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Attitudes of staff nurses toward nursing students and influencing factors Tyson, Florence M. 1993

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ATTITUDES OF STAFF NURSES TOWARD NURSING STUDENTS AND INFLUENCING FACTORS by FLORENCE MARY TYSON B.S.N., University of Victoria at Cariboo College, 1991  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (The School of Nursing)  We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA April, 1993 © Florence Mary Tyson, 1993  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.  (Signature  44€43artment—e4-  sfliv.,..640,te -  The University of British Columbia Vancouver, Canada  Date  DE-6 (2/88)  car, /993  ii  ABSTRACT Clinical learning experiences are an essential component of nursing education. A literature review revealed a considerable amount of anecdotal literature addressing the effect of the clinical milieu on student learning and numerous studies of nursing students' perceptions about their clinical experiences. However, there were no studies which addressed staff nurses' perceptions about working with students. Because staff nurses play a significant role in students' clinical experiences, this descriptive study was designed to assess their attitudes toward students and the factors that might influence them. A model of role adapted from Kahn et al. (1964) was used to guide the study. Sixty-four medical and/or surgical staff nurses participated in the study. A questionnaire developed by the researcher was used to collect the data. The data were analyzed quantitatively, with data from open-ended responses being subjected to content analysis to form meaning categories. The data revealed that staff nurse attitudes were positive and there were factors which contributed to their positive attitudes. For example, they enjoyed teaching students and the assistance students provided. Despite their positiveness, staff nurses expressed concerns. They had concerns about such things as the unavailability of teachers, patient  iii safety, and disruptions in their work when students were on the units. Participants identified organizational factors, such as patient acuity and staffing, that limited the amount of time they had to spend with students. They were required to work with a variety of students from different programs and many were uncertain about their role in working with students. The study findings have implications for nursing education, service, and research related to the clinical aspect of students' education and staff nurse roles in that education.  iv  TABLE OF CONTENTS  ABSTRACT  ^ii  TABLE OF CONTENTS ^  iv  LIST OF TABLES ^  vii  LIST OF FIGURES ^  viii  ACKNOWLEDGEMENTS ^  ix  CHAPTER ONE: Introduction  ^1  Background to the Problem  ^1  Problem Statement and Research Questions  ^5  Conceptual Framework  ^6  Organizational Factors  ^7  Role Senders  ^7  Focal Person  ^8  Personality Factors  ^8  Interpersonal Relations  ^8  Application of the Conceptual Framework  ^9  Significance of the Study  ^10  Definition of Terms  ^11  Attitude  ^11  Nursing Student  ^11  Staff Nurses  ^11  Assumptions  ^11  Limitations  ^12  Overview of Thesis Content  ^12  v CHAPTER TWO: Literature Review  ^14  Introduction  ^14  Attitude  ^14  Role  ^18  Student Clinical Experiences  ^23  Regular Clinical Experiences  ^24  Preceptored Experiences  ^25  Education/Service Gap  ^27  Summary of Literature Review  ^29  CHAPTER THREE: Methods  ^31  Introduction  ^31  Research Design  ^31  Subjects  ^31  Instruments  ^32  Data Collection  ^33  Data Analysis  ^34  Protection of Human Rights  ^34  Summary  ^35  CHAPTER FOUR: Presentation and Discussion of Findings  ^36  Introduction  ^36  Characteristics of Subjects  ^36  Attitudes Toward Nursing Students as Role Senders  ^39  General Attitude  ^40  Student Attributes  ^40  vi  Positive Aspects of Working With Students  ^45  Negative Aspects of Working With Students ^ 47 Focal Person Attitudes That May Influence Attitudes Toward Students Influencing Factors  ^49 ^56  Organizational Factors  ^57  Role Sender Factors  ^62  Role Conceptions of Focal Persons  ^65  Additional Comments Summary ^  ^69 70  CHAPTER FIVE: Summary, Conclusions, and Implications for Nursing Summary ^  ^72 72  Conclusions  ^74  Implications for Nursing  ^75  Nursing Education  ^75  Nursing Practice  ^79  Nursing Research  ^80  REFERENCES  ^83  APPENDICES  ^91  Appendix A: Research Questionnaire  ^91  Appendix B: Subject Information Sheet  ^99  Appendix C: Introduction to Staff Nurses ^ 100 Appendix D: Explanatory Letter for Agency Consent ^ 102  vi i LIST OF TABLES  TABLE 1  Nurses' Age Distribution ^  37  2  Nurses' Education ^  38  3  General Attitude ^  40  4  Behaviours Described as Lack of Accountability ^  41  5  Inappropriate Knowledge Level ^  44  6  What Was Liked Most About Working With Students ^  46  7  Perceived Benefits From Working With Students ^  47  8  What Was Liked Least About Working With Students ^  49  9  Unit Characteristics That Enhance Student Learning  59  10  Unit Characteristics That Impede Student Learning ^  60  11  Insufficient Time to Devote to Students ^  67  viii  LIST OF FIGURES  FIGURE 1 Model of Role  ^6  ix  ACKNOWLEDGEMENTS  I wish to acknowledge and thank the staff nurses who participated in this study. I am encouraged by their positive attitudes toward students and appreciate their willingness to share their thoughts. I wish to thank the members of my Thesis Committee, Professor Anne Wyness, Doctor Marilyn Willman, and Professor Linda Leonard for their guidance, support, and encouragement throughout this study. I am grateful to my friends, family, and classmates for their encouraging words and am especially thankful that I was accompanied during the thesis experience by my friend and classmate, Leanne. My very special thanks to Bob, for believing in me.  1  CHAPTER ONE Introduction Background to the Problem Clinical experience is a vital component of every nursing student's education (Mogan & Knox, 1987; Windsor, 1987). Prior to nursing education being moved into the main education stream, most schools of nursing were associated with an acute care hospital (Baumgart & Larsen, 1988). In these hospital-based training schools, clinical experience was of a service-oriented, apprenticeship nature (Baumgart & Larsen; Christy, 1980; MacPhail, 1988). In this researcher's experience, a clinical teacher was assigned to each unit and was responsible for the teaching and supervision of nursing students on that unit. The clinical teacher was also a resource person for staff nurses. However, due to the unavailability of nursing teachers on evening and night shifts, a great deal of the teaching that occurred in the clinical setting was left to the staff nurses. Due to constant exposure to nursing students, staff nurses were familiar with their role in, and responsibilities for, the clinical aspect of the students' education. Today, the role of the staff nurse in the clinical education of nursing students has changed. The move from service-oriented training to college- and university-based  2 nursing education has separated education from service (Christy, 1980; Johnson, 1980; MacPhail, 1988; Sleightholm, 1985). Nursing teachers and students have become guests in the clinical setting (Baker, 1981; Christy; Johnson; McPhail, 1975; Petersen, 1978; Shah & Pennypacker, 1992; Sleightholm; Smith, 1988), and staff nurses no longer identify students as "their students" (MacPhail). A significant portion of clinical education is still obtained in the acute care setting. However, some of what was previously taught and practiced in the clinical area now occurs in a laboratory environment. This change, and the increasing use of other settings for clinical experiences, has reduced the amount of contact between hospital staff nurses and nursing students. Some authors suggest that there is a "gap" between education and service due to different value systems (Christy, 1980; Johnson, 1980; Sleightholm, 1985). In addition, staff nurses' changed role in teaching and supervising students, as well as decreased exposure to students, may influence their attitudes toward nursing students. Other factors may also influence these attitudes. Increased patient acuity and decreased nursing staff ratios (Brown, 1991; Hendrickson, Doddato, & Kovner, 1990; O'BrienPallas & Baumann, 1992) result in increased workplace demands on staff nurses. The fact that it is not always  3 possible for nursing teachers to secure clinical settings suitable to the level of student learner (Mundt, 1990; Smith, 1988) and the additional responsibilities staff nurses encounter when working with students (Brown; Myrick, 1988; Windsor, 1987) further complicate the role of staff nurses. These factors may negatively influence the attitudes of staff nurses toward nursing students. There is little in the literature to suggest that staff nurses generally treat nursing students poorly during their clinical experiences. However, some studies of student perceptions of their clinical experiences reveal concerns about how nursing students are treated in clinical settings (Pierce, 1991; Windsor, 1987). Pierce found students worried about staff nurses who were critical and not receptive. Windsor alludes to attitude concerns that were reflected in negative behaviours toward nursing students. In her study of students' perceptions of their clinical experiences, she found that staff nurses were generally perceived positively. However, they were perceived negatively when they displayed negative behaviours toward them. Attitudes such as those referred to above can have a detrimental influence on the nursing student. Kelly (1992) notes that development of professional role identity and self-concept by students are related to the caring attitudes  4 of role-models. Attitudes of role-models also have a significant impact on the behaviour of students (Betz, 1985). Reilly and Oermann (1985) indicate that the milieu, or psychosocial climate within which learning takes place, is a major factor influencing student learning. They state that contributing to the clinical learning milieu may be service and learning goals, and/or administrative and professional goals. Both sets of goals may or may not be in competition. In this researcher's experience, the clinical milieu varies between institutions and even from unit to unit within the same institution. In magnet hospitals, where progressive administrative philosophies and practices serve to attract and retain nursing staff, McLure, Poulin, Sovie, and Wandelt (1983) found that the attitudes of staff nurses toward nursing students and their affiliated educational programs were very positive. This finding suggests that there are organizational characteristics, such as administrative philosophy and practices, which affect the clinical milieu by either positively or negatively affecting staff nurses' attitudes toward nursing students. It stands to reason that nursing student learning will be enhanced by staff nurse opinions or behaviours that reflect positive attitudes toward students and hampered by those that reflect negative attitudes. Therefore, it is  5 important to gain an understanding of staff nurse attitudes toward nursing students and the factors that influence the formation of those attitudes. Such information has the potential to lead to changes that might improve the clinical experience for both nursing students and staff nurses. Problem Statement and Research Questions Clinical learning remains a critical aspect of the education of nursing students. There is considerable literature that addresses nursing students' perceptions of their experiences in the clinical field (Beck & Srivastava, 1991; Davidhizar & McBride, 1985; Kelly, 1992; Kleehammer, Hart, & Keck, 1990; Pierce, 1991; Windsor, 1987). Some of this literature reveals that there are concerns with how students are treated in the clinical setting (Davidhizar & McBride, 1985; Pierce, 1991; Windsor, 1987). However, there is a paucity of literature that addresses the attitudes of staff nurses toward nursing students or the factors that influence the formation of those attitudes. Therefore, this descriptive study was designed to answer the following questions: 1. What are the attitudes of staff nurses toward nursing students? 2. What factors influence staff nurses' attitudes toward nursing students?  6 Conceptual Framework A model of role adapted from Kahn, Wolfe, Quinn, Snoek and Rosenthal's (1964) model of factors involved in adjustment to role conflict and ambiguity was used to guide this study (see Figure 1).  Figure 1. Model of role adapted from "A theoretical model for role conflict and ambiguity" (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964).  The model developed by Kahn et al. was chosen because it represents a complete cycle of role sending, response of the focal person, and the effects of that response on the role senders. It includes the organizational factors, personality factors, and the character of the interpersonal relationships between the focal person and the role senders which influence the focal person's response.  7 In the adapted model the focal person's response is defined in terms of attitudes and behaviour. The model provides a means of identifying and understanding the factors which influence the role and, therefore, the attitudes and behaviour of an individual toward the role senders in the context of an organization. According to Kahn et al. (1964), the major concepts are described as follows. Organizational Factors To a considerable extent, the role expectations of the role senders and the role conceptions of the focal person are both predetermined by the broad organizational structure and function. The division of labour and the formal reward system are specified. For example, the hospital may have a written job description for staff nurses that includes what is expected of the staff nurse in relation to nursing students' clinical experiences. As well, organizational conditions determine in part the expectations and pressures imposed by the role senders. Role Senders A role sender is an individual who has a set of role expectations of another person (focal person) and that person's behaviour on the job. Therefore, the role sender exerts pressure on the focal person to perform in a certain manner. In an acute-care hospital, role senders include  8 patients, doctors, head nurses, peers, nursing teachers, and nursing students who have role expectations of the focal person (staff nurse). Focal Person The focal person (staff nurse) is the focus of the role sender's expectations and experiences role pressure related to the expectations. At any given moment, pressure from a variety of role senders' expectations may result in the focal person experiencing role conflict or role strain. The focal person responds to the expectations based on his/her abilities to do so, perception of what is being demanded, conception of what his/her role is, and attitudes or behaviours which are either productive or counterproductive in the situation. Personality Factors As defined by Kahn et al. (1964), personality factors are a person's propensities to behave in certain ways. They include motives, values, sensitivities, fears, and habits. They are important determinants of differential elicitations and differential responses to role pressure. Interpersonal Relations Interpersonal relations refers to the patterns of interaction between a focal person and the role senders and their orientations toward each other. These patterns may arise from formal organizational structures or informal  9 interactions. They are influenced by power differences, affective bonds, dependence, and communication between the focal and role sender persons. The degree of role pressure exerted and experienced will depend on these relations. Application of the Conceptual Framework The model of role adapted from Kahn et al.'s (1964) model of factors involved in adjustment to role conflict and ambiguity provided an appropriate framework for the study of staff nurses' attitudes toward nursing students and the factors that influence those attitudes. Factors related to the organization and the role senders guided the formulation of questions in the development of the questionnaire used in the study. The inclusion of the focal person's personal characteristics directed the researcher to ascertain the education and experience of staff nurses in order to include these factors in the description of factors affecting their attitudes toward nursing students. As well, the effects of role expectations, role pressures, and role conceptions on staff nurses' attitudes were addressed in the questionnaire. Assessment of role sender and focal person personalities was beyond the scope of this study. In this study, the focal person was the staff nurse who was involved in working with nursing students and the role senders were head nurses, unit managers, patients, physicians, other staff nurses, nursing faculty, and nursing  10  students. The organizational factors were such things as patient acuity, staffing ratios, and institutional policies. Role expectations were the demands placed on staff nurses which relate to the provision of nursing care or working with nursing students. The study concentrated on focal persons' attitudes toward students and factors that influenced those attitudes. Significance of the Study The significance of this study is that a) it provides participating staff nurses with an opportunity to gain insight into their attitudes and the factors that influence those attitudes in order that they become more effective in working with students, b) it provides nursing administrators, educators, staff, and students with a means of assessing whether there is cause for concern, need for improvement, or if the attitudes and influencing factors are appropriate, c) it provides a means of assessing collaboration and communication between education and service personnel, and d) it provides a basis for considering ways to improve clinical learning experiences. The study also provides a better understanding of the pressures on staff nurses. It identifies positive factors that should be reinforced and negative factors that should be alleviated or reduced. The nature of the identified factors indicates who should address the concern.  11  With limited clinical experience time and increased competition for clinical placements, the findings of this study have the potential to assist staff nurses, faculty, and nursing students to optimize the benefits of the clinical experience for all concerned. Definition of Terms Attitude An attitude is an implicit response oriented toward approaching or avoiding, reacting favourably or unfavourably toward, an object or symbol (Insko, 1967). In this study, attitudes are expressed as opinions or beliefs and are assessed from responses to questions on the study questionnaire. Nursing Student A nursing student is an individual enroled in a nursing education program that leads to a diploma or undergraduate degree in nursing, excluding those baccalaureate nursing students who are registered nurses. Staff Nurses A staff nurse is a registered nurse who is employed at the general duty level in an acute care hospital on a medical and/or surgical unit. Assumptions The study was based on the following assumptions: 1. Attitudes are expressed as either opinions or  12 beliefs. 2. Most attitudes are held strongly enough to direct behaviour. 3. Staff nurses are aware of and able to express their attitudes and the factors influencing those attitudes. 4. Staff nurses' attitudes have an impact on student learning experiences. 5. Participant responses are thorough and truthful. Limitations Generalizability of the findings of this study is limited due to the sample size and non-probability sampling used. Because the participants were from medical-surgical units of two acute-care urban teaching hospitals, the findings are not generalizable to nurses working with students in other clinical settings. The examination of personality factors was beyond the scope of this study. Therefore, the study cannot be said to address all factors which may influence staff nurses' attitudes toward nursing students. As well, the use of a self-report questionnaire limits the findings to what participants were willing to report. Overview of Thesis Content This thesis is comprised of five chapters. In this introductory chapter the following study components have been addressed: background to the problem, problem  13  statement, research questions, conceptual framework, significance, assumptions, and limitations. Chapter Two presents a review of the literature pertinent to the study. Chapter Three provides a detailed description of the research methods used. Chapter Four presents the analysis of participant responses on the research questionnaire and a discussion of the findings. In the final chapter, a summary of the study findings, conclusions, and implications for nursing education, practice, and research are presented.  14 CHAPTER TWO Literature Review Introduction  This chapter presents a review of the literature which is pertinent to the study of staff nurses' attitudes toward nursing students. The literature review is presented in four sections addressing the purpose of the study and the concepts which are central to it. These are attitude, role, student clinical experience, and the education/service gap. The chapter concludes with a summary of the literature review. Attitude  The concept of attitude is central to the purpose of this study. "The basic rationale for understanding attitudes hinges on the notion that attitudes reveal something about probable behaviour" (Kahle, 1984, p.105). In the literature, attitude is defined in a variety of ways by a number of authors (Fishbein & Ajzen, 1975; Insko, 1967; Kiesler, Collins, & Miller, 1969; Zimbardo, Ebbeson, & Maslach, 1977). The authors agree, however, that it is a tendency to respond in a certain manner to an object or symbol. To explain the concept further, some authors break attitude into three components; affective, cognitive, and behavioural (Fishbein & Ajzen; Rajecki, 1990; Sudman & Bradburn, 1983; Zimbardo, Ebbeson, & Maslach). The  15 affective component consists of a person's evaluation of, or emotional response to, something. It can be measured by physiologic responses or verbal statements. The cognitive component consists of a person's beliefs about or knowledge of something. It can be measured by self-reports about beliefs or amounts of knowledge. The behavioural component involves behavioural intentions and may be measured by direct observation of a person's overt behaviour toward something. According to Fishbein and Ajzen, the best predictor of behaviour is intention. Although the relationship between attitude and behaviour is not absolutely clear, many authors argue that attitudes exert a strong influence on behaviour (Fishbein & Ajzen, 1975; Insko, 1967; Kahle, 1974; Rajecki, 1990). Rajecki reports that, due to recent research findings, there is renewed optimism regarding this attitude-behaviour link. He concludes that behaviour is influenced by attitude, "whereby attitude is the cause, and behaviour is the effect" (Rajecki, p.4). Hinshaw (1988) states "attitudes are assumed to guide role judgments and behaviors" (p. 345) whereas, Henerson, Morris, and Fitz-Gibbon (1987) state "we can only infer that a person has attitudes by his/her words and actions" (p. 12). Therefore, for the purpose of this study, attitude and behaviour are viewed as separate responses with attitudes influencing behaviour.  16 Although both situational and personality variables moderate the attitude-behaviour link (Eiser & vander Pligt, 1988; Fazio,1986; Rajecki,1990), this study addresses only situational variables. According to Rajecki, attitudes are formed or moulded by a variety of circumstances and stem from different sources or experiences. Attitudes formed on the basis of a direct, behavioural experience with an attitude object are more predictive of later behaviour than are attitudes formed via indirect, nonbehavioural experiences (Fazio). Therefore, direct experience with an attitude object promotes attitude-behaviour consistency (Eiser & vander Pligt; Fazio; Rajecki). Tesser & Schaffer (1990) argue that the primary purpose of holding an attitude is object appraisal. This appraisal involves making evaluative judgements about an object that will have clear behavioural implications. Therefore, attitudes serve as a guide to behaviour. Attitudes also allow one to identify with others, promote acceptance by others, make one's world predictable and orderly, and motivate behaviour (Ostrom, 1968; Rajecki, 1990). Attitudes are learned expressions of life's experiences (Fishbein & Ajzen, 1975; Schumann, 1990). Therefore, they help to explain individual differences (Kiesler, Collins, & Miller, 1969).  17 That attitudes are formed from experience suggests that education, past experiences, and individuals' role-related experiences will have an influence on their attitudes and, therefore, their behaviour. According to Fishbein and Ajzen (1975), some attitudes are relatively stable over time while others exhibit frequent shifts. This suggests that there is potential to change negative attitudes to positive attitudes. If attitudes have the potential to change, and if student learning can be adversely affected by negative attitudes, it follows that it is important to determine attitudes toward learners and factors that influence those attitudes. To do this, Henerson, Morris, and Fitz-Gibbon (1987) suggest that self-reports represent the most direct type of attitude assessment and should be employed unless subjects are unable or unwilling to provide the necessary information. Several authors have documented the impact of staff nurses' attitudes on student learning. Betz (1985) states that as role models in the clinical setting, staff nurses' norms, beliefs, and attitudes have a significant impact on student learning and behaviour. Davidhizar and McBride (1985) found that students described negative attitudes of staff nurses toward them as one cause of their failures in providing nursing care. Infante (1985) stresses the positive impact staff nurses can have on, and Reilly and  18 Oermann (1985) stress the importance of a supportive clinical milieu to, student learning. Because staff nurse attitudes are formed from experiences, it is important to review how staff nurses experience their roles. Role  Individuals in society occupy positions, and their role performance in these positions is determined by social norms, demands, and rules; by the role performance of others in their respective positions; by those who observe and react to the performance; and by the individual's particular capabilities and personality (Thomas & Biddle, 1964, p.4). Literature pertaining to nursing roles was reviewed in order to gain a better understanding of the role expectations, role conceptions, and role pressures experienced by staff nurses who are involved in working with nursing students. Role expectations involve the formal and informal demands of the nurse's position, role conceptions are what the nurse thinks his/her job is, and role pressures are the role expectations the nurse feels from others (Schmalenberg & Kramer, 1979). Corwin and Taves (1962) relate the rights and obligations perceived as role conceptions to attitude generation. Role conceptions may be congruent with role expectations. However, when there is little information about what is expected, or differences  19 between role expectations and role conceptions, role ambiguity occurs (Hardy & Hardy, 1988). The resulting increase in role pressure may result in negative attitudes toward role senders. Myers (1992), in an article addressing issues confronting contemporary nurses, reported that many staff nurses are experiencing role strain, that is, having difficulty fulfilling role expectations. Patient acuity levels are increasing (Hendrickson & Doddato, 1989; Myers) and staff nurses wonder if administrators understand their day-to-day stresses (Mauksch, 1990; Myers). In some clinical areas, there has been a decrease in nursing staff ratios over the past ten years (Brown, 1991). In their review of nursing worklife studies, O'Brien-Pallas and Baumann (1992) found increasing patient acuity and chronicity and lack of adequate staffing to be recurring issues. In a study of how nurses use their time, Hendrickson, Doddato, and Kovner (1990) found medicalsurgical units to have the lowest nurse/patient ratios. Organizational factors such as these create role pressures for staff nurses which often overshadow the learning needs of nursing students in the clinical setting (Brown; Corcoran, 1977; Hendrickson, Doddato, & Kovner). Even more troubling is the significant number of students who are discouraged from, or ridiculed for, entering nursing by  20  stressed staff nurses (Hegyvary, 1990). This may be the result of excessive role pressures and/or negative role conceptions. In regular clinical experiences, the staff nurse role in nursing education is that of professional role model and resource person to students (Infante, 1985). In this role, any teaching they do is usually informal and often involves answering questions when nursing teachers are unavailable. They are responsible for providing patient information to students and recieving report from the students about the care they provide. Staff nurses are also responsible for maintaining patient safety while the patient is being cared for by a nursing student (Windsor, 1987). Lewis and Deans (1991) report that a concern for safety is shared by many staff nurses when students care for patients. Schmalenberg and Kramer (1979) report that being responsible for the care given by nursing students contributes to the uncertainty of the new graduate nurse. This uncertainty might be associated with concerns for patient safety. McKenzie (1991) and Smith (1988) reported that units are assigned students from a variety of nursing programs who have varying levels of knowledge and skills. This mix makes it difficult for staff nurses to support and assist the students in meeting their learning objectives (McKenzie), thereby resulting in increased role pressure.  21 Although the above concerns may arise in both regular and preceptored experiences, the role expectations of the staff nurse in preceptored experiences change. In preceptorships, staff nurses are sometimes expected to take on additional responsibility for teaching and evaluating students without adequate preparation to do so (Myrick, 1988). However, McKenzie (1991) reported that giving staff nurses direct responsibility for a group of students resulted in increased motivation and knowledge, with nurses actively pursuing experiences for the nursing students and becoming involved in aspects of teaching. Similarly, Chickerella and Lutz (1981) found that staff nurses who volunteered to be preceptors wanted to help students and improve their own knowledge, leadership abilities, and teaching skills. For them, the result of precepting was an enhanced sense of responsibility and increased job satisfaction. However, Chickerella and Lutz reported that others found the experience frustrating and time-consuming, and that there was too little time to spend with students. When evaluating a Halifax preceptor project, Caty and Scott (1988) found the fast pace of the unit to be a problem. The pace resulted in nurses feeling guilty when they were unable to work with students or answer their questions. With an awareness of the positive and negative aspects of working with students, Limon, Bargagliotti, and Spencer  22 (1982) stressed that administrators must be able to provide direct support for staff nurses to facilitate and reward them in their role as preceptor. Alpach's (1987) Preceptor's Bill of Rights outlined supports required by clearly stating the rights of preceptors that come with assuming the responsibility of working with nursing students. In the magnet hospitals where administrators are cognizant of these rights and supports are in place, staff nurse preceptors reported working with students as a very positive experience (McLure, Poulin, Sovie, & Wandelt, 1983). Factors which have implications for the preceptor role may also have an impact on the role of the staff nurse in regular clinical experiences. For instance, the pace of the unit, the time-consuming aspects of working with students, and the preparation and supports required to work effectively with students are common to both experiences. Corcoran (1977), questioning the ethics of using a service setting for clinical experiences in general, asks "What about the rights and responsibilities of staff members?" Several authors have responded. Care must be taken so that staff and patients do not get a "student overdose" (Bevil & Gross, 1981; Goldenburg & Iwasiw, 1988; Little & Carnavali, 1972; Nail & Singleton, 1983). The unit must be adequately staffed and staff nurses must be made  23  aware of the objectives of the clinical experience and what is expected of them (Barr, 1980; Nail & Singleton). Also, students should be helped to realize the emotional and physical pressures of the staff nurse's role (Barr). It is not difficult to determine that role-related factors may influence the development of staff nurse attitudes toward nursing students in clinical experiences. Staff nurses who experience increased role pressures may respond negatively to nursing students, whereas, those whose rights are respected and who are supported may respond in a positive manner. Student Clinical Experiences A review of the literature pertaining to nursing student clinical experiences was undertaken to gain an understanding of how students perceive staff nurses. It is reasonable to think that these perceptions are influenced by staff nurses' attitudes toward the students. As most nursing student clinical experiences are part of a regular nursing course, this study focused on the attitudes related to those experiences. In regular clinical experiences, faculty members are responsible for teaching and supervising a group of nursing students. In a preceptorship, a staff nurse is delegated some responsibility for teaching and serves as a role model to an individual nursing student. It is acknowledged that there are differences in student and  24 staff nurse experiences between regular clinical and preceptored experiences. However, it is assumed that many of the findings in preceptored experience studies also apply to regular clinical experiences. Therefore, research on both regular clinical experiences and preceptored experiences is reviewed. Regular Clinical Experiences  Several researchers have found that regular clinical experiences are a major source of stress to most nursing students at one time or another (Beck & Srivastava, 1991; Carver & Tamlyn 1983; Garrett, Manuel, & Vincent, 1976; MacMaster, 1979). Both McMaster and Garrett, Manuel, and Vincent found that this stress was primarily related to the physical care of patients and interpersonal relationships. Relationships with instructors were found to create more stress than those with staff nurses. They also found that the stress experienced in clinical settings decreased as students progressed through the nursing program, perhaps because of their increasing knowledge and skills. This is supported by other researchers. Beck and Srivastava found that a lack of clinical knowledge and skills was one of the greatest sources of stress among baccalaureate nursing students. Carver and Tamlyn found similar results in their study of third year baccalaureate students. This decrease in stress may also reflect different attitudes of staff to  25  students as the students become increasingly competent. In a qualitative study of nine senior baccalaureate students' clinical experiences, Windsor (1987) found that staff nurses were generally viewed as knowledgable, helpful, and understanding. Students valued relating to them and worried about receiving their approval. Students wanted frequent honest feedback and did not want staff nurses to do their work as it ruined their confidence. Staff nurses were perceived negatively when they made derogatory comments, gave disparaging looks, told students to go to their instructors for help, and frequently checked up on the students. Students reported that staff nurses generally conveyed negative feelings by manner rather than by overt behaviour. Students often asked peers questions as this was less threatening than asking the staff nurses. In a cross-sectional study of diploma students' explanations for their success and failure in clinical experiences, Davidhizar and McBride (1985) found "the highest number of attributions in explaining failures in nursing care were related to staff characteristics" (p.288). Characteristics cited were lack of helpfulness, a negative attitude toward students, not appreciating student contributions, not having time for explanations, not contributing to student learning, and not being friendly.  26 Preceptored Experiences  In a descriptive study of 44 preceptored nursing students, Peirce (1991) found that students wanted to be able to care for a variety of patients in a supportive environment where they were welcomed by nursing staff, and where the staff nurse working with students was interested in doing so and had the necessary clinical and teaching skills. Clinical site factors that influenced the student experience were identified as organizational expectations, availability of help and instruction, feedback, a chance to participate in the life of the unit, and receptive staff nurses. In 1990, Hsieh and Knowles identified seven themes as being important to the preceptorship relationship between staff nurses and nursing students. These were trust, clearly defined expectations, support systems, honest communication, mutual respect and acceptance, encouragement, and mutual sharing. When these themes were not established early in the preceptorship, students lagged behind their peers in achievement. The reviewed research studies demonstrate student appreciation of positive staff nurse attitudes and the detrimental effects that negative attitudes can have. In non-research-based literature, Reilly and Oermann (1985) stress the importance of the clinical milieu to nursing  27 student achievement, satisfaction, and professional role socialization. The latter occurs through identification with a positive role model (Dobbs, 1988). As major contributors to the clinical milieu, Kelly (1992) found staff nurses who were caring role-models to be a major influential force in students' development of a professional self-concept. Education/Service Gap  How staff nurses perceive and/or experience factors associated with the relationship between nursing education and nursing service may influence their attitudes toward nursing students. Numerous authors have reported a gap between nursing education and service due to different value systems (Blanchard, 1983; Christy, 1980; Johnson, 1980; McPhail, 1975, 1988, 1991; Mauksch,1990; Sleightholm, 1985). Some of the different values relate to the importance of research, conceptualizations of practice, priorities of care, and theoretical foundations of practice (McPhail, 1991). These differences are reflected in what several authors describe as idealistic nursing education rather than education based on the realities of nursing practice (Blanchard; Douglas, 1978; Hammerstad & Murphy, 1979; Mauksch; McPhail; Sleightholm; Suess, Schweitzer, & Williams, 1982). Education, work setting, autonomy, and status differences between nursing educators and nursing  28 staff also contribute to the gap (McPhail, 1991). For the above reasons, nursing teachers and students are often considered as guests in the clinical setting (Baker, 1981; Christy, 1980; Johnson, 1980; McPhail, 1975; Petersen, 1978; Shah & Pennypacker, 1992; Sleightholm, 1985; Smith, 1988). This may result in limited communication and collaboration between nursing education and practice (Kruger, 1985). The biggest losers when this estrangement occurs are nursing students (Eschbach, 1983). Therefore, nurses from both sides are developing strategies to prevent this gap from occurring or to close it if it has occurred. Several models have been developed in an attempt to alleviate the education-service gap. In 1972, the University of Rochester and Rush University instituted collaboration/unification models in which one individual has responsibility for both education and service. Faculty practice is an integral part of both models. Case Western Reserve University initiated the interorganizational model where education and service remain separate but share costs of faculty-clinicians and the time and talents of clinical and associate appointees. According to McPhail (1991), these collaborative models have resulted in enhanced student learning, changes in attitudes of staff toward learners, and improved role models for students. One American college developed an eight-week role  29 exchange program between education and practice which has also resulted in more favourable attitudes of staff nurses toward nursing students (Eschbach, 1983). Joint appointments also offer potential improvements in bridging the gap and have had some success in changing the attitudes of staff nurses toward students, thereby enhancing the learning climate (McPhail; Joel, 1985). Kruger (1985) reports that students felt more accepted as a result of joint faculty/practice positions. Summary of Literature Review The literature suggests that attitudes are strongly linked to behaviour, with positive attitudes reflected in positive behaviours and vice versa. Attitudes are learned from experience, are functional, that is, they promote acceptance and motivate behaviour, and are potentially changeable. Attitudes are said to be influenced by institutional and role-related factors. Staff nurses' attitudes have an influence on student learning and behaviour in clinical settings. Staff nurses are experiencing increasing role pressures due to a variety of factors, including organizational factors and role expectations. Working with nursing students during their clinical experiences has the potential to increase role pressure. These factors may result in negative role experiences that may be reflected in negative  30  attitudes toward students. The gap identified between nursing service and education may also negatively affect staff nurse attitudes. The importance of a positive milieu for the clinical learning experiences of nursing students is emphasized in the literature. As role-models, staff nurses also have a significant influence on the role socialization and selfconcept of nursing students. Although the literature addresses all of the above areas related to staff nurse attitudes toward students and the factors that may influence them, little or no attention has been directed to the attitudes and factors as reported by the staff nurses themselves. Therefore, this study was designed to do so using a model of role adapted from the work of Kahn et al. (1964).  31 CHAPTER THREE Methods Introduction In this chapter, the research methods are discussed. These include the research design, subject selection, data collection procedures, instruments, data analysis and protection of human rights. Research Design In this study, descriptive research methodology was used to investigate and describe the attitudes of staff nurses toward nursing students and the factors that might influence those attitudes. Descriptive research provides a portrayal of an individual, situation or group to discover new meaning, describe what exists, determine the frequency with which something occurs, and identify relationships without establishing causality (Burns & Grove, 1987). Therefore, this design was congruent with the purpose of the study and was appropriate for investigating a topic about which little is known. Subjects Subjects were registered nurses who were currently working with nursing students in a regular clinical experience or had done so in the past six months. They were employed full-time or part-time (a minimum of a 0.5 fulltime equivalent) in two acute care urban teaching hospitals  32  on medical and/or surgical units. Nurses from medical and/or surgical units were selected because nursing students are frequently assigned to these units for clinical experiences. The sample included staff nurses who were working with different levels of nursing students from various nursing programs. ^• The sample consisted of 64 of the 99 staff nurses who demonstrated an interest in participating in the study. Two nurses who completed and returned questionnaires did not meet the sample criteria and, for unknown reasons, the remaining  33  nurses chose not to participate. Instruments  Two instruments were used in this study. A questionnaire was developed by the investigator to collect data about the attitudes of staff nurses toward nursing students and the factors that influence those attitudes. The initial questionnaire was pretested by four staff nurses and one nurse educator to assess for content validity and clarity and to ensure that the questions elicited answers that fulfilled the research purpose. The suggestions obtained were incorporated into the instrument (see Appendix A) . A subject information sheet was also developed by the investigator. It was used to obtain demographic information and other characteristics of the subjects. A copy of the  33  instrument is presented in Appendix B. Data Collection After required approvals had been obtained, a list of medical/surgical units used for nursing student clinical experiences was compiled for each hospital. Seventeen head nurses were contacted by telephone and opportunities were set up to discuss the study with staff nurses. Twenty-nine fifteen minute presentations were made to groups of one to six staff nurses. Three of the presentations were in conjunction with staff meetings while the others were at times convenient to the units and staff. During the presentations, the investigator briefly introduced herself and described the study. The purpose, significance, benefits, criteria for participation, ethical considerations including consent, and dissemination of results were explained and staff nurses' queries were addressed. Packages containing an introduction to the study (see Appendix C), a research questionnaire, a subject information sheet, and a self-addressed stamped return envelope were provided to staff nurses who demonstrated an interest in participating in the study. Staff nurses were requested to address their responses to regular, non-preceptored student experiences and write on the questionnaire any pertinent information not addressed by the questions.  34 Data Analysis Both instruments used in the study were coded to facilitate data analysis while maintaining participant anonymity. Data from the subject information sheet were compiled and described in terms of frequency distributions and measures of central tendency. The frequency of responses to closed-answer questions specific to attitude measurement and factors influencing attitudes were tabulated. Responses to open-answer questions were subjected to content analysis and were placed in categories. Protection of Human Rights Procedures for protection of human rights were approved by the UBC Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects. Research committees of the two hospitals involved were approached with an explanatory letter outlining the study and the degree of institutional involvement required (see Appendix D). Approval to conduct the study was received from both hospital research committees prior to data collection. During unit presentations and in an introductory letter, potential participants were informed that participation in the study was voluntary, there would be no repercussions for not participating, and completion and return of the questionnaire indicated consent to  35  participate. The purpose and benefits of the study were also explained. Anonymity of the participants was maintained by having participants mail the questionnaires directly to the investigator and by use of a coding system that allowed the investigator to match questionnaires with subject information sheets.  Summary In this chapter, the research design, subject selection, data collection procedures, instruments, and data analysis methods used in the study were described as were procedures followed to protect human rights.  36 CHAPTER FOUR Presentation and Discussion of Findings Introduction In this chapter, the study findings are presented and discussed in four sections. The first section includes demographic information and other characteristics of the subjects. In the second section, findings and discussion related to the first research question regarding focal person attitudes toward nursing students as role senders are considered. Findings related to the second research question regarding influencing factors, specifically organizational and role sender factors, are presented and discussed in the third section. Additional comments provided by the subjects are addressed in the final section. Characteristics of Subjects Of the 99 staff nurses who indicated an interest in participating in the study, 66 (67%) returned completed questionnaires. Two respondents were excluded from the study as they did not meet the criteria for participation. The study sample consisted of the remaining 64 respondents (N = 64), whose questionnaires were completed sufficiently to be included in the study. The majority of the subjects, 49 (77%), were female, 14 (22%) were male, and there were no data for one. The average age was 34 with a range of 23 to 61 years. Although  37 the average age was 34, 39 subjects (61%) were 35 or under, and 29 (45%) were from 20 to 30 years of age (see Table 1).  Table 1 Nurses' Age Distribution Age  Frequency  Percent  20-25  12  18.7  26-30  17  26.6  31-35  10  15.6  36-40  6  9.4  41-45  7  10.9  46-50  4  6.2  51-55  1  1.6  56-60  3  4.7  Over 60  1  1.6  Did not indicate  3  Total  64  4.7 100  As shown in Table 2, the majority of subjects, 51 (80%), were prepared at the diploma level. Most subjects, 46 (72%), worked full-time and the average number of years in nursing practice was 9.75, with a range of 4 months to 35 years. The number of years employed in the present position ranged from 2 months to 30 years, with an average of 6  38 years. Subjects' areas of work were evenly distributed: 30 from medical units, 29 from surgical units, 3 from combined medical-surgical units. Two subjects did not indicate a work area. Subjects were from a variety of units: cardiology, ear/nose/throat, gastro-enterology, geriatrics, neurology, orthopedics, rheumatology, and vascular surgery.  Table 2 Nurses' Education Education  Frequency  Percent  43  67.2  Diploma & Postgraduate  7  10.9  Diploma & Bachelor of Arts  1  1.6  12  18.7  1  1.6  64  100  Diploma  Baccalaureate Degree in Nursing Did not indicate Total  It is likely that the wide ranges in years of experience and years in present position had some effect on the staff nurse attitudes revealed in this study. Some of the participants had limited nursing experience or were new to the unit. It may be difficult for these novices or new staff members to work with students because they are trying to assimilate the complexities of a new role, become  39  familiar with the unit, and develop organizational skills. For these nurses, the challenge of working with students may be stressful and this stress may provoke negative attitudes. On the other hand, having recently graduated, novices may be more understanding of students and the expectations nursing teachers have for student performance. The sample included a large number of diploma-prepared participants and half of the participants had approximately ten years experience in nursing. These facts suggest that a considerable portion of the sample may have been educated according to a more skill-focused philosophy than some nursing students are today. Therefore, their attitudes toward students or their concerns about student education may reflect such a philosophy rather than the more holistic philosophy of some nursing education programs today. Attitudes Toward Nursing Students as Role Senders In part I of the study questionnaire, participants (focal persons) were questioned about their general attitude toward nursing students and about particular attributes of nursing students. Responses to these questions are reported as attitudes regarding nursing students as role senders. The responses to other questions which may relate to, but are not specific to, students are presented as attitudes held by the focal persons that may influence their attitudes toward students.  40 General Attitude  The majority of participants, 61 (95%), described their general attitude toward nursing students as positive (see Table 3). The two participants who felt slightly negative toward students were baccalaureate-prepared nurses. Table 3 General Attitude ^ Rating  Frequency^Percent  Very positive^  18^28.1  Positive^  37^57.8  Slightly positive^  6^9.4  Slightly negative^  2^ 3.1  Negative^  -^  -  Very negative^  -^  -  No response^  1^1.6  Total^  64^ 100  Student Attributes  Most participants rated student interest in the clinical learning experiences on their unit as being moderate (37 or 58%) to high (26 or 41%), whereas one rated it as low to moderate. One participant qualified her moderate rating by stating that interest varied among  41 students and with schools of nursing depending on the emphasis placed on learning versus performing tasks. The majority of subjects, 58 (91%), thought students displayed accountability for the care they provided. However, four of these respondents noted considerable variance in individual student accountability and one respondent noted variance in accountability between students of different programs. Six participants did not think students displayed accountability. The reasons they gave in a multiple response explanation are categorized as: failure to communicate (patient information and/or reporting off), failure to complete care, failure to complete charting, over-reliance on the instructor, and medication cards displaced or medications not charted (see Table 4). Patient safety was a concern of 45 subjects (70%) when patients were being cared for by nursing students. In a multiple response format, these subjects attributed their concerns to safety being their responsibility (43), students not being supervised closely enough (16), and students not having enough knowledge or skills to be considered safe (11). Other reasons given were uncertainty about student capabilities (4), weak and/or overconfident students (3), and patient acuity (2). In addition, each of the following reasons was listed once: increased chance of errors due to student fears and anxieties, students overlooking safety  42 issues while task-focused, unfamiliarity with equipment, lack of experience to draw on, and mistakes are part of learning. As well as safety concerns, 35 participants (55%) were concerned about fragmentation of care when nursing students were on the unit. As noted above, some safety concerns related to student knowledge and skill levels and these may have influenced concerns about fragmented care.  Table 4 Behaviours Described as Lack of Accountability  Categories^  Frequency of Behaviour Noted (n = 6)  Failure to communicate with ^ staff nurse  5  Failure to complete patient care ^4 Failure to complete charting ^ 3 Reliance on instructor for^ accountability  2  Creation of problems in medication ^2 system  Forty-eight respondents (75%) thought that students' knowledge levels were appropriate to meet the requirements of the clinical experience. Three of these respondents qualified their answer with "sometimes." These respondents indicated that although most students had an adequate  43  knowledge level for basic care, they were task-focused and not proficient at basic patient care; they lacked pharmacology and etiology knowledge; and possession of appropriate knowledge depended on their level in the nursing program. Interestingly, similar explanations were given for inappropriate knowledge levels by the 16 respondents (25%) who either thought students lacked necessary knowledge (15) or were unsure of the appropriateness of knowledge (1). Several (4) of these 16 respondents commented that it was difficult to assess the appropriateness of student knowledge levels because they either did not know the level of the student or the requirements/objectives of the clinical experience. According to three respondents, whether or not the knowledge level was appropriate depended on the specific instructor and/or nursing program. Other possible reasons • for inappropriate knowledge were related to patient acuity, medications, diagnoses, basic care skills, being taskfocused, requiring considerable supervision, difficulty in applying theory to practice, and lack of specific knowledge. The multiple responses of the 16 respondents are summarized in Table 5. When participants were questioned about skill competency, 15 respondents (23%) thought students demonstrated a lack of skill competency. Considering both  44 their knowledge and skill competency, the majority of  Table 5 Inappropriate Knowledge Level ^ Areas  Subjects Reporting Inappropriate Knowledge (n = 16)  Lack of medication knowledge ^  2  Lack of diagnosis/etiology knowledge ^2 Miss experience opportunities due to^2 lack of knowledge and patient acuity Lack of specific knowledge ^ (e.g., neuro-assessment, chest tubes)  2  Lack of knowledge and/or application ^1 of basic care skills Too task/skill-focused, miss "big" picture ^1 Amount of guidance/supervision needed^1 Difficulty applying theoretical knowledge ^1 Other: Difficult to assess^  4  Depends on instructor/program^  3  participants (42 or 66%) thought students were suitably confident, 14 found them underconfident, and two rated them as overconfident. Six respondents chose not to rate them, stating that confidence varied. Three of those who rated  45 them as suitably confident also noted variability. Six respondents stated that confidence is very individual and two thought it was influenced by staff attitudes and relationships with the nursing teacher. Respondents did not speak specifically to variability in confidence among levels of students. However, one respondent commented that some students were afraid to perform certain skills and that this made her job more difficult when the instructor was not around to support and assist them. Positive Aspects of Working With Students The overwhelming majority of participants, 63 (98%) listed what they liked "most" about working with students. Their multiple responses were categorized according to similarities in meaning (see Table 6). The most frequent responses referred to teaching (13). Several of these respondents qualified their answer with "when I have time" and "when students are receptive." Some respondents also appreciated the assistance students provided with care which helped reduce their individual workloads (10). Ten respondents mentioned being challenged or stimulated by students to keep up to date and/or to learn new things. Student positiveness and enthusiasm were enjoyed and found to be contagious (9). Several respondents (6) also liked the fact that students were eager to learn. Others (5) enjoyed being involved in and contributing to the students'  46 learning experiences. Five respondents liked the fact that patients benefitted from the care and increased attention provided by students. Staff nurses also mentioned that they liked to see students progress, their pleasantness/ friendliness, the positive feedback they provide, and the opportunity to attract potential new staff.  Table 6 What Was Liked Most About Working With Students  Categories^  Frequency of Response (n = 63)  Enjoy teaching^  13  Help with care/workload^  10  Stimulates keeping up to date/new learning ^10 Enthusiasm/positive attitudes ^  9  Eagerness to learn^  6  Enjoy being part of/contributing to learning ^5 experience Patients benefit from increased attention^5  Although 63 participants (98%) listed what they liked most about working with students, only 58 participants (91%) indicated that they actually liked working with nursing students. The explanations for this were almost identical to the responses regarding what participants liked most  47  about working with students (see Table 6). The above findings were markedly similar to the benefits cited by the 56 participants (87%) who perceived benefits from working with students (see Table 7).  Table 7 Perceived Benefits From Working With Students Categories^  Frequency of Response (n = 56)  Learning opportunity^ (reinforces or stimulates updating clinical knowledge and skills)  35  Opportunity to teach and share experiences ^16 Increased self-awareness or personal skills ^9 (communication, leadership, confidence) Help with workload^  8  Positiveness/enthusiasm is catching ^7 Increased job satisfaction^  7  Add variety, refreshing change^  5  Increased awareness of own learning needs ^3 Positive feedback from students ^  3  Other:^ (opportunity to contribute to the profession, meet young people, and recruit new staff)  3  Negative Aspects of Working With Students Besides describing what they liked most about working  48  with students, almost as many participants (59 or 92% versus 63 or 98%) listed what they liked least about working with students. The responses were collapsed into meaning categories. The most frequent responses (16) related to disruptions in work, followed by additional responsibilities/workload (12), and having to check up on students to see what was done and/or to complete care (12). Other common concerns were lack of supervision (9), not knowing what students can and cannot do (7), the number of questions and time required to explain when already busy (7), fragmentation of care including decreased contact with own patients (7), not having time to properly assist students (6), slowness that delayed care and tired patients (5), lack of communication regarding patients or failing to report off (5), and the increased stress/confusion on the unit which was related to the number and variety of students (3) (see Table 8). Responses that did not group were related to lack of prior preparation for patient care, overconfidence, not being assertive enough with patient care (ambulation), getting in the way in emergency situations, misplaced medication cards, inflexibility, lack "big" picture, and staff nurses not knowing what is expected of them. Comments of the five participants who did not like working with nursing students were consistent with the above with the exception of these negative descriptors: lazy,  49 unwilling, lacking motivation, unsafe, and incompetent.  Table 8 What Was Liked Least About Working With Students Categories^  Frequency of Response (n = 59)  Disrupts own work and organization ^  16  Additional responsibility/workload ^  12  Having to check up on/complete care ^  12  Unavailability of instructor/lack of supervision^9 Not knowing what students can/cannot do ^7 Number of questions/amount of explaining ^7 Fragmentation of care/lack of patient contact ^7 Insufficient time to properly assist students ^6 Slowness delays patient care/tires patients ^5 Lack of communication/reporting off ^  5  Increased stress/confusion on unit ^  3  Focal Person Attitudes That May Influence Attitudes Toward Students Thirty-five subjects (55%) thought the goals set for nursing students were idealistic, whereas 23 (36%) thought they were realistic. Two respondents thought this varied depending on the instructor. Of the three who did not  50 respond, one was not familiar with the goals. One respondent commented that students were expected to be perfect. These responses may reflect either attitudes toward the instructor and/or the nursing education program. Although it depended on the program, compared to the students they worked with, participants rated the clinical component of their own nursing education as being superior (30 or 47%), similar (27 or 42%), inferior (4), and two did not respond. They rated their theoretical component as being similar (32 or 50%), superior (18 or 28%), inferior (4), and 17 (27%) reported no basis for judgement. The majority of participants (51 or 80%) encouraged nursing as a career. Eight did not, one did sometimes, and one did rarely. Three did not respond. It is assumed that their responses reflect their attitude toward nursing. Staff nurses' overall positive attitudes toward working with students were consistent with findings regarding their thoughts about specific student attributes, what they liked about working with students, and the benefits they perceived from working with them. The writer noted similarities between the positive perceptions of the participants and Windsor's (1987) finding that student perceptions of staff nurses were generally positive. Findings of other studies of student clinical experiences suggest that staff nurses do not present a major concern for students (Carver & Tamlyn,  51 1985; Kelly, 1992; Pagana, 1988; Soukup, 1983). Therefore, it is assumed that if students were perceived negatively by staff it would be reflected in how they in turn perceived staff. Although the participants generally thought positively about students, over two-thirds had concerns about patient safety which was consistent with the findings of others. Lewis and Dean (1991) reported increased staff nurse concerns for patient safety and their own liability when students were on the unit and Schmalenberg and Kramer (1979) stated that being responsible for the care given by nursing students made recent graduates feel uneasy. According to Petersen (1978), patient welfare may be threatened by fragmented care. Therefore, the reported fragmentation of care as well as reports of incomplete care and inappropriate communication about patients, may be related to participant concerns about patient safety. Because of the nature of clinical learning experiences, safety will always be a concern and fragmentation of care will continue to occur. However, participant concerns support the need for effective communication among, and adequate orientation of, those involved in clinical experiences in order to reduce these concerns. The fact that lack of skill competency was also a reason given for safety concerns and that participants felt  52  the clinical component of their education was superior may reflect the nursing perspective of diploma-prepared nurses. Perhaps those participants who were concerned about skill competency might identify with Mowry's (1982) statement, "staff nurses feel annoyed and frustrated by the limited skill levels which students bring to the unit" (p. 160). Although not a concern of most participants, 25% had concerns about the appropriateness of students' knowledge levels. A few of these participants stated that it was difficult to assess student knowledge because they were unaware of the student level and/or the objectives of the clinical experience. This lack of awareness and the fact that there are no specific standards on which to base judgements, supports the need for teachers to effectively communicate the knowledge various levels of students are expected to have and the specific objectives of the clinical learning experience. This communication would avoid students being prematurely judged against standards that staff nurses have for their own practice which may be in a specialty such as neurology or vascular surgery. Although student lack of confidence was not an issue for most participants, variation in confidence levels was noted. Other studies have reported that students lacked confidence. Pagana (1988) found a lack of confidence among students in initial medical/surgical experiences, and Ellis  53  (1980) found senior baccalaureate students lacking in confidence. McMaster (1979) found that relationships with instructors created stress for students, which might affect their confidence levels. One would think that there might be staff frustrations related to the underconfident or overconfident students which would have caused nurses to view students somewhat negatively. Clearly, this was not the case. What participants liked about, and the benefits they derived from working with students are consistent with those reported in the literature. Reilly and Oermann (1985) state that quality of care improves in the presence of students because staff nurses rethink and update their care. Corcoran (1977) and Lewis (1990) claim that staff members enjoy the stimulation that students provide and enjoy assisting in the development of professional nurses. According to Chickerella and Lutz (1981), staff nurses enjoy teaching, learning, and improving their leadership skills. Students usually have more time to spend with clients; time to listen, explain, and share (Corcoran, 1977). With increasing demands on their own time, it is understandable that staff nurses appreciate the increased attention students are able to give patients. It is obvious that students play a role in enhancing the quality of care patients receive and providing staff development  54 opportunities that otherwise might not occur. Therefore, the student clinical experience is a "give and take" situation for staff as well as students. Several things that staff disliked about working with students reflect time pressures that may relate to factors such as acuity, staffing levels, and unavailability of nursing instructors. Dislikes such as the number of questions and having to complete care might be dealt with by nursing instructors being readily available and both students and staff nurses knowing what is expected of them. Although the findings regarding what staff disliked about working with students are not reflected in their attitudes towards students, they are consistent with factors reported in the literature which have an impact on staff nurses' time and their provision of care. According to Windsor (1987), Myrick (1988), and Brown (1991), staff nurse responsibilities increase when working with nursing students. The presence of students requires expenditures of staff time in helping, reporting, and in answering questions (Corcoran, 1977). In addition, the continuity of care is interrupted when students intermittently care for patients. When their continuity of service is interrupted, staff nurses may experience decreased job satisfaction (Corcoran). According to Blanchard (1983), nursing education's greatest flaw lies in the amount and kind of clinical  55 experience students receive. Perhaps the 16 participants who thought students' knowledge levels were inappropriate for the clinical experience would agree with Blanchard. Their concerns about students' inadequate clinical preparation, lack of basic care skills, failure to see the big picture, and failure to complete work may be reflective of the kind of clinical instruction students receive. Some of these student deficiencies may also relate to the priority clinical teaching is given in nursing programs. In this researcher's experience it is often the least experienced teachers who are given the responsibility for clinical teaching. The above concerns may reflect differences between the values of nurse educators and those of nursing practitioners (Christy, 1980; Dalme, 1983; Eschbach, 1983; Johnson, 1980; Infante, 1986; Sleightholm, 1985), who are often more service-oriented. A difference in values is also suggested by slightly more than half of respondents who thought goals set for students were idealistic rather than realistic. This finding is supported by the many authors who have described nursing students' education as being idealistic rather than based on the realities of nursing practice (Blanchard, 1983; Douglas, 1978; Hammerstad & Murphy, 1979; Kramer, 1974; Mauksch, 1990; McPhail, 1991; Sleightholm, 1985; Suess, Schweitzer, & Williams, 1982).  56 The above concerns and differences, in addition to participants' perceived lack of information regarding the philosophies and clinical objectives of the various nursing programs they encounter, suggest the existence of a gap between education and service. In this researcher's opinion this gap was closing as staff nurses became accustomed to nursing programs that were not hospital-based. However, this gap may be widening again because some staff nurses are feeling pressured as a result of the current move to baccalaureate preparation as requirement for entry to practice. Hegyvary (1990) found some students faced discouragement and ridicule for entering nursing from stressed staff nurses. Therefore, it was expected that participants who did not encourage nursing as a career might hold negative attitudes toward students. However, this was not the case. There were organizational and role sender factors that supported the generally positive attitudes. However, there were also factors that supported participant concerns or dislikes about working with nursing students. Influencing Factors In the following section, findings related to factors that may influence attitudes are reported and discussed. These include findings which are related to organizational  57  factors, pressures and expectations created by role senders, interpersonal relationships between role senders and focal persons, and conceptions and expectations of the focal person. Organizational Factors The majority of participants (58 or 91%) found the administrative atmosphere in their hospitals to be pro-education. Of those who did not (6), the following reasons were given: insufficient money or relief staffing to allow nursing staff to attend conferences or seminars, inservices at awkward hours, insufficient staff to teach students thoroughly, and a poor learning environment created when busy staff nurses have the additional responsibility for students. There was considerable uncertainty about the commitment and role of the nursing department in relation to nursing student education. Of the participants, 21 (33%) did not know if this commitment was reflected in the philosophy and/or mission statement, and 42 (66%) either did not recall or stated that this role was not explained/discussed during the orientation of new staff. Fifty-nine participants (92%) believed that contributing to nursing education was one of their professional responsibilities. A lack of awareness of, or agreement with, the nursing department's role in nursing education may be reflected by the five participants  58 who did not believe this was part of their professional responsibilities. Although most staff nurses, 42 (66%), thought that their units were adequately staffed, 21 (33%) did not. As one participant commented on the administrative atmosphere regarding education, "we are not staffed properly to teach students thoroughly." Most staff nurses, 50 (78%), also thought the level of patient acuity was appropriate to the level of student on the unit. Only 14 (22%) stated that the patients were too acute. One respondent stated patient acuity was appropriate because "it is reality nursing but students are not prepared for it." Others who responded negatively said patient acuity was appropriate for higher level students but not students in the early stages of their program. Two respondents commented that it depended on the school of nursing. One of these respondents found diploma program students better able to care for acute patients than degree program students. In contrast to those who thought patients were too acute, 31 of the 57 participants (89%) who thought there were unit characteristics which enhanced student learning, listed factors related to high acuity as providing excellent opportunities to increase knowledge, improve skills, and practice organization. Of the 32 participants (50%) who thought there were factors which impeded student learning, eight mentioned  59 issues related to staffing, eight the fast pace, seven patient acuity, and five physical/space issues. Factors described as enhancing and impeding student learning are summarized in Tables 9 and 10, respectively.  Table 9 Unit Characteristics That Enhance Student Learning Characteristics^  Frequency of Response  Percent of Respondents (n = 57)  Suitability of patients (acuity/variety of diagnoses, experiences & skills)  28  49  Teamwork/cooperation among staff  11  19  Emphasis on teaching/learning  9  16  Educational resource materials  8  14  Receptivity to students  7  12  Good communication  6  10  Friendly atmosphere  6  10  Educational opportunities (ward rounds, patient care/family conferences, inservices)  5  9  Head Nurse (good relationship with staff, unit well focused/directed/organized)  4  7  Others: (health care team approach, basic care opportunities, young staff, and adequate senior staff)  7  12  60 Table 10 Unit Characteristics That Impede Student Learning Characteristics  Frequency of^Percent of Response^Respondents (n = 32)  Inadequate staffing (too busy/no additional staff)  8  25  Fast pace  8  25  Patients too acute  7  22  Physical/spacial setup (size/overcrowding)  5  16  Poor teamwork/communications  3  9  Lack of interest/involvement in students  2  6  Physician-related issues  2  6  3 Others: (high staff turnover, low instructor:student ratio, slightly negative attitude toward degree students)  9  Other organizational factors that may have influenced staff nurses were having to work with a variety of levels of students (58 or 91% of participants) and a variety of nursing programs (56 or 88%). Bendall (1971) stressed the importance of institutional influences on staff nurse attitudes and McLure, Poulin, Sovie, and Wandelt (1983) related administrative philosophies and supportive practices to positive staff  61 attitudes. The majority of participants thought the administrative atmosphere was pro-education. However, it is interesting to note that attitudes toward students did not reflect that 21 participants were unaware of the nursing departments' role in student education or that six participants identified insufficient supports for education. Concerns related either directly or indirectly to staffing and patient acuity levels became a theme that was repeated throughout the responses. Concerns related to staffing are consistent with O'Brien-Pallas and Baumann's (1992) finding that lack of adequate staffing is a recurring issue. According to Little and Carnevali (1972), staffing is a significant organizational factor to be considered in planning student learning experiences. The literature supports the position that units must be adequately staffed before accommodating nursing students (Barr, 1980; Nail & Singleton, 1983) and that medical/surgical units have the lowest nurse:patient ratios (Hendrickson, Doddato, & Kovner, 1990). Findings related to acuity were consistent with those of Caty and Scott (1988) who found the fast pace of the unit to be problematic for student learning, Myers (1992) who stated patient acuity was increasing, and Mundt (1990) and Smith (1988) who found it was not always possible to secure clinical settings suitable to the level of student learner.  62  Not only were areas not always perceived as suitable for students, but consistent with what McKenzie (1991) and Smith (1988) found, the majority of participants were required to work with various levels of students from several nursing programs. McKenzie argues that this mix makes it difficult for staff nurses to support and assist students in meeting their learning objectives. In this study, some staff nurses stated that they lacked information about what students could and could not do when providing care. However, these concerns were not reflected in negative attitudes toward students. Role Sender Factors Staff nurse perceptions of factors related to role senders are considered in this section. These include head nurse, nursing teacher, and nursing student expectations and pressures on staff nurses. Factors related to other role senders as well as interpersonal relationships between staff nurses and role senders are also reported. Participants thought head nurses were either very receptive (52 or 81%) or moderately receptive (12 or 19%) to having students on the unit. When asked about the ward atmosphere, all of the participants said good teamwork, 62 (97%) said good communication, and 52 (81%) said good relationships between head nurse and staff nurses existed on their units. The majority of participants, 50 (78%),  63 thought that the unit atmosphere had a considerable influence on their attitudes toward nursing students. Forty-five participants (70%) reported that they were expected to work with students rather than being asked if they wished to do so. Fifty-five (86%) thought their contribution to nursing students' education was respected by nursing teachers. Slightly more (59 or 92%) thought they were respected as a valuable resource for students. However, four did not know what nursing teachers thought of them. Thirty-eight participants (59%) were consulted about student assignments and asked for evaluative opinions about students. Only 22 (34%) were oriented to the specific objectives of the clinical experience and 19 (30%) were oriented to the philosophy of the nursing program. Only two participants were invited to attend clinical conferences. The difference in the number of participants who thought their contribution was respected by nursing teachers and the number who felt respected as a valuable resource to students is perplexing. Perhaps this difference reflects a perception that nursing teachers appreciate staff nurse assistance when they are unavailable to students (resource), but may not necessarily value the quality of assistance students receive (contribution). The importance of the clinical milieu to student learning has been documented (Reilly & Oerrman, 1985) as has  64 the crucial role of the head nurse in establishing this milieu (Orton, 1981). In this study, aspects of the clinical milieu, which directly related to head nurses and staff nurses, were described as quite positive and the atmosphere was, therefore, conducive to student learning. According to Seymour and Buscherhof (1991), staff valued recognition, respect, and appreciation of their various roles of which one was teaching. Similarly, Blegen, Goode, Johnson, Maas, McCloskey and Moorhead (1992) found that formal recognition by the head nurse was important to staff nurses. Participants reported feeing valued and respected for their contribution in student education; however, this is somewhat inconsistent with nursing teachers not consistently including them in decision making and head nurses seldom formally acknowledging their contributions to student learning. The limited communication and collaboration between nursing education and practice, associated by Kruger (1985) with nursing educators being guests in the clinical setting, was apparent. In addition, although the value of attending clinical conferences is documented (Barr, 1980; Mowry, 1982), only two of the participants reported attendance at such conferences. These findings indicate that the perceived value and respect felt by staff nurses is not necessarily consistent with role sender behaviours.  65 Although not specifically reported as role sender factors, the unavailability of, and lack of supervision provided by, nursing teachers was a theme in the responses. This finding suggests that less than ideal student:teacher ratios exist and may reflect the high student:teacher ratios Pierce (1991) claims exist in traditional clinical experiences and result in very little actual teaching time per student. The perceived unavailability of teachers may not only contribute to increased pressures on staff nurses, but may reflect the difficulties nursing teachers experience when they have students on more than one unit. Role Conceptions of Focal Persons The majority of participants (58 or 91%) were required to work with different levels of nursing students from different programs. Of those, 26 worked with two levels, 11 with three levels, 11 with four levels, three with five levels, and two with six levels. Five were uncertain what level of student they worked with. Fifty-six of the 58 worked with different nursing programs. Of these 56, 54 listed the nursing education programs they worked with: 24 worked with two programs, 27 with three programs, and 3 with four programs. Among those who worked with various levels of students/programs (n = 58), understanding of their role and responsibilities toward students varied. Only 19 (33%) knew  66 what was expected of them at all times; 23 (39%) knew sometimes; and 16 (27%) found it difficult to know what was expected of them. Not only were participants uncertain about their role with students, but 46 (72%) did not devote as much time to students as they would have liked. When asked to indicate what organizational and role sender factors contributed to this uncertainty, patient acuity, pace of the unit, and staff shortages were the most frequent reasons cited by participants (see Table 11). Similarly, when participants were asked if students expected more of them than they had time to give, 22 (34%) responded yes and four sometimes. They (n = 26) attributed this expectation to students thinking their educational needs take priority over other staff nurse responsibilities (5), and that staff are more available (25), less threatening (15), and more clinically competent (1) than nursing teachers. Only 36 participants (56%) felt supported in working with nursing students. Of these, 16 said nursing teachers suggested ways to work with students, eight said nursing teachers oriented them to their role with students, and six said their workload was adjusted to reflect the increased responsibility of working with students (one said the head nurse actually increased her patient assignment). Other  67 supports were from the head nurse (3), coworkers (2), nursing teachers in other ways (2), and staff development sessions (1).  Table 11  Insufficient Time To Devote To Students Contributing Factors^Frequency of Response  Percent of Respondents (n = 46)  Acuity of patients  41  89  Pace of unit  38  83  Staff shortages  23  50  Physician demands  17  37  Responsibility to supervise new or relief staff  16  35  Lack of encouragement from nursing teacher  5  11  Lack of appreciation from students  5  11  Lack of confidence in own teaching abilities  2  4  Lack of encouragement of head nurse  1  2  Although not always supported, the majority of participants (50 or 78%) felt recognized for working with students: 44 through a thank you note, 17 on their performance appraisal, three by a gift of flowers or food to  68 the unit, and two by students' verbal comments. McKenzie (1991) reports additional role pressures on staff nurses when they are required to work with various levels of students from different programs. Barr (1980) and Nail and Singleton (1983) stressed that nurses must be made aware of the objectives of the clinical experience and what is expected of them. Infante (1986) also stressed the importance of role clarity to students' learning experiences. That participants worked with a variety of students and were uncertain of their role in, or the objectives of, students' clinical experiences suggests that the participants were experiencing role pressures. Evidence of role pressure is also apparent in participants' responses that they did not have as much time as they would have liked to devote to students. Participant responses indicative of role pressures were consistent with reports in the literature. Several authors found that the increasing acuity and staffing concerns associated with the changing nature of acute care hospitals result in increased role pressures on staff nurses and impede the learning of nursing students (Brown, 1991; Hendrickson, Doddato, & Kovner, 1990; Myers, 1992; O'Brien-Pallas & Bauman, 1992). Role pressures were exacerbated for more than a third of participants who thought students not only expected more of them than they had time to give, but also placed their  69  needs before staff nurse responsibilities. These student behaviours may reflect the differences in priorities that exist between education and service (Sleightholm, 1985). Although Barr (1980) recommended that students be helped to realize the emotional and physical pressures on staff nurses, the findings suggest this is not done on a consistent basis. Additional Comments Twenty-one participants added additional comments at the end of the questionnaire. Although there was little new information, participants stressed the differences in students among nursing programs. They also stressed the need for nursing teachers to adequately explain the school philosophy, clinical experience objectives, and staff nurses' role with students. One thought it should be the students' responsibility to let the staff nurse know exactly what they can and cannot do. Another suggested that nursing teachers, students, and staff nurses meet regularly to discuss concerns. Concerns about the unavailability of nursing teachers as well as students' insufficient clinical preparation, lack of basic care skills, focus on tasks versus the big picture, and leaving unfinished work were reiterated. Summary In summary, the findings indicated that the attitudes  70 of the participants toward nursing students were remarkably homogeneous and positive in nature. A number of positive factors were identified that may have influenced those attitudes. For example, participants enjoyed teaching, receiving assistance with patient care, and being stimulated by students to keep up-to-date. The findings also indicated that participants had some concerns about students and factors associated with their clinical learning experiences. Safety posed considerable concern as did organizational factors which had an impact on the time staff nurses had to devote to students. Many of the participants' concerns were congruent with or were supported by those identified in the literature. Based on the various concerns expressed by the participants, the researcher's experience as a staff nurse and head nurse, and anecdotal reports from both students and staff members, it was not expected that attitudes toward students would be as overwhelmingly positive as they were found to be in this study. The findings lead the researcher to question the consistency of the attitude-behaviour link reported in the literature (Eiser & vander Pligt, 1988; Fazio, 1986; Rajecki 1990). To get a true understanding of attitudes, perhaps it is necessary to study behaviours at the same time as eliciting self-reports of the affective and cognitive attitude components that are described in the  71 literature (Fishbein & Ajzen, 1975; Rajecki, 1990). As role-models, staff nurses have a significant impact on students (Betz, 1985; Kelly, 1992). This is reaffirmed by the following student viewpoint, "It is important to remember, we trust, learn, and are socialized through our identification with you, and often adopt your values and emulate your behaviour" (Lillard, 1982, p.12). Due to the significance of this impact, it would be reassuring to know that participants' positive attitudes were reflected in their behaviours toward students. Otherwise, staff nurses might unknowingly reflect their concerns in behaviours which could be misinterpreted as negative attitudes toward students.  72 CHAPTTER FIVE Summary, Conclusions, and Implications for Nursing Summary The purpose of this descriptive study was to determine the attitudes of staff nurses toward nursing students and the factors that might influence those attitudes. The conceptual framework used to guide this study was a model of role adapted from the theoretical model for role conflict and ambiguity developed by Kahn et al. (1964). The major components of the model which were addressed were organizational factors, role sender expectations, focal person perceptions, interpersonal relationships between role senders and focal persons, and attitudes of focal persons toward role senders. The participants in the study were 64 registered nurses who worked full- or part-time on medical and/or surgical units of two acute care teaching hospitals. These staff nurses were either presently working with or had worked with nursing students in the six months previous to the study. A questionnaire, developed by the researcher, was used to elicit participants' perceptions about their attitudes and influencing factors. Questions addressed the major components of the conceptual framework and were based on knowledge gained from pertinent literature, as well as the researchers' knowledge and experience with students in the  73  clinical setting. Overall, participants' attitudes toward students were positive. They enjoyed teaching students, the assistance with their workloads, and the learning challenges students provided. However, there was considerable concern about patient safety, fragmentation of care, additional responsibilities, and disruptions in work when students were on the units. Concerns were also expressed about student skill levels, confidence levels, lack of provision of basic patient care, and lack of appropriate communications regarding patients. The existence of an education/service gap was suggested by the majority of participants who thought that the goals for students were idealistic rather than realistic, that their own clinical education had been superior, and who were uncertain about clinical experience objectives or their role as staff nurses in student education. Although there was perceived administrative support for education, participants had concerns related to organizational factors. They were uncertain about nursing department roles in student education and concerned about staffing and patient acuity levels. Factors influenced by the head nurse were generally viewed positively. However, factors related to nursing teachers and nursing education caused concern. Teacher unavailability and lack of  74 appropriate supervision of students were recurring themes in participant responses. Consultation with staff nurses regarding assignments or student performance was inconsistent. Participants were also required to work with several levels of students from a variety of programs with little understanding of the philosophies of the programs, the objectives of students' clinical experience, or their role in student education. Support in working with students was also sporadic. Factors associated with time pressures were also evident in participant responses. The majority of participants would have liked to have more time to devote to students. Consistent with this, over a third of the participants reported that students expected more of them than they had time for. Conclusions The relatively small sample size and the restricted study setting limit the generalizability of the findings. However, the following conclusions can be drawn from the study findings. 1.  Attitudes toward nursing students were positive, there were many things staff nurses liked about working with students, and they perceived benefits from working with them.  2.  Characteristics of the clinical milieu that related  75  to head nurses and nursing co-workers were conducive to student learning in clinical experiences. 3.  Participants expressed concerns about the unavailability of nursing instructors and/or insufficient supervision of students.  4.  Participants had insufficient time to devote to students. They identified numerous organizational factors that had an impact on the availability of their time.  5.  Participant responses suggested the existence of an education/service gap.  6.  Participants were uncertain about their role in the education of students. The variability among nursing students, teachers, and nursing programs may have contributed to this uncertainty. Implications for Nursing  Nursing Education The findings of this study have several important implications for nursing education. Ways to involve staff nurses and capitalize on their strengths and abilities in the clinical education of students need to be explored. Nursing teachers need to orient staff nurses to the philosophy of the nursing program, the objectives of the clinical experience, and to their expectations regarding the  76  staff nurse's role with students. If nursing teachers feel they are already doing this, they may wish to investigate why the majority of participants thought the above information was not provided. Perhaps the information is being left to head nurses to disseminate or it has not been recently provided. An orientation would help clarify roles as well as enlighten staff nurses about the values and priorities of the teachers. Because staff nurses may not be receptive to a time-consuming formal orientation, nursing teachers might attempt to find creative ways of providing this information informally. With a clearer understanding of their role in student education, staff nurses might be less concerned about the unavailability of teachers. Not only must nursing teachers orient staff nurses to their role with students, but the findings suggest that students need help to appreciate the social context associated with nursing units. This appreciation would provide students with an understanding of the staff nurse role and help them to respect staff nurse priorities and the limited space on nursing units. Students would be better able to determine when it is inappropriate to interrupt staff nurses or to ask them questions. Nursing education should explore the perceived lack of availability of nursing teachers to supervise students. If this perception is found to be a problem, more clinical  77  teachers may need to be employed. If the ratio of teacher to students is found to be adequate, then the effectiveness of the teachers may need to be assessed. Other alternatives to address this perception may be joint appointments or providing designated staff nurses with the necessary supports to act as clinical resource persons to students when nursing teachers are unavailable. Any of the above might reduce the impact that the unavailability of teachers has on staff nurses' time. Although participants feel respected as a valuable resource to students, nursing teachers may not be making sufficient use of this valuable resource. Students would likely benefit if there were more collaboration between nursing teachers and staff nurses. For instance, although it is not always possible, increasing the amount of consultation with staff nurses about student assignments and performance might have several benefits. It might reduce concerns about students caring for patients who are inappropriate for their level of knowledge and skill, give staff nurses greater insight into the objectives of the clinical experience, and enhance relationships between education and service personnel. Nursing educators need to continue to address participants' concerns regarding patient safety, incomplete charting and care, lack of competency in performing basic  78  care, and lack of appropriate communication with staff nurses regarding patient conditions. Some of these concerns may be alleviated by ensuring that students are oriented to the expectations of the clinical experience. Others may be addressed in the nursing laboratory where provision of basic care and skills can be taught and practiced until there is sufficient competency to promote safety in clinical learning experiences. Role playing would be one way to help students improve communications. In addition, role modelling care in the clinical environment would be an excellent way for nursing teachers to reinforce previous teaching and gain credibility with nursing staff and students. Findings related to the variety of student levels and nursing programs to which participants were exposed need to be addressed. This will require continued collaboration among nursing educators from various programs using acute care facilities for clinical experiences. If it is possible, greater consistency in placements would result in increased staff familiarity with clinical objectives and avoid loss of valuable clinical time spent orienting students to the various hospitals. If students were to spend more time on one unit they could develop skills and confidence that would be transferrable to other areas. Also, concerns about patient acuity and lack of staffing need to be addressed by nursing teachers thoroughly  79  assessing the appropriateness of a given unit for clinical placements. Further attention to the above may help alleviate staff nurse concerns and enhance opportunities for student learning. Nursing Practice The study findings also have implications for nursing service personnel. Nursing service administrators need to ensure that the commitment and role of the nursing department in relation to nursing student education is clearly outlined in department philosophies and mission statements. Staff nurses need to be made aware of this commitment during their orientation. Head nurses and/or unit managers need to monitor and evaluate the increased role pressures staff nurses experience when working with students and the appropriateness of the patients students care for. They also need to be cognizant of findings related to staffing issues to ensure adequate staffing without relying on student assistance with workloads. Head nurses also have a role in soliciting staff concerns regarding students and in establishing processes for addressing these concerns. The processes should include nursing teachers and should require staff nurses to be accountable for expressing their concerns formally. Head nurses should also formally recognize staff nurse  80 contributions to student education in appropriate ways. When staff nurses are uncertain about the philosophy of the nursing program, clinical objectives, student capabilities or their role with students they have a responsibility to find out what these are. Staff nurses need to be more assertive in requesting this information. They need to clarify their role with students as necessary and determine what is to be done when nursing teachers are unavailable to students. If staff nurses are not approached regarding student assignments or evaluative opinions of student performance, they should fell free to approach the nursing teachers with this information. Staff nurses must also be cognizant that they are role models for nursing students and that their attitudes and behaviours have a considerable impact on student learning. Head nurses have a responsibility to reinforce this. Nursing Research The findings of this study demonstrate that staff nurses have positive attitudes toward nursing students although they have concerns related to experiences with them. Replication of this study using a large, randomly selected sample is required to validate the findings, yield further information, and increase generalizability of the findings. The addition of a correlational component between staff nurses' responses and their characteristics would also  81 be valuable. This study was subject to the limitations inherent in the instrument design. Participants would have liked a greater range of choices in some questions. As well, there may have been a tendency to choose "correct" answers. Therefore, construct validity and reliability should be further investigated. A qualitative study might also reveal or stress areas of concern that the questionnaire failed to elicit. There is a need for a correlational study to determine if there is congruency between staff nurses' perceptions of their attitudes toward students and students' perceptions of staff nurses attitudes toward them. Because this study looked at nursing students in general, there is a lack of information regarding the differences in attitudes toward diploma and degree nursing students and comparing attitudes toward students from similar programs. There is also a need to replicate this study focusing on preceptorship experiences and registered nurse refresher programs. The study findings suggest inconsistencies among nursing teachers, such as the amount of information staff nurses are provided and the degree to which they are included in student clinical experiences. Therefore, research on the practices of nursing teachers may increase the understanding of staff nurses' concerns related to  82 nursing students and might identify areas for improvement that would enhance student learning. In this descriptive study, staff nurses' attitudes toward students remained positive in spite of identified factors which may be viewed as negative. The increasing pressures associated with the changing health care environment can be expected to have an impact on staff nurses and student learning. Therefore, it is important that studies continue to focus on examining factors associated with clinical learning experiences so that the clinical milieu remains conducive to student learning.  83 REFERENCES Alspach, J. G. (1987). The Preceptor's Bill of Rights. Critical Care Nurse, 7(1), 1. Baker, C. M. (1991). Moving toward interdependence: Strategies for collaboration. Nurse Educator, 6(5), 2731. Barr, F. (1980). 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Tesser, A. & Shaffer, D. R. (1990). Attitudes and attitude change. Annual Review of Psychology, 41, 479-523. Thomas, E.J. & Biddle, B. J. (1964). The nature and history of role theory. In B. J. Biddle & E. J. Thomas (Eds.), Role theory: Concepts and research (pp. 3-19). New York: John Wiley & Sons. Windsor, A. (1987). Nursing students' perceptions of clinical experience. Journal of Nursing Education, 26, 150-154. Zimbardo, P. G., Ebbesen, E. B., & Maslach, C. (1977). Influencing attitudes and changing behaviour: An introduction to method, theory, and applications of social control and personal power. Don Mills, Ont: Addison-Wesley.  91 Appendix A Research Questionnaire ATTITUDES OF STAFF NURSES TOWARD NURSING STUDENTS AND INFLUENCING FACTORS Investigator: Florence Tyson, MScN Student Phone: 264-8911 This questionnaire is designed to identify staff nurses' attitudes toward nursing students and the factors that influence those attitudes. Information obtained will assist nursing educators and administrators to ensure regular student clinical experiences are positive experiences for both nursing students and staff nurses. You are not obligated to participate in the study, nor will your participation affect your employment in any way. However, your consent to participate in the study will be assumed if you complete and return this questionnaire. You are free to refuse to answer any question on the questionnaire by leaving it blank and you are not required to identify yourself in any manner. Unless requested to do otherwise, please respond with one answer per question by ticking the space that corresponds with the answer that best represents your thoughts, feelings, or beliefs. Please explain your response when requested. It is estimated that it will take approximately forty-five minutes to complete the questionnaire and accompanying subject information sheet.  92  RESEARCH QUESTIONNAIRE  Code #  PART I: ATTITUDES 1)  Are the goals set by nursing teachers for the quality of patient care delivered by students in their clinical experiences ^ idealistic ? realistic ?  2)  Is student interest in the clinical learning experiences on your unit high ? moderate ? low ?  3)  In general, do nursing students display accountability for the care they provide? Yes^No If not, please explain  4)  In general, do students come to the clinical area with the appropriate level of knowledge to provide the necessary patient care to meet the requirements of their clinical experience? Yes^No If not, please explain  5)  In general, do nursing students demonstrate the level of skill competency required in their clinical learning experiences on your unit? Yes^No ^ If not, do they demonstrate ^ advanced skill competency? a lack of skill competency?  6)  With their level of knowledge and skill, are students ^ overly confident ? ^ suitably confident ? under confident ?  93  7)  Are you concerned for the safety of patients when they are being cared for by nursing students? Yes^No If yes, why? (*tick all applicable responses) ^ safety of the patient is my responsibility students are not supervised closely enough ^ students do not have the knowledge and/or skills to be considered safe other  8)  In general, are you concerned about fragmentation of patient care when nursing students are on the unit? Yes^No  9)  How would you rate your general attitude toward nursing students? very positive positive slightly positive slightly negative negative very negative  10) What do you like least about working with students?  11) What do you like most about working with students?  12) Do you encourage potential students to take up nursing as a career? Yes^No PART II: FACTORS THAT MAY INFLUENCE ATTITUDES 1) Do you consider the administrative atmosphere in the hospital to be pro education? Yes^No If no, please explain how it is not  -  94  2)  Does the philosophy and/or mission statement of the nursing department reflect a commitment to nursing student education? Yes^No^Do not know  3)  Is the role of the nursing department in relation to nursing student education explained/discussed during the orientation of new staff nurses? Yes^No^Do not recall  4)  Is the patient acuity level on your nursing unit appropriate to the level of students' learning on the unit? Yes^No If no, patients are too acute for the level of nursing student. patients are not acute enough to provide the required experiences for the students.  5)  How would you rate the appropriateness of staffing levels on your unit overstaffed ? adequately staffed ? understaffed ?  6)  How receptive is the head nurse to having students on the unit? very receptive, views it as an excellent opportunity for students and staff moderately receptive, views it as necessary for student learning unreceptive, views it as an undesirable obligation  7)  Are the following part of the ward atmosphere? Yes^No^Good teamwork Yes^No Good communication Good relationships between head Yes^No nurse and staff nurses  8) Are there unit characteristics which enhance student learning? Yes^No If yes, please explain  95 9) Are there unit characteristics which impede student learning? Yes^No If yes, please explain  10) To what extent do you think the unit atmosphere influences your attitude toward nursing students? a great deal quite a bit ^ somewhat very little 11) Are you asked if you wish to work with students or is it and expectation? asked expected 12) In general, do you feel your contribution to nursing student's education is respected by the nursing teachers? Yes^No 13) Do nursing teachers generally Yes ^ No^consult you about patient assignments for the students? Yes ^ No^respect you as a valuable resource to students? Yes^No^ask you for your evaluative opinions about student performance? Yes^No ^ invite you to attend clinical conferences? Yes^No^provide orientation to the philosophy of the particular nursing program? Yes ^ No^provide orientation to the specific objectives of the clinical experience? 14) Do you believe that contributing to nursing students' education is one of your professional responsibilities? Yes^No 15) Do you work with students at different levels in their nursing education? Yes^No  96  If so, what level of college students first year ? second year ? what level of university students ^ first year ? second year ? third year ? fourth year ? or,^uncertain what level ? 16) Do you work with students from more than one nursing program? Yes^No If yes, please specify which programs ^  17) If yes to either #15 or #16, what is your understanding of your role and responsibilities to the various students? ^ I know what is expected of me at all times sometimes I am unsure of what is expected of me with the differences in students I find it difficult to know what is expected of me at any given time 18) Do you like working with nursing students? Yes ^ No Please explain your response ^  19) Do you devote as much time as you would like to students? Yes^No If not, please check the factors that contribute to the amount of time you spend with nursing students ^ acuity of patients pace of unit physician demands responsibility to supervise new or relief staff staff shortages uncooperative coworkers lack of encouragement from the head nurse lack of encouragement from the nursing teacher ^ lack of appreciation from the students lack of confidence in own teaching abilities  97  20) Do nursing students expect more of you than you have time to give? Yes^No If yes, why so you think this is so? Please check all responses which you think are applicable: students are less threatened by asking questions of staff nurses than they are of nursing teachers. students think staff nurses are more clinically competent than their teachers. staff nurses are more available than the nursing teachers. ^ student nurses think their educational needs take priority over other staff nurse responsibilities. 21) How so you rate the theoretical component of your nursing education compared to that of the students you work with? It was: superior similar inferior no basis for judgement 22) How do you rate the clinical component of your nursing education compared to that of the students you work with? It was: superior similar inferior 23) Are you supported in working with nursing students? Yes ^ No If yes, check all applicable responses: nursing teachers suggest ways to offer guidance to the students. nursing teachers offer an orientation to the role of the staff nurse in working with students. my workload is adjusted to reflect the increased responsibility and time commitment of working with students. other 24) Are you recognized for working with students? Yes^No  98  If yes, how are you recognized? ^ commendation on my performance appraisal ^ thank you note from the students and/or nursing faculty a tea in honour of my contribution ^ other, please specify 25) Do you benefit from working with students? Yes^No If so, what are the benefits?  Additional comments  THANK YOU FOR DECIDING TO PARTICIPATE IN THIS STUDY.  99 Appendix B SUBJECT INFORMATION SHEET  Code #  You are requested to provide the following information which will be used to enhance the researcher's description of staff nurse attitudes toward student nurses and the factors that influence them. 1. Age: 2. Sex:  ^  female^male  3. Basic nursing education:^diploma program BSN program Year of graduation 4. Higher education (tick all that apply): post-RN diploma or certificate, please specify BSN other baccalaureate, please specify MSN other master's, please specify 5. Number of years of practice in nursing since completion of basic nursing education program 6. How long have you been employed in your present staff nurse position? 7. Are you employed^full-time? part-time? 8. What type of medical-surgical unit do you work on general medicine general surgery other, please specify 9. Name of hospital  100  Appendix C Introduction to Staff Nurses  School of Nursing The University of British Columbia Vancouver, B.C. Dear staff nurses: My name is Florence Tyson. I am presently enrolled in the master's program in nursing at the University of British Columbia. For my thesis study, I have chosen the topic of "Attitudes of staff nurses toward nursing students and influencing factors." My interest in this topic stems from my own experience as a staff nurse, and as an emergency head nurse in working with students in the clinical setting. As well, I am planning on becoming a clinical teacher and feel this study would provide me with valuable information to take to a teaching role. I hope to learn about this topic by having staff nurses complete a questionnaire to determine their attitudes to nursing students and to determine what factors might influence those attitudes. If you are a registered nurse employed as a staff nurse on a medical-surgical unit, have worked with nursing students in regular clinical experiences during the past six months, and are interested in the subject, I would appreciate your being a participant in this study. If you agree to participate, you will be asked to complete a questionnaire and a subject information sheet and mail them to me in a stamped return envelope that will be provided. Your consent to participate in the study will be assumed if you complete and return the questionnaire and information sheet. It is estimated that completion of the questionnaire will take approximately forty-five minutes. A coding system will be used for the purpose of matching questionnaire and subject information data. However, your name will not be required and the name of the hospital will be kept confidential. Although, it is hoped that you would complete each question you are free to refuse to answer any question by leaving it blank. You are not obligated to participate in this study, nor will your participation affect your employment or role as a staff nurse in any way. If you have any questions please contact me at 264-8911 or my Thesis Chairperson, Anne Wyness at 822-7485.  101  I anticipate that this study will with student clinical experiences changes that would benefit you in At the completion of the study, a made available to you. Thank you for your cooperation. Sincerely, Florence Tyson, RN, BScN  benefit all those involved and may serve to initiate your role with students. copy of the thesis will be  102 Appendix D Explanatory Letter For Agency Consent School of Nursing The University of British Columbia Vancouver, B.C. Dear My name is Florence Tyson. I am presently enrolled in the master's program in nursing at the University of British Columbia. For my thesis, I am interested in studying the attitudes of staff nurses toward nursing students and the factors that influence those attitudes. My interest in this topic arises from my experience as a staff nurse and as an emergency department head nurse involved in working with nursing teachers and nursing students during student clinical experiences. I anticipate that the findings of this study will enhance the understanding of staff nurses' attitudes toward students and will lead to recommendations for both nursing education and nursing practice that will benefit all those involved in the clinical experiences of nursing students. Also, I will benefit by being able to use the study findings in my future role as a nursing teacher. I would like to request the volunteer participation of members of your medical-surgical nursing staff. I hope to explain the study to the staff nurses and have those who are willing to participate complete a questionnaire and subject information sheet. Participation time will be approximately forty-five minutes. The name of the institution will be kept confidential and participation will be anonymous. At the completion of the study, a copy of the thesis will be made available to participants. As part of its review process, the University's ethical review committee requires a written consent from your institution. If you require further information, I may be contacted at my home phone number 264-8911 or you may contact my Thesis Chairperson, Anne Wyness at 822-7485. Thank you for your attention to my request. Sincerely, Florence Tyson, RN, BScN  


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