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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 STUDENTSAND INFLUENCING FACTORSbyFLORENCE MARY TYSONB.S.N., University of Victoria at Cariboo College, 1991A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIES(The School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAApril, 1993© Florence Mary Tyson, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature44€43artment—e4- sf-liv.,..640,te The University of British ColumbiaVancouver, CanadaDate car, /993DE-6 (2/88)i iABSTRACTClinical learning experiences are an essentialcomponent of nursing education. A literature reviewrevealed a considerable amount of anecdotal literatureaddressing the effect of the clinical milieu on studentlearning 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 staffnurses play a significant role in students' clinicalexperiences, this descriptive study was designed to assesstheir attitudes toward students and the factors that mightinfluence them. A model of role adapted from Kahn et al.(1964) was used to guide the study. Sixty-four medicaland/or surgical staff nurses participated in the study. Aquestionnaire developed by the researcher was used tocollect the data. The data were analyzed quantitatively,with data from open-ended responses being subjected tocontent analysis to form meaning categories. The datarevealed that staff nurse attitudes were positive and therewere factors which contributed to their positive attitudes.For example, they enjoyed teaching students and theassistance students provided. Despite their positiveness,staff nurses expressed concerns. They had concerns aboutsuch things as the unavailability of teachers, patientiiisafety, and disruptions in their work when students were onthe units. Participants identified organizational factors,such as patient acuity and staffing, that limited the amountof time they had to spend with students. They were requiredto work with a variety of students from different programsand many were uncertain about their role in working withstudents. The study findings have implications for nursingeducation, service, and research related to the clinicalaspect of students' education and staff nurse roles in thateducation.ivTABLE OF CONTENTSABSTRACT  ^iiTABLE OF CONTENTS ^  ivLIST OF TABLES  viiLIST OF FIGURES ^  viiiACKNOWLEDGEMENTS  ixCHAPTER ONE: Introduction  ^1Background to the Problem  ^1Problem Statement and Research Questions  ^5Conceptual Framework  ^6Organizational Factors  ^7Role Senders  ^7Focal Person  ^8Personality Factors  ^8Interpersonal Relations  ^8Application of the Conceptual Framework  ^9Significance of the Study  ^10Definition of Terms  ^11Attitude  ^11Nursing Student  ^11Staff Nurses  ^11Assumptions  ^11Limitations  ^12Overview of Thesis Content  ^12vCHAPTER TWO: Literature Review  ^14Introduction  ^14Attitude  ^14Role  ^18Student Clinical Experiences  ^23Regular Clinical Experiences  ^24Preceptored Experiences  ^25Education/Service Gap  ^27Summary of Literature Review  ^29CHAPTER THREE: Methods  ^31Introduction  ^31Research Design  ^31Subjects  ^31Instruments  ^32Data Collection  ^33Data Analysis  ^34Protection of Human Rights  ^34Summary  ^35CHAPTER FOUR: Presentation and Discussion of Findings  ^ 36Introduction  ^36Characteristics of Subjects  ^36Attitudes Toward Nursing Students as Role Senders  ^39General Attitude  ^40Student Attributes  ^40viPositive Aspects of Working With Students  ^45Negative Aspects of Working With Students ^ 47Focal Person Attitudes That May InfluenceAttitudes Toward Students  ^49Influencing Factors  ^56Organizational Factors  ^57Role Sender Factors  ^62Role Conceptions of Focal Persons  ^65Additional Comments  ^69Summary ^  70CHAPTER FIVE: Summary, Conclusions, and Implicationsfor Nursing ^72Summary ^  72Conclusions  ^74Implications for Nursing  ^75Nursing Education  ^75Nursing Practice  ^79Nursing Research  ^80REFERENCES  ^83APPENDICES  ^91Appendix A: Research Questionnaire  ^91Appendix B: Subject Information Sheet  ^99Appendix C: Introduction to Staff Nurses ^ 100Appendix D: Explanatory Letter for Agency Consent ^ 102vi iLIST OF TABLESTABLE1 Nurses' Age Distribution ^ 372 Nurses' Education ^ 383 General Attitude 404 Behaviours Described as Lack of Accountability ^ 415 Inappropriate Knowledge Level ^ 446 What Was Liked Most About Working With Students ^ 467 Perceived Benefits From Working With Students ^ 478 What Was Liked Least About Working With Students ^ 499 Unit Characteristics That Enhance Student Learning 5910 Unit Characteristics That Impede Student Learning ^ 6011 Insufficient Time to Devote to Students ^ 67viiiLIST OF FIGURESFIGURE1 Model of Role ^6ixACKNOWLEDGEMENTSI wish to acknowledge and thank the staff nurses whoparticipated in this study. I am encouraged by theirpositive attitudes toward students and appreciate theirwillingness to share their thoughts. I wish to thank themembers of my Thesis Committee, Professor Anne Wyness,Doctor Marilyn Willman, and Professor Linda Leonard fortheir guidance, support, and encouragement throughout thisstudy.I am grateful to my friends, family, and classmates fortheir encouraging words and am especially thankful that Iwas accompanied during the thesis experience by my friendand classmate, Leanne.My very special thanks to Bob, for believing in me.1CHAPTER ONEIntroductionBackground to the ProblemClinical experience is a vital component of everynursing student's education (Mogan & Knox, 1987; Windsor,1987). Prior to nursing education being moved into the maineducation stream, most schools of nursing were associatedwith an acute care hospital (Baumgart & Larsen, 1988). Inthese hospital-based training schools, clinical experiencewas of a service-oriented, apprenticeship nature (Baumgart &Larsen; Christy, 1980; MacPhail, 1988). In thisresearcher's experience, a clinical teacher was assigned toeach unit and was responsible for the teaching andsupervision of nursing students on that unit. The clinicalteacher was also a resource person for staff nurses.However, due to the unavailability of nursing teachers onevening and night shifts, a great deal of the teaching thatoccurred in the clinical setting was left to the staffnurses. Due to constant exposure to nursing students, staffnurses were familiar with their role in, andresponsibilities for, the clinical aspect of the students'education.Today, the role of the staff nurse in the clinicaleducation of nursing students has changed. The move fromservice-oriented training to college- and university-based2nursing education has separated education from service(Christy, 1980; Johnson, 1980; MacPhail, 1988; Sleightholm,1985). Nursing teachers and students have become guests inthe clinical setting (Baker, 1981; Christy; Johnson;McPhail, 1975; Petersen, 1978; Shah & Pennypacker, 1992;Sleightholm; Smith, 1988), and staff nurses no longeridentify students as "their students" (MacPhail). Asignificant portion of clinical education is still obtainedin the acute care setting. However, some of what waspreviously taught and practiced in the clinical area nowoccurs in a laboratory environment. This change, and theincreasing use of other settings for clinical experiences,has reduced the amount of contact between hospital staffnurses and nursing students.Some authors suggest that there is a "gap" betweeneducation and service due to different value systems(Christy, 1980; Johnson, 1980; Sleightholm, 1985). Inaddition, staff nurses' changed role in teaching andsupervising students, as well as decreased exposure tostudents, may influence their attitudes toward nursingstudents. Other factors may also influence these attitudes.Increased patient acuity and decreased nursing staff ratios(Brown, 1991; Hendrickson, Doddato, & Kovner, 1990; O'Brien-Pallas & Baumann, 1992) result in increased workplacedemands on staff nurses. The fact that it is not always3possible for nursing teachers to secure clinical settingssuitable to the level of student learner (Mundt, 1990;Smith, 1988) and the additional responsibilities staffnurses encounter when working with students (Brown; Myrick,1988; Windsor, 1987) further complicate the role of staffnurses. These factors may negatively influence theattitudes of staff nurses toward nursing students.There is little in the literature to suggest that staffnurses generally treat nursing students poorly during theirclinical experiences. However, some studies of studentperceptions of their clinical experiences reveal concernsabout how nursing students are treated in clinical settings(Pierce, 1991; Windsor, 1987). Pierce found studentsworried about staff nurses who were critical and notreceptive. Windsor alludes to attitude concerns that werereflected in negative behaviours toward nursing students.In her study of students' perceptions of their clinicalexperiences, she found that staff nurses were generallyperceived positively. However, they were perceivednegatively when they displayed negative behaviours towardthem.Attitudes such as those referred to above can have adetrimental influence on the nursing student. Kelly (1992)notes that development of professional role identity andself-concept by students are related to the caring attitudes4of role-models. Attitudes of role-models also have asignificant 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 statethat contributing to the clinical learning milieu may beservice and learning goals, and/or administrative andprofessional goals. Both sets of goals may or may not be incompetition.In this researcher's experience, the clinical milieuvaries between institutions and even from unit to unitwithin the same institution. In magnet hospitals, whereprogressive administrative philosophies and practices serveto attract and retain nursing staff, McLure, Poulin, Sovie,and Wandelt (1983) found that the attitudes of staff nursestoward nursing students and their affiliated educationalprograms were very positive. This finding suggests thatthere are organizational characteristics, such asadministrative philosophy and practices, which affect theclinical milieu by either positively or negatively affectingstaff nurses' attitudes toward nursing students.It stands to reason that nursing student learning willbe enhanced by staff nurse opinions or behaviours thatreflect positive attitudes toward students and hampered bythose that reflect negative attitudes. Therefore, it is5important to gain an understanding of staff nurse attitudestoward nursing students and the factors that influence theformation of those attitudes. Such information has thepotential to lead to changes that might improve the clinicalexperience for both nursing students and staff nurses.Problem Statement and Research Questions Clinical learning remains a critical aspect of theeducation of nursing students. There is considerableliterature that addresses nursing students' perceptions oftheir experiences in the clinical field (Beck & Srivastava,1991; Davidhizar & McBride, 1985; Kelly, 1992; Kleehammer,Hart, & Keck, 1990; Pierce, 1991; Windsor, 1987). Some ofthis literature reveals that there are concerns with howstudents are treated in the clinical setting (Davidhizar &McBride, 1985; Pierce, 1991; Windsor, 1987). However, thereis a paucity of literature that addresses the attitudes ofstaff nurses toward nursing students or the factors thatinfluence the formation of those attitudes. Therefore, thisdescriptive study was designed to answer the followingquestions:1. What are the attitudes of staff nurses towardnursing students?2. What factors influence staff nurses' attitudestoward nursing students?6Conceptual FrameworkA model of role adapted from Kahn, Wolfe, Quinn, Snoekand Rosenthal's (1964) model of factors involved inadjustment to role conflict and ambiguity was used to guidethis study (see Figure 1).Figure 1. Model of role adapted from "A theoretical modelfor role conflict and ambiguity" (Kahn, Wolfe, Quinn, Snoek,& Rosenthal, 1964).The model developed by Kahn et al. was chosen becauseit represents a complete cycle of role sending, response ofthe focal person, and the effects of that response on therole senders. It includes the organizational factors,personality factors, and the character of the interpersonalrelationships between the focal person and the role senderswhich influence the focal person's response.7In the adapted model the focal person's response isdefined in terms of attitudes and behaviour. The modelprovides a means of identifying and understanding thefactors which influence the role and, therefore, theattitudes and behaviour of an individual toward the rolesenders in the context of an organization. According toKahn et al. (1964), the major concepts are described asfollows.Organizational Factors To a considerable extent, the role expectations of therole senders and the role conceptions of the focal personare both predetermined by the broad organizational structureand function. The division of labour and the formal rewardsystem are specified. For example, the hospital may have awritten job description for staff nurses that includes whatis expected of the staff nurse in relation to nursingstudents' clinical experiences. As well, organizationalconditions determine in part the expectations and pressuresimposed by the role senders.Role Senders A role sender is an individual who has a set of roleexpectations of another person (focal person) and thatperson's behaviour on the job. Therefore, the role senderexerts pressure on the focal person to perform in a certainmanner. In an acute-care hospital, role senders include8patients, doctors, head nurses, peers, nursing teachers, andnursing students who have role expectations of the focalperson (staff nurse).Focal PersonThe focal person (staff nurse) is the focus of the rolesender's expectations and experiences role pressure relatedto the expectations. At any given moment, pressure from avariety of role senders' expectations may result in thefocal person experiencing role conflict or role strain. Thefocal person responds to the expectations based on his/herabilities to do so, perception of what is being demanded,conception of what his/her role is, and attitudes orbehaviours which are either productive or counterproductivein the situation.Personality Factors As defined by Kahn et al. (1964), personality factorsare a person's propensities to behave in certain ways. Theyinclude motives, values, sensitivities, fears, and habits.They are important determinants of differential elicitationsand differential responses to role pressure.Interpersonal Relations Interpersonal relations refers to the patterns ofinteraction between a focal person and the role senders andtheir orientations toward each other. These patterns mayarise from formal organizational structures or informal9interactions. They are influenced by power differences,affective bonds, dependence, and communication between thefocal and role sender persons. The degree of role pressureexerted and experienced will depend on these relations.Application of the Conceptual FrameworkThe model of role adapted from Kahn et al.'s (1964)model of factors involved in adjustment to role conflict andambiguity provided an appropriate framework for the study ofstaff nurses' attitudes toward nursing students and thefactors that influence those attitudes. Factors related tothe organization and the role senders guided the formulationof questions in the development of the questionnaire used inthe study. The inclusion of the focal person's personalcharacteristics directed the researcher to ascertain theeducation and experience of staff nurses in order to includethese factors in the description of factors affecting theirattitudes toward nursing students. As well, the effects ofrole expectations, role pressures, and role conceptions onstaff nurses' attitudes were addressed in the questionnaire.Assessment of role sender and focal person personalities wasbeyond the scope of this study.In this study, the focal person was the staff nurse whowas involved in working with nursing students and the rolesenders were head nurses, unit managers, patients,physicians, other staff nurses, nursing faculty, and nursing1 0students. The organizational factors were such things aspatient acuity, staffing ratios, and institutional policies.Role expectations were the demands placed on staff nurseswhich relate to the provision of nursing care or workingwith nursing students. The study concentrated on focalpersons' attitudes toward students and factors thatinfluenced those attitudes.Significance of the StudyThe significance of this study is that a) it providesparticipating staff nurses with an opportunity to gaininsight into their attitudes and the factors that influencethose attitudes in order that they become more effective inworking with students, b) it provides nursingadministrators, educators, staff, and students with a meansof assessing whether there is cause for concern, need forimprovement, or if the attitudes and influencing factors areappropriate, c) it provides a means of assessingcollaboration and communication between education andservice personnel, and d) it provides a basis forconsidering ways to improve clinical learning experiences.The study also provides a better understanding of thepressures on staff nurses. It identifies positive factorsthat should be reinforced and negative factors that shouldbe alleviated or reduced. The nature of the identifiedfactors indicates who should address the concern.1 1With limited clinical experience time and increasedcompetition for clinical placements, the findings of thisstudy have the potential to assist staff nurses, faculty,and nursing students to optimize the benefits of theclinical experience for all concerned.Definition of Terms Attitude An attitude is an implicit response oriented towardapproaching or avoiding, reacting favourably or unfavourablytoward, an object or symbol (Insko, 1967). In this study,attitudes are expressed as opinions or beliefs and areassessed from responses to questions on the studyquestionnaire.Nursing Student A nursing student is an individual enroled in a nursingeducation program that leads to a diploma or undergraduatedegree in nursing, excluding those baccalaureate nursingstudents who are registered nurses.Staff Nurses A staff nurse is a registered nurse who is employed atthe general duty level in an acute care hospital on amedical and/or surgical unit.Assumptions The study was based on the following assumptions:1. Attitudes are expressed as either opinions or12beliefs.2. Most attitudes are held strongly enough to directbehaviour.3. Staff nurses are aware of and able to express theirattitudes and the factors influencing those attitudes.4. Staff nurses' attitudes have an impact on studentlearning experiences.5. Participant responses are thorough and truthful.Limitations Generalizability of the findings of this study islimited due to the sample size and non-probability samplingused. Because the participants were from medical-surgicalunits of two acute-care urban teaching hospitals, thefindings are not generalizable to nurses working withstudents in other clinical settings. The examination ofpersonality factors was beyond the scope of this study.Therefore, the study cannot be said to address all factorswhich may influence staff nurses' attitudes toward nursingstudents. As well, the use of a self-report questionnairelimits the findings to what participants were willing toreport.Overview of Thesis Content This thesis is comprised of five chapters. In thisintroductory chapter the following study components havebeen addressed: background to the problem, problem13statement, research questions, conceptual framework,significance, assumptions, and limitations.Chapter Two presents a review of the literaturepertinent to the study. Chapter Three provides a detaileddescription of the research methods used. Chapter Fourpresents the analysis of participant responses on theresearch questionnaire and a discussion of the findings. Inthe final chapter, a summary of the study findings,conclusions, and implications for nursing education,practice, and research are presented.14CHAPTER TWOLiterature ReviewIntroductionThis chapter presents a review of the literature whichis pertinent to the study of staff nurses' attitudes towardnursing students. The literature review is presented infour sections addressing the purpose of the study and theconcepts 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 literaturereview.AttitudeThe concept of attitude is central to the purpose ofthis study. "The basic rationale for understandingattitudes hinges on the notion that attitudes revealsomething about probable behaviour" (Kahle, 1984, p.105).In the literature, attitude is defined in a variety ofways 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 atendency to respond in a certain manner to an object orsymbol. To explain the concept further, some authors breakattitude into three components; affective, cognitive, andbehavioural (Fishbein & Ajzen; Rajecki, 1990; Sudman &Bradburn, 1983; Zimbardo, Ebbeson, & Maslach). The15affective component consists of a person's evaluation of, oremotional response to, something. It can be measured byphysiologic responses or verbal statements. The cognitivecomponent consists of a person's beliefs about or knowledgeof something. It can be measured by self-reports aboutbeliefs or amounts of knowledge. The behavioural componentinvolves behavioural intentions and may be measured bydirect observation of a person's overt behaviour towardsomething. According to Fishbein and Ajzen, the bestpredictor of behaviour is intention.Although the relationship between attitude andbehaviour is not absolutely clear, many authors argue thatattitudes exert a strong influence on behaviour (Fishbein &Ajzen, 1975; Insko, 1967; Kahle, 1974; Rajecki, 1990).Rajecki reports that, due to recent research findings, thereis 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 areassumed to guide role judgments and behaviors" (p. 345)whereas, Henerson, Morris, and Fitz-Gibbon (1987) state "wecan only infer that a person has attitudes by his/her wordsand actions" (p. 12). Therefore, for the purpose of thisstudy, attitude and behaviour are viewed as separateresponses with attitudes influencing behaviour.16Although both situational and personality variablesmoderate the attitude-behaviour link (Eiser & vander Pligt,1988; Fazio,1986; Rajecki,1990), this study addresses onlysituational variables. According to Rajecki, attitudes areformed or moulded by a variety of circumstances and stemfrom different sources or experiences. Attitudes formed onthe basis of a direct, behavioural experience with anattitude object are more predictive of later behaviour thanare attitudes formed via indirect, nonbehaviouralexperiences (Fazio). Therefore, direct experience with anattitude object promotes attitude-behaviour consistency(Eiser & vander Pligt; Fazio; Rajecki).Tesser & Schaffer (1990) argue that the primary purposeof holding an attitude is object appraisal. This appraisalinvolves making evaluative judgements about an object thatwill have clear behavioural implications. Therefore,attitudes serve as a guide to behaviour. Attitudes alsoallow one to identify with others, promote acceptance byothers, make one's world predictable and orderly, andmotivate behaviour (Ostrom, 1968; Rajecki, 1990). Attitudesare learned expressions of life's experiences (Fishbein &Ajzen, 1975; Schumann, 1990). Therefore, they help toexplain individual differences (Kiesler, Collins, & Miller,1969).17That attitudes are formed from experience suggests thateducation, past experiences, and individuals' role-relatedexperiences will have an influence on their attitudes and,therefore, their behaviour.According to Fishbein and Ajzen (1975), some attitudesare relatively stable over time while others exhibitfrequent shifts. This suggests that there is potential tochange negative attitudes to positive attitudes. Ifattitudes have the potential to change, and if studentlearning can be adversely affected by negative attitudes, itfollows that it is important to determine attitudes towardlearners and factors that influence those attitudes. To dothis, Henerson, Morris, and Fitz-Gibbon (1987) suggest thatself-reports represent the most direct type of attitudeassessment and should be employed unless subjects are unableor unwilling to provide the necessary information.Several authors have documented the impact of staffnurses' attitudes on student learning. Betz (1985) statesthat as role models in the clinical setting, staff nurses'norms, beliefs, and attitudes have a significant impact onstudent learning and behaviour. Davidhizar and McBride(1985) found that students described negative attitudes ofstaff nurses toward them as one cause of their failures inproviding nursing care. Infante (1985) stresses thepositive impact staff nurses can have on, and Reilly and18Oermann (1985) stress the importance of a supportiveclinical milieu to, student learning. Because staff nurseattitudes are formed from experiences, it is important toreview how staff nurses experience their roles.Role Individuals in society occupy positions, and their roleperformance in these positions is determined by socialnorms, demands, and rules; by the role performance ofothers in their respective positions; by those whoobserve and react to the performance; and by theindividual's particular capabilities and personality(Thomas & Biddle, 1964, p.4).Literature pertaining to nursing roles was reviewed inorder to gain a better understanding of the roleexpectations, role conceptions, and role pressuresexperienced by staff nurses who are involved in working withnursing students. Role expectations involve the formal andinformal demands of the nurse's position, role conceptionsare what the nurse thinks his/her job is, and role pressuresare the role expectations the nurse feels from others(Schmalenberg & Kramer, 1979). Corwin and Taves (1962)relate the rights and obligations perceived as roleconceptions to attitude generation. Role conceptions may becongruent with role expectations. However, when there islittle information about what is expected, or differences19between role expectations and role conceptions, roleambiguity occurs (Hardy & Hardy, 1988). The resultingincrease in role pressure may result in negative attitudestoward role senders.Myers (1992), in an article addressing issuesconfronting contemporary nurses, reported that many staffnurses are experiencing role strain, that is, havingdifficulty fulfilling role expectations. Patient acuitylevels are increasing (Hendrickson & Doddato, 1989; Myers)and staff nurses wonder if administrators understand theirday-to-day stresses (Mauksch, 1990; Myers). In someclinical areas, there has been a decrease in nursing staffratios over the past ten years (Brown, 1991). In theirreview of nursing worklife studies, O'Brien-Pallas andBaumann (1992) found increasing patient acuity andchronicity and lack of adequate staffing to be recurringissues. In a study of how nurses use their time,Hendrickson, Doddato, and Kovner (1990) found medical-surgical units to have the lowest nurse/patient ratios.Organizational factors such as these create role pressuresfor staff nurses which often overshadow the learning needsof nursing students in the clinical setting (Brown;Corcoran, 1977; Hendrickson, Doddato, & Kovner). Even moretroubling is the significant number of students who arediscouraged from, or ridiculed for, entering nursing by20stressed staff nurses (Hegyvary, 1990). This may be theresult of excessive role pressures and/or negative roleconceptions.In regular clinical experiences, the staff nurse rolein nursing education is that of professional role model andresource person to students (Infante, 1985). In this role,any teaching they do is usually informal and often involvesanswering questions when nursing teachers are unavailable.They are responsible for providing patient information tostudents and recieving report from the students about thecare they provide. Staff nurses are also responsible formaintaining patient safety while the patient is being caredfor by a nursing student (Windsor, 1987). Lewis and Deans(1991) report that a concern for safety is shared by manystaff nurses when students care for patients. Schmalenbergand Kramer (1979) report that being responsible for the caregiven by nursing students contributes to the uncertainty ofthe new graduate nurse. This uncertainty might beassociated with concerns for patient safety.McKenzie (1991) and Smith (1988) reported that unitsare assigned students from a variety of nursing programs whohave varying levels of knowledge and skills. This mix makesit difficult for staff nurses to support and assist thestudents in meeting their learning objectives (McKenzie),thereby resulting in increased role pressure.21Although the above concerns may arise in both regular andpreceptored experiences, the role expectations of the staffnurse in preceptored experiences change. In preceptorships,staff nurses are sometimes expected to take on additionalresponsibility for teaching and evaluating students withoutadequate preparation to do so (Myrick, 1988). However,McKenzie (1991) reported that giving staff nurses directresponsibility for a group of students resulted in increasedmotivation and knowledge, with nurses actively pursuingexperiences for the nursing students and becoming involvedin aspects of teaching. Similarly, Chickerella and Lutz(1981) found that staff nurses who volunteered to bepreceptors wanted to help students and improve their ownknowledge, leadership abilities, and teaching skills. Forthem, the result of precepting was an enhanced sense ofresponsibility and increased job satisfaction. However,Chickerella and Lutz reported that others found theexperience frustrating and time-consuming, and that therewas too little time to spend with students. When evaluatinga Halifax preceptor project, Caty and Scott (1988) found thefast pace of the unit to be a problem. The pace resulted innurses feeling guilty when they were unable to work withstudents or answer their questions.With an awareness of the positive and negative aspectsof working with students, Limon, Bargagliotti, and Spencer22(1982) stressed that administrators must be able to providedirect support for staff nurses to facilitate and rewardthem in their role as preceptor. Alpach's (1987)Preceptor's Bill of Rights outlined supports required byclearly stating the rights of preceptors that come withassuming the responsibility of working with nursingstudents. In the magnet hospitals where administrators arecognizant of these rights and supports are in place, staffnurse preceptors reported working with students as a verypositive experience (McLure, Poulin, Sovie, & Wandelt,1983).Factors which have implications for the preceptor rolemay also have an impact on the role of the staff nurse inregular clinical experiences. For instance, the pace of theunit, the time-consuming aspects of working with students,and the preparation and supports required to workeffectively with students are common to both experiences.Corcoran (1977), questioning the ethics of using aservice setting for clinical experiences in general, asks"What about the rights and responsibilities of staffmembers?" Several authors have responded. Care must betaken so that staff and patients do not get a "studentoverdose" (Bevil & Gross, 1981; Goldenburg & Iwasiw, 1988;Little & Carnavali, 1972; Nail & Singleton, 1983). The unitmust be adequately staffed and staff nurses must be made23aware of the objectives of the clinical experience and whatis expected of them (Barr, 1980; Nail & Singleton). Also,students should be helped to realize the emotional andphysical pressures of the staff nurse's role (Barr).It is not difficult to determine that role-relatedfactors may influence the development of staff nurseattitudes toward nursing students in clinical experiences.Staff nurses who experience increased role pressures mayrespond negatively to nursing students, whereas, those whoserights are respected and who are supported may respond in apositive manner.Student Clinical Experiences A review of the literature pertaining to nursingstudent clinical experiences was undertaken to gain anunderstanding of how students perceive staff nurses. It isreasonable to think that these perceptions are influenced bystaff nurses' attitudes toward the students. As mostnursing student clinical experiences are part of a regularnursing course, this study focused on the attitudes relatedto those experiences. In regular clinical experiences,faculty members are responsible for teaching and supervisinga group of nursing students. In a preceptorship, a staffnurse is delegated some responsibility for teaching andserves as a role model to an individual nursing student. Itis acknowledged that there are differences in student and24staff nurse experiences between regular clinical andpreceptored experiences. However, it is assumed that manyof the findings in preceptored experience studies also applyto regular clinical experiences. Therefore, research onboth regular clinical experiences and preceptoredexperiences is reviewed.Regular Clinical Experiences Several researchers have found that regular clinicalexperiences are a major source of stress to most nursingstudents at one time or another (Beck & Srivastava, 1991;Carver & Tamlyn 1983; Garrett, Manuel, & Vincent, 1976;MacMaster, 1979). Both McMaster and Garrett, Manuel, andVincent found that this stress was primarily related to thephysical care of patients and interpersonal relationships.Relationships with instructors were found to create morestress than those with staff nurses. They also found thatthe stress experienced in clinical settings decreased asstudents progressed through the nursing program, perhapsbecause of their increasing knowledge and skills. This issupported by other researchers. Beck and Srivastava foundthat a lack of clinical knowledge and skills was one of thegreatest sources of stress among baccalaureate nursingstudents. Carver and Tamlyn found similar results in theirstudy of third year baccalaureate students. This decreasein stress may also reflect different attitudes of staff to25students as the students become increasingly competent.In a qualitative study of nine senior baccalaureatestudents' clinical experiences, Windsor (1987) found thatstaff nurses were generally viewed as knowledgable, helpful,and understanding. Students valued relating to them andworried about receiving their approval. Students wantedfrequent honest feedback and did not want staff nurses to dotheir work as it ruined their confidence. Staff nurses wereperceived negatively when they made derogatory comments,gave disparaging looks, told students to go to theirinstructors for help, and frequently checked up on thestudents. Students reported that staff nurses generallyconveyed negative feelings by manner rather than by overtbehaviour. Students often asked peers questions as this wasless threatening than asking the staff nurses.In a cross-sectional study of diploma students'explanations for their success and failure in clinicalexperiences, Davidhizar and McBride (1985) found "thehighest number of attributions in explaining failures innursing care were related to staff characteristics" (p.288).Characteristics cited were lack of helpfulness, a negativeattitude toward students, not appreciating studentcontributions, not having time for explanations, notcontributing to student learning, and not being friendly.26Preceptored Experiences In a descriptive study of 44 preceptored nursingstudents, Peirce (1991) found that students wanted to beable to care for a variety of patients in a supportiveenvironment where they were welcomed by nursing staff, andwhere the staff nurse working with students was interestedin doing so and had the necessary clinical and teachingskills. Clinical site factors that influenced the studentexperience were identified as organizational expectations,availability of help and instruction, feedback, a chance toparticipate in the life of the unit, and receptive staffnurses.In 1990, Hsieh and Knowles identified seven themes asbeing important to the preceptorship relationship betweenstaff nurses and nursing students. These were trust,clearly defined expectations, support systems, honestcommunication, mutual respect and acceptance, encouragement,and mutual sharing. When these themes were not establishedearly in the preceptorship, students lagged behind theirpeers in achievement.The reviewed research studies demonstrate studentappreciation of positive staff nurse attitudes and thedetrimental effects that negative attitudes can have. Innon-research-based literature, Reilly and Oermann (1985)stress the importance of the clinical milieu to nursing27student achievement, satisfaction, and professional rolesocialization. The latter occurs through identificationwith a positive role model (Dobbs, 1988). As majorcontributors to the clinical milieu, Kelly (1992) foundstaff nurses who were caring role-models to be a majorinfluential force in students' development of a professionalself-concept.Education/Service Gap How staff nurses perceive and/or experience factorsassociated with the relationship between nursing educationand nursing service may influence their attitudes towardnursing students. Numerous authors have reported a gapbetween nursing education and service due to different valuesystems (Blanchard, 1983; Christy, 1980; Johnson, 1980;McPhail, 1975, 1988, 1991; Mauksch,1990; Sleightholm, 1985).Some of the different values relate to the importance ofresearch, conceptualizations of practice, priorities ofcare, and theoretical foundations of practice (McPhail,1991). These differences are reflected in what severalauthors describe as idealistic nursing education rather thaneducation based on the realities of nursing practice(Blanchard; Douglas, 1978; Hammerstad & Murphy, 1979;Mauksch; McPhail; Sleightholm; Suess, Schweitzer, &Williams, 1982). Education, work setting, autonomy, andstatus differences between nursing educators and nursing28staff also contribute to the gap (McPhail, 1991).For the above reasons, nursing teachers and studentsare 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 andcollaboration between nursing education and practice(Kruger, 1985). The biggest losers when this estrangementoccurs are nursing students (Eschbach, 1983). Therefore,nurses from both sides are developing strategies to preventthis gap from occurring or to close it if it has occurred.Several models have been developed in an attempt toalleviate the education-service gap. In 1972, theUniversity of Rochester and Rush University institutedcollaboration/unification models in which one individual hasresponsibility for both education and service. Facultypractice is an integral part of both models. Case WesternReserve University initiated the interorganizational modelwhere education and service remain separate but share costsof faculty-clinicians and the time and talents of clinicaland associate appointees. According to McPhail (1991),these collaborative models have resulted in enhanced studentlearning, changes in attitudes of staff toward learners, andimproved role models for students.One American college developed an eight-week role29exchange program between education and practice which hasalso resulted in more favourable attitudes of staff nursestoward nursing students (Eschbach, 1983). Jointappointments also offer potential improvements in bridgingthe gap and have had some success in changing the attitudesof staff nurses toward students, thereby enhancing thelearning climate (McPhail; Joel, 1985). Kruger (1985)reports that students felt more accepted as a result ofjoint faculty/practice positions.Summary of Literature ReviewThe literature suggests that attitudes are stronglylinked to behaviour, with positive attitudes reflected inpositive behaviours and vice versa. Attitudes are learnedfrom experience, are functional, that is, they promoteacceptance and motivate behaviour, and are potentiallychangeable. Attitudes are said to be influenced byinstitutional and role-related factors. Staff nurses'attitudes have an influence on student learning andbehaviour in clinical settings.Staff nurses are experiencing increasing role pressuresdue to a variety of factors, including organizationalfactors and role expectations. Working with nursingstudents during their clinical experiences has the potentialto increase role pressure. These factors may result innegative role experiences that may be reflected in negative30attitudes toward students. The gap identified betweennursing service and education may also negatively affectstaff nurse attitudes.The importance of a positive milieu for the clinicallearning experiences of nursing students is emphasized inthe literature. As role-models, staff nurses also have asignificant influence on the role socialization and self-concept of nursing students.Although the literature addresses all of the aboveareas related to staff nurse attitudes toward students andthe factors that may influence them, little or no attentionhas been directed to the attitudes and factors as reportedby the staff nurses themselves. Therefore, this study wasdesigned to do so using a model of role adapted from thework of Kahn et al. (1964).31CHAPTER THREEMethodsIntroductionIn this chapter, the research methods are discussed.These include the research design, subject selection, datacollection procedures, instruments, data analysis andprotection of human rights.Research DesignIn this study, descriptive research methodology wasused to investigate and describe the attitudes of staffnurses toward nursing students and the factors that mightinfluence those attitudes. Descriptive research provides aportrayal of an individual, situation or group to discovernew meaning, describe what exists, determine the frequencywith which something occurs, and identify relationshipswithout establishing causality (Burns & Grove, 1987).Therefore, this design was congruent with the purpose of thestudy and was appropriate for investigating a topic aboutwhich little is known.Subjects Subjects were registered nurses who were currentlyworking with nursing students in a regular clinicalexperience or had done so in the past six months. They wereemployed full-time or part-time (a minimum of a 0.5 full-time equivalent) in two acute care urban teaching hospitals3 2on medical and/or surgical units. Nurses from medicaland/or surgical units were selected because nursing studentsare frequently assigned to these units for clinicalexperiences. The sample included staff nurses who wereworking with different levels of nursing students fromvarious nursing programs.^•The sample consisted of 64 of the 99 staff nurses whodemonstrated an interest in participating in the study. Twonurses who completed and returned questionnaires did notmeet the sample criteria and, for unknown reasons, theremaining 33 nurses chose not to participate.Instruments Two instruments were used in this study. Aquestionnaire was developed by the investigator to collectdata about the attitudes of staff nurses toward nursingstudents and the factors that influence those attitudes.The initial questionnaire was pretested by four staff nursesand one nurse educator to assess for content validity andclarity and to ensure that the questions elicited answersthat fulfilled the research purpose. The suggestionsobtained were incorporated into the instrument (see AppendixA) .A subject information sheet was also developed by theinvestigator. It was used to obtain demographic informationand other characteristics of the subjects. A copy of the33instrument is presented in Appendix B.Data CollectionAfter required approvals had been obtained, a list ofmedical/surgical units used for nursing student clinicalexperiences was compiled for each hospital. Seventeen headnurses were contacted by telephone and opportunities wereset up to discuss the study with staff nurses. Twenty-ninefifteen minute presentations were made to groups of one tosix staff nurses. Three of the presentations were inconjunction with staff meetings while the others were attimes convenient to the units and staff. During thepresentations, the investigator briefly introduced herselfand described the study. The purpose, significance,benefits, criteria for participation, ethical considerationsincluding consent, and dissemination of results wereexplained and staff nurses' queries were addressed.Packages containing an introduction to the study (seeAppendix C), a research questionnaire, a subject informationsheet, and a self-addressed stamped return envelope wereprovided to staff nurses who demonstrated an interest inparticipating in the study. Staff nurses were requested toaddress their responses to regular, non-preceptored studentexperiences and write on the questionnaire any pertinentinformation not addressed by the questions.34Data Analysis Both instruments used in the study were coded tofacilitate data analysis while maintaining participantanonymity. Data from the subject information sheet werecompiled and described in terms of frequency distributionsand measures of central tendency. The frequency ofresponses to closed-answer questions specific to attitudemeasurement and factors influencing attitudes weretabulated. Responses to open-answer questions weresubjected to content analysis and were placed in categories.Protection of Human Rights Procedures for protection of human rights were approvedby the UBC Behavioural Sciences Screening Committee forResearch and Other Studies Involving Human Subjects.Research committees of the two hospitals involved wereapproached with an explanatory letter outlining the studyand the degree of institutional involvement required (seeAppendix D). Approval to conduct the study was receivedfrom both hospital research committees prior to datacollection.During unit presentations and in an introductoryletter, potential participants were informed thatparticipation in the study was voluntary, there would be norepercussions for not participating, and completion andreturn of the questionnaire indicated consent to35participate. The purpose and benefits of the study werealso explained.Anonymity of the participants was maintained by havingparticipants mail the questionnaires directly to theinvestigator and by use of a coding system that allowed theinvestigator to match questionnaires with subjectinformation sheets.SummaryIn this chapter, the research design, subjectselection, data collection procedures, instruments, and dataanalysis methods used in the study were described as wereprocedures followed to protect human rights.36CHAPTER FOURPresentation and Discussion of FindingsIntroductionIn this chapter, the study findings are presented anddiscussed in four sections. The first section includesdemographic information and other characteristics of thesubjects. In the second section, findings and discussionrelated to the first research question regarding focalperson attitudes toward nursing students as role senders areconsidered. Findings related to the second researchquestion regarding influencing factors, specificallyorganizational and role sender factors, are presented anddiscussed in the third section. Additional commentsprovided by the subjects are addressed in the final section.Characteristics of Subjects Of the 99 staff nurses who indicated an interest inparticipating in the study, 66 (67%) returned completedquestionnaires. Two respondents were excluded from thestudy as they did not meet the criteria for participation.The study sample consisted of the remaining 64 respondents(N = 64), whose questionnaires were completed sufficientlyto 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. Theaverage age was 34 with a range of 23 to 61 years. Although37the 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 1Nurses' Age DistributionAge Frequency Percent20-25 12 18.726-30 17 26.631-35 10 15.636-40 6 9.441-45 7 10.946-50 4 6.251-55 1 1.656-60 3 4.7Over 60 1 1.6Did not indicate 3 4.7Total 64 100As 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 innursing practice was 9.75, with a range of 4 months to 35years. The number of years employed in the present positionranged from 2 months to 30 years, with an average of 638years. Subjects' areas of work were evenly distributed: 30from medical units, 29 from surgical units, 3 from combinedmedical-surgical units. Two subjects did not indicate awork area. Subjects were from a variety of units:cardiology, ear/nose/throat, gastro-enterology, geriatrics,neurology, orthopedics, rheumatology, and vascular surgery.Table 2Nurses' EducationEducation Frequency PercentDiploma 43 67.2Diploma & Postgraduate 7 10.9Diploma & Bachelor of Arts 1 1.6Baccalaureate Degree in Nursing 12 18.7Did not indicate 1 1.6Total 64 100It is likely that the wide ranges in years ofexperience and years in present position had some effect onthe staff nurse attitudes revealed in this study. Some ofthe participants had limited nursing experience or were newto the unit. It may be difficult for these novices or newstaff members to work with students because they are tryingto assimilate the complexities of a new role, become3 9familiar with the unit, and develop organizational skills.For these nurses, the challenge of working with students maybe stressful and this stress may provoke negative attitudes.On the other hand, having recently graduated, novices may bemore understanding of students and the expectations nursingteachers have for student performance.The sample included a large number of diploma-preparedparticipants and half of the participants had approximatelyten years experience in nursing. These facts suggest that aconsiderable portion of the sample may have been educatedaccording to a more skill-focused philosophy than somenursing students are today. Therefore, their attitudestoward students or their concerns about student educationmay reflect such a philosophy rather than the more holisticphilosophy 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 attitudetoward nursing students and about particular attributes ofnursing students. Responses to these questions are reportedas attitudes regarding nursing students as role senders.The responses to other questions which may relate to, butare not specific to, students are presented as attitudesheld by the focal persons that may influence their attitudestoward students.40General AttitudeThe majority of participants, 61 (95%), described theirgeneral attitude toward nursing students as positive (seeTable 3). The two participants who felt slightly negativetoward students were baccalaureate-prepared nurses.Table 3General AttitudeRating^ Frequency^PercentVery positive^ 18 28.1Positive 37^57.8Slightly positive^ 6 9.4Slightly negative 2^3.1Negative^ - -Very negative -^ -No response^ 1 1.6Total^ 64^100Student Attributes Most participants rated student interest in theclinical learning experiences on their unit as beingmoderate (37 or 58%) to high (26 or 41%), whereas one ratedit as low to moderate. One participant qualified hermoderate rating by stating that interest varied among41students and with schools of nursing depending on theemphasis placed on learning versus performing tasks.The majority of subjects, 58 (91%), thought studentsdisplayed accountability for the care they provided.However, four of these respondents noted considerablevariance in individual student accountability and onerespondent noted variance in accountability between studentsof different programs. Six participants did not thinkstudents displayed accountability. The reasons they gave ina multiple response explanation are categorized as: failureto communicate (patient information and/or reporting off),failure to complete care, failure to complete charting,over-reliance on the instructor, and medication cardsdisplaced or medications not charted (see Table 4).Patient safety was a concern of 45 subjects (70%) whenpatients were being cared for by nursing students. In amultiple response format, these subjects attributed theirconcerns to safety being their responsibility (43), studentsnot being supervised closely enough (16), and students nothaving enough knowledge or skills to be considered safe(11). Other reasons given were uncertainty about studentcapabilities (4), weak and/or overconfident students (3),and patient acuity (2). In addition, each of the followingreasons was listed once: increased chance of errors due tostudent fears and anxieties, students overlooking safety42issues while task-focused, unfamiliarity with equipment,lack of experience to draw on, and mistakes are part oflearning. As well as safety concerns, 35 participants (55%)were concerned about fragmentation of care when nursingstudents were on the unit. As noted above, some safetyconcerns related to student knowledge and skill levels andthese may have influenced concerns about fragmented care.Table 4Behaviours Described as Lack of AccountabilityCategories^ Frequency of Behaviour Noted(n = 6)Failure to communicate with^ 5staff nurseFailure to complete patient care^4Failure to complete charting 3Reliance on instructor for^ 2accountabilityCreation of problems in medication^2systemForty-eight respondents (75%) thought that students'knowledge levels were appropriate to meet the requirementsof the clinical experience. Three of these respondentsqualified their answer with "sometimes." These respondentsindicated that although most students had an adequate43knowledge level for basic care, they were task-focused andnot proficient at basic patient care; they lackedpharmacology and etiology knowledge; and possession ofappropriate knowledge depended on their level in the nursingprogram.Interestingly, similar explanations were given forinappropriate 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 wasdifficult to assess the appropriateness of student knowledgelevels because they either did not know the level of thestudent or the requirements/objectives of the clinicalexperience. According to three respondents, whether or notthe knowledge level was appropriate depended on the specificinstructor and/or nursing program. Other possible reasons• for inappropriate knowledge were related to patient acuity,medications, diagnoses, basic care skills, being task-focused, requiring considerable supervision, difficulty inapplying theory to practice, and lack of specific knowledge.The multiple responses of the 16 respondents are summarizedin Table 5.When participants were questioned about skillcompetency, 15 respondents (23%) thought studentsdemonstrated a lack of skill competency. Considering both44their knowledge and skill competency, the majority ofTable 5Inappropriate Knowledge LevelAreas^ Subjects ReportingInappropriate Knowledge(n = 16)Lack of medication knowledge^ 2Lack of diagnosis/etiology knowledge^2Miss experience opportunities due to 2lack of knowledge and patient acuityLack of specific knowledge^ 2(e.g., neuro-assessment, chest tubes)Lack of knowledge and/or application^1of basic care skillsToo task/skill-focused, miss "big" picture^1Amount of guidance/supervision needed^1Difficulty applying theoretical knowledge^1Other:Difficult to assess^ 4Depends on instructor/program^ 3participants (42 or 66%) thought students were suitablyconfident, 14 found them underconfident, and two rated themas overconfident. Six respondents chose not to rate them,stating that confidence varied. Three of those who rated45them as suitably confident also noted variability. Sixrespondents stated that confidence is very individual andtwo thought it was influenced by staff attitudes andrelationships with the nursing teacher. Respondents did notspeak specifically to variability in confidence among levelsof students. However, one respondent commented that somestudents were afraid to perform certain skills and that thismade her job more difficult when the instructor was notaround 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 tosimilarities in meaning (see Table 6). The most frequentresponses referred to teaching (13). Several of theserespondents qualified their answer with "when I have time"and "when students are receptive." Some respondents alsoappreciated the assistance students provided with care whichhelped reduce their individual workloads (10). Tenrespondents mentioned being challenged or stimulated bystudents to keep up to date and/or to learn new things.Student positiveness and enthusiasm were enjoyed and foundto be contagious (9). Several respondents (6) also likedthe fact that students were eager to learn. Others (5)enjoyed being involved in and contributing to the students'46learning experiences. Five respondents liked the fact thatpatients benefitted from the care and increased attentionprovided by students. Staff nurses also mentioned that theyliked to see students progress, their pleasantness/friendliness, the positive feedback they provide, and theopportunity to attract potential new staff.Table 6What Was Liked Most About Working With Students Categories^ Frequency of Response(n = 63)Enjoy teaching^ 13Help with care/workload^ 10Stimulates keeping up to date/new learning^10Enthusiasm/positive attitudes^ 9Eagerness to learn^ 6Enjoy being part of/contributing to learning^5experiencePatients benefit from increased attention^5Although 63 participants (98%) listed what they likedmost about working with students, only 58 participants (91%)indicated that they actually liked working with nursingstudents. The explanations for this were almost identicalto the responses regarding what participants liked most47about working with students (see Table 6).The above findings were markedly similar to thebenefits cited by the 56 participants (87%) who perceivedbenefits from working with students (see Table 7).Table 7Perceived Benefits From Working With StudentsCategories^ Frequency of Response(n = 56)Learning opportunity^ 35(reinforces or stimulates updating clinicalknowledge and skills)Opportunity to teach and share experiences^16Increased self-awareness or personal skills^9(communication, leadership, confidence)Help with workload^ 8Positiveness/enthusiasm is catching^7Increased job satisfaction^ 7Add variety, refreshing change 5Increased awareness of own learning needs^3Positive feedback from students^ 3Other:^ 3(opportunity to contribute to theprofession, meet young people, and recruitnew staff)Negative Aspects of Working With Students Besides describing what they liked most about working48with students, almost as many participants (59 or 92% versus63 or 98%) listed what they liked least about working withstudents. The responses were collapsed into meaningcategories. The most frequent responses (16) related todisruptions in work, followed by additionalresponsibilities/workload (12), and having to check up onstudents to see what was done and/or to complete care (12).Other common concerns were lack of supervision (9), notknowing what students can and cannot do (7), the number ofquestions and time required to explain when already busy(7), fragmentation of care including decreased contact withown patients (7), not having time to properly assiststudents (6), slowness that delayed care and tired patients(5), lack of communication regarding patients or failing toreport off (5), and the increased stress/confusion on theunit which was related to the number and variety of students(3) (see Table 8). Responses that did not group wererelated 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 ofthem. Comments of the five participants who did not likeworking with nursing students were consistent with the abovewith the exception of these negative descriptors: lazy,49unwilling, lacking motivation, unsafe, and incompetent.Table 8What Was Liked Least About Working With StudentsCategories^ Frequency of Response(n = 59)Disrupts own work and organization^ 16Additional responsibility/workload 12Having to check up on/complete care^ 12Unavailability of instructor/lack of supervision^9Not knowing what students can/cannot do^7Number of questions/amount of explaining 7Fragmentation of care/lack of patient contact^7Insufficient time to properly assist students^6Slowness delays patient care/tires patients 5Lack of communication/reporting off^ 5Increased stress/confusion on unit 3Focal Person Attitudes That May Influence Attitudes TowardStudents Thirty-five subjects (55%) thought the goals set fornursing students were idealistic, whereas 23 (36%) thoughtthey were realistic. Two respondents thought this varieddepending on the instructor. Of the three who did not50respond, one was not familiar with the goals. Onerespondent commented that students were expected to beperfect. These responses may reflect either attitudestoward the instructor and/or the nursing education program.Although it depended on the program, compared to thestudents they worked with, participants rated the clinicalcomponent of their own nursing education as being superior(30 or 47%), similar (27 or 42%), inferior (4), and two didnot respond. They rated their theoretical component asbeing 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%) encouragednursing as a career. Eight did not, one did sometimes, andone did rarely. Three did not respond. It is assumed thattheir responses reflect their attitude toward nursing.Staff nurses' overall positive attitudes toward workingwith students were consistent with findings regarding theirthoughts about specific student attributes, what they likedabout working with students, and the benefits they perceivedfrom working with them. The writer noted similaritiesbetween the positive perceptions of the participants andWindsor's (1987) finding that student perceptions of staffnurses were generally positive. Findings of other studiesof student clinical experiences suggest that staff nurses donot present a major concern for students (Carver & Tamlyn,511985; Kelly, 1992; Pagana, 1988; Soukup, 1983). Therefore,it is assumed that if students were perceived negatively bystaff it would be reflected in how they in turn perceivedstaff.Although the participants generally thought positivelyabout students, over two-thirds had concerns about patientsafety which was consistent with the findings of others.Lewis and Dean (1991) reported increased staff nurseconcerns for patient safety and their own liability whenstudents were on the unit and Schmalenberg and Kramer (1979)stated that being responsible for the care given by nursingstudents made recent graduates feel uneasy.According to Petersen (1978), patient welfare may bethreatened by fragmented care. Therefore, the reportedfragmentation of care as well as reports of incomplete careand inappropriate communication about patients, may berelated to participant concerns about patient safety.Because of the nature of clinical learning experiences,safety will always be a concern and fragmentation of carewill continue to occur. However, participant concernssupport the need for effective communication among, andadequate orientation of, those involved in clinicalexperiences in order to reduce these concerns.The fact that lack of skill competency was also areason given for safety concerns and that participants felt52the clinical component of their education was superior mayreflect the nursing perspective of diploma-prepared nurses.Perhaps those participants who were concerned about skillcompetency might identify with Mowry's (1982) statement,"staff nurses feel annoyed and frustrated by the limitedskill levels which students bring to the unit" (p. 160).Although not a concern of most participants, 25% hadconcerns about the appropriateness of students' knowledgelevels. A few of these participants stated that it wasdifficult to assess student knowledge because they wereunaware of the student level and/or the objectives of theclinical experience. This lack of awareness and the factthat there are no specific standards on which to basejudgements, supports the need for teachers to effectivelycommunicate the knowledge various levels of students areexpected to have and the specific objectives of the clinicallearning experience. This communication would avoidstudents being prematurely judged against standards thatstaff nurses have for their own practice which may be in aspecialty such as neurology or vascular surgery.Although student lack of confidence was not an issuefor most participants, variation in confidence levels wasnoted. Other studies have reported that students lackedconfidence. Pagana (1988) found a lack of confidence amongstudents in initial medical/surgical experiences, and Ellis53(1980) found senior baccalaureate students lacking inconfidence. McMaster (1979) found that relationships withinstructors created stress for students, which might affecttheir confidence levels. One would think that there mightbe staff frustrations related to the underconfident oroverconfident students which would have caused nurses toview students somewhat negatively. Clearly, this was notthe case.What participants liked about, and the benefits theyderived from working with students are consistent with thosereported in the literature. Reilly and Oermann (1985) statethat quality of care improves in the presence of studentsbecause staff nurses rethink and update their care.Corcoran (1977) and Lewis (1990) claim that staff membersenjoy the stimulation that students provide and enjoyassisting in the development of professional nurses.According to Chickerella and Lutz (1981), staff nurses enjoyteaching, learning, and improving their leadership skills.Students usually have more time to spend with clients; timeto listen, explain, and share (Corcoran, 1977). Withincreasing demands on their own time, it is understandablethat staff nurses appreciate the increased attentionstudents are able to give patients. It is obvious thatstudents play a role in enhancing the quality of carepatients receive and providing staff development54opportunities 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 withstudents reflect time pressures that may relate to factorssuch as acuity, staffing levels, and unavailability ofnursing instructors. Dislikes such as the number ofquestions and having to complete care might be dealt with bynursing instructors being readily available and bothstudents and staff nurses knowing what is expected of them.Although the findings regarding what staff dislikedabout working with students are not reflected in theirattitudes towards students, they are consistent with factorsreported in the literature which have an impact on staffnurses' time and their provision of care. According toWindsor (1987), Myrick (1988), and Brown (1991), staff nurseresponsibilities increase when working with nursingstudents. The presence of students requires expenditures ofstaff time in helping, reporting, and in answering questions(Corcoran, 1977). In addition, the continuity of care isinterrupted when students intermittently care for patients.When their continuity of service is interrupted, staffnurses may experience decreased job satisfaction (Corcoran).According to Blanchard (1983), nursing education'sgreatest flaw lies in the amount and kind of clinical55experience students receive. Perhaps the 16 participantswho thought students' knowledge levels were inappropriatefor the clinical experience would agree with Blanchard.Their concerns about students' inadequate clinicalpreparation, lack of basic care skills, failure to see thebig picture, and failure to complete work may be reflectiveof the kind of clinical instruction students receive. Someof these student deficiencies may also relate to thepriority clinical teaching is given in nursing programs. Inthis researcher's experience it is often the leastexperienced teachers who are given the responsibility forclinical teaching.The above concerns may reflect differences between thevalues of nurse educators and those of nursing practitioners(Christy, 1980; Dalme, 1983; Eschbach, 1983; Johnson, 1980;Infante, 1986; Sleightholm, 1985), who are often moreservice-oriented. A difference in values is also suggestedby slightly more than half of respondents who thought goalsset for students were idealistic rather than realistic.This finding is supported by the many authors who havedescribed nursing students' education as being idealisticrather 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).56The above concerns and differences, in addition toparticipants' perceived lack of information regarding thephilosophies and clinical objectives of the various nursingprograms they encounter, suggest the existence of a gapbetween education and service. In this researcher's opinionthis gap was closing as staff nurses became accustomed tonursing programs that were not hospital-based. However,this gap may be widening again because some staff nurses arefeeling pressured as a result of the current move tobaccalaureate preparation as requirement for entry topractice.Hegyvary (1990) found some students faceddiscouragement and ridicule for entering nursing fromstressed staff nurses. Therefore, it was expected thatparticipants who did not encourage nursing as a career mighthold negative attitudes toward students. However, this wasnot the case.There were organizational and role sender factors thatsupported the generally positive attitudes. However, therewere also factors that supported participant concerns ordislikes about working with nursing students.Influencing Factors In the following section, findings related to factorsthat may influence attitudes are reported and discussed.These include findings which are related to organizational57factors, pressures and expectations created by role senders,interpersonal relationships between role senders and focalpersons, and conceptions and expectations of the focalperson.Organizational Factors The majority of participants (58 or 91%) found theadministrative atmosphere in their hospitals to bepro-education. Of those who did not (6), the followingreasons were given: insufficient money or relief staffing toallow nursing staff to attend conferences or seminars,inservices at awkward hours, insufficient staff to teachstudents thoroughly, and a poor learning environmentcreated when busy staff nurses have the additionalresponsibility for students.There was considerable uncertainty about the commitmentand role of the nursing department in relation to nursingstudent education. Of the participants, 21 (33%) did notknow if this commitment was reflected in the philosophyand/or mission statement, and 42 (66%) either did not recallor stated that this role was not explained/discussed duringthe orientation of new staff. Fifty-nine participants (92%)believed that contributing to nursing education was one oftheir professional responsibilities. A lack of awarenessof, or agreement with, the nursing department's role innursing education may be reflected by the five participants58who did not believe this was part of their professionalresponsibilities.Although most staff nurses, 42 (66%), thought thattheir units were adequately staffed, 21 (33%) did not. Asone participant commented on the administrative atmosphereregarding education, "we are not staffed properly to teachstudents thoroughly." Most staff nurses, 50 (78%), alsothought the level of patient acuity was appropriate to thelevel of student on the unit. Only 14 (22%) stated that thepatients were too acute. One respondent stated patientacuity was appropriate because "it is reality nursing butstudents are not prepared for it." Others who respondednegatively said patient acuity was appropriate for higherlevel students but not students in the early stages of theirprogram. Two respondents commented that it depended on theschool of nursing. One of these respondents found diplomaprogram students better able to care for acute patients thandegree program students. In contrast to those who thoughtpatients were too acute, 31 of the 57 participants (89%) whothought there were unit characteristics which enhancedstudent learning, listed factors related to high acuity asproviding excellent opportunities to increase knowledge,improve skills, and practice organization.Of the 32 participants (50%) who thought there werefactors which impeded student learning, eight mentioned59issues related to staffing, eight the fast pace, sevenpatient acuity, and five physical/space issues. Factorsdescribed as enhancing and impeding student learning aresummarized in Tables 9 and 10, respectively.Table 9Unit Characteristics That Enhance Student LearningCharacteristics^ Frequency ofResponsePercent ofRespondents(n = 57)Suitability of patients(acuity/variety of diagnoses,experiences & skills)28 49Teamwork/cooperation among staff 11 19Emphasis on teaching/learning 9 16Educational resource materials 8 14Receptivity to students 7 12Good communication 6 10Friendly atmosphere 6 10Educational opportunities(ward rounds, patient care/familyconferences, inservices)5 9Head Nurse(good relationship with staff, unitwell focused/directed/organized)4 7Others:(health care team approach,7 12basic care opportunities, young staff,and adequate senior staff)60Table 10Unit Characteristics That Impede Student LearningCharacteristics Frequency of^Percent ofResponse^Respondents(n = 32)Inadequate staffing(too busy/no additional staff)8 25Fast pace 8 25Patients too acute 7 22Physical/spacial setup(size/overcrowding)5 16Poor teamwork/communications 3 9Lack of interest/involvement instudents2 6Physician-related issues 2 6Others: 3 9(high staff turnover, lowinstructor:student ratio, slightlynegative attitude toward degree students)Other organizational factors that may have influencedstaff nurses were having to work with a variety of levels ofstudents (58 or 91% of participants) and a variety ofnursing programs (56 or 88%).Bendall (1971) stressed the importance of institutionalinfluences on staff nurse attitudes and McLure, Poulin,Sovie, and Wandelt (1983) related administrativephilosophies and supportive practices to positive staff61attitudes. The majority of participants thought theadministrative atmosphere was pro-education. However, it isinteresting to note that attitudes toward students did notreflect that 21 participants were unaware of the nursingdepartments' role in student education or that sixparticipants identified insufficient supports for education.Concerns related either directly or indirectly tostaffing and patient acuity levels became a theme that wasrepeated throughout the responses. Concerns related tostaffing are consistent with O'Brien-Pallas and Baumann's(1992) finding that lack of adequate staffing is a recurringissue. According to Little and Carnevali (1972), staffingis a significant organizational factor to be considered inplanning student learning experiences. The literaturesupports the position that units must be adequately staffedbefore accommodating nursing students (Barr, 1980; Nail &Singleton, 1983) and that medical/surgical units have thelowest nurse:patient ratios (Hendrickson, Doddato, & Kovner,1990).Findings related to acuity were consistent with thoseof Caty and Scott (1988) who found the fast pace of the unitto be problematic for student learning, Myers (1992) whostated patient acuity was increasing, and Mundt (1990) andSmith (1988) who found it was not always possible to secureclinical settings suitable to the level of student learner.62Not only were areas not always perceived as suitablefor students, but consistent with what McKenzie (1991) andSmith (1988) found, the majority of participants wererequired to work with various levels of students fromseveral nursing programs. McKenzie argues that this mixmakes it difficult for staff nurses to support and assiststudents in meeting their learning objectives. In thisstudy, some staff nurses stated that they lacked informationabout what students could and could not do when providingcare. However, these concerns were not reflected innegative attitudes toward students.Role Sender Factors Staff nurse perceptions of factors related to rolesenders are considered in this section. These include headnurse, nursing teacher, and nursing student expectations andpressures on staff nurses. Factors related to other rolesenders as well as interpersonal relationships between staffnurses and role senders are also reported.Participants thought head nurses were either veryreceptive (52 or 81%) or moderately receptive (12 or 19%) tohaving students on the unit. When asked about the wardatmosphere, all of the participants said good teamwork, 62(97%) said good communication, and 52 (81%) said goodrelationships between head nurse and staff nurses existed ontheir units. The majority of participants, 50 (78%),63thought that the unit atmosphere had a considerableinfluence on their attitudes toward nursing students.Forty-five participants (70%) reported that they wereexpected to work with students rather than being asked ifthey wished to do so. Fifty-five (86%) thought theircontribution to nursing students' education was respected bynursing teachers. Slightly more (59 or 92%) thought theywere respected as a valuable resource for students.However, four did not know what nursing teachers thought ofthem. Thirty-eight participants (59%) were consulted aboutstudent assignments and asked for evaluative opinions aboutstudents. Only 22 (34%) were oriented to the specificobjectives of the clinical experience and 19 (30%) wereoriented to the philosophy of the nursing program. Only twoparticipants were invited to attend clinical conferences.The difference in the number of participants whothought their contribution was respected by nursing teachersand the number who felt respected as a valuable resource tostudents is perplexing. Perhaps this difference reflects aperception that nursing teachers appreciate staff nurseassistance when they are unavailable to students (resource),but may not necessarily value the quality of assistancestudents receive (contribution).The importance of the clinical milieu to studentlearning has been documented (Reilly & Oerrman, 1985) as has64the crucial role of the head nurse in establishing thismilieu (Orton, 1981). In this study, aspects of theclinical milieu, which directly related to head nurses andstaff nurses, were described as quite positive and theatmosphere was, therefore, conducive to student learning.According to Seymour and Buscherhof (1991), staffvalued recognition, respect, and appreciation of theirvarious roles of which one was teaching. Similarly, Blegen,Goode, Johnson, Maas, McCloskey and Moorhead (1992) foundthat formal recognition by the head nurse was important tostaff nurses. Participants reported feeing valued andrespected for their contribution in student education;however, this is somewhat inconsistent with nursing teachersnot consistently including them in decision making and headnurses seldom formally acknowledging their contributions tostudent learning.The limited communication and collaboration betweennursing education and practice, associated by Kruger (1985)with nursing educators being guests in the clinical setting,was apparent. In addition, although the value of attendingclinical conferences is documented (Barr, 1980; Mowry,1982), only two of the participants reported attendance atsuch conferences. These findings indicate that theperceived value and respect felt by staff nurses is notnecessarily consistent with role sender behaviours.65Although not specifically reported as role senderfactors, the unavailability of, and lack of supervisionprovided by, nursing teachers was a theme in the responses.This finding suggests that less than ideal student:teacherratios exist and may reflect the high student:teacher ratiosPierce (1991) claims exist in traditional clinicalexperiences and result in very little actual teaching timeper student. The perceived unavailability of teachers maynot only contribute to increased pressures on staff nurses,but may reflect the difficulties nursing teachers experiencewhen they have students on more than one unit.Role Conceptions of Focal Persons The majority of participants (58 or 91%) were requiredto work with different levels of nursing students fromdifferent programs. Of those, 26 worked with two levels, 11with three levels, 11 with four levels, three with fivelevels, and two with six levels. Five were uncertain whatlevel of student they worked with. Fifty-six of the 58worked with different nursing programs. Of these 56, 54listed the nursing education programs they worked with: 24worked with two programs, 27 with three programs, and 3 withfour programs.Among those who worked with various levels ofstudents/programs (n = 58), understanding of their role andresponsibilities toward students varied. Only 19 (33%) knew66what was expected of them at all times; 23 (39%) knewsometimes; and 16 (27%) found it difficult to know what wasexpected of them.Not only were participants uncertain about their rolewith students, but 46 (72%) did not devote as much time tostudents as they would have liked. When asked to indicatewhat organizational and role sender factors contributed tothis uncertainty, patient acuity, pace of the unit, andstaff shortages were the most frequent reasons cited byparticipants (see Table 11).Similarly, when participants were asked if studentsexpected more of them than they had time to give, 22 (34%)responded yes and four sometimes. They (n = 26) attributedthis expectation to students thinking their educationalneeds take priority over other staff nurse responsibilities(5), and that staff are more available (25), lessthreatening (15), and more clinically competent (1) thannursing teachers.Only 36 participants (56%) felt supported in workingwith nursing students. Of these, 16 said nursing teacherssuggested ways to work with students, eight said nursingteachers oriented them to their role with students, and sixsaid their workload was adjusted to reflect the increasedresponsibility of working with students (one said the headnurse actually increased her patient assignment). Other67supports were from the head nurse (3), coworkers (2),nursing teachers in other ways (2), and staff developmentsessions (1).Table 11Insufficient Time To Devote To StudentsContributing Factors^Frequency ofResponsePercent ofRespondents(n = 46)Acuity of patients 41 89Pace of unit 38 83Staff shortages 23 50Physician demands 17 37Responsibility to supervisenew or relief staff16 35Lack of encouragementfrom nursing teacher5 11Lack of appreciation from students 5 11Lack of confidence in ownteaching abilities2 4Lack of encouragement of head nurse 1 2Although not always supported, the majority ofparticipants (50 or 78%) felt recognized for working withstudents: 44 through a thank you note, 17 on theirperformance appraisal, three by a gift of flowers or food to68the unit, and two by students' verbal comments.McKenzie (1991) reports additional role pressures onstaff nurses when they are required to work with variouslevels of students from different programs. Barr (1980) andNail and Singleton (1983) stressed that nurses must be madeaware of the objectives of the clinical experience and whatis expected of them. Infante (1986) also stressed theimportance of role clarity to students' learningexperiences. That participants worked with a variety ofstudents and were uncertain of their role in, or theobjectives of, students' clinical experiences suggests thatthe participants were experiencing role pressures.Evidence of role pressure is also apparent inparticipants' responses that they did not have as much timeas they would have liked to devote to students. Participantresponses indicative of role pressures were consistent withreports in the literature. Several authors found that theincreasing acuity and staffing concerns associated with thechanging nature of acute care hospitals result in increasedrole pressures on staff nurses and impede the learning ofnursing students (Brown, 1991; Hendrickson, Doddato, &Kovner, 1990; Myers, 1992; O'Brien-Pallas & Bauman, 1992).Role pressures were exacerbated for more than a thirdof participants who thought students not only expected moreof them than they had time to give, but also placed their69needs before staff nurse responsibilities. These studentbehaviours may reflect the differences in priorities thatexist between education and service (Sleightholm, 1985).Although Barr (1980) recommended that students be helped torealize the emotional and physical pressures on staffnurses, the findings suggest this is not done on aconsistent basis.Additional Comments Twenty-one participants added additional comments atthe end of the questionnaire. Although there was little newinformation, participants stressed the differences instudents among nursing programs. They also stressed theneed for nursing teachers to adequately explain the schoolphilosophy, clinical experience objectives, and staffnurses' role with students. One thought it should be thestudents' responsibility to let the staff nurse know exactlywhat they can and cannot do. Another suggested that nursingteachers, students, and staff nurses meet regularly todiscuss concerns. Concerns about the unavailability ofnursing teachers as well as students' insufficient clinicalpreparation, lack of basic care skills, focus on tasksversus the big picture, and leaving unfinished work werereiterated.SummaryIn summary, the findings indicated that the attitudes70of the participants toward nursing students were remarkablyhomogeneous and positive in nature. A number of positivefactors were identified that may have influenced thoseattitudes. For example, participants enjoyed teaching,receiving assistance with patient care, and being stimulatedby students to keep up-to-date. The findings also indicatedthat participants had some concerns about students andfactors associated with their clinical learning experiences.Safety posed considerable concern as did organizationalfactors which had an impact on the time staff nurses had todevote to students. Many of the participants' concernswere congruent with or were supported by those identified inthe literature.Based on the various concerns expressed by theparticipants, the researcher's experience as a staff nurseand head nurse, and anecdotal reports from both students andstaff members, it was not expected that attitudes towardstudents would be as overwhelmingly positive as they werefound to be in this study. The findings lead the researcherto question the consistency of the attitude-behaviour linkreported in the literature (Eiser & vander Pligt, 1988;Fazio, 1986; Rajecki 1990). To get a true understanding ofattitudes, perhaps it is necessary to study behaviours atthe same time as eliciting self-reports of the affective andcognitive attitude components that are described in the71literature (Fishbein & Ajzen, 1975; Rajecki, 1990).As role-models, staff nurses have a significant impacton students (Betz, 1985; Kelly, 1992). This is reaffirmedby the following student viewpoint, "It is important toremember, we trust, learn, and are socialized through ouridentification with you, and often adopt your values andemulate your behaviour" (Lillard, 1982, p.12). Due to thesignificance of this impact, it would be reassuring to knowthat participants' positive attitudes were reflected intheir behaviours toward students. Otherwise, staff nursesmight unknowingly reflect their concerns in behaviours whichcould be misinterpreted as negative attitudes towardstudents.72CHAPTTER FIVESummary, Conclusions, and Implications for NursingSummaryThe purpose of this descriptive study was to determinethe attitudes of staff nurses toward nursing students andthe factors that might influence those attitudes.The conceptual framework used to guide this study was amodel of role adapted from the theoretical model for roleconflict and ambiguity developed by Kahn et al. (1964). Themajor components of the model which were addressed wereorganizational factors, role sender expectations, focalperson perceptions, interpersonal relationships between rolesenders and focal persons, and attitudes of focal personstoward role senders.The participants in the study were 64 registered nurseswho worked full- or part-time on medical and/or surgicalunits of two acute care teaching hospitals. These staffnurses were either presently working with or had worked withnursing students in the six months previous to the study. Aquestionnaire, developed by the researcher, was used toelicit participants' perceptions about their attitudes andinfluencing factors. Questions addressed the majorcomponents of the conceptual framework and were based onknowledge gained from pertinent literature, as well as theresearchers' knowledge and experience with students in the73clinical setting.Overall, participants' attitudes toward students werepositive. They enjoyed teaching students, the assistancewith their workloads, and the learning challenges studentsprovided. However, there was considerable concern aboutpatient safety, fragmentation of care, additionalresponsibilities, and disruptions in work when students wereon the units. Concerns were also expressed about studentskill levels, confidence levels, lack of provision of basicpatient care, and lack of appropriate communicationsregarding patients. The existence of an education/servicegap was suggested by the majority of participants whothought that the goals for students were idealistic ratherthan realistic, that their own clinical education had beensuperior, and who were uncertain about clinical experienceobjectives or their role as staff nurses in studenteducation.Although there was perceived administrative support foreducation, participants had concerns related toorganizational factors. They were uncertain about nursingdepartment roles in student education and concerned aboutstaffing and patient acuity levels. Factors influenced bythe head nurse were generally viewed positively. However,factors related to nursing teachers and nursing educationcaused concern. Teacher unavailability and lack of74appropriate supervision of students were recurring themes inparticipant responses. Consultation with staff nursesregarding assignments or student performance wasinconsistent. Participants were also required to work withseveral levels of students from a variety of programs withlittle understanding of the philosophies of the programs,the objectives of students' clinical experience, or theirrole in student education. Support in working with studentswas also sporadic.Factors associated with time pressures were alsoevident in participant responses. The majority ofparticipants would have liked to have more time to devote tostudents. Consistent with this, over a third of theparticipants reported that students expected more of themthan they had time for.Conclusions The relatively small sample size and the restrictedstudy setting limit the generalizability of the findings.However, the following conclusions can be drawn from thestudy findings.1. Attitudes toward nursing students were positive,there were many things staff nurses liked aboutworking with students, and they perceivedbenefits from working with them.2. Characteristics of the clinical milieu that related7 5to head nurses and nursing co-workers wereconducive to student learning in clinicalexperiences.3. Participants expressed concerns about theunavailability of nursing instructors and/orinsufficient supervision of students.4. Participants had insufficient time to devote tostudents. They identified numerous organizationalfactors that had an impact on the availability oftheir time.5. Participant responses suggested the existence of aneducation/service gap.6. Participants were uncertain about their role in theeducation of students. The variability amongnursing students, teachers, and nursing programsmay have contributed to this uncertainty.Implications for NursingNursing Education The findings of this study have several importantimplications for nursing education. Ways to involve staffnurses and capitalize on their strengths and abilities inthe clinical education of students need to be explored.Nursing teachers need to orient staff nurses to thephilosophy of the nursing program, the objectives of theclinical experience, and to their expectations regarding the76staff nurse's role with students. If nursing teachers feelthey are already doing this, they may wish to investigatewhy the majority of participants thought the aboveinformation was not provided. Perhaps the information isbeing left to head nurses to disseminate or it has not beenrecently provided. An orientation would help clarify rolesas well as enlighten staff nurses about the values andpriorities of the teachers. Because staff nurses may not bereceptive to a time-consuming formal orientation, nursingteachers might attempt to find creative ways of providingthis information informally. With a clearer understandingof their role in student education, staff nurses might beless concerned about the unavailability of teachers.Not only must nursing teachers orient staff nurses totheir role with students, but the findings suggest thatstudents need help to appreciate the social contextassociated with nursing units. This appreciation wouldprovide students with an understanding of the staff nurserole and help them to respect staff nurse priorities and thelimited space on nursing units. Students would be betterable to determine when it is inappropriate to interruptstaff nurses or to ask them questions.Nursing education should explore the perceived lack ofavailability of nursing teachers to supervise students. Ifthis perception is found to be a problem, more clinical77teachers may need to be employed. If the ratio of teacherto students is found to be adequate, then the effectivenessof the teachers may need to be assessed. Other alternativesto address this perception may be joint appointments orproviding designated staff nurses with the necessarysupports to act as clinical resource persons to studentswhen nursing teachers are unavailable. Any of the abovemight reduce the impact that the unavailability of teachershas on staff nurses' time.Although participants feel respected as a valuableresource to students, nursing teachers may not be makingsufficient use of this valuable resource. Students wouldlikely benefit if there were more collaboration betweennursing teachers and staff nurses. For instance, althoughit is not always possible, increasing the amount ofconsultation with staff nurses about student assignments andperformance might have several benefits. It might reduceconcerns about students caring for patients who areinappropriate for their level of knowledge and skill, givestaff nurses greater insight into the objectives of theclinical experience, and enhance relationships betweeneducation and service personnel.Nursing educators need to continue to addressparticipants' concerns regarding patient safety, incompletecharting and care, lack of competency in performing basic78care, and lack of appropriate communication with staffnurses regarding patient conditions. Some of these concernsmay be alleviated by ensuring that students are oriented tothe expectations of the clinical experience. Others may beaddressed in the nursing laboratory where provision of basiccare and skills can be taught and practiced until there issufficient competency to promote safety in clinical learningexperiences. Role playing would be one way to help studentsimprove communications. In addition, role modelling care inthe clinical environment would be an excellent way fornursing teachers to reinforce previous teaching and gaincredibility with nursing staff and students.Findings related to the variety of student levels andnursing programs to which participants were exposed need tobe addressed. This will require continued collaborationamong nursing educators from various programs using acutecare facilities for clinical experiences. If it ispossible, greater consistency in placements would result inincreased staff familiarity with clinical objectives andavoid loss of valuable clinical time spent orientingstudents to the various hospitals. If students were tospend more time on one unit they could develop skills andconfidence that would be transferrable to other areas.Also, concerns about patient acuity and lack of staffingneed to be addressed by nursing teachers thoroughly79assessing the appropriateness of a given unit for clinicalplacements. Further attention to the above may helpalleviate staff nurse concerns and enhance opportunities forstudent learning.Nursing PracticeThe study findings also have implications for nursingservice personnel. Nursing service administrators need toensure that the commitment and role of the nursingdepartment in relation to nursing student education isclearly outlined in department philosophies and missionstatements. Staff nurses need to be made aware of thiscommitment during their orientation.Head nurses and/or unit managers need to monitor andevaluate the increased role pressures staff nursesexperience when working with students and theappropriateness of the patients students care for.They also need to be cognizant of findings related tostaffing issues to ensure adequate staffing without relyingon student assistance with workloads.Head nurses also have a role in soliciting staffconcerns regarding students and in establishing processesfor addressing these concerns. The processes should includenursing teachers and should require staff nurses to beaccountable for expressing their concerns formally. Headnurses should also formally recognize staff nurse80contributions to student education in appropriate ways.When staff nurses are uncertain about the philosophy of thenursing program, clinical objectives, student capabilitiesor their role with students they have a responsibility tofind out what these are. Staff nurses need to be moreassertive in requesting this information. They need toclarify their role with students as necessary and determinewhat is to be done when nursing teachers are unavailable tostudents. If staff nurses are not approached regardingstudent assignments or evaluative opinions of studentperformance, they should fell free to approach the nursingteachers with this information. Staff nurses must also becognizant that they are role models for nursing students andthat their attitudes and behaviours have a considerableimpact on student learning. Head nurses have aresponsibility to reinforce this.Nursing ResearchThe findings of this study demonstrate that staffnurses have positive attitudes toward nursing studentsalthough they have concerns related to experiences withthem. Replication of this study using a large, randomlyselected sample is required to validate the findings, yieldfurther information, and increase generalizability of thefindings. The addition of a correlational component betweenstaff nurses' responses and their characteristics would also81be valuable.This study was subject to the limitations inherent inthe instrument design. Participants would have liked agreater range of choices in some questions. As well, theremay have been a tendency to choose "correct" answers.Therefore, construct validity and reliability should befurther investigated. A qualitative study might also revealor stress areas of concern that the questionnaire failed toelicit.There is a need for a correlational study to determineif there is congruency between staff nurses' perceptions oftheir attitudes toward students and students' perceptions ofstaff nurses attitudes toward them. Because this studylooked at nursing students in general, there is a lack ofinformation regarding the differences in attitudes towarddiploma and degree nursing students and comparing attitudestoward students from similar programs. There is also a needto replicate this study focusing on preceptorshipexperiences and registered nurse refresher programs.The study findings suggest inconsistencies amongnursing teachers, such as the amount of information staffnurses are provided and the degree to which they areincluded in student clinical experiences. 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The criticalteaching partnership. Nurse Educator, 17(2), 10-12.Sleightholm, B. J. (1985). The real world of the nurseeducator. The Canadian Nurse, 81(11), 28-30.Smith, D. L. (1988). Clinical education for professionalpractice in nursing. In J. Kerr & J. MacPhail (Eds.),Canadian nursing: Issues and perspectives (pp. 283-295).Toronto: McGraw-Hill Ryerson.Soukup, M. C. (1983). Reality shock alleviation: Studentexperience in a preceptored advanced clinical nursingpracticum. In B. Bullough, V. Bullough, & M. C. Soukup(Eds.), Nursing issues and nursing strategies for the eighties (pp. 266-275). New York: Springer.90Sudman, S. & Bradburn, N. M. (1983). Asking questions: Apractical guide to questionnaire design. San Francisco:Jossey-Bass.Suess, L. R., Schweitzer, B. J., & Williams, C. A. (1982).Nursing students experiment with reality. NurseEducator, 7(2), 28-33.Tesser, A. & Shaffer, D. R. (1990). Attitudes and attitudechange. Annual Review of Psychology, 41, 479-523.Thomas, E.J. & Biddle, B. J. (1964). The nature and historyof 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 ofclinical experience. Journal of Nursing Education,26, 150-154.Zimbardo, P. G., Ebbesen, E. B., & Maslach, C. (1977).Influencing attitudes and changing behaviour: Anintroduction to method, theory, and applications ofsocial control and personal power. Don Mills, Ont:Addison-Wesley.91Appendix AResearch Questionnaire ATTITUDES OF STAFF NURSES TOWARD NURSING STUDENTSAND INFLUENCING FACTORSInvestigator: Florence Tyson, MScN StudentPhone: 264-8911This questionnaire is designed to identify staffnurses' attitudes toward nursing students and the factorsthat influence those attitudes. Information obtained willassist nursing educators and administrators to ensureregular student clinical experiences are positiveexperiences for both nursing students and staff nurses. Youare not obligated to participate in the study, nor will yourparticipation affect your employment in any way. However,your consent to participate in the study will be assumed ifyou complete and return this questionnaire. You are free torefuse to answer any question on the questionnaire byleaving it blank and you are not required to identifyyourself in any manner.Unless requested to do otherwise, please respond withone answer per question by ticking the space thatcorresponds with the answer that best represents yourthoughts, feelings, or beliefs. Please explain yourresponse when requested. It is estimated that it will takeapproximately forty-five minutes to complete thequestionnaire and accompanying subject information sheet.92RESEARCH QUESTIONNAIRECode #PART I: ATTITUDES1) Are the goals set by nursing teachers for the quality ofpatient care delivered by students in their clinicalexperiences^ idealistic ?realistic ?2) Is student interest in the clinical learning experienceson your unithigh ?moderate ?low ?3) In general, do nursing students display accountabilityfor the care they provide?Yes^NoIf not, please explain4) In general, do students come to the clinical area withthe appropriate level of knowledge to provide thenecessary patient care to meet the requirements of theirclinical experience?Yes^NoIf not, please explain5) In general, do nursing students demonstrate the level ofskill competency required in their clinical learningexperiences 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 ?937) Are you concerned for the safety of patients when theyare being cared for by nursing students?Yes^NoIf yes, why? (*tick all applicable responses)^ safety of the patient is my responsibilitystudents are not supervised closely enough^ students do not have the knowledge and/orskills to be considered safeother8) In general, are you concerned about fragmentation ofpatient care when nursing students are on the unit?Yes^No9) How would you rate your general attitude toward nursingstudents?very positivepositiveslightly positiveslightly negativenegativevery negative10) 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 nursingas a career?Yes^NoPART II: FACTORS THAT MAY INFLUENCE ATTITUDES1) Do you consider the administrative atmosphere in thehospital to be pro education?Yes^NoIf no, please explain how it is not942) Does the philosophy and/or mission statement of thenursing department reflect a commitment to nursingstudent education?Yes^No^Do not know3) Is the role of the nursing department in relation tonursing student education explained/discussed during theorientation of new staff nurses?Yes^No^Do not recall4) Is the patient acuity level on your nursing unitappropriate to the level of students' learning on theunit?Yes^NoIf no,patients are too acute for the level of nursingstudent.patients are not acute enough to provide therequired experiences for the students.5) How would you rate the appropriateness of staffinglevels on your unitoverstaffed ?adequately staffed ?understaffed ?6) How receptive is the head nurse to having students onthe unit?very receptive, views it as an excellentopportunity for students and staffmoderately receptive, views it as necessary forstudent learningunreceptive, views it as an undesirableobligation7) Are the following part of the ward atmosphere?Yes^No^Good teamworkYes No- Good communicationYes^No Good relationships between headnurse and staff nurses8) Are there unit characteristics which enhance studentlearning?Yes^NoIf yes, please explain959) Are there unit characteristics which impede studentlearning?Yes^NoIf yes, please explain10) To what extent do you think the unit atmosphereinfluences your attitude toward nursing students?a great dealquite a bit^ somewhatvery little11) Are you asked if you wish to work with students or is itand expectation?askedexpected12) In general, do you feel your contribution to nursingstudent's education is respected by the nursingteachers?Yes^No13) Do nursing teachers generallyYes ^ No^consult you about patientassignments for the students?Yes ^ No^respect you as a valuable resourceto students?Yes^No^ask you for your evaluative opinionsabout student performance?Yes^No ^ invite you to attend clinicalconferences?Yes^No^provide orientation to thephilosophy of the particular nursingprogram?Yes ^ No^provide orientation to the specificobjectives of the clinicalexperience?14) Do you believe that contributing to nursing students'education is one of your professional responsibilities?Yes^No15) Do you work with students at different levels in theirnursing education?Yes^No96If so, what level of college studentsfirst 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 nursingprogram?Yes^NoIf yes, please specify which programs ^17) If yes to either #15 or #16, what is your understandingof your role and responsibilities to the variousstudents?^ I know what is expected of me at all timessometimes I am unsure of what is expected of mewith the differences in students I find itdifficult to know what is expected of me at anygiven time18) Do you like working with nursing students?Yes ^ NoPlease explain your response ^19) Do you devote as much time as you would like tostudents?Yes^NoIf not, please check the factors that contribute to theamount of time you spend with nursing students^ acuity of patientspace of unitphysician demandsresponsibility to supervise new or relief staffstaff shortagesuncooperative coworkerslack of encouragement from the head nurselack of encouragement from the nursing teacher^ lack of appreciation from the studentslack of confidence in own teaching abilities9720) Do nursing students expect more of you than you havetime to give?Yes^NoIf yes, why so you think this is so? Please check allresponses which you think are applicable:students are less threatened by askingquestions of staff nurses than they are ofnursing teachers.students think staff nurses are more clinicallycompetent than their teachers.staff nurses are more available than thenursing teachers.^ student nurses think their educational needstake priority over other staff nurseresponsibilities.21) How so you rate the theoretical component of yournursing education compared to that of the students youwork with?It was:superiorsimilarinferiorno basis for judgement22) How do you rate the clinical component of your nursingeducation compared to that of the students you workwith?It was:superiorsimilarinferior23) Are you supported in working with nursing students?Yes ^ NoIf yes, check all applicable responses:nursing teachers suggest ways to offer guidanceto the students.nursing teachers offer an orientation to therole of the staff nurse in working withstudents.my workload is adjusted to reflect theincreased responsibility and time commitment ofworking with students.other24) Are you recognized for working with students?Yes^No98If yes, how are you recognized?^ commendation on my performance appraisal^ thank you note from the students and/or nursingfacultya tea in honour of my contribution^ other, please specify25) Do you benefit from working with students?Yes^NoIf so, what are the benefits?Additional commentsTHANK YOU FOR DECIDING TO PARTICIPATE IN THIS STUDY.99Appendix BSUBJECT INFORMATION SHEETCode #You are requested to provide the following information whichwill be used to enhance the researcher's description ofstaff nurse attitudes toward student nurses and the factorsthat influence them.1. Age:2. Sex:^female^male3. Basic nursing education:^diploma programBSN programYear of graduation4. Higher education (tick all that apply):post-RN diploma or certificate,please specify BSNother baccalaureate,please specify MSNother master's,please specify5. Number of years of practice in nursing since completionof basic nursing education program6. How long have you been employed in your present staffnurse position?7. Are you employed^full-time?part-time?8. What type of medical-surgical unit do you work ongeneral medicinegeneral surgeryother,please specify9. Name of hospital100Appendix CIntroduction to Staff NursesSchool of NursingThe University of British ColumbiaVancouver, B.C.Dear staff nurses:My name is Florence Tyson. I am presently enrolled in themaster's program in nursing at the University of BritishColumbia. For my thesis study, I have chosen the topic of"Attitudes of staff nurses toward nursing students andinfluencing factors." My interest in this topic stems frommy own experience as a staff nurse, and as an emergency headnurse in working with students in the clinical setting. Aswell, I am planning on becoming a clinical teacher and feelthis study would provide me with valuable information totake to a teaching role.I hope to learn about this topic by having staff nursescomplete a questionnaire to determine their attitudes tonursing students and to determine what factors mightinfluence those attitudes. If you are a registered nurseemployed as a staff nurse on a medical-surgical unit, haveworked with nursing students in regular clinical experiencesduring the past six months, and are interested in thesubject, I would appreciate your being a participant in thisstudy.If you agree to participate, you will be asked to complete aquestionnaire and a subject information sheet and mail themto me in a stamped return envelope that will be provided.Your consent to participate in the study will be assumed ifyou complete and return the questionnaire and informationsheet. It is estimated that completion of the questionnairewill take approximately forty-five minutes. A coding systemwill be used for the purpose of matching questionnaire andsubject information data. However, your name will not berequired and the name of the hospital will be keptconfidential. Although, it is hoped that you would completeeach question you are free to refuse to answer any questionby leaving it blank. You are not obligated to participatein this study, nor will your participation affect youremployment or role as a staff nurse in any way. If you haveany questions please contact me at 264-8911 or my ThesisChairperson, Anne Wyness at 822-7485.101I anticipate that this study will benefit all those involvedwith student clinical experiences and may serve to initiatechanges that would benefit you in your role with students.At the completion of the study, a copy of the thesis will bemade available to you.Thank you for your cooperation.Sincerely,Florence Tyson, RN, BScN102Appendix DExplanatory Letter For Agency ConsentSchool of NursingThe University of British ColumbiaVancouver, B.C.DearMy name is Florence Tyson. I am presently enrolled in themaster's program in nursing at the University of BritishColumbia. For my thesis, I am interested in studying theattitudes of staff nurses toward nursing students and thefactors that influence those attitudes. My interest in thistopic arises from my experience as a staff nurse and as anemergency department head nurse involved in working withnursing teachers and nursing students during studentclinical experiences.I anticipate that the findings of this study will enhancethe understanding of staff nurses' attitudes toward studentsand will lead to recommendations for both nursing educationand nursing practice that will benefit all those involved inthe clinical experiences of nursing students. Also, I willbenefit by being able to use the study findings in my futurerole as a nursing teacher.I would like to request the volunteer participation ofmembers of your medical-surgical nursing staff. I hope toexplain the study to the staff nurses and have those who arewilling to participate complete a questionnaire and subjectinformation sheet. Participation time will be approximatelyforty-five minutes. The name of the institution will bekept confidential and participation will be anonymous. Atthe completion of the study, a copy of the thesis will bemade available to participants.As part of its review process, the University's ethicalreview committee requires a written consent from yourinstitution. If you require further information, I may becontacted at my home phone number 264-8911 or you maycontact 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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