varying opinions on the exact meaning of mentor in the nursing literature. Being a mentor is often thought to mean a commitment to a long-term relationship and that it has a greater range of depth than simply passing on knowledge and skills (Funderburk, 2008). Fawcett (2002) discusses how mentors often not only exhibit the normal attributes of patience, enthusiasm, and knowledge, but are also able to give advice on career paths for new nurses and serve as a confidant. Orientation: This refers to the period of time after a nurse is hired until they are prepared to participate fully as a staff member. During this time the new nurse is building knowledge, skills, and abilities usually with the support of a more experienced nurse. Typically this is a one to three month period (Murrells, Robinson & Griffiths, 2008). Quality Practice Environment: This term describes ideal conditions on a nursing unit where professional practice is able to occur at a high standard due to the procedures, communication, and education that are in place (College of Registered Nurses of British Columbia, 2005). Senior Nurse: The term senior nurse for the purpose of this thesis refers to nurses who are over the age of 55 and nearing retirement. 1.4 Significance Considering the large number of nurses nearing retirement (Hart, 2007), it is critical to fmd ways to engage this group that has mutual benefits for the nurse and the workforce. For many nurses who have worked for years in the profession of nursing, the feeling of wanting the work they have done to matter and for nursing to remain an important piece of healthcare for generations to come is evident in the literature (Cohen,  5  2006). As a nurse educator who is interested in different strategies available to engage direct care nurses in discussions of how they can contribute to their practice environments, I volunteered to assist with this project. This thesis work gave me the opportunity to learn more about the nursing shortage from an educator perspective, and to try out new techniques, such as conducting focus groups and analyzing data from focus groups. I also believe that from a human resources perspective, senior nurses are a valuable asset and we have to find ways to engage them before they leave the profession. Senior nurses have lived through many changes to the profession and are able to see how the financial constraints and constant pressure of working understaffed is affecting every aspect of health care. It is now becoming imperative that nurses choose to stay as active members of the system. With engagement and understanding of the global issues that are contributing to the moral distress of nurses, today’s senior nurses may be able to influence changes that will have positive outcomes for generations to come. It is anticipated that the body of research described in this thesis will inform institutions as to how senior nurses feel they can be best utilized prior to retirement to aid in the professional development and maturation of newer nurses. 1.5 Outline for Thesis Chapter Two provides a literature review of the major topics discussed in this thesis and was derived from the key findings in the results section. Included in this review is a synopsis of the literature on the current nursing shortage and its causes. As mentoring was a key finding in the results of this thesis, a review of how this role could be established and maintained is discussed. The focus of the research question for this thesis is how senior nurses impact the learning environment of their workplaces. Therefore a  6  discussion on creating a quality practice environment and a culture of safety will conclude this chapter. Chapter Three includes a detailed description of the methods used to recruit focus group participants, conduct the focus groups, and analyze the data. These focus groups were conducted in order to identify the kinds of projects senior nurses might have interest in completing. The focus group methods allowed the senior nurses to voice their opinions about how they would want to share their knowledge; what they wanted to pass on to the next generation of nurses; and the types of resources they felt they required to make their ideas reality. The ideas generated in these focus groups were informative for subsequent phases of the Senior Nurse Mentor Project, which included formal project applications, a committee selection process, and the eventual implementation of senior nurse projects. Content analysis was used in this study to analyze the data from the focus group sessions using thematic groupings. Chapter Four focuses on the results of the focus groups conducted with senior nurses and their managers. The results from the six focus group questions are discussed in detail with quotes taken verbatim from the sessions to support the thematic analysis groupings. Results show an overwhelming interest from the senior nurses to mentor new nurses. They see themselves doing this in the traditional sense of one-on-one mentoring and in a more dynamic fashion such as creating long lasting resources or providing education sessions to larger groups of nurses. Results also focused on a need for resources such as time, manager support, peer support, and backfill or replaced staff nurse time. The final chapter discusses the potential roles identified by the focus group participants and how they view themselves as able to contribute to their workplaces,  7  especially in terms of providing education and mentoring to younger staff. Topics examined in this chapter include the nursing shortage, generational gap and workplace conflict, mentoring, resources, and innovation and change. Each of these discussion topics highlights key findings from the results of this study. The participants in this study were aware of the challenges in their work environments and they were able to express their concerns and commitment to correcting the problems. This chapter concludes with a discussion on study limitations and recommendations for future research.  8  2 LITERATURE REVIEW 2.1 Introduction Literature reviews were conducted on the three main ideas that will be presented in this thesis. The first topic, the nursing shortage examines how the large of nurses nearing retirement is impacting the workforce. Reasons contributing to the nursing shortages in Canada and worldwide will also be discussed. The next section on mentoring serves as a guide to understanding its valuable role in the retention and recruitment of nursing staff. A discussion on how mentoring is currently being used in nursing and what logistical challenges exist will be presented. There will also be a discussion on how interpersonal relationships and unit climate can impact mentoring. Finally the last section focuses on quality practice environments and the senior nurses’ role in creating these in their workplaces. Issues related to patient safety and competency development of nurses will be discussed. Literature review was completed using data bases PubMed, CINAHL, and Google Scholar. Key words used to identify literature for the nursing shortage section included, nursing, nursing shortage, retention, recruitment, aging workforce, and Canada. Key words used to identify literature for the mentoring section included mentoring, nursing, new graduate nurses, mentors, mentorship, mentee, retention, nursing shortage, recruitment, leadership, orientation, professional practice, competency, preceptoring, and preceptor. Key words used to identify literature for the quality practice environment section included nursing, nurse development, professional practice, practice environment, competence development, leadership, nursing education, nursing and working conditions, communication, and communication skills. The focus of the literature review was  9  original research articles but also included were reviews, practice guidelines, and editorials. 2.2 Nursing Shortage 2.2.1 Background Chronic nursing shortages are a major problem both in Canada and worldwide (Cooper, 2003; Auerbach, Buerhaus, & Staiger, 2000; Bally, 2007). As a larger percentage of the current workforce reaches the age of retirement, there will be an increasing number of unfilled nursing positions in the near future (O’Brien-Pallas, Duffield, & Alksnis, 2004; Robert Wood Johnson Foundation, 2006). The baby boomer generation is leading the retirement drive, with the average age of nurses increasing from 44.5 years in 2003 to 45.1 years in 2007 (Canadian Institute for Health Information, 2008). These statistics suggest that rapid improvement is unlikely. In addition, there appears to be a lack of willingness from nurses who have reached the allowed age for retirement, to remain in the workforce, as they choose instead to take their full retirement at the first available opportunity (Cooper, 2003). The nursing shortage problem is multifaceted. Traditionally, young women have made up the large majority of the nursing workforce. An increase in alternative employment opportunities for women is creating absences in the nursing field that have been difficult to fill (Buerhaus, et al., 2000). In addition, many provinces in Canada have experienced significant reductions in healthcare and education budgets over the last two decades (Cooper, 2003). This has occurred at a time when the need to increase the amount of nurses graduating is essential to keep up with the demand. Although efforts have been made to increase the number of seats in nursing schools and to lower attrition  10  rates of students, the financial struggles of many institutions continues to provide challenges (Canadian Association of Schools of Nursing, 2003). In British Columbia, there has been an increased number of nursing seats created since 2003 but a waiting list for students to get into nursing school still exists (Canadian Association of Schools of Nursing, 2008). It is estimated that in order to correct the nursing shortage, 12000 new nurses a year will be needed in Canada (Canadian Nursing Association, 2002). In 2007, only 6800 nurses graduated from nursing programs in Canada and only 1100 of these graduates were in British Columbia (Canadian Association of Schools of Nursing, 2008). This highlights how current numbers will not meet the expected need in the years to come. 2.2.2 Role for Senior Nurses The experience possessed by senior nurses is a valuable resource. As more of these nurses are lost to retirement, it is critical that their ability to share their experiences with newer nurses be utilized to its fullest potential. It has been documented in the United States that nurses retire earlier than people in other professions (Auerbach, et al., 2000). Finding ways to retain these senior nurses in the workforce or to have them actively participate in programs that allow for successful transfer of knowledge and skills to newer nurses may have significant benefits on the workplace environment (Robert Wood Johnson Foundation, 2006). It has been demonstrated that novice nurses who can gain valuable knowledge and support from their experienced coworkers are less likely to leave the profession (Cooper, 2003), thereby adding to the importance of senior nurse involvement.  11  As nurses age, the fast pace and demanding workload of today’s overcrowded hospitals begins to take a toll. With high rates of physical injuries such as chronic back pain, and other issues related to aging, many nurses are unable to continue with the demands of shift work once they reach the age of retirement (Cooper, 2003). Many strategies have been developed to keep nurses who are eligible for retirement at the bedside. Having the option of taking on a different role in their workplace, such as the role of the mentor for newly hired staff, could be a unique way to encourage senior nurses to stay in the workplace and remain involved (Mion, Hazel & Cap, 2006). Other programs, including working less than full time hours for full time wages on shifts that are difficult to fill such as weekends, or the creation of rotations that have less night shifts and more day shifts could be potential retention strategies for senior nurses (Buerhaus, et al. 2000). Mion, et al. (2006) conducted focus groups with senior nurses nearing retirement to find out how to keep them from retiring. They generated at list of ideas including expanded roles for senior staff, such as the role of discharge nurse. This role includes the review of teaching materials with patients and making follow-up arrangements. Other ideas included the provision of equipment that is lighter and more mobile, and work environments with ergonomic designs to decrease body strain. Alternatively, nurses in this study expressed interest in continuing their work at the hospital in a volunteer format, either with patients or as mentors for new graduate nurses (Mion, et al., 2006). Although volunteer work that is directly involved in nursing education and patient care may be problematic in Canada due to the unionized system of nursing employment, the concept  12  presented in the Mion et al. (2006) article does highlight that senior nurses may continue to show commitment to the profession even after they have retired. 2.2.3 Blending of Experiences An additional issue that may affect both rates of retirement of senior nurses and retention of younger, newer nurses is a perceived generational gap or “disunity” (Neal, 2003, p. 22) in the nursing profession. Evidence suggests that both groups can become frustrated with each other, especially as newer nurses try to gain experience and advance their careers (Neal, 2003). These feelings of frustration can be borne out of a perceived lack of commitment from younger nurses to the profession (Neal, 2003). In decades past, nursing training occurred primarily in the hospital, with nursing students living and working together in this setting. The focus of education was on skill development, with practical, hands-on training being the norm. With nursing education moving from the hospital to college or university, some senior nurses have expressed a sense that newer nurses lack this sense of commitment and camaraderie to both the profession and their colleagues (Neal, 2003). Nurses in Neal’s (2003) study felt that the decrease in clinical hours and responsibilities that has come with the university-based programs has led to less ability for nurses to find a connection with.a hospital since they do not receive education in one location, but often train in many different hospitals and settings (Neal, 2003). The sense of disunity that exists between senior and newer nurses may exacerbate the nursing shortage by cultivating a less inviting workplace. Finding ways to break the barriers that exist between senior nurses and novice nurses could therefore significantly benefit retention of different generations and recruitment of younger nurses (Latham, Hogan, & Ringi, 2008).  13  2.3 Mentoring 2.3.1 Defining Mentoring The concept of mentoring has been examined by several researchers as a method for recruiting and retaining newer nurses (Andrews & Wallis, 1999; Barton, Goudy, Hawthorne, 2005; Bryson, 2005; Cohen, 2006). Despite this focus in the current nursing literature there remains confusion at the clinical level about the differences between mentoring and preceptoring. The participants of this study were not clear on the differences between these two terms and often used them interchangeably. Preceptor programs were created to assist new graduate nurses to become comfortable in their new work environments, typically ending after a pre-determined orientation period. Kanaskie (2006) defines preceptor as, “(someone who) is generally assigned for a set period of time to assist a new employee to orient to ajob or new role. This teaching role ends when the novice is able to perform independently (p. 248).” These preceptor programs, however, are different from mentoring. In fact, the definition of mentoring versus preceptoring has been a topic of debate in the nursing literature. Yonge, Billay, Myrick & Luhanga (2007) summarized definitions and the differences between mentoring and preceptoring focusing on the importance of establishing clear definitions for each term in order to avoid overlap and misuse of resources when organizing programs. Kanaskie (2006) differentiated between a preceptor and a mentor by saying that a preceptor has the role of educator, with the focus being on the teaching relationship, and the mentor is focused on a broader scope that is longer in duration.  14  Mentoring will be the term discussed in this thesis. A definition for mentoring, for the purpose of this thesis, can be found in Chapter 1. Mentoring includes a voluntary relationship between the mentor and mentee, where the mentor acts as a source of knowledge and guidance (Hurst & Koplin-Baucum, 2003). The mentor assists the mentee to reach their learning goals. By taking the time to ensure that the new nurse is transitioning into the workplace, the mentor can identify problems early and intervene to ensure the new nurse feels supported and valued (Canadian Nursing Association, 2004) (Bally, 2007). 2.3.2 Informal Mentorship Research on mentoring has focused on what can be measured and the ability to show improvements based on statistics—typically formal mentorship programs. These statistics may outweigh the interest by researchers to understand more thoroughly the impact of senior nurses’ informal mentorship roles. Nurses who are experienced are often asked for advice on patient care or for assistance with skills by younger nurses. The passing on of information and skills is very much a part of the nursing culture (Tourigny & Pulich, 2005). In the Mion et al., (2006) article, senior nurses were asked what types of roles they would be able to fill other than standard beside care. Four focus groups were conducted, three with nurses aged 46-73 and one with nurses aged 22-29, to determine nurses’ perceptions of each other and their work environments. Discussion in the focus group focused on the importance of older nurses in the workforce, generational differences, roles the older nurse could fill, and ways to support the older nurses. The article identifies initiatives the institution was willing to adopt such as utilizing senior nurses as discharge nurses or as trainers for a program that teaches volunteers how to  15  assist with patient care. The senior nurses in Mion’s (2006) study were not asked what they were already doing on an informal basis to support their workplaces. They also did not have input after the initial focus groups on which initiatives were tried or adopted (Mion et al., 2006). Having formal programs to allow time for proper mentoring relationships to be formed and for both mentor and mentee to see that the institution understands the value of these relationships is important. Tourigny & Pulich (2005) completed a comparative analysis of informal and formal mentoring from the current nursing literature. The advantages of formal mentoring identified were greater organizational commitment and career planning for the mentee. Disadvantages of formal mentoring included the difficulties of mentor/mentee matching and the need for roles to be rigidly defmed. The advantages of informal mentoring included feedback delivery to the mentee and easier integration into the workplace for the mentee. Disadvantages of informal mentoring were identified as an increase in conflict between management and nursing staff, a lack of education planning for the mentee, and no recognition for the work of mentors (Tourinay & Pulich, 2005). 2.3.3 Mentor and Mentee Pairing Mentoring needs to be performed by someone the mentee respects and trusts (Fawcett, 2002; Moseley & Davies, 2007; Grindel, 2003). This calls into question the best way for a mentor/mentee pairing to be created. In many cases the preceptorship relationship develops naturally into an informal mentorship (Kanaskie, 2006). In other instances pairings are made or assigned as part of formal mentorship programs (Leners, Wilson, Connor, & Fenton, 2006; Funderburk, 2008). A formal mentorship program  16  requires two critical aspects, a suitable pool of senior nurses to draw upon, and a successful method of matching these nurses with their mentees. This is highlighted by Grindel (2003) who discussed the importance of matching newly hired nurses with appropriate mentors. For a newer nurse, the process of finding a mentor can lead to inappropriate matching or no matching at all. Therefore, institutional guidance may be required for newer nurses to decide what their learning needs are, how they best learn, and who can best match them (Wilson, 1998). 2.3.4 Requirements to Be a Mentor  Being a successful mentor requires many skills and attributes. Patience, enthusiasm, knowledge, a sense of humor, and respect has been identified as important mentor traits (Fawcett, 2002). It is also critical that the mentor be experienced in the area of nursing, and confident in their ability to share their knowledge and skills (McKinley, 2004) although there is no consensus on the amount of nursing experience needed to be a mentor. Bryson (2005) discussed how the mentor should be an expert in their field and applied Benner’ s stages of clinical competence (Benner, 1984) to define what constitutes an expert. According to this definition, the expert nurse is someone who has an enormous amount of experience and who can understand situations rapidly with ease (Beriner, 1984). Although Benner failed to defme the experience in terms of a quantified amount of time, it is often assumed that in order to have had the time to gain the necessary experience to be considered an expert, the nurse will be older. Although the average age of the new nurse in Canada is increasing (Canadian Association of Schools of Nursing, 2008), this still means that often nurses are older in terms of age than the new graduate nurses they are asked to mentor (Greene, 2002). The concept of generational  17  gap, as mentioned previously in this chapter, can have a large influence on communication and how work is approached, causing conflict between the mentor and mentee (Kanaskie, 2006). Although a formal mentorship program offers a chance for nurses of different generations to get to know each other and to find ways to work together the generational gap must also be considered when pairing senior nurses with new graduate nurses (Funderburk, 2008). If values are too different between the mentor and the mentee, conflict may result. Mentoring programs require a sufficient pooi of potential mentors. By limiting that pool exclusively to senior nurses, the possibility exists that insufficient numbers of mentors exist to fill the requirements of the unit (Funderburk, 2008). Hospitals need to decide how much experience is necessary for nurses to successfully mentor. Management must decide the number of years worked versus other factors, such as educational background, involvement in hospital work such as committees, and attitude or personality. Years worked in an institution may not be the only qualifring factor for selecting a nurse to be a mentor and may not guarantee success (Kanaskie, 2006). 2.3.5 Structure of a Mentorship Program A successful mentoring program requires organizational support such as time for the mentor and mentee to meet on a regular basis. Education should be provided for both mentors and mentees that focuses on communication and to ensure that clear expectations about the relationship are known upfront (Latham, et al. 2008). Poor treatment of newer nurses by senior nurses has been identified as an ongoing problem. It has been identified that if senior nurses are unhappy, and under constant work-related stress they may not present the unit in a way that is welcoming or  18  supportive (Daiski, 2004). An unsupportive work environment does not allow for easy retention of nursing staff who do not want to be subjected to abuse by their coworkers (Latham, et al. 2008; Daiski, 2004; Dellasega, 2009). The bullying or horizontal violence that is happening in many workplaces today may be diminished by a mentoring program that allows for new nurses and senior nurses to come together for open communication (Latham, et al. 2008). Also, the role of mentor is often regarded highly by senior nurses and has a sense of pride attached to it that could also help reduce abuse (Latham, et al. 2008). Education of mentors about the culture of the unit they work on, as well as the struggles a new person faces when coming to work, may allow for a more productive mentoring experience (Bryson, 2005). 2.3.6 Potential Benefits of Mentorship Programs  With fewer nurses to choose from, recruiting and retaining new graduate nurses is necessary for hospitals to have enough staff (Funderburk, 2008). Although many hospitals have created an orientation program for the first one to three months of employment, many new nurses are leaving the nursing profession within their first year (North, Johnson, Knotts & Whelan, 2006). The cost factor of providing orientation to new nurses is enormous (North, et al. 2006; Barton, et al. 2005; Neuhauser, 2002), and more concerning is the lack of replacements for the newer nurses who are leaving (Funderburk, 2008). Finding ways to assist new nurses beyond the orientation phase and through their first year on the job is an apparent necessity. Many studies have indicated that mentoring has the ability to fill the gap between orientation and the remainder of the first year of employment (Kanaskie, 2006; Funderburk, 2008; Dyer, 2008; Bryson, 2005). Mentoring can provide newer nurses with an opportunity to discuss learning plans and  19  share concerns with aspects of the job, such as skill development and communication (Funderburk, 2008). Mentoring can therefore have a significant positive impact on creating work environments that are cohesive and functional, thus increasing the likelthood that new graduate nurses will want to stay (Bryson, 2005). In the formative years of practice, which is often considered the first one to two years, new nurses will learn communication skills, problems solving skills, and critical thinking skills that will be used throughout their careers (Hom, 2003). Having the ability to meet with another nurse on a regular basis who can provide necessary coaching and encouragement can help a new nurse to see nursing as a challenging profession in which they can make a difference (Horn, 2003). 2.4 Quality Practice Environment 2.4.1 Creating a Quality Practice Environment The creation of a quality practice environment requires several key aspects including workload management, competent and well-prepared nurse leaders, control over nursing practice, opportunities for continuing professional development, and organizational support (CRNBC, 2005). Contribution made by senior nurses towards any of the abovementioned categories should be considered an important part of building a quality practice environments. A quality practice environment can only be created when the working conditions on a unit are satisfactory (Tabari-Khomeiran, Yekta, Kiger, & Abmadi, 2006). This includes a communication system between staff members that is clear and respectful as well as frequent and clear communication from management. A quality practice environment also requires that management provide a clear and  20  understandable vision for the unit that meets the needs of both the nurses and their patients (LaMar, 2008). 2.4.2 Safe Nursing Practice Feeling comfortable in their skills and abilities is an important aspect of any professional’s work. Having opportunities to attend education sessions and increase knowledge is also a vital part of creating a quality practice environment (Grab, 2001). This on-going education is necessary to competently care for patients. Patient safety is a major concern for all hospitals. When errors occur, ensuing investigations will look to identify the root causes of the problem (Pronovost, Weast, Rosenstein, Sexton, Holzmueller, Paine, et a!. 2005). Sometimes included in this analysis are the systems of communication, knowledge translation, evaluation of current best practices, and standards of care (Reason, 2000). Provonost et a!. (2005) acknowledges that practice environments should strive for the provision of standardized care to all patients with similar injuries and illnesses, newest technology, and best practice evidence. There needs to be a commitment from the staff to report incidents and to create a culture of safety (Pronovost, et al. 2005). The creation of a culture of safety and a quality practice environment are things that senior nurses can help to achieve and sustain in workplaces. Through involvement in mentoring or education programs, senior nurses can use their influence to assist newer nurses to learn safe, effective, evidence-based care (Santucci, 2004). Senior nurses can also assist with passing on the attitudes and compassion that are necessary to create a quality practice environment. Although typically not quantifiable, it is equally important to note the major role of caring and emotional support that nurses offer to their patients  21  (Tabari-Khomeiran, et al. 2006) and how these activities influence the practice environment of a unit. If caring is considered a highly valued activity in the unit, newer nurses who are exposed to this practice are more likely to adopt it as part of patient care (LaMar, 2008). Senior nurses can influence the creation of workplace that meets the needs of staff and patients (LaMar, 2008). 2.4.3 Competence Development Competence development is identified as being of key importance to new graduate nurses (Santucci, 2004). Tabari-Khomeiran et al. (2006) identified six areas that influence a nurse’s ability to develop competence. These are experiences, opportunities, environment, personal characteristics, motivation, and theoretical knowledge. Each of these has the opportunity to be influenced by senior nurse involvement and may have a direct impact on the quality of the practice environment. Hospitals that have begun to involve senior nurses in the direct education and development of new staff competencies have enjoyed great success (Donner, Levonian, Slutsky, 2005; LaMar, 2008). For instance LaMar (2008) described their program called ‘Compass,’ which allowed nurses to complete credits for work performed towards improving their competence in specific aspects of nursing, such as knowledge and decision making. These credits could be applied to professional development, such as attending conferences or paying tuition for degree programs. Most of these nurses worked with a senior nurse mentor in order to reach their learning goals. Feedback from the program was positive from both senior nurse mentors and staff nurse participants. When the three year study was complete, 78% of the nurses who had been involved were still employed with the institution and 23% of those nurses had moved to management or advanced practice role inside the institution  22  (LaMar, 2008). Programs such as Compass provide valuable insight into the possibilities that exist for senior nurses to assist with the retention of newer nurses. 2.5 Conclusions This literature review provides an overview of the challenges facing the nursing profession due to the current nursing shortage. Utilization of senior nurses to both mentor newer nurses and create quality practice environments in their workplaces is vital to the sustainability of the nursing profession. As is identified in this literature review, nursing has undergone many changes over the last few decades and it can only be anticipated that more changes will occur. Addressing the rapidly changing needs of healthcare will likely require the involvement of these senior nurses prior to their retirement. These nurses have experience that is needed to guide practice changes and improve working environments. Many nurses already are involved in their workplaces and are acting as informal mentors for newer nurses. Senior nurses also have the conimunication skills and ability to assist newer nurses in learning methods of care that are safe and effective. Involving senior nurses will not be without its challenges. Generational gaps and differing opinions are hurdles that will have to be overcome. The complex problem of increasing newer nurses’ competence and comfort could be assisted by senior nurses and warrants further investigation. Despite the amount of current literature on mentoring and generational gap, very little research has been conducted with senior nurses direct input to date. There is a gap in the understanding of how senior nurses could share their expertise. The pool of senior nurses is starting to shrink and action must be taken quickly to capture their knowledge and ideas before they retire. Senior nurses’ viewpoints and ideas may hold  23  valuable information that could help formulate plans for the future. The study presented in this thesis, by asking for senior nurse input, will contribute to the nursing literature how senior nurses themselves feel they could best be utilized to pass on their skills and knowledge all in an effort to increasing clinical learning and improve healthcare environments.  24  3 RESEARCH DESIGN AND METHODS 3.1 Research Approach and Rationale The Senior Nurse Mentor Project steering committee decided to obtain nurses opinions about the types of projects they would want to complete if given the opportunity. The format of conducting focus groups allowed for the collection of qualitative data with lead questions that could help inform the design of subsequent funded programs and set criteria for the application process. Six open-ended questions determined by the steering committee were used during the sessions (Appendix C). These questions aimed to open discussion on learning environments that exist in workplaces at present. The committee wanted nurses to be able to work on projects that were important to them. It was hoped that the focus groups would provide a safe environment for senior nurses to share their ideas and begin to embrace their passions and to explore how to pass on valuable knowledge prior to retirement. Projects needed to be do-able from a logistics stand point and the committee felt that they would be able to judge if this was the case from the information collected during the focus groups. Focus groups allow for efficient collection of information by bringing together groups of people to discuss an issue (Creswell, 2004). In this case allowing the nurses to have an opportunity to share their knowledge and to use each other’s ideas to help create new ones, enabled the design of the projects to become much more visible to both the nurses and the program planners. 3.2 Ethical Issues Ethics approval was received from the agencies involved. This was a joint project between the University of British Columbia, the University of Victoria, Vancouver  25  Coastal Health, Fraser Health Authority, and Nurses Bargaining Association. Written consent to participate was received from all participants who attended the focus groups (Appendix D). The consent also discussed the use and storage of digital recordings from the focus groups. The digital recordings and notes taken during the focus groups have no personal identifiers. Participation in the focus group was voluntary. Financial compensation in the form of a $50 honorarium was given to nurses who attended a focus group on their day off. This honorarium was provided by the BC Nurse’s Union (BCNU). Since the focus groups were held at lunch hour, lunch was provided for the participants. As with all focus groups, confidentiality was an issue. Discussion about keeping the ideas expressed in the focus groups private was also presented in the consent form. Nurses were asked as part of their consent for the focus group if they were willing to be contacted in the future in order to clarify project ideas. All those who were involved in the focus groups were made aware of their ability to withdraw from the project at any time without any consequences (Appendix D). Nurses who participated in the focus groups were not expected to submit project proposals. They were also informed if they did submit proposals taking part in the focus group did not ensure their project would be chosen. 3.3 Participants Focus group participants came from two British Columbia health authorities, Vancouver Coastal Health (VCH) and Fraser Health (FHA). Population wise, these are the two largest health authorities in the province. An invitation went out to all senior nurses, defmed as any nurse age 55 or older, in these health authorities via emails from the BCNU. BCNU stewards were provided with information about the project and asked  26  to place recruitment posters in their work areas (Appendix B). Nurse Managers from VCH and FHA were also contacted and asked to inform their staff about the research project and focus groups. Of the 69 nurses who responded to the invitations, 40 senior nurses attended focus groups. There were 16 participants from VCH (40%) and 24 participants from FHA (60%). Thirty-nine of the forty nurses who participated were female, and all were over the age of 55. The nurses came from a variety of practice backgrounds including community, acute, and psychiatry. Demographic information about each nurse was not collected as it was felt unnecessary by the steering committee to answer the research questions. Managers were also invited to attend the sessions. This was done to gather information on what the managers felt would be necessary as supports for the nurses in order to make the projects possible and to foster collaboration between the two groups. In total seven managers attended, three coming from FHA and four coming from VCH. Their backgrounds included managing areas such as long term care facilities, acute care units, and community nursing programs. 3.4 Setting The focus groups were held in local hospitals and community health centers within the lower mainland of Vancouver, British Columbia. The groups were held in 11 different locations for 12 groups in total. The focus groups consisted of as little as two participants and as many as nine, with the average being four members in each group. The groups were held for one hour time slots, and nurses were welcome to attend any session, not necessarily a session in the hospital or community center that they were  27  employed. This was done to allow for easiest access, since many nurses actually lived closer to where another group session was being held than their place of employment. 3.5 Study Procedures Explanation of the Senior Nurse Project, along with its connection to the larger Clinical Educator Pathway Project, was discussed with the study participants. Nurses were given an opportunity to ask questions about the Senior Nurse Project and the purpose of the research being conducted. The consent form was explained to the participants and an opportunity was given to ask questions before the session was started were given. 3.6 Data Collection There were 12 one hour focus groups completed, with 40 senior nurse participants and 7 managers in total. Each focus group was conducted by two researchers, one being the main facilitator and the other the main note taker. As the main facilitator, I read each question to prompt the discussion. I took notes during the session and the other researcher recorded notes on large pieces of paper for the group to see and to help guide them through the experience. All sessions were digitally recorded. Six open-ended pre determined questions were used and a list of the questions that would be discussed was provided to the participants at least twenty-four hours ahead of time (Appendix C). Managers and senior nurse participants attended the same focus groups and no identifiers were used to distinguish one group from the other on either the notes or the digital recordings.  28  3.7 Data Analysis In performing the data analysis, a method was utilized that combines aspects of content analysis described by both Neuendorf (2002) and Krippendorf (2004). The goal of my content analysis was to identify common themes represented in the data. Neuendorf (2002) describes content analysis as a process of coding messages received during the research phase, which in this case are the focus groups. Her description of content analysis as summarizing most closely fits with the method performed in this study. She states that, “. .  .a content analysis summarizes rather than reports all details concerning a  message set. This is consistent with a nomothermic approach to scientific investigations (ie. seeking to generate generalizable conclusions), rather than the idiographic approach (focusing on a full and precise conclusion about a particular case”Q,. 15). She also states that it is important to understand the quantitative underlay that is connected to content analysis which makes counting the responses in order to identify their overall meaning necessary (p. 15). For this study, the counting of the number of times a specific theme is mentioned may have been influenced by the fact that the data came from focus groups. Krippendorf (2004) describes methods of content analysis as one of five types: physical distinction, syntactical distinction, categorical distinction, propositional distinction, and thematic distinctions. There are two of these five, categorical and thematic that fit with the methods used in this study. The definition of categorical distinction is,  “. . .  defme units by their membership in a class, or category—by  their having something in common”  (p.  105). The definition of thematic distinction is not  29  as clearly stated but does include the grouping of repeated ideas, thoughts or images (p. 106). Although thematic distinction is mostly used to analyze longer texts or stories by individuals, the main idea behind this type of analysis is to draw conclusions on the themes of the story. He states, “The rearticulation of any part of a story in these terms constitutes a thematic unit” (p. 108). The data for this study are broken into themes and sub-themes by using the techniques described in the categorical distinction section of Krippendorf s text. The use of quotations to describe and group the participant’s personal experiences and ideas is considered a method of thematic analysis by Krippendorf’s definitions. Words and phrases were taken verbatim to create sub-themes. Frequencies were tallied for each sub-theme. Sub-themes with similar activities or purposes were organized into main themes. The numbers of sub-themes per main theme were also tallied (See Appendix E). The frequencies of sub-themes and the numbers of sub-themes per theme are illustrative of where respondents placed their emphasis during the focus groups. In order to keep the data organized, data collected in note form and on digital recordings were first organized into a single chart for each question, for each of the 12 focus groups, which created 72 charts in total. The data were then amalgamated onto one chart for each question so that all of the information for all 12 focus groups was on the same chart, creating six charts in total. The six charts, one question at a time, were then analyzed to allow for summaries of the data (Neuendorf, 2002) and categories to be determined (Krippendorf, 2004). The number of themes and sub-themes identified for each of the questions varied. Sub  30  themes were identified by utilizing the exact phrasing of the participants. For instance, being a “go to” person was given as an answer for question one. It was recorded onto the chart, once for each time it was stated during a focus group. This made it possible to group all of the statements for each sub-theme by color. Once the sub-themes were identified, all points in each chart were color coded on the computer into the sub-theme they were most closely related to. In a few cases I had to consider a term for a sub-theme that slightly deviated from the exact stated words of the participants, for instance deciding the difference between communicating with families and communicating with patients, but the context of the discussion made these sub-theme titles obvious. Data were organized into sub-themes and main theme titles were closely related to what type of activity each of the sub-themes described (Appendix E). 3.8 Data Transformation The grouping of the data into main themes and sub-themes allowed for the number of items that fell into each category to be counted. The color-coding of the data assisted with this process. By counting the numbers of times a topic was discussed, numerical transformation of the qualitative data identified which themes were most commonly mentioned during the focus groups. As discussed by Neuendorf (2002), this allows the researcher to notice the points that are most common or ones that stand out from the group. The numerical values in this study allowed the author to understand what participants were interested in by displaying the frequency of nurse project themes and sub-themes (Appendix E).  31  3.9 Measures: Reliability and Validity  The concepts of reliability and validity are important for ensuring the rigor or trustworthiness of a research study. The qualitative definitions for these terms are different than what is utilized in quantitative research. The qualitative definition of reliability is defmed by Morse and Field (1995) as, “The measure of the extent to which random variation may have influenced stability and consistency of the results” (p. 243). When determining reliability it is important to consider the accuracy of the information gathered from the study participants and the consistency with which the data is collected (Dempsey & Dempsey, 2000). The qualitative definition for validity is defined by Morse and Field (1995) as, “The extent to which the research findings represent reality” (p. 243). As the researcher collects new data it is important that this data is compared to what has already been collected by the researcher to ensure that it reflects past findings (Dempsey & Dempsey, 2000). To ensure rigor, a researcher needs to consider how reliability and validity will be met during each step of the research study; from the design phrase straight through to the reporting of findings (Morse, 1995). This process was followed for this study to ensure that the data presented here are accurate and unbiased. Guba and Lincoln (1981) grouped the terms reliability and validity together and formulated criteria for researchers to consider when creating qualitative works (Morse, Barret, Mayan, Olson, & Spiers, 2002). These criteria include credibility, transferability, dependability, and confirmability (Guba & Lincoln, 1981) and will now be discussed in more detail as each step pertains to the work in this thesis.  32  Credibility is determined by four aspects—negative case analysis, triangulation, constant comparative analysis, and member checking. The first aspect, negative case analysis, is when the researcher is expected to search their data for unusual cases and decide on a method to explain or report these (Craig & Smyth, 2002). For this thesis all data, even those outlier cases, were considered and placed into tables. It was felt that all ideas presented by senior nurses were of value and even if only one nurse presented an idea it was still included in the data tables. An example of this is in the answers for the third question. Only two nurses commented that they would like to take on leadership roles as part of project work and their answers were included in the data summaries. The next criteria, triangulation, where more than one method is used to draw conclusions from (Creswell, 1994), was completed by the data being both recorded digitally and in note form. Sub-themes were first identified by the researcher utilizing field notes and then were expanded upon by adding in data from the digital recordings. Questions and specific focus group responses were kept separate from each other during the data analysis and only merged when data had been drawn from both the author’s field notes and the digital recordings (Creswell, 1994). The criteria of constant comparative analysis, was completed by findings for each question from each focus group being independently analyzed and then compared. For example after the first focus group, the author organized the participants’ responses for the first question and recognized common sub-themes. The data was analyzed in the same manner for the second focus group and the sub-themes compared with the first. This was done for all twelve focus groups and allowed for common sub-themes to be recognized while highlighting participants’ responses that were unique. The last criterion of the credibility section,  33  member checking, was not completed as part of this research study and will be discussed further in the study limitations section. Transferability consists of thick description and theoretical triangulation (Craig & Smyth, 2002). In order to meet the requirement of thick description, details of how the author recruited participants, where the focus group sessions occurred, and how the data was collected and analyzed can all be found in chapter three. By providing thick description it is believed that others can determine how the researcher came to their conclusions and should allow for repeat of the study utilizing the same methods (Craig & Smyth, 2002). As part of the thick description for this study, an audit trail was created with the author’s notes that allowed for decisions that were made about how to organize the data to be tracked (Creswell, 1994). It is stated by Craig and Smyth (2002) that when completing theoretical triangulation a researcher should,  “. . .  approach the data with  multiple perspectives and hypotheses in mind so that different theoretical points of view can be compared and contrasted (p. 166).” It was believed by the author that many senior nurses would have strong feelings about being involved in their workplaces. The concept of mentoring was one that the author had experienced in her own clinical experience and expected to hear during the focus groups. It was the magnitude of responses on the topic of mentoring that was unexpected. Also unexpected, thus providing an opportunity for the researcher to expand the point of view, were the large variety of ideas for projects and the recognition by participants of larger problems within the healthcare system. Both of these factors led to the data being compared with current nursing literature, aside from mentoring literature, and discussion on these topics being presented in this thesis.  34  Dependability is determined by four aspects—flexibility in research design, mechanical recordings, verbatim transcription, and researcher triangulation (Craig & Smyth, 2002). The first aspect flexibility in research design did not play a large role in this study and will not be discussed. Mechanical recording devices were used to collect data during the focus group sessions. Permission for use of these recordings was collected from each participant and the tapes have been stored as per institutional policy. These recording have no identifying features and there was no differentiation between senior nurses and managers who participated. Verbatim transcription of comments made during the focus groups were used to both create the data charts for the analysis and to choose the sub-theme titles. It is noted by Craig and Smyth (2002) that dependability of the results is based on how accurate the data presented is. By using direct quotes of participants, it was felt that misinterpretation of what they have said would be avoided and in-depth comparison of ideas participant-to-participant was possible. Researcher triangulation was conducted by agreement on themes and sub-themes gained by the author and another researcher. Validation of the author’s findings was completed by comparing my analysis with that of the other researcher on the project and by also gathering input from the project steering committee. Comparative analysis was completed with the current literature in order to validate what has been identified and to assess for novel findings. The last criterion, confirmability is determined by thick description and reflexivity. The utilization of thick description for this study is described in the transferability section above. Reflexivity was conducted by the author in numerous ways. The author presented the questions during the focus group sessions in a consistent  35  manner, attempting to allow for organic responses without guidance or influence. Notes that were taken during the focus group sessions were recorded as statements from the participants with limited adaptations by the author—thoughts or comments about what was happening during the focus group sessions were recorded but on the margins of the page and not embedded in the notes themselves. For the data analysis, utilizing verbatim quotes to create sub-theme topics, the author was able to keep personal assumptions from entering into the data. By using quotes to ensure the points being made reflect the actual context, the author was able to establish trustworthiness of the data or to represent the participant’s experience in a truthful way (Guba & Lincoln, 1981). In the content analysis the frequencies of responses were added together to provide a clearer picture of what the participants felt was important. The author created these data charts without any alterations in the original data so that the appropriate reflection of the information was maintained.  36  4 RESULTS 4.1 Introduction This chapter gives examples of the answers to the focus group questions provided by participants and the topics discussed during the sessions. As described in the data analysis section of chapter three, responses have been grouped into sub-themes and then main themes. Verbatim quotations from each of the six questions, which provide evidence of each sub-theme, are provided in this chapter. These quotations were used as indicators for the chapter five discussion topics and show the in-depth involvement of the participants during the focus groups. 4.2 Question 1 Question 1: Have you ever had the opportunity to share your nursing practice skills/knowledge at your workplace in a unique and effective way? Ifyou have, please describe it. For Question 1 there are three main themes; Working with Peers, Resources, and Facilitation of Change. In the Working with Peers main theme there are six sub-themes; Mentoring/Preceptoring, Teaching, Working with Students, Go To Person, Skills, and Orientation. In the Resources main theme there are two sub-themes; Policy Work and Materials. In the third main theme, Facilitation of Change there are four sub-themes; Leadership, Presenting, Research, and Committees. 4.2.1 Working with Peers Question 1 allowed the nurses the chance to discuss their previous experiences. The group discussed experiences working with their peers in various ways, and this theme represented 70% of the comments for this question.  37  Mentoring/Preceptoring This theme included both mentoring and preceptoring, which was stated in every focus group. Mentoring was described as something that was done on a regular basis but could benefit from more emphasis and designated time. It was identified by one nurse that, “More time to teach allows the new nurse to run the assignment (while) I shadow the new nurse. Time for one on one discussion of how the day is going and how to solve problems is needed.” Mentoring was identified as both an important aspect of the senior nurse role and one that they perform frequently. Teaching Being able to pass on knowledge to students and teaching other nurses was of importance to the nurses in this study. One nurse commented, “I really like working with the younger nurses, they are so keen and enthusiastic. Some of them that have only been working for a couple of years are lacking in a little bit of self confidence, not knowledge, just confidence to take on something.. .1 often take these nurses aside first before they see the patient so that they can bounce things off of me. I really like this part of my job. We work together and it is good.” Being able to spend time with teaching other nurses is something many senior nurses stated that they had experience with and enjoyed. Students The nurses spoke often of what they knew best, which included working with students. Working with Students is something that is valued as an important contribution to the growth of the nursing profession by the senior nurses. One nurse commented, “I  38  have worked for 30 years and I still enjoy having the students to preceptor.” Senior nurses felt comfortable with this role due to its repetition, almost every area of practice today has students in some capacity so senior nurses were very familiar with the role of working directly with students. Go-To Person This is a term that was used by the senior nursing group to describe what their current role often looks like in their units. They are often the person who is asked for assistance when someone does not know how to do something, where to find something, or who else to ask. This informal role is something that is embraced by many of the senior nurses. One participant commented, “There is going to be a big gap when we retire. One of my younger cohorts mentioned, ‘what are we going to do when you’re not here? Who will we turn to?’ This quote shows how the senior nursing group is relied on for information and skills on a regular basis in many practice areas. Skills It was noted that many nurses may not be able to perform all of the necessary skills when they first are hired. Many practice areas now have lots of specialty equipment that requires advanced training and knowledge. One participant commented that, “The first time you see all of the equipment it is scary. I remember I was scared, I didn’t know how they worked, scared if I did something wrong I would kill the patient. If I can explain to them what to watch for, what is important. then they . .  would feel more comfortable.”  39  Taking the time to offer assistance to new nurses and to give encouragement for new staff to build skills was identified during the focus groups as something senior nurses were confident in doing. Orientation The senior nurses also viewed themselves as useful in helping to orientate new staff to the unit, since they are able to help them to learn the routines and expectations of the area. One nurse commented, “Efficiency is very important. .Patient flow, it is time wasted if you haven’t got .  your patients ready (for tests) and being able to prioritize is extremely important and knowing the flow of the patients is important to the communication on the unit.” With often high turn over rates in many units, senior nurses who participated in this study identified that helping new nurses learn the policies and procedures was often a large par of their role both formally and informally. 4.2.2 Resources The next theme identified was Resources. Nurses on their own accord have worked on developing nursing policies and resource materials that benefited nurses at the bedside. Policy Work With the rapid changes that are occurring in every work environment it was noted by the participants that spending time working on updating policies was something they were often asked to do and saw value in. One nurse who had been involved in such work  40  commented, “I have been asked to write some new policies for the new equipment that has come, help to sort out what needs to be done to make it happen (smoothly).” It was also noted that policy work often gets delayed due to the large volume of work being done by nurses who are in leadership roles and that this was an area they have assisted with in the past. Materials One nurse when asked if they had ideas on how to transfer the knowledge required for the area she works in responded about the value of creating resource materials, “I would have something written up with the main points.. .without something to guide them they may forget some of the important things.” It was discussed in a few focus groups that with the proposed project time, more of this important work could get done. 4.2.3 Facilitation of Change The last theme, Facilitation of Change, shows how involved senior nurses are in their institutions. Committees Many of the nurses volunteered for committee work, working on committees for everything from pharmacy issues to creating orientation programs for new graduate  nurses. One senior nurse stressed her concern over the changing environment of the hospital and how committee work is changing,  “. .  .previously lots of committee work was  done (that) was useful and is now missed. Now it is too top heavy in the hospital. Committees were very successful and are now lost. (The) field voice is disappearing.”  41  Senior nurses in this study were clear that they felt the committee work they had done was valuable and that they would like to see more front-line staff involvement. Presenting Presenting nursing information at conferences and workshops are also important parts of senior nurse’s work. The experience of being able to share their knowledge with a larger audience was also noted to be of importance to many members of the focus groups. It was noted by one nurse that, “Presenting at conferences, speaking, (and) not necessarily to other nurses (but) for the general public or at grand rounds is important.” Having the opportunity to share the ideas of their own workplaces and their own expertise was something that senior nurses have done in the past and would enjoy doing more of in the future. Leadership Being involved in functioning of the unit at a leadership level was also discussed by a few nurses, who often found themselves in the role of charge nurse. One nurse stated, “(With) many new people and changes, there is lots of varied experiences that require role modeling and (still) allowing them to lead in their own way, facilitating.” Senior nurses commented on how their experiences made transitioning into leadership roles possible. Research The concept of nursing research shows how the role of the senior nurse is immense and changes frequently. One nurse who had worked as a research nurse (type of research not mentioned during the focus group) commented,  42  “The one thing I really enjoyed was that I got our college to agree to take nursing students to show them what research was about, what kind of research we were doing in the hospital, that was a lot of fun and actually a couple of those nurses applied for jobs there when they graduated.” Being involved in research projects is something that senior nurses have been involved and expressed interest in continuing to be involved in for the reason’s stated in the quote. 4.3 Question 2 Question 2: Many nurses have described aspects of their practice that they are keen to share with others. What would this be for you? For example, it could be knowledge, a skill, an attitude, or anything else that you think is important. Question 2 has four main themes; Nursing Work Life, Attitude, Knowledge and Skills, and Communication. In the main theme of Nursing Work Life there are six subthemes; Working as a Nurse, Adjusting to Being a Nurse, Orientation, Mentorship, Role Modeling, and Giving Feedback. The main theme of Attidude has no sub-themes. The main theme of Knowledge and Skills has the three sub-themes of Knowledge Development, Nursing Skills, and Equipment Use. The fourth main theme, Communication, has three sub-themes, Working with Families, Working with Patients, and Communication. 4.3.1 Nursing Work Life The first theme related to this question is Nursing Work Life. It is clear by the number of answers that the participants felt very strongly about this issue. This question had 179 responses, the most responses for any question.  43  Working as a Nurse When discussing the difficulties in adjusting to working as a nurse, and learning to cope with the challenges a variety of patients each day, a participant commented, “(You) can’t change the patients, this is sometimes difficult (for new nurses to deal with and remember) that patients go to institutions for a reason. (The new nurse need to ask themselves) how can I work in this environment and be productive.” If given the time to coach and guide a new nurse through the complex relationships with patients and families senior nurses discussed how they could improve a new nurses confidence. Adjusting to Being a Nurse Adjusting to being a nurse and learning how to work as a nurse after graduation are items that were identified as important aspects of new nurse development. 40% of the nurses who answered this question felt that they could share their expertise. One nurse identified the importance of, “Probing the new grads to go through thought process and connect the dots for the clinical process.” Many senior nurses identified the difficulties to adjusting to all of the demands of being a nurse and they were willing to try and improve a new nurse’s experience by sharing what they have learned along the way. Orientation Other ideas identified in this question include assisting with orientation. Although it is standard for all new nurses to undergo an orientation when hired, it was felt by many that this orientation could be expanded and improved upon with their assistance. It was noted by one nurse that there is,”. lots of orientation but not as . .  44  specific as it should be.. ..nurses need to be not just orientated but mentored.” Another nurse noted that, “Specialty areas need more than just orientation in order to make them (new nurses) feel safe and secure.. .they need the practical aspects.” Senior nurses felt they could contribute to orientation in a way that could make it more meaningful and relevant to clinical practice. Mentoring Of the participants who gave responses to question two, 40% felt that they would be able to share their practice with other nurses by Mentoring. The sub-theme of Mentoring was strongly identified throughout all the focus groups and half the focus group questions. One senior nurse noted that mentoring gives,  “. .  .visible recognition that  they (new nurses) are important.” Another nurse noted that, “Mentoring can help new nurses to contribute to the team, (learn) how to work with families, how to work with people, and tricks on how to do things.” Taking on the task of assisting a new nurse to grow takes time. One nurse stated that, “(It is) important to find out where exactly they (new nurses) are at and what they need. They are all doing the best with what they’ve got.” Senior nurses had an obvious interest and passion about mentoring and wanted to find ways to continue to mentor that are better supported by their workplaces. Role Modeling Many participants noted the difficulty new nurses have adapting to,  “. .  .putting  your values on the back burner”, or how to deal with families in crisis. It was simply stated by one nurse that senior nurses need to,  “. .  .model the type of behavior you want  the new nurse to learn.” Role modeling behaviors, skills, and communication to newer  45  nurses also was identified as important contributions senior nurses could make to help expand the practice of others. Giving Feedback The last sub-theme discussed in this category is Giving Feedback. Many participants felt it is important to provide feedback to newer nurses who are trying to learn and grow their skills. Lack of time and resources to care for high acuity patients were identified as factors in a nurse’s inability to give positive feedback to newer nurses, “Constant crisis mode leads to lack of encouragement, communicating positives is not happening enough.” Without this feedback, the senior nurses recognized that newer nurses may not know they are completing tasks well, or what they could improve on, or how. One nurse stated that it is important for new nurses to know, “That it is OK if you are scared here.” It was also noted that it is important to encourage new nurses. One senior nurse who has given feedback to new nurses stated, “(I) like to see people learn, I like to encourage them and see them move ahead.” Although not directly stated, I detected a sense of pride when senior nurses spoke of seeing newer nurses learn and grow and knowing that they had been a part of this in some way. Despite the demands of the day to day workload, senior nurses in this study were committed to providing feedback to their peers. 4.3.2 Attitude The next theme, Attitude, was discussed by many as something that they have seen change over time no matter what the level of experience. Participants were quick to acknowledge what types of behaviours they would like to see change in their own group  46  as well as what attitudes they would like to pass onto the next generation of nurses. Attitude When discussing Attitudes and behaviors participants would like to see in new nurses’ one nurse simply stated, “(I) want to see new nurses with compassion join our profession.” Participants also expressed how they feel that new nurses are often bombarded with the negativity that exists in many units, being told that nursing is too difficult, that the area is above a new graduate’s skills level, and that the working conditions are not acceptable. One senior nurse even went so far as to say, “Getting senior nurses to move around (the hospital) may be helpful for the units. If you like your job stay, if not, leave.” Participants reflected that newer nurses often feel disconnected from their team, their patients, and the profession. One stated, “Due to the (nursing) shortage learning to work as part of a team is vital.” It was noted that learning how to develop relationships may take time but that senior nurses have the experiences and expertise to guide new nurses. “When it comes to caring, (we) can help them to believe that they can do it.” Also, “Confidence to advocate is something important that we can teach new nurses.” The second issue raised was the initiation of new nurses to units, which was described as a type of intimidation that often occurs but needs to change. “How can you encourage these nurses to stay in the profession if you are not helpful and kind and supportive?” When a supportive environment exists that allows for learning to occur without extra stress and the ability to ask questions without scrutiny, participants felt that newer nurses are capable of quickly becoming part of the team and learning how to do  47  the work. One nurse noted that, “If you put someone in over their head they are going to run away.” Attitudes needed to deal with patients, families, and the difficult situations that are faced daily by nurses were also discussed as something that senior nurses would like to pass on. Senior nurses can show newer nurses how to, “Put tasks and nurturing hand in hand.” By sharing experiences and the importance of being there for the patient, it was felt that new nurses would be able to see the role they play in the bigger picture, in terms of patient care and not just as a series of tasks, “Enjoying being able to spend more time with patients is important.” This highlights the importance of finding support for new nurses and surrounding them with positive attitudes. 4.3.3 Knowledge and Skills The next theme, Knowledge and Skills, was mentioned often throughout the focus groups as something senior nurses felt comfortable sharing. Knowledge Development The most talked about idea in this sub-theme was Knowledge Development. Although new graduate nurses complete school with the most up to date textbook knowledge, practical knowledge and knowledge of their new workplace are things they will need to learn. One senior nurse noted that, “I draw on my past experiences every day. I started in obs (obstetrics) and now I am a case manager, very different. (It is) important to have experiences to draw from, knowledge from different experiences.” Senior nurses are interested in helping new nurses learn the things they need to know to perform in their work environment and for the future.  48  Nursing Skills  Many participants identified passing on nursing skills, whether assessment or motor-based skills such as giving an injection, as a regular part of their work life. For the purpose of this sub-theme, nursing skills refers mainly to skills that it would be expected a new graduate nurse come prepared to do without extra on-the-job training. It was stated that, “I know where to fmd the information and can take them to it.” Being able to pass on skills and assist new nurses to become comfortable with the large array of procedures they need to learn was another area senior nurses felt they could be useful. Equipment Use  Mentioned not as frequently but also fitting close to the nursing skills concept is the use of specialized equipment. Showing a newer nurse how to use complex equipment is a role senior nurses have stated they are able to fill. One participant noted, “Machines make noise when they need attention.. .knowing what to listen for and monitor and how to check the equipment makes it (the job) easier.” Although some would say that using equipment is a nursing skill, the high-tech, computerized equipment that requires many extra hours of training outside of basic nursing education is the reason for this sub-theme. Senior nurses recognized these requirements and feel they could assist new nurses with hands on experience with this equipment to help them gain confidence. 4.3.4 Communication Communication is the last sub-theme for this section. It was discussed by many senior nurses that a new nurse often needs assistance with learning to communicate with the healthcare team and their clients.  49  Working with Families The ability to communicate with a family in crisis is something that senior nurses feel they are able to pass on to other nurses if given the chance. It was noted that, “Caring is something that brings people to the nursing profession.” The desire to care for others needs to be fostered in an environment that allows for the time to make this a priority. Senior nurses have shown that they understand the value of caring that is often forgotten in a system driven by finances and scarce resources. Working with Patients Many senior nurses in our study expressed their comfort in Working with Patients, especially during difficult times. Building trusting relationships and taking the time to care were identified by senior nurses as important to professional nursing practice. One participant noted that when a new nurse isn’t sure what to do, they need to seek assistance. “Don’t panic in front of the client. Be calm and quiet, get help. You will lose trust if you don’t keep calm.” The skills needed to work with patients was discussed by the senior nurses and identified as items that senior nurses could help new nurses to learn by using mentorship, role-modeling, and listening to the concerns of the new nurses. Communication Learning to be a team member, including when and who to ask for help, how to find resources, and avoiding dangerous shortcuts is an important first step for a new hire. One nurse noted that, “People are difficult, unhappy sick people especially.  . . .  it is important for these  nurses (new nurses) to be able to look back at the day and know that I made a  50  difference.. .often you walk onto a ward that has newer nurses and the atmosphere is just wound up. Without a lot of assistance from others it is difficult for new nurses to communicate. This is where they learn shortcuts that are unsafe.. .new grads should have a mentor, not lots, but one who they can be hooked up with (periodically) and go over situations and get questions answered” In the hectic environment of a unit it can be difficult for new nurses to even realize that more than what is happening in their own patient assignment is even going on. Senior nurses recognize this and are willing to work with new nurses to help them to learn to communicate as a team member and not feel overwhelmed. 4.4 Question 3 Question 3: Ifyou were given an opportunity (e.g., 30 days over the next year) to share your knowledge/skills, what wouldyou like to do? Question 3 has three main themes; Working with Peers, Resources, and Facilitation of Change. The main themes for this question are the same as those identified for question one due to the similarity in responses for both questions. There are some differences in the sub-theme categories that will be discussed. The sub-themes for the Working with Peers include Mentorship, Education, Orientation, and being a Go To Person. The main theme Resources has the sub-themes Materials and Policy Update. The last main theme Facilitation of Change includes sub-themes Committee and Leadership. 4.4.1 Working with Peers The first main theme, Working with Peers, shows that senior nurses in this study are committed to helping the frontline staff by acting as a resource person or a “go-to” person.  51  Mentoring  As was answered for question 1, many of the participants wanted to be involved in Mentoring newer nurses. 42 of the 91 responses for this question focused on their interest in mentoring. One participant noted that she would be able to help newer nurses by, “(Helping with) difficult patients as a mentor and guide them. Or having them shadow me for the difficult patients, or follow me for a longer period of time overall.” Some senior nurses referred to mentoring as a way to retain newer staff and help decrease burnout of staff members. It was stated that mentoring would give the senior nurses a chance to, “ask them what they like, where do you want to go in your practice, and try to find supports for these.” The idea of having time set aside to spend one-on-one time with new nurses or meeting in small groups was identified as a valuable way to pass on skills, knowledge, attitudes, and encouragement. Education  Educating existing staff members is also a role that senior nurses discussed as a potential way they could see themselves spending time. It was discussed that with so many changes, it is challenging to keep up with current practices. A project idea that was mentioned would be to find out what the frontline nurses feel they need to learn about and provide education on these topics. Educating students on the employment possibilities that exist was also mentioned as an area of interest. One participant noted that a good way is to, “Ask if (students) are interested in certain areas, help (them to) design a learning plan.” A feeling of the need for better recruiting was common and a role that the senior nurses in this study felt they could fill. By educating students on the different employment possibilities, such as  52  working in long term care or community, it was felt that they could make a difference in helping students choose a career path. Orientation Being involved in staff orientation allows experienced nurses to ensure that the expectations of the unit are addressed right at the beginning and that, new nurses are welcomed appropriately. Also assisting new nurses with competence assessment and learning plans is something senior nurses identified that they could do, “Could help them go through an educational pathway, help them to be comfortable with skills and expectations.” By showing an interest in new nurses at orientation, the senior nurses identified that retention of these staff may increase. Go-To Person By being on the frontline, acting as a go-to person, the senior nurse is able to give real time answers to questions and guidance through tasks that may be complex. It was noted by one nurse that, “(A nurse) learns way better in a non-threatening situation. (1) would be there to hold their hand if they fall apart, if it is just too much sometimes.” By having dedicated time to devote to assisting other nurses, instead of trying to help others while managing their own patient assignment, senior nurses noted that they would be able to focus their attention on the needs of their team mates and share their expertise. 4.4.2 Resources The next main theme discussed was the Development of Resources. Many nurses identified the lack of Policy development and resource Materials that is occurring in institutions today.  53  Policy Update With rapidly changing best practices it has been difficult to keep for policy current. It was noted by one of the participants that, “Changing the approach from the top is what needs to happen. People at our level are the people to do it but we are never consulted on anything. .when it comes to policy.” It was expressed that senior nurses .  with bedside knowledge can assist with best practice updates for the entire staff. It was felt that nurses could be more involved with policy development but that this would require change. Materials One nurse identified that a project she would like to work on would be to, “Create a resource binder. All of the info that is floating around the department could be put into one binder. I would also like to see the unwritten policies. .be written.” Participants .  noted that senior nurses are knowledgeable about what resources are lacking both for nurses and families in their units. 4.4.3 Facilitation of Change The last main theme, Facilitation of Change, although not mentioned often, still shows the senior nurses’ commitment to working on committees and performing other leadership roles in their institutions. Committees Committee work is a way for nurses to meet other senior staff working in other departments and network to solve institutional problems. One participant noted that, “Recruiting new nurses is so important now. .we (senior nurses) should be involved; we .  (senior nurses and management) could work together.” Participants in this study were  54  interested in being involved in committees for various purposes such as recruitment of new nurses, workplace issues, and to bring together expertise for specialized types of care such as wound care. Leadership Many of the participants had experience acting as a charge nurse but during the focus groups it was discussed how some would like to assist with orientation, including completing performance appraisals with new hires at the three to six month stage— activities that are usually completed by nurses in leadership roles. One nurse suggested that the skills of the staff could be better used to educate others, “Find out what the expertise of the staff are and then have these people educate other staff. lots of . .  knowledge and skills in the unit that are not used.” By finding ways to use the talents of those already in the workplace, the entire team could benefit and it takes a leader to be mindful of the skills of others and to encourage the team to draw from these skills. 4.5 Question 4 Question 4: What supports would you need to be able to share your knowledge/skills? Question 4 has main themes of Logistics, Support, and Education and Training. The sub-themes for the Logistics theme are Time and Funding. The sub-themes for the Support theme are Support from Management, Additional Staff, Support from Peers, and Collaboration. The last main theme, Education and Training has the sub-themes of Additional Training and Mentor for Themselves.  55  4.5.1 Logistics The main theme of logistics covers the two sub-themes most often described as needs—time and funding. Time Senior nurses identified the need to have time away from the bedside to focus on their projects. It was stated that, “Time needs to be built in to do mentoring. Otherwise you end up putting it aside.” This could not be done however if the nurses were not replaced, as it was stated that they would not want to leave the unit short staffed. The difficulty of fmding nurses to replace those completing projects is an ever-present concern. Funding Funding was mentioned as necessary to guarantee backfill and purchase materials for project work. It was noted by one nurse, “I would love to see money dedicated to the mentorship of new grads.. .there should be mentors in the system and whether (the money) is used for backfill within the hospital.. .there needs to be something to acknowledge it (the need for mentoring) because spending the dollars there will keep nurses in nursing longer and we won’t have the shortages.” Without money to complete projects, especially for staff replacements, senior nurses end up juggling their own workload plus the needs of the newer nurses on the unit. Funding, as is mentioned in the quote, is one way of ensuring that senior nurses are used in a respectable way that allows for the best transfer of learning to occur for the new nurse.  56  4.5.2 Support It was identified by the senior nurses that support of those they worked with and for would be essential to projects being successful. The senior nurses felt that the dynamics of the unit, in terms of not only manger support but, also support from colleagues and replacement staff were vital to consider before proceeding with any project work. Supportfrom Managers Support from managers was viewed by many as a requirement for progressing through the project. One nurse stated, “Whatever program was put in place the managers would have to agree to allow flexibility of their staff to provide the opportunity for students because obviously it takes time away from your work.” Managers are important resources as often they need to approve the time away from usual assignments as well take on the responsibility of backfill. Additional Staff It was important to participants to have enough nurses to allow for mentors and preceptors to have the necessary time and lighter patient assignments so that they can spend time teaching. Finding nurses to replace staff who agree to mentor is a challenge but still necessary. It was discussed that plans need to be creative to ensure that staff can be replaced. One participant noted that, “You cannot rely on casuals to fill in all of the empty slots.” The participants stated that more permanent solutions and arrangements need to be made in order for teaching to be ongoing.  57  Supportfrom Peers The senior nurses also recognized that in order to have their projects be successful it would be most beneficial to have peer support. It was noted by a participant that, “To make projects work we need teamwork and support from our colleagues.” They also noted that peer support would ensure they would have the dedicated time necessary to do the work. Collaboration Lastly, participants noted that collaboration, where they could approach other staff members to assist was important to ensure their projects were successful. An example of this was mentoring, where the senior nurse felt that staff consistency and buy in would be necessary for success. One participant commented that, “The mindset of how we deal with our nurses is important.” They noted that there needs to be collaboration between the institutions and the universities to ensure that new nurses are up to date and prepared for the workforce. As one participant stated when discussing the need for new nurses to be mentored and for acceptance of this mentoring by the entire unit, “Mentors are different that educators, they can help with retention. We need nurses.” Collaboration between all members of the healthcare team was discussed as a vital part of success. 4.5.3 Education and Training The last main theme, Education and Training, was identified as an increase in knowledge that the senior nurse themselves felt would be needed for success.  58  Additional Training Participants noted that an understanding of adult education principles and ways to effectively teach were important to their growth. One participant stated that, “Understanding how adults learn and how to work with them needs to happen first.” By having this knowledge, it was noted by senior nurses that they would feel more confident to deliver education to new nurses. Mentorfor Themselves They also noted that having a mentor for them, someone to go to with their questions and concerns, would make the adjustment to project work easier and give them confidence in their plans. It was stated that, “Lots of support for the mentors (is needed) because the reality is that they (senior nurses) must always mentor, it is just the way of the world of nursing now and there will always be pressures (to mentor).” Senior nurses noted that having a person who can guide them was important and would contribute to their own growth and development as nursing professionals. 4.6 Question 5 Question 5: Given a maximum of3O days over the year, how wouldyou see the time being used? (Please provide examples ofpossibilities such as: two blocks of 15 days, one day per weekfor 30 weeks, etc.) There are four main themes related to this question but due to the limited answers, no sub-themes. 4.6.1 Blocks of Time  This question was answered differently by nurses who had an idea for a project versus those who did not. Blocks of time, the first theme, was the most frequently  59  suggested time division for the projects. Many nurses felt it would be beneficial to have blocks of time in order to get their projects organized and off the ground. They also recognized that having an arrangement of one day a week for 30 weeks to work on their projects could be a realistic way to organize their time. Since mentoring dominated the discussion, many nurses who wanted to mentor felt that having a set day of the week or period of time would be the best way to manage the mentorship time. It was noted by more than one nurse that, “Blocks of time make it possible to follow (mentor) an RN”. If mentoring was to be part of the project plan, it was identified by the senior nurses that blocks of time could be the most efficient was to do this. 4.6.2 Flexible Scheduling The next main theme, Flexible Scheduling, was also discussed as being project dependent and was seen by some as a beneficial way to divide time if mentoring was how the time was to be spent. This was felt necessary to be able to meet up with nurses who are working shift work and therefore different days each week. It was also noted by a participant that, “Time needs to be flexible in order to meet the needs of the unit. Skill mix of staff has to be considered.” Due to the wide differences in the types of clinical areas represented in this study, many senior nurses felt that having an ability to flex a schedule could be beneficial for senior nurses wanting to mentor or provide clinical support to their workplaces. 4.6.3 More Time  The third main theme, More Time, was identified by a few nurses who felt that in order to make a real difference they would need more time than the funded 30 days laid out by this project. This was noted mostly by nurses who wanted to mentor, “Mentoring  60  needs to be ongoing and will take longer than 30 days.” The senior nurses felt that 30 days would be a good start but that they would like to have the option to continue on if the mentee needed the support. 4.6.4 Less Time The last main theme, Less Time, was identified by one person who felt they could complete their project idea with less than 30 days. 4.7 Question 6 Question: What would your area of practice need to support these ideas? Question 6 has three main themes; Logistics, Support, and Education and Training. The sub-themes for Logistics include Time, Support Materials, Funding, and Technology. Under the main theme of Support are the sub-themes of Staffmg, Mangerial Support, and Front-line Nursing Support. The last main theme Education and Training includes sub-themes of Adult Education Theory and Orientation. This question is very similar to question four and the answers reflect this. There are three main themes for this question, as there were for question four. The sub-themes for this question, also very similar to those in question four, had fewer answers than what was given for question four. 4.7.1 Logistics Time Participants identified that in order to complete their project, their department would need to be able to give them the time to work on their projects. As one participant stated, “Creativity with my work hours (is important).” This also means that they would need to be replaced from their place of work. Some senior nurses suggested that they  61  could possibly be replaced for project time by nurses who have already retired but who are willing to work occasionally. Support Materials It was noted that senior nurses need Support Materials to complete their projects. Things such as demonstration equipment and space were thought to be necessities by the participants to make their projects successful. One participant noted, “Having demo equipment to practice with, such as supplies and even CPR dolls, really make a difference to learning.” By having actual equipment to work with it was felt by the senior nurses they would be able to provide richer experiences for the learner. Funding In order to ensure they can complete their projects, their areas of practice would need the funding to afford to have them replaced, one participant even pointed out that, “...  a formalized budget would be helpful in order to ensure the money is there”. By  managers giving funding to projects senior nurses noted that they would feel a greater sense of guarantee that the project would continue since they could more easily be replaced. Technology Senior nurses also noted that they may need access to technology in order to complete project ideas. One senior nurse vocalized the need for support for online learning modules that can be done by the nurses anywhere there is a computer. It was stated, “Technology support or online learning modules is essential.” Since technology plays such a large role in not only healthcare but the world today, many senior nurses  62  recognized the importance of using new communication and education methods to reach out to younger nurses. 4.7.2 Support Staffing In order for their projects to be successful the area of practice would need enough nursing staff to function with a project going on in the unit. It was noted by one participant that, “Student friendly environments can be difficult to accommodate with workload demands, understanding the difficulty of doing both mentoring and work (highlights) the need for more staff.” Having time away from the regular workload to focus on project work was identified as a necessity for any project to be successful. Front-line Nursing Support Aside from the actual nurses to fill the empty positions, having the support of the nurses was viewed as vital to have the project work. Front-line nursing support was mentioned as a necessary part of ensuring that efforts to integrate their project work into the unit would be possible. One nurse felt that it is important for them to, “Encourage other older nurses to understand that there is a necessity for (newer) nurses to replace the existing ones.” This will mean that they will have a presence on the unit and that they need to be supported. Managerial Support Lastly, managerial encouragement would allow for the transition of the project work into the unit. Being able to approach the manager with needs and feel like they would be heard was a sentiment prevalent in the focus group data. It was stated by one nurse that, “There needs to be manager support for extra training. Money and time are  63  also important to obtain from them (managers)”. One manager who attended the focus group noted that they would like to see, “Goals of the RN. Do they fit with what the needs are of educators and managers.” Knowing that they had manager support was expressed by some senior nurse as the main factor for interest in completing project work. 4.7.3 Education and Training  The last main theme, Education and Training, focused on two things—education in Adult Education Theory and better Orientation for new hires. Adult Education Theory Some senior nurse felt that nursing education would help meet their need by allowing for a better understanding of those who their projects were designed for. One nurse commented that she would feel more confident with education for herself because, “Adults learn differently and what I want to do may not work for all nurses.” Having the extra education for themselves, senior nurses commented would allow for a better understanding of how to reach some nurses who may be struggling with conventional education methods. Orientation for New Hires A more detailed all-inclusive orientation phase was identified by many nurses as an important first step towards the integration of new nurses into their units of practice. It was noted by a participant that, “Better overall orientation for all new nurses is a must.” Control over decisions about orientation was viewed by the senior nurses as within the manager’s role something that they would like to become involved in.  64  4.8 Conclusion Senior nurses who participated in the focus groups had a vast amount of experience and insight into the nursing profession. Their input into the questions was broad and was approached with a refreshing sense of honesty. Their passion to not only pass on their knowledge and skills but to also encourage the nurses of tomorrow was profound. It is obvious from the depth of their answers and their eagerness to participate that they are committed to assisting with changing the profession for the better.  65  5 DISCUSSION 5.1 Introduction The findings from this study have allowed me to understand the roles that senior nurses currently fill in their workplaces; what types of activities they would want to spend time doing; the skills and knowledge they would like to pass on to newer nurses; and what resources they felt necessary to complete project ideas. Their responses are the guiding force for this chapter. This discussion will include a review of how nursing has changed over time, particularly how these changes may have influenced the results of this research. The differences in generations working together will provide insight into the challenges of today’s nursing workforce. The primary interest of many senior nurses in this study, mentoring, will be another topic discussed.  The discussion will include a  look at the required resources and how the nursing shortage may play a role in the ability to implement projects. There will also be an examination of the challenges of creating change and adopting innovation. The discussion chapter concludes the study’s limitations and recommendations for future research with senior nurses. 5.2 The Changing Face of Nursing 5.2.1 Hospital-Based Nursing Education The nursing profession is constantly evolving. The way in which nurses are educated and socialized into the workplace today is very different than in decades past. When the baby boomer generation completed nursing education, times were very different. It was popular for women entering the workforce in this era to choose careers as teachers, or nurses (Neal, 2003). Women who did choose nursing in this generation attended hospital-based diploma programs. The senior nurses who participated in the  66  focus groups for this thesis were predominantly completed basic nursing education in hospital-based diploma programs. These hospital-based nursing programs included the nursing students living in a nursing residence and having complete integration into the hospital—both studying and living there. In lieu of payment for the work they provided to the hospitals as students. Often these programs covered the cost of tuition, and room and board. This made nursing a vital option for young woman desiring independence (Mcintyre, Thomlinson, & McDonald, 2006). These programs allowed for relationships and, quite often, bonds to form between the students, the staff, and often the instructors. With so much time spent in the hospital, many nurses identified closely with the institution that trained them and were excited to move up the ranks from student to staff nurse upon graduation (Mcintyre et al. 2006). Nursing students were expected in many cases to take on increasing responsibility and leadership roles as they grew closer to graduation. Most nursing students had the chance to be in charge of a unit prior to graduation. Taking on this role was good for understanding the advanced roles in nursing and likely added to the confidence of the student (Mcintyre et al. 2006). in the text by Mcintyre, Thomlinson, & McDonald (2006) it is discussed that although hospital-based diploma programs had many advantages for young women wanting an education, they also had their downfalls. Hospitals were mainly staffed by students, which allowed institutions to save money, but lead to a lack of leadership and problem solving that would have been beneficial in guiding newer nurses (Mcintyre et al. 2006). As the system moved from hospital-based to college and then university, the way in which students were mentored and the education they received changed (Mcintyre, 2006).  67  5.2.2 University-Based Nursing Education  As the nursing profession began to take on more complex tasks and extra responsibilities, it became increasingly important for nurses to receive training in a different way. As nursing decided to spread it wings and move from a skills-based profession, to independent practice and decision making, the need for higher education and training has become paramount (Mcintyre et al. 2006). The nursing profession has grown increasingly important over the years, becoming a partner in care instead of being subordinate to physicians. In order to ensure new graduate nurses have the necessary attributes to succeed in the healthcare system of today, Canada in the 1980’s made the decision to expand university programs so that all entry level nurses would be university baccalaureate prepared by 2000 (Mcintyre, 2006). Although this has not occurred without opposition and challenges, all provinces with the exception of Quebec have followed suit. Quebec has maintained college-based, non-baccalaureate degree nursing education, largely due to its unique educational system in Canada (Canadian Nursing Association, 2008). Moving nursing education from the hospital to the university was not without challenges. Many nurses who trained in hospital-based programs still view these programs as superior to university-based programs (Neal, 2003). These nurses feel that they were better prepared to deal with the workload of a nurse upon graduation than today’s nurses. The basic critical thinking, communication, and leadership skills taught in universities today are often viewed by senior nurses as having less value than more traditional skills needed to complete everyday tasks. Conflict between diploma nurses and university educated nurses began after nursing programs moved to universities,  68  which mainly occurred in the late 1980’s and 1990’s , and persists today (McIntyre et al. 2006). With the move to university-based programs the length of time to become a nurse and the cost to attend a program has risen. Today, most first degree university-based nursing programs are three to four years in length although excelerated programs are being developed to meet the nursing shortage. Ways to get nurses educated quicker has become a focus in Canada. University programs must still consider the many competencies required for entry level practice by governing bodies such as the Canadian Nurses Association (CNA, 2008). Finding innovative ways to educate nurses within the confmes of current nursing education is at the forefront of nursing issues that need rapid solutions. 5.2.3 Recruiting New Nurses Senior nurses have many ideas on how to recruit students into areas of practice that are looking for more staff. Ideas provided by senior nurses in this study include senior nurses going to schools to provide nursing students with information about their practice areas. Acting as guest lecturers and having more students’ complete practicums in specialty areas such as emergency to increase exposure were also mentioned as possible ideas. It was stated during one focus group that,  “. . .  it is interesting for students  to see that there are so many different aspects of nursing.... (To) show them possibilities that are out there.” Another comment speaks to the usefulness of nurses visiting schools, “I think in the school setting they tend to listen to outside nurses coming in even more in some ways than to their regular instructors that gets up and stands in front of a class day to day.” Senior nurses were asked in this study, have you ever had the opportunity to  69  share your nursing practice skills/knowledge at your workplace in a unique and effective way? If you have, please describe it, involved students. Sixteen percent of the answers given during the focus group for this question involved the need to assist and encourage student nurses in order to ensure there are nurses to replace them when it is time to retire. This sentiment reflects closely the results of a research study completed by Thompson (2007) where she interviewed operating room (OR) nurses who had worked in the OR for various amounts of time, asking them what drew them to this particular area of practice and why they have stayed. She found that nurses choose the OR mainly if they had been exposed to this area of nursing in school. Many of the nurses in this study had worked in other areas first but had always known their goal was to gain experience so that they could apply for a position in the OR. Some nurses in Thompson’s (2007) study commented that the opportunity existed for them to begin as their first job out of school, with special training programs in place. Programs that allowed for this type of training and recruited nurses right out of school proved successful considering many of these nurses still remain in the OR today. As is discussed in section 4.3.2 under the theme Attitude, exposing new nurses to a positive work environment is one way to encourage them to stay. Similarly, Thompson (2007) found that what keeps nurses in a specialty area such as the OR, is having a good relationship with their teammates, life long learning, and feeling as though they were making a difference. The knowledge gained from both this study and the work of Thompson (2007) is important to consider when utilizing senior nurses for projects. By senior nurses contributing to creating practice environments that are welcoming to new  70  nurses and by encouraging newer nurses to grow their knowledge-base the ability to both find and keep nursing staff could be increased. 5.3 Generational Gap and Workplace Conflict 5.3.1 Generational Gap Making use of senior nursing staff is not without its challenges. The senior nurses in this study recognized that their ideas about nursing were often different than the newer nurses. Differences in work ethics, communication styles, and teamwork were all discussed during the focus group sessions. Senior nurses were aware of these differences although they did not use generational terminology to describe what they saw. Understanding the meaning of generational gaps could allow nurses to fmd new ways to work together and be more accepting of each other. Generational gaps can manifest in the various age groups when they have different thoughts, actions and beliefs (Clausing, Kurtz, Prendeville & Walt, 2003). First discussed by Mannhiem in 1952, the idea of generational cohorts was compared to socio economic classes. Mannhiem noted that people are usually born into a socio-economic class, much the same way as they are born into a generation. The experiences of being in a certain class can change one’s outlook on life and while it is possible to move between social classes, generational cohorts always remain the same (Marmhiem, 1952; Misztal, 2003). In many cases there are four different generations still working in nursing—Veterans born in the years 1925-1942; Baby Boomers born in the years 19431960; Generation X’ers 1961-1981; and Millennials born in the years 1982-2003 (Carver, & Candela, 2008). The definitions of these generations have been theorized and debated in the nursing literature. Some of the more popular, currently used definitions appear  71  below. It is felt in the current nursing literature that each of these generational groups tends to have characteristics and roles that are important to consider when examining the nursing workforce (Carver & Candela, 2008). The Veteran group has lived through a World War, experienced an extensive advancement in technology as it applies both to healthcare and general living, as well as changes to the family unit. It is suggested that individuals from this generation are often very loyal to their workplace and are willing to work hard. They want to know they are valued by their employer and are currently working towards impending retirement (Carver & Candela, 2008). The next group, the Baby Boomers has lived through the expanded democracy of the 1960’s, war protests, and the expanding roles of women in the workplace. The role of this group in the institution is often one of leadership. They have reached the top of the organization, often filling top-rank management positions and with their work ethic, plan to stay there. They expect to be respected for their work and want to be rewarded with benefits and increased pay (Swearingen & Liberman, 2004). The Generation X’ers are most known for their adaptation to technology, their experience of parental divorce, and their desire for work/life balance. They are looking to improve their skills and overall resumé. They are often independent and creative (Thompson, 2006). The last group, the Millennial Generation has lived through increased terrorism, the rapid advancement of technology for communication, and a refocus on parental involvement. They want to be well orientated to a work environment and desire constnictive feedback. They work well in groups and prefer to share responsibility with others (Carver & Candela, 2008).  72  5.3.2 Organizational Commitment The generation of which the nurse belongs, along with the way they are educated and socialized, plays a large role in the satisfaction of the nurse (Neal, 2003). The senior nurses in the focus groups for this study recognized that often new nurses showed their commitment to the profession in a different way then what they themselves were use to. Discussion on how new nurses are willing to change jobs more often and take on challenging roles earlier, speak to the differences in the generations currently in the workforce. Organizational commitment is thought to be predictable based on the generational cohort to which a nurse belongs. By considering the generation a worker is from, institutions may be able to focus on retention strategies for each cohort (Carver & Candela, 2008). In the article by Carver and Candela (2008) it is identified that, “True commitment is not just staying in a job, but being more satisfied, productive and engaged in the work” (p. 985). Institutions interested in keeping their nursing staff should consider the importance of organizational commitment in combination with the traditional measure ofjob satisfaction (Carver & Candela, 2008). By becoming involved in the Senior Nurse Mentor Project, the senior nurse participants in the focus groups showed that they were interested in continuing to be a part of the team by contributing to their workplaces. This commitment to the nursing profession could possible be enhanced by senior nurses receiving recognition for their knowledge and being given dedicated time and support for project work. By considering individual needs of the groups, it may be possible to increase retention. Carver and Candela (2008) give examples of these such as honor ceremonies for those in the veteran age group, ergonomic supports for the  73  Baby Boomer generation, flexible scheduling for the Generation X’ers, and rotation of leadership roles for those in the millennial generation. Although I do agree that the ideas presented by Carver and Candela (2008) could be helpful tools to increase organizational commitment, involving nurses, especially senior nurses in the development and growth of new nurses is something that has not been discussed in detail in the current nursing literature. The research presented in this thesis highlights how simply asking senior nurses what they would want to do and their ideas about how to improve their workplaces can yield simple solutions that allow for true engagement at the grassroots level. 5.3.3 Disunity Among Nurses The conversation on generation gaps is timely. Knowledge on the differences between generations can give senior nurses a better understanding of the challenges in their workplace. The senior nurses in this study were aware of the differences in work ethic, attitude, and team involvement of the newer nurses. One nurse commented on the newer nurse’s eagerness to work independently, “They want (newer nurses) to be up and running right away, they don’t realize that it takes many, many years to get there and they don’t like answering questions or asking questions because that sort of makes them feel like they shouldn’t be doing that (task).” Despite this knowledge creating a work environment that allows for cohesion of up to four different generations is challenging. Changes in nursing curriculum and the expansion of university education programs have led to a feeling that Neal (2003) describes as disunity among nurses of differing generations. Frustration and lack of communication between nurses from different generations can lead to ongoing problems  74  in the workplace that may leave some feeling dissatisfied (Neal, 2003). Conflict that can result from misunderstandings when more than one generation cares for patients as a team has led to discussion on ways to improve communication and teamwork. When a nurse chooses an area of practice, the knowledge that they will be accepted into the nursing team can have a substantial influence on their initial acceptance of a position and on their willingness to remain in that position (Thompson, 2007). By recognizing the existence of generational gaps, and educating nurses on the differences that exist between generations, it is thought that the different groups will be better prepared to work with and support each other (Kanaskie, 2006). Research has focused mainly on the identification of the generational issue and not on the possible solutions (Clausing et al. 2003; Swearingen & Liberman, 2004; Thompson, 2007). One idea would be to formalize education that could raise awareness of the problem and help the climate of the workplace. As part of a mentoring program, Latham et al. (2008) included education on generational differences for both the mentors and mentees in order to create an easier transition for the multi-generational pairs. By having communication on this topic it may be possible for more productive work and learning to occur in the workplace (Kanaskie, 2006). The fourth focus group question in this study asked senior nurses what supports would be required in order for them to be able to share knowledge/skills. Senior nurses identified a need to have support of management. In fact the need for management support was identified by at least one nurse in every focus group highlighting the importance of having leadership that understands the struggles of nurses on the front lines and is willing to help the different generations become cohesive. Managers,  75  especially at the front-lines, who must deal daily with the conflicts that may arise on the unit that are directly related to generational differences may also benefit from education in this area. The managers who were included in the focus groups for this study recognized that often there is a great deal of tension in the workplace between groups of senior nurses and new nurses. If managers want to increase not only job satisfaction but also organizational commitment they need to understand the differences in communication styles of all groups. The Carver & Candela (2008) article discusses that in light of the nursing shortage it is now as important for nursing managers to understand generational differences as it is for them to understand cultural diversities. This research presented in this thesis has shown that senior nurses value the support of their managers and understand that the attitude of workers in every age cohort can have an impact on the work environment. Additional research that involves the ideas of senior nurses and managers on generational topics could provide solutions to conflicts and issues of disunity that are currently occurring in the workplace. 5.3.4 The Role of Senior Nurses in Closing the Generation Gap The role of senior nurses in moderating the conflict created by generational gaps needs to be considered. Awareness by senior nursing staff and management of the need for their unit to overcome the differences among team members could allow for change to occur more easily. As discussed in section 4.3.2 under the theme of Attitude, many senior nurses in the focus groups identified the attitudes of not only the newer nurses but also the senior nurses as problematic. When the senior nurses were asked during the focus group what they would like to pass on to new nurses, one participant responded,  76  “For me it is attitude about accepting new grads and understanding them. In (the) emerg(ency department) it is tough. .when you hit the ground running to make .  the time, but we have to make the time so that they (new nurses) can become proficient too, so that they can relieve us or there isn’t going to be anybody.” Also discussed in section 4.3.2 under the theme of Attitude was the amount of negativity that new nurses are exposed to and how this can affect morale on units. One nurse noted just how the negative impact of the nursing staff could affect new nurses, who are just entering the workforce, “There is also the attitude that nursing is a good job, my daughter’s experience (daughter is currently studying to be a nurse) right from the first day she went to clinical (she witnessed) the bad, cynical attitude of nurses right on the floor. She said (her daughter), ‘They are so bad we come on the floor and there are eight of us with big bright eyes and you have a nurse moaning that they have arrived.’ That is not a way to keep them (new nurses) there for years, they just started and they are going to be gone tomorrow. It is all about the attitude.” Newer nurses are not the only ones who encounter abuse or negativity. A nurse manager participant during a focus group told the story of a newly employed manager having a senior nurse approach them and say, “I wonder how long it is going to take before you cry?” The nurse manager participant, one of only two participants in this particular focus group, goes on to comment that in a conversation about the situation it was noted that this nurse (and likely others) speaks to new people on their unit in a similar fashion and that this may explain the large amount of empty nursing positions on this particular unit.  77  These examples, along with many others from the focus groups, highlight the awareness of a problem. In nursing today there exists in many cases a system of bullying and horizontal violence in the workplace. In her research on disempowering relationships in nursing, Daiski (2004) identifies that in order to decrease abuse that is occurring in the workplace between groups, such as differing generations, it is vital that the change come from within the nursing profession. She identifies that managers have a role to play in creating non-hierarchical relationships that allow for the expression of nursing staff and input into policies and changes that directly affect nursing practice. She also identifies that nurses are indoctrinated into a culture where it is socially acceptable to,  “. .  .eat their young” (p. 46). During the interviews conducted by Daiski (2004) it was  noted that nurses both have memories of living through the difficult adjustment period to working as a nurse and also the awful treatment they were shown. At the same time, they were able to identify times when they had given the poor treatment to a new nurse, either not including them or allowing them to struggle unnecessarily (Daiski, 2004). Although it was not raised as a project idea during this study, senior nursing staff are often the official and unofficial leaders of their units, and it seems reasonable to consider them to have the power to change practice and attitudes. There will never be a complete elimination of conflict in the workplace but finding ways to manage its impact is vital. If senior nurses in conjunction with management (Weston, 2001) were to create projects that allowed for easier integration of new nurses into a workplace, this could have tremendous effects on retention of new staff (Mion et al. 2006). In the current study, 63% of senior nurses identified mentoring as how they would want to share their knowledge and skills. With the wide-spread abuse and conflict that is occurring in  78  nursing, where multi-generational differences and cultural norms support horizontal violence (Latham et al. 2008), it seems reasonable to the author to utilize senior nurses to not only mentor new nurses into the profession but to also mentor other senior nurses about successful integration of new staff. If one influential senior nurse was to change their practice and encourage others to do the same, workplaces would be able to become more cohesive and productive. These factors could only lead to better patient care and improved overall outcomes. Finding ways to embrace the generational differences and use these to the advantage of team creation should be the goal of healthcare institutions (Mion et al. 2006). Every nurse, no matter from which generation they come, has something to contribute and should be included. Senior nurses may hold the key to creating harmony and understanding in the workplace. 5.4 Mentoring 5.4.1 Focus Group Responses Results from the focus group data indicate that senior nurses have spent time with newer nurses and they are interested in continuing to do so. Responses to focus group Questions 1 and 3 predominately centered on mentoring. The first question asked senior nurses how they have shared their skills and knowledge in the past. More than one quarter of responses were related to mentoring. The third question asked the senior nurses to express what they would want to spend project time doing. Nearly half of the responses to this question (46%) were also related to mentoring. An additional 28% of responses had to do with working with peers in some format. The responses to focus group Question 1 and Question 3 show the senior nurses’ interest and belief in their ability to work with peers, primarily in the format of mentorship. In section 4.2.1 in the  79  sub-theme of teaching there is a quote that highlights the senior nurses’ confidence in their ability to influence the behavior and skills of a newer nurse. Partnerships built on trust and enthusiasm can only increase the practice environment of a workplace and allow for growth of the entire unit (CRNBC, 2005). Many senior nurses identified the importance of these partnerships not only to the newer nurse but also to their own growth and development. One nurse commented, “Over the years I have realized that I am in a learning relationship and that I learn as much from them as they do from me. You have to be open to that happening.” An understanding like the one this nurse has shown not only allows for growth of the new nurse but encourages learning opportunities for all nurses no matter their level of experience. 5.4.2 Orientating a New Nurse The senior nurses in this study raised issues about new nurses often being encouraged to go into advanced practice areas such as emergency, intensive care, or the operating room, directly out of school. This is due largely in part to today’s nursing shortage (Santucci, 2004). There are obvious difficulties in trying to ensure a successful transition of new nurses into advanced practice areas. It was stated in the focus groups that, “Specialty areas need more than just orientation in order to make them (new nurses) feel safe and secure.. .they need the practical aspects.” In order for the transition to be a smooth one from student to graduate nurse, many senior nurses in this study identified the need for mentorship that lasts longer than the typical orientation period now currently in place. Senior nurses noted that overall orientation alone was not preparing new nurses well enough, “(There is) lots of orientation but not as specific as it should be.. .nurses .  need to be not just orientated but mentored.” The introduction of new graduate nurses  80  into advanced practice areas has created many new challenges for new and senior nursing staff as well as management. Issues of staffing skill mix, availability of preceptors and mentors, and cost factors of prolonged orientation programs have all been discussed in the literature (Bally, 2007; Santucci, 2004; Moseley & Davies, 2007). By allowing senior nurses the opportunity to mentor new nurses, institutions may see benefits not only in the retention of nursing staff but also in terms of better patient outcomes as retention rates climb and the average skill level of nurses in the unit increases (Aiken, Clarke, Sloane, Sochaiski, & Silber, 2002). Currently, a typical orientation period for a new nurse is one to three months in duration. After this period, the new nurse is considered to be ready for independent work. Unfortunately, funding and organizational norms often do not allow for extension of this time frame or additional training (Leners et al. 2006). The results presented in this study echo the current literature that orientation needs to be increased or better support systems need to be in place for new nurses for a longer period of time. Senior nurses who participated in this study were willing to be involved in the development of new nurses’ skills and knowledge. Finding ways to involve senior nurses in the transition period of student to staff nurse has potential to improve the climate, of not only advanced practice settings, but all areas of healthcare that warrants further investigation. 5.4.3 Senior Nurses as Mentors Although the nurses in this study may not have understood fully the definitional differences between being a preceptor or a mentor and often used these terms interchangeably, they were able to identify what they saw as the role of the mentor. Most of the senior nurses felt that they would want to have the opportunity to spend one-on  81  one time with a newer nurse. How they viewed themselves using this time varied but common themes included helping new nurses to create learning plans and identif’ knowledge gaps; having them shadow the senior nurse in order to learn how to care for complex patients; and encouraging their ability to advocate for patients. One nurse summarized it by saying, “(I) could help them go through an educational pathway, help them to be comfortable with skills and expectations.” Senior nurses also identified the complexity of learning critical thinking skills and how experience plays a large role in building this competency. This was another example of an area that senior nurses felt they could pass on their knowledge by, “probing the new grads to go through thought process and connect the dots for the clinical process.” The reality of the current situation dictates that newer nurses will continue to need to be hired into more complex areas. With the current nursing shortage, methods of improving staff recruiting and retention must be given serious thought. The article by Latham et al. (2008) focuses on the role education can play in making the transition from student to new graduate nurse easier for all involved. It was noted by 13% of the senior nurses in this study that in order to feel confident to be a mentor for newer nursing staff they would need additional education for themselves. The first item they identified was education on adult learning principles. Many senior nurses stressed that they did not have formal training in adult education and would like to be given the opportunity to expand their knowledge in this area before attempting to teach new nurses in a prolonged mentorship experience. By providing these nurses with additional support, the workplace gains an educated nurse who has the  82  experience and skills that are needed to allow for the transition of new nurses successfully into the profession. 5.4.4 Support for Mentor and Mentee In order for project ideas presented in the focus groups that involved mentoring to be successful it was identified by many senior nurses that additional education and support would be needed for both the mentor and the mentee. Senior nurses in this study identified that in order to feel confident to participate in a mentorship program they would like to have a mentor or support system for themselves. The identification of this topic was two-pronged. First many senior nurses who felt inexperienced at providing formal mentorship wanted to ensure that they were completing the task appropriately. Secondly, the senior nurses wanted to ensure that they would have the necessary support to complete a mentorship, which included enough time to spend with their mentee away from the demands of their regular workload. One nurse expressed this by saying, “Lots of support for the mentors (is needed) because the reality is that they (senior nurses) must always mentor, it is just the way of the world of nursing now and there will always be pressures (to mentor).” Education for mentors on how to create a successful mentorship experience has been researched. Latham et al. (2008) stress the importance of not only providing education to the mentors about the experience but also to the mentee. In Latham et al. (2008), classes were held for the mentor and mentee pair that covered topics such as the value of mentoring, the differences between mentorship and preceptorship, the issues of cultural differences, and how to problem solve. Goals were set together and expectations were defined. All of these items allowed for an improved transition into the mentorship  83  program for both sides (Latham et al. 2008). Unfortunately, the authors did not provide education on the issue of generational gaps, which may have further improved the mentor/mentee relationship. The research presented in this thesis shows that senior nurses are willing to become mentors and this adds to the current literature the idea that with some support and education, nurses who are nearing retirement could have an opportunity to share their knowledge and skills with new nurses before they are gone. The actual use of senior nurses as formal mentors and the outcomes from such work warrants continued research in the future. 5.4.5 Time to Mentor Many nurses in this study expressed their concern over competing interests due to the nursing shortage and were keen to be given dedicated, protected project time that would allow them to meet high standards for mentoring. When questioned about the amount of time required and how this time should be organized (focus group question 5), senior nurses identified that either blocks of time or flexible scheduling would work best. Most nurses answered this question through the lens of wanting to complete mentorships with newer nurses who would require regular meeting times and possibly support during shifts on the ward. Senior nurses had not been asked in the current literature how much time they feel they would need to complete mentoring projects and this study provides insight into the time commitment needed from both the senior nurse and management to make such projects reality. 5.4.6 Finding a Mentorship Fit Senior nurses in this study were very interested in mentoring as part of their project work but there was no discussion on how mentoring would be set up or  84  mentor/mentee matches decided. Despite obvious enthusiasm from senior nurses to mentor issues of generational gaps and the conflict that can arise from mentoring need to be considered prior to a system for pairing mentors and mentees is adopted. Simply put, it needs to be considered whether or not senior nurses are the most suitable choice for mentors of newer nurses who are from differing generations and who may have different values and visions of what nursing is. Although there discussion in the current nursing literature about how to best match mentor and mentees, further discussion on this topic with senior nurses may produce novel concepts. As discussed in earlier sections of this thesis, finding ways to have various generations work together can be difficult (Carver & Candela, 2008). Even with education and training for all groups involved, fundamental differences in beliefs that could be overcome in a team environment may persist when working one-on-one. In nursing, change is often slow and although there may be more than one way to complete a task, unit culture tends to dictate what is right or wrong, often overriding best practice (Berwick, 2003). If these issues can be tackled through advanced education for both mentor and mentee and by persistent follow up and encouragement by management then overcoming the generational gap in order to produce successful mentorships is likely possible (Thomka, 2007). 5.4.7 Positives of Mentorship By increasing involvement of senior nurses in the workplace, units have much to gain. Many senior nurses in this study were not currently involved in formal mentoring programs and identified that formal mentorship programs did not currently exist in their institutions. It should also be noted that many nurses mentor informally with no support  85  or acknowledgement from their institution as was identified in focus group Question 1. With that knowledge, it could be considered that although mentorship is not the only possible solution for bridging the gap between different levels of nurses, the interest from senior nurses in this study shows, that if done properly, it has potential to create change in the current workforce. Funderburk (2008) identifies that there are many positive outcomes for the participants of mentorship. For the mentor, there is development of self-awareness, building relationships with professional colleagues, and stimulation to question practice. For the mentee there is the familiarization with the institution, increased self-confidence, development of problem-solving skills, and insight about unwritten rules and politics (Funderburk, 2008). Therefore, it is possible that the provision of education for potential mentors may aid in the formation of relationships between newer and senior nurses. Bryson (2005) points to the value of mentorship in the development of quality practice environments. By creating mentorship programs it is identified that nurses are able to enjoy increased job satisfaction. The connection between these two ideas is made by considering that mentoring allows senior nurses to practice in an expanded scope which can lead to increased overall satisfaction with the profession. If nurses are made to feel that they are powerless or undervalued, their commitment to their workplace may be limited (Bryson, 2005). By allowing senior nurses to mentor newer nurses, their reputation and prominence in the unit may be increased. This study, unlike others in the current literature, asked senior nurses what they think is valuable to spend their time doing, with the understanding that their time as working nurses will soon come to an end. Capturing the passion and interest of these senior nurses has allowed this study to fill a  86  gap in the literature. This study sheds light on the fact that senior nurses want to be involved in the development of new nurses and also the types of resources they will need to make it possible. 5.5 Project Resources In order to make senior nurse projects reality, resources are necessary. Two of the  focus group questions focused on measures that senior nurses felt they would need for project success. Question 4 asked senior nurses what they felt they would need personally to complete projects and Question 6 focused on what the senior nurse’s thought their practice area would need for support. Currently in the literature, very few studies have asked nurses what resources are needed to complete projects or make changes in their workplaces. The engagement of senior nurses to uncover the needs of their workplaces provides insight into the possibilities of bringing project ideas to life. 5.5.1 Time Senior nurses identified time as the most necessary resource for both Question 4 and Question 6. Having time to prepare and complete projects was considered to be vital to the success of projects. On an individual basis nurses identified that if they were to try to complete projects without dedicated, protected time, they would end up not being able to devote the time to the project that it would need, noticeably mentoring projects. In terms of the theme of time as an answer for what the unit would need for support, senior nurses pointed to the need for their time to be replaced by other nurses. Senior nurses were not keen on the idea of leaving the unit short staffed in order to work on projects. The reality is that in many cases there may not be anyone to replace senior nurses who want to do project work. This leaves senior nurses and management with tough decisions  87  on how to prioritize and choose between responding to staff shortages versus implementing senior nurse projects that will have a long term effect on the entire unit. 5.5.2 Manager Support Many senior nurses also expressed the need to have managers support their projects. In order to know if projects have potential of succeeding a senior nume commented, “Whatever program was put in place the managers would have to agree to allow flexibility of their staff to provide the opportunity for students because obviously it takes time away from your work.” This quote shows the senior nurses’ awareness of the vital role of management. Since many senior nurses identified mentoring as the type of project they would like to work on, it is also important to note the role of managers in this type of work. Bally (2007) notes that mentoring needs to be considered a long term strategy that has benefits of staff retention, job satisfaction, and better patient outcomes. Managers need to understand the overall value of projects, such as mentoring, and include this in long term planning for their units. Awareness of the benefits of such project work could be utilized by managers to lobby for an increase to overall resources in their units or for institutions to take on creation and management of projects that could benefit the entire organization, such as an institution wide mentorship program. 5.5.3 Support of Peers Senior nurses also noted that they would need to have support from their peers in order to have their projects be successful. If nurses were to mentor newer nurses as their project work, their co-workers would likely be aware of this. Some nurse mentors may even spend time in the unit with their mentee. The visibility of the mentoring role means that senior nurses could face scrutiny from their peers. If there is disunity on the unit and  88  a culture exists that does not welcome newer nurses, senior nurses who show interest in newcomers may themselves become outcasts (Neal, 2003). Prior to beginning project work, such as mentoring, it may be necessary for senior nurses to spend time preparing their units. Opening up communication on units about norms and acceptable behaviors could be completed by senior nurses with the assistance of managers. If senior nurse project work can create cultural change in the workplace, the lasting effects from this could be beneficial for years to come and will ensure the long-term sustainability managers will want to see attached to these projects. 5.6 Innovation and Change  5.6.1 Senior Nurse Involvement in Change Change is known to best be disseminated when it is simple and reflects the realities of the situation (Berwick, 2003). Recognizing that change is necessary and possible is only a small piece of what is required for sustainability. It is important to consider that, nurses who work on the frontlines and know the dynamics of the work environment could be useful in helping to create and sustain changes. Senior nurses have shown in this study that they are motivated and interested in being involved in projects that benefit their places of work. One senior nurse commented, “We need to start to leave a legacy behind because most of us will be gone in the next 5 years. Self learning modules could help to capture some of that knowledge so that new staff has some tools to start to work with.” Changes that originate from management may include creative ways to solve problems, but they don’t necessarily resonate with frontline nurses. Senior nurses could filter the information that is provided and examine how the ideas fit with their current work  89  environments. One nurse commented on her frustration saying, “Nurses at our level (bedside) should be the people to do it (make change), it shouldn’t come from the top down. it requires a cultural shift.” Senior nurses want to be involved in the changes that . .  have a direct affect on their work, finding ways to involve these nurses, such as asking for there opinions as we have done in this study, could be very valuable in addressing the real needs of workplaces. 5.6.2 Adapting Other Ideas When management is deciding on what changes to implement, the buy-in and acceptance of the change may not be as good as it would be if senior nurses are involved. Senior nurses know their work environments and the needs of their area well. Senior nurses in this study were able to identify specific and broad changes are needed to current systems in their workplaces. Some nurses expressed interest in attending conferences to share the successes their own workplace has had and to learn about what has worked in other locations. Finding ideas from others and adapting them is key to moving forward and something that senior nurses could assist with. Adaptation means that an idea from one place is morphed into something this is manageable for another area of practice (Berwick, 2003). This often happens when nurses find simpler, faster or more efficient ways of using a suggested change (Berwick, 2003). Physical space, numbers of staff, patient flow, types of services offered, and lack of resources have been reasons that adaptation may take place. Although it may be difficult to overcome all of these barriers, if senior nurses are able to have input into decisions about changes, more may get accomplished (Kanter, 1997).  90  5.6.3 Finding Innovative Ideas Collaboration with others plays a role in not only finding innovative ideas but creative ways to disseminate them. If a culture is created where a nurse who attends a conference or inter-agency meeting is able to actively look for new ideas, the organization is likely to benefit (Kanter, 1997). Nurses did express interest in activities such as conferences and some stated they had found it beneficial when they had attended these in the past. One nurse commented, “I have presented at conferences and not only for nurses but also for the general public which has been very interesting.” The next important step in this process is the sharing of these ideas with the people in positions of power. The senior nurses in this study expressed their belief in needing to have support of management to make project work successful and noted that forming a solid relationship with the manage is vital to moving forward. Nurses need to have access to their leaders in order to pass on what has been learned to encourage uptake of ideas within the institution (Kanter, 1997). There also needs to be resources in place to encourage imagination of nurses who acquire these ideas to have time to be able to formulate how they could be implemented into their workplaces (Kanter, 1997). All of these activities could possibly be performed by a senior nurse who often has access to peers in different areas or who would be willing to attend meetings where collaboration could occur. To ask senior staff to assist with finding ways to implement change is one thing, but as we have seen in this study, asking these individuals to think of innovative ideas proves more difficult. Innovation or new ideas play a key role in choosing changes to implement (Berwick, 2003). The answers to the focus group questions would not be  91  considered by many to be innovative. Most of the answers focus on what the senior nurses are already doing or have done in the past. There were not a lot of categories created in the results section purely based on the fact that many of the nurses said the same thing. For instance mentoring was mentioned in every focus group and often dominated the conversation—what they liked about it, what they thought could be done better, how they would like to fill the role of mentor, their past mentor experiences. Considering what it takes to be innovative it is not surprising that senior nurses’ responses were not far reaching in scope. Innovation is challenging and often not encouraged in hierarchical, management driven settings. In a book by Kanter (1997) it is discussed that innovation is stifled for many reasons in institutions, such as isolation of “mavericks” or those who seek change; lack of resources and time for anything new; lack of imagination; and having departments or staff competing against each other. Despite this, innovation is valued by topperforming organizations and the literature (Berwick, 2003). It is first important to understand that change most often comes from the outside (Berwick, 2003; MacPhee, 2007). In order to acquire a vision that is broader than your own, it is important for people to have different experiences and learn other view points (Kanter, 1997). Senior nurses in this study expressed interest in being exposed to new ideas and being involved in projects that would be new for their areas of practice. These findings should be considered by managers and institutions when they are trying to choose new initiatives and projects since involvement of senior nurses has the potential to change the outcomes in a positive way.  92  5.6.4 Senior Nurses as Early Adopters Berwick (2003) describes the difficulties and challenges faced when trying to adopt changes. One senior nurse noted, “Things often start out well and then fade into the background because there is not time, the other work gets in the way.” Presently, we may not be able to expect our senior nurses to be innovative within their current institutional and workplace restraints; they could fill the role that Berwick (2003) describes as early adopters. Early adopters are those who are willing and interested in utilizing innovation they are considered to be trend setters (Berwick, 2003). It almost seems counter-intuitive to consider this concept in relation to senior nurses. If not the influence of the technological age alone, society often assumes that it will be the younger people who quickly adopt new ideas. If senior nurses were utilized as early adopters and encouraged to collaborate with innovators, a greater sphere of influence could occur (Zimmerman, Lindberg, Plsek, & Edgeware, 1998; MacPhee, 2007). Berwick (2003) discusses how early adopters need to have access to what he calls the early majority, or those who will adopt change quickly once the early adopters show it is worthy. He emphasizes that in order to reach the early majority it is important for communication to happen through, “social channels” (p. 7). For senior nurses who often have large peer groups at their workplace, utilizing them as early adopters makes even more sense. Disseminating change takes time and requires commitment. The more buy-in that is possible early on in the process, the faster the uptake will be (Berwick, 2003). Having change be successful quickly could aid in the practice environment of a unit, where many nurses find differing practices frustrating and confusing (Garb, 2001). Involving senior nurses in roles that allow them to be part of change from the beginning could be a  93  wonderful way to acknowledge their skills and influence while making a quality practice environment possible (Garb, 2001). The interest of the senior nurses to work on projects that will improve the environment of their workplace shows that utilizing senior nurses in change projects warrants further investigation and possibly trials of senior nurses as early adopters in order to test the theory presented here. 5.7 Study Limitations 5.7.1 Number of Participants The power of a study of this nature is increased with larger numbers of participants. In the current study, 47 individuals participated in the focus group sessions; 40 senior nurses and 7 managers. While this number of participants allowed for the collection of a great deal of data, it is possible that information provided by the focus group participants may have been different had the group sizes been larger. Invitations to the focus group sessions were sent out to a large group of senior nurses, however only 58% of those chose to participate. With a participation rate ofjust greater than half, we were unable to capture the opinions of a large cohort of additional nurses. To the author’s knowledge, there are no previous studies that have completed focus groups with the goals of collecting similar information, resulting in the lack of a benchmark cohort size for a study of this nature. To address this study limitation, an additional set of focus groups could be conducted with a different cohort of senior nurses, possibly from different surrounding healthcare institutions, with a subsequent comparison with data from the initial focus group sessions.  94  5.7.2 Focus Group Questions The questions used during the focus group sessions were organized in advance by the project committee. It was because of this that the author was not able to make adjustments to the questions or ensure that the questions reflected the current findings in the literature (Morse et al., 2002). Six questions was a large number to discuss in a short, one hour sessions with the nurses. Conversation at times had to be cut short in order to ensure coverage of all of the questions. Although the committee was careful to choose questions that did not use the term mentoring, the title of the program and details that were given in both the consent form and focus group question list may have had some influence on the participants of the group when they were formulating their answers. Since many of the nurses brought up ideas at first that were purely projects around the concept of mentoring, some probing for additional ideas may not have allowed the process to be as organic as I envisioned within a focus group setting. 5.7.3 Focus Group Method Focus groups were the chosen methodology for collecting data from the group of senior nurses who participated in this study. Although focus groups can provide information from a large group of people quickly, there are dynamics of a focus group that may not have been ideal for the information that this study sought to collect (Pout & Beck, 2008). For example, it is possible that some people may not be comfortable sharing their opinions in a group atmosphere, therefore contributing to a lack of participation by these individuals (Creswell, 2004). In addition, given that some individuals may not wish to speak in a focus group session, it is possible that  95  participation rates were decreased as a result of a non-willingness to share opinions with a group. Focus group data may not be as diverse as the data that would be collected under a different method due to the nature of focus groups, where participants are exposed to others ideas. This exposure may lead to similar responses being received more often. Since the goal of this study was to gain a general understanding of themes that were important to senior nurses, consideration of the dynamic of the groups themselves is not seen as a limiting factor at this time. In order to further validate findings from this study, it may be worth considering additional research being conducted with senior nurses in a different format, such as one-on-one interviews, that may allow for a different dynamic for communication. 5.7.4 Presence of Managers The level of participation in the focus groups may have additionally been affected by the presence of managers. It is possible that some nurses may have felt disempowered to speak with someone from management in the room. The power structure involved in the nurse/manager relationship is complex and may have had a greater impact on the results of the focus groups than was originally anticipated. One particular example of how this relationship dynamic affected senior nurse participation is highlighted by the following observation. A single nurse had attended one of the sessions and was actively participating in answering the questions. Approximately 30 minutes into the one-hour group session, the manager arrived, causing an immediate shift in the dynamic of communication. The senior nurse became quiet and waited for the manager to answer questions first before responding. The senior nurse’s responses were remarkably shorter  96  in the second half of the focus group than the first. This example suggests that having managers attend these focus groups may have skewed the data in some way. Fortunately, manager participation was low, with this group being present at only half of the focus groups and in most cases there were a greater number of staff nurses at the focus group. The larger presence of staff nurses seemed to allow for comfort of senior nurses to answer the questions without considering that there was a manager in attendance. Research has identified the importance of participation and buy-in from managers (Greene & Puetzer, 2002). The goal of having the managers attend these focus groups was to ensure they were aware of the nurses’ needs and could have input into the focus group question, about resources to allow senior nurses to complete projects. Despite this, collecting managers opinions at a separate time or having discussions with them about the preliminary results of this study may have been more appropriate then having them attend focus groups with the senior nurses. 5.7.5 Data Collection and Analysis All focus group participants were recruited at once and focus group sessions were pre-arranged. Due to these factors determining if the data collected had reached saturation and deciding if more or less focus group sessions were necessary was not possible (Morse et al., 2002). Data saturation is defined by Morse et al. (2002) as, “replication in categories; replication verifies, and ensures comprehension and completeness” (p. 12). In order to ensure data saturation is reached, an appropriate number of participants are necessary. In the case of this study, there were common themes and sub-themes noted which does indicate a level of saturation was obtained.  97  Despite the author’s triangulation with other researchers, the data was not taken back to the participants for verification and this made it difficult to determine if the decisions to group the data into specific sub-theme categories was valid. Discussion in the current nursing literature does however imply that returning data to the participant for verification can be problematic (Morse, 1998). Through the process of content analysis, data is categorized into themes and often closely linked words or phrases are grouped together (Krippendorf, 2004). This may make it difficult for a participant to recognize their own ideas inside of the data set and them unable to verify the data (Morse, 1998). Content analysis itself is subjective even with the guidelines that were followed from the literature (Krippendorf, 2004; Neuendorf, 2002). Although agreement was reached by the researchers working on this project, there remains the possibility that another researcher would have created different sub-themes and themes with the same data set (Krippendorf, 2004). 5.7.6 Responses of Senior Nurses Although the senior nurses’ responses to many of the focus group questions may not necessarily be considered novel or innovative, it does show their level of commitment to the profession of nursing and interest in being involved. Most of the senior nurses responded to questions with answers that were closely related to what they had experienced. For instance, many senior nurses provided an answer of working with or mentoring students or new nurses for the Question 1. Answers for the Question 3, which asked senior nurses how they would want to spend their project time, identified primarily projects that involved working with new nurses or providing one-on-one mentorship.  98  This falls very closely in line with what they had previously discussed in the first question and related to what they previously experienced. The range of creative ideas for projects was limited possibly due to the project title and questions. It would be interesting to know what could have happened with a different title and more open-ended, less leading questions. If mentoring still came up as a potential contribution by senior nurses this would allow for verification of the importance of mentoring as their primary interest for spending project time. 5.8 Recommendations Many ideas presented in this study highlight senior nurse willingness and enthusiasm with becoming involved in project work that has a direct impact on their workplace. Asking senior nurses for their opinions and ideas is a valid method of collecting information about current practices of nurses and conditions of their work environments. More qualitative studies that allow for expression of senior nurses could provide greater insight into the current challenges and potential solutions of healthcare problems. Included in this research could be topics such as senior nurse involvement in implementing best practice guidelines, creating a culture where safety of patients and staff is central to all aspects of work-life, and reducing barriers to communication between nurses and other health care professionals. Aside from these potential areas for input, senior nurses in this study expressed their interest in acting as mentors for newer nurses. In a time when fmding nurses to employ is challenging, any method that can be utilized to recruit nurses needs to be explored. Many studies have pointed to the success of mentorship programs in retaining and recruiting staff (Green & Puezter, 2002; Beecroft et al. 2006; Latham et al. 2008;  99  Leners  Ct  al. 2006). The beliefs of the senior nurses in this study echo the findings in the  current literature that show how mentoring can increase the morale and practice environment of a workplace (Bryson, 2005). Senior nurses are aware of the nursing shortage. Many of the participants in this study continue to work on the front lines of healthcare where the shortages are most immediately felt. Finding ways to actively recruit new nurses is something that hospitals need to invest in possibly by using senior nurses. Whether it is speaking to students at schools about nursing, or mentoring a new graduate nurse one-on-one, senior nurses have expressed in this study that they feel they are able and prepared to be involved. Managers of healthcare institutions need to consider the magnitude of this offer and fmd innovative ways to use this group of multitalented nurses to their full advantage. Senior nurses were also careful to point out that they are tired of trying to mentor and help new staff with limited resources. To adequately mentor a newer nurse, participants of this study highlighted the need for dedicated time and commitment from all involved, including management. Release time for senior nurses to work on projects or to provide mentorship in a meaningful way was one requirement most highlighted by the senior nurses. Before committing to projects for senior nurses, it is recommended that institutions provide senior nurses with the resources necessary to complete their work. Additional research on the time demands of mentoring and how best to supply the mentors with sufficient time to participate fully in a committed mentorship role may lead to an improved understanding of how best to implement such a project.  100  5.9 Conclusions Senior nurses play a tremendous role in the healthcare system. The senior nurses who participated in the focus groups for this study were able to articulate their commitment and desire to improve the nursing profession. This study has closed existing research gaps by showing us how senior nurses want to contribute their knowledge to the practice environment. There are limited studies that have asked senior nurses these types of questions. The information gathered in the study can be used to inform future research involving senior nurses on a variety of topics and has shown the value of obtaining input from senior nurses who understand the current challenges of the clinical setting. The senior nursing group has seen nursing change dramatically over the years, from hospital-based education programs to university-based; from a medically driven system to one of collaboration; and from a skills emphasis to a patient-centered evidencebased focus. Senior nurses now also work with multiple generations and must find ways to navigate the differing values and ideas of the varying age groups. Awareness of the issues of unit disharmony and bullying, were identified during the focus groups as items of concern. Senior nurses expressed interest in passing on their knowledge and skills in the form of mentoring newer nurses. Challenges with creating and regulating a mentorship program do exist, along with issues of overcoming generational gaps. In order to complete any project work, nurses were clear that they would have needs in terms of dedicated time and support. One of the strengths of the senior nurses in this study was their ability to recognize the importance of change and their willingness to try and influence change.  101  Organizations and leaders must find ways to utilize these nurses so that they are able to encourage an uptake of new ideas and foster an environment that allows for innovation. No study is without limitations. This study does provide insight into the ability of senior nurses to assist with problem solving and their desire to be involved. With the use of different methods, senior nurses could be included in future research studies that may look at how else to expand their role and what leadership activities may be possible. Finding ways to capture senior nurses’ skills and knowledge before retirement is vital in the current nursing shortage. Research that is focused on their desire and ability to be involved is important. Senior nurses have the ability to provide unique information that could only be formulated after many years of practice. There willingness to share this with the next generation of nurses is both inspiring and exciting. Hopefully the knowledge gained in this study will help us engage senior nurses more effectively before they retire. Without this group to support the practice of today, the nurses of tomorrow will have a much tougher road ahead.  102  References Aiken, L., Clarke, S., Sloane, D., Sochaiski, J. & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal ofthe American Medical Association, 288(16), 1987-1933. Andrews, M. & Wallis, M. (1999). Mentorship in nursing: A literature review. Journal ofAdvanced Nursing, 29(1), 201-207. Anthony, M. K., Standing, T. S., Glick, J., Duffy, M., Paschall, F., Sauer, M. R., Sweeney, D., Modic, M., & Dumpe, M. (2005). 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FOR WHAT: to take part in a sirortiocus groupto discuss bDwlean-irg at the silt/site can be enhaiced and the ide that you could clay in Ills.  WHY: to inform the design of the senior nurse Cover 55) portion of the Eäicatr Patway project Nurses tahd, part lithe focus groups wd be elgible, abng with others, to ply to be selected as one of the 30 F4isjRPNs employed by Vancotneer Coastal Dr F -ramydays is  These itiliat. s will be develcp .ictui with your manager r • 1 Ihern. Managers will be frwfled tic. the focus groups with you.  WIEP& ‘focus groups viii take Øace fl FetruarØAarch. In crder to clan these, we need to esaess htereth soon. ‘tawaism rd rekadnti inaNe .:5  1  if ycu cc interested in particiØa&ig in a focus group clease ccritact [lena Cathy at 604 875 4111 bed 63145 or Uaiacaffreyach.ca tti February 15, fl8wto the folcrwhg infomra&n: • Name • trksite • Wrbal confirmation of ageSS redder * Manager% name • Fhone nunter • Email address if appIbable  v*dfl  For more information ci the Edtroator Pathway project visit your health authority intranet: Fraser Health htaret click cci Education & Pesouroes %roII than to PrUfessional Practice & litegratbn, scroll a Itlie further rid then> ckkon ff4 I6?F* EducatorCareer Pathway Project. VarrowerCoastal Heath: htwwxchaclWrd*ti .sthwayage338O3.hhn.  .jtpporWedttatoraeer  sea.  116  Appendix C  Preparing a Nursing Workforce to Advance Health Services: A 3-Year Pilot Project to Build Nursing Educator Capacity in the Health Authorities Funding: Human Resources and Social Development Canada Senior Nurses Focus Group Questions  The primary goal of this focus group is to gather senior nurses’ input regarding their role in enhancing the learning environment in their areas of practice and in the design of the Senior Nurse Mentor portion of the Educator Pathway Project. We are also interested in the input of the managers of senior nurse participants and we ask that managers consider these questions in terms of informing the committee of the context of the supportive role they engage in with the nurses and identifying resources to support the nurses on their projects. Please reflect on the following questions in preparation for the taking part in the focus group: 1. Have you ever had the opportunity to share your nursing practice skills/knowledge at your workplace in a unique and effective way? If you have, please describe it. 2. Many nurses have described aspects of their practice that they are keen to share with others. What would this be for you? For example, it could be knowledge, a skill, an attitude, or anything else that you think is important. 3. If you were given an opportunity (e.g., 30 days over the next year) to share your knowledge/skills, what would you like to do? 4. What supports would you need to be able to share your knowledge/skills? 5. Given a maximum of 30 days over the year, how would you see the time being used? (Please provide examples of possibilities such as: two blocks of 15 days, one day per week for 30 weeks, etc.) 6. What would your area of practice need to support these ideas?  117  Appendix D  h iaiü i’fraserhea1I Better health. Best health care.  CD?l1A The Best Place on Earth  UNIVERSITY OF BRITISH COLUMBIA  te  Thomoing weUnesa. Ensw-ir1g care,  Canadi  Ihb1 University  N  BargainingAsseclatlon  HEALTH  .  Preparing a Nursing Workforce to Advance Health Services: A 3-Year Pilot Project to Build Nursing Educator Capacity in the Health Authorities Funding: Human Resources and Social Development Canada INFORMATION & CONSENT  —  Senior Nurses & Managers FOCUS GROUP  Principal Investigators: Fraser Health: Cora McRae, Clinical Practice Consultant, Professional Practice & Integration Vancouver Coastal Health: Pat Semeniuk, Director of Learning & Career Development UBC: Maura MacPhee, Assistant Professor, UBC School of Nursing UVic: Jane Milliken, Associate Professor, UVic School of Nursing Contact Information: BCNU: Patricia Wejr, Senior Policy Analyst, BC Nurses’ Union. 604-433-2268 Ext. 2105 VCH: Linda Frost, Project Manager, Educator Pathway. 604-875-4111 Ext. 68895 FH: Cora McRae, Fraser Health Project Lead. 604-953-5112. Ext. 69089 UBC: Maura MacPhee, Assistant Professor, UBC School of Nursing. 604-822-2891 UVic: Jane Milliken, Associate Professor, UVic School of Nursing. 250-721-7964 A partnership between Fraser Health (FH), Vancouver Coastal Health (VCH), the University of British Columbia School of Nursing (UBC), the University of Victoria School of Nursing (UVic), and the Nurses’ Bargaining Association (NBA) has been established to develop, implement, and evaluate an educator pathway for nurses. This educator pathway will include novice preceptors, advanced preceptors, senior nurse (over 55 yrs) mentors, expert clinical mentors, and advanced practice nurses in education faculty roles. These nurse educator resources will be shared between the practice and academic sectors, and over 3 years, major goals include increased education supports for nursing students and staff, and ultimately, the creation of a quality learning environment for students and staff.  Senior Nurses and the Educator Pathway The senior nurse has accrued vital knowledge and skills over years of service that make her/him an invaluable and essential part of the learning environment. An important goal of the Educator Pathway, therefore, is to facilitate and augment the role of nurses over the age of 55 in enhancing the quality of the learning environment on their unit or site. To this end, we are developing a 118  mentorship initiative designed to support senior nurses to pass on their indispensable knowledge. We are conducting focus groups to gather senior nurses’ input regarding their role in enhancing the learning environment in their areas of practice and in the design of the Senior Nurse Mentor portion of the Educator Pathway Project. This focus group will consist of nurses over 55 and nursing managers. We are interested in the input of the managers of senior nurse participants and we ask that managers consider the focus group questions in terms of informing the committee of the context of the supportive role they engage in with the nurses and identifying resources to support the nurses on their projects. Focus group session will last no more than one hour. For focus group participants who attend a group on a day off from work, we are offering a $50 honorarium. Refreshments will be provided for participants during the group session. By participating as a member of a focus group, a breech of confidentiality is an identified risk to you. Precautions are in place to protect your confidentiality, but due to the nature of the group format, only limited confidentiality can be provided. When you participate in the focus group, please respect the privacy and confidentiality of other participants’ comments and opinions. An audio recording of the focus groups will be made for the purposes of analyzing the content of the dialogue for general themes. Specific names and/or personal identifiers will not be included in any data documents, presentations, or written material, including the final report. The audio recordings will be stored in a secure location for a period of five years, as per research protocol. Only the primary investigator, the program manager, and research assistant will have access to the locked file where the audio recordings will be stored. At the end of the required 5-year storage period, audio recordings will be destroyed and any written records, such as consent forms, will be shredded for disposal. There is no actual or potential conflict of interest on the part of the investigator or the funding agency. Your participation (consent for us to use your focus group information) is entirely voluntary and will not affect current or future employment with Fraser Health, Vancouver Coastal Health, UBC, or UVic. You may choose to withdraw from this study at any time without concern for adverse consequences. However, because an individual’s contributions to the group conversations will not be identified, the comments you made prior to withdrawal cannot be deleted from the data and will be used in the analysis.  119  Please feel free to contact the following co-investigators if you have any questions about the research study: VCH: Linda Frost, at 604-875-4111 Ext. 68895 FH: Cora McRae, at 604-953-5112 Ext. 69089 UBC: Maura MacPhee, at 604-822-2891 UVic: Jane Milliken, at 250-721-7964  I -  -  VCH/IJBC: Research Subject Information Line, UBC Office of Research Services, at 604-822-  8598 UV1c: Human Research Ethics Office, at 250-472-4545 or email to ethics@uvic.ca  CONSENT Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study. NAME OF PARTICIPANT (printed): SIGNATURE OF PARTICIPANT: DATE OF PARTICIPANT’S SIGNATURE:  Fraser Health Participants: NAME OF FH PROJECT LEADER (printed): SIGNATURE OF FH PROJECT LEAD: DATE OF FH PROJECT LEAD’S SIGNATURE:  120  Appendix E DATA CHARTS  QUESTION I WORKING WITH PEERS Mentoring/Preceptoring Teaching Students GoTo Skills Orientation RESOURCES Policy Work Materials FACILIATION OF CHANGE Leadership Presenting Research Committee  #of Responses 75 28 15 12 10 5 5 4 2 2 28 3 9 2 14  %of Total Responses 70% 37% 20% 16% 13% 7% 7% 4% 50% 50% 26% 11% 32% 7% 50%  Question 2 NURSING WORK LIFE Working as a Nurse Adjusting to Being a Nurse Orientation Mentorship Role Modeling Giving Feedback ATTITUDE Attitude KNOWLEDGE AND SKILLS Knowledge Development Nursing Skills Equipment Use COMMUNICATION Working with Families Working with Patients Communication  # of Responses 95 8 29 5 38 8 7 26 26 34 22 10 2 24 4 3 17  % of Total Responses 53% 8% 31 % 5% 40% 8% 7% 15% 100% 19% 65% 29% 6% 13% 17% 13% 71% 121  QUESTION 3 WORKING WITH PEERS Mentorship Education Orientation GoTo RESOURCES Materials Policy Update FACILIATION OF CHANGE Committee Leadership  QUESTION 4 LOGISITICS Time SUPPORT Support from Management Additional Staff Support from Peers Collaboration EDUCATION AND TRAINING Additional Training Mentor for Themselves  QUESTION 5 BLOCKS OF TIME FLEXIBLE SCHEDULING MORE TIME LESS TIME  #of Responses 67 42 15 5 5 17 13 4 7 5 2  #of Responses 31 21 10 28 12 7 6 3 9 6 3  #of Responses 23 10 4 I  %of Total Responses 74% 63% 22% 7% 7% 19% 76% 24% 8% 71% 29%  %of Total Responses 46% 68% 32% 41% 43% 25% 21% 11 % 13% 67% 33%  % of Total Responses 61% 26% 11% 3%  122  QUESTION 6 LOGISTICS Time Support Materials Funding Technology SUPPORT Staffing Managerial Support Front Line Nursing Support EDUCATION AND TRAINING Adult Education Theory Orientation for New Hires  #of Responses 23 15 4 3 1 32 13 13 6 10 3 7  %of Total Responses 35% 65% 17% 13% 4% 49% 41% 41% 19% 15% 30% 70%  123  Appendix F  ETHICS APPROVAL  I Ui3C  The University of British Columbia Office of Research Servtces Behavioural Resea,vh Ethics Board Suite 102, 6190 Agronomy Road, Vancouver, B.C. V6T 1Z3  CERTIFICATE OF APPROVAL- MINIMAL RISK RENEWAL ?RINCIPAL INVESTIGATOR:  DEPARTMENT:  UBC BREB NUMBER:  Maura MacPhee  UBClApplied SciencelNursing  H07-00601  INSTITUTION(S) WHERE RESEARCH WILL BE CARRIED OUT: /ancouver Coastal lancouver Coastal /ancouver Coastal fancouver Coastal  Institution (VCHRINCHA) (VCHRI)VCHA)  Health Health Health Health  (VCHRINCHA)  (VCHRINCHA) /ancouver Coastal Health (VCHRINCHA) /ancouver Coastal Health (VCHRINCHA) /ancouver Coastal Health (VCHRINCHA) /ancouver Coastal Health (VCHRIIVCHA)  -  —  Site  Powell RiverlSunsn,ne coast Vancouver General Hospital Lions Gate Hospital USC Hospital OF Strong Rehabilitation Centre North Shore Community (including Horseshoe Bay arid up to Lions Bay)  Richmond Health Services Sea to Sky Corridor (including Bella Bella, Bella Coola, Squamish, Whistler and Pemberton)  /ancouver Coastal Health (VCHRINCHA) Vancouver Community ther locations where the research will be conducted; e are iniplernenting a nursing educator pathway for nurse employees in Vancouver Coastal Health (VCH) and Fraser Health (FH) authorities. This study is a program evaluation of the nursing educator pathway. JHVO P P3P. I  ‘atricia Semeniuk  SPONSORING AGENCIES: Human Resources and Social Development Canada ROJECT TITLE: 1  ‘reparing a nursing workforce to advance health services: a 3-year pilot project to build nursing educator apacity in the health authorities EXPIRY DATE OF THIS APPROVAL: December 29, 2009  IPPROVAL DATE: December 29. 2008 he Annual Renewal for Study have been reviewed and the procedures were found to be acceptable on ethical rounds for research involving human subjects.  Approval Is Issued on behalf of the Behavioural Research Ethics Board Dr. M. Judith Lynam, Chair Dr. Ken Craig, Chair Dr. Jim Rupert, Associate Chair Dr. Laurie Ford, Associate Chair Dr. Daniel Salhani, Associate Chair Dr. Anita Ho, Associate Chair  124  

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