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The effect of a relationship-building activity on nursing student anxiety in the clinical setting Sundberg, Sharon Eloise 1988

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THE EFFECT OF A RELATIONSHIP-BUILDING ACTIVITY ON NURSING STUDENT ANXIETY IN THE CLINICAL SETTING by SHARON ELOISE SUNDBERG BSNf The U n i v e r s i t y of B r i t i s h Columbia, 1969 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES. School of Nursing We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August 1988 © Sharon E. Sundberg/ 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Nursing  The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date August 15, 1988 i i A b s t r a c t A p r e - t e s t p o s t - t e s t group design was used to determine whether student nurses who received a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n would ra t e t h e i r r e l a t i o n s h i p w i t h the i n s t r u c t o r higher than those who received a placebo/ whether student nurses who received the i n t e r v e n t i o n would have l e s s s t a t e anxiety than those who received a placebo/ and whether there was a r e l a t i o n s h i p between r a t i n g s of s t a t e a n x i e t y and s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p s . The i n t e r v e n t i o n was designed to occur over a three-day p e r i o d . Data were c o l l e c t e d from a homogenous sample of 30 c o n t r o l nursing students and 31 experimental nursing students. E f f e c t i v e n e s s of the i n t e r v e n t i o n was determined by measuring student anxiety l e v e l s using the S t a t e - T r a i t Anxiety Inventory (Spielberger/ Gorsuch/ & Lushene/ 1970) and by measuring the s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p using the R e l a t i o n s h i p Questionnaire (adapted from Truax & Carkhuff/ 1967). A d d i t i o n a l data were c o l l e c t e d from a S t r e s s f u l Event Questionnaire/ a demographic data form/ and a d e b r i e f i n g s e s s i o n w i t h p a r t i c i p a t i n g i n s t r u c t o r s . A n a l y s i s of data i n d i c a t e d a treatment main e f f e c t was s t a t i s t i c a l l y s i g n i f i c a n t . Members of the experimental group rated the perceived r e l a t i o n s h i p w i t h the i n s t r u c t o r higher than members of the c o n t r o l group. There was no s i g n i f i c a n t d i f f e r e n c e between groups i n t h e i r r a t i n g s of anxiety. There was a trend/ however/ f o r those i n the experimental group to have lower s t a t e a n x i e t y than tho i n the c o n t r o l group. C o r r e l a t i o n s between the s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p scores and the a n x i e t y scores were low but were i n the a n t i c i p a t e d n e gative d i r e c t i o n . i v T a b l e o f C o n t e n t s P a ge A b s t r a c t i i L i s t o f T a b l e s v i i i A c k n o w l e d g e m e n t s i x CHAPTER ONE I n t r o d u c t i o n 1 B a c k g r o u n d t o t h e P r o b l e m 1 P r o b l e m 4 P u r p o s e 5 D e f i n i t i o n o f Terms . . . . . 5 A s s u m p t i o n s 7 E t h i c s a n d Human R i g h t s 8 S i g n i f i c a n c e t o N u r s i n g 9 CHAPTER TWO C o n c e p t u a l Framework and L i t e r a t u r e R e v i e w 10 C o n c e p t u a l Framework 10 L i t e r a t u r e R e v i e w 14 The C l i n i c a l S e t t i n g a s a S o u r c e o f A n x i e t y a n d S t r e s s 14 I n t e r v e n t i o n s f o r A n x i e t y i n G r o u p s o f N u r s i n g S t u d e n t s 23 The E f f e c t o f I n t e r p e r s o n a l R e l a t i o n s h i p s o n S t u d e n t A n x i e t y L e v e l s 27 V Page CHAPTER THREE Methodology 34 Research Design 34 Co n t r o l of V a r i a b l e s 34 S e t t i n g and Sample 38 Instruments 39 S t a t e - T r a i t Anxiety Inventory 39 R e l a t i o n s h i p Questionnaire 40 S t r e s s f u l Event Questionnaire 42 Demographic Data 43 Procedure 43 Data A n a l y s i s 46 CHAPTER FOUR Results and D i s c u s s i o n 48 Resu l t s 48 A t t r i t i o n 48 Demographic C h a r a c t e r i s t i c s of Subjects . . . 48 Hypothesis One: E f f e c t of I n t e r v e n t i o n on Stud e n t - I n s t r u c t o r R e l a t i o n s h i p 49 Hypothesis Two: E f f e c t of I n t e r v e n t i o n on State Anxiety 52 Hypothesis Three: R e l a t i o n s h i p Between Student-Instructor R e l a t i o n s h i p Score and State Anxiety Score 55 v i Page A Comparison of T r a i t Anxiety Scores of C o n t r o l and Experimental Groups 56 Data from Stress Questionnaire 56 D e s c r i p t i v e Information from a D e b r i e f i n g Session w i t h I n s t r u c t o r s 58 Di s c u s s i o n 60 I n t e r v e n t i o n E f f e c t on Student-I n s t r u c t o r R e l a t i o n s h i p 60 I n t e r v e n t i o n E f f e c t on Student State Anxiety 61 C o r r e l a t i o n Between Scores of Student-I n s t r u c t o r R e l a t i o n s h i p and Anxiety . . . . 63 L i m i t a t i o n s 63 CHAPTER FIVE Summary/ Conclusions/ and Recommendations f o r Further Research 65 Summary of the Study 65 Conclusions 68 I m p l i c a t i o n s f o r Nursing Education 69 Recommendations f o r Further Research 71 References 74 Appendixes A. S e l f - E v a l u a t i o n Questionnaire STAI FORM X - l 81 v i i Page B. S e l f - E v a l u a t i o n Questionnaire STAI FORM X-2 84 C. R e l a t i o n s h i p Questionnaire 87 D. R e l a t i o n s h i p - b u i l d i n g A c t i v i t i e s Package . . 91 E. Explanatory L e t t e r - D i r e c t o r r L e v e l I Co-ordinator 100 F. Explanatory L e t t e r - P a r t i c i p a t i n g F i r s t Year I n s t r u c t o r s 103 G. Explanatory L e t t e r - Subjects f o r Instrument V a l i d a t i o n Test 106 H. Explanatory L e t t e r - Co n t r o l and Experimental Subjects 109 I . S t r e s s f u l Event Questionnaire 112 J . Demographic Data Form 114 K. Figure 1: P l o t of State Anxiety Scores by Treatment Group 116 L. Figure 2: P l o t of State Anxiety Scores by I n s t r u c t o r s 118 v i i i L i s t of Tables Table Page 1. Plan f o r Con t r o l Group 36 2. Pl a n f o r Experimental Group 37 3. A Comparison of Experimental and Co n t r o l Subjects by Age/ Sex* M a r i t a l Status* and Occupation P r i o r to Enrollment 49 4. Response Rates and Mean Student-I n s t r u c t o r R e l a t i o n s h i p Scores of Con t r o l and Experimental Groups 50 5. Summary of A n a l y s i s of Variance f o r I n t e r v e n t i o n and I n s t r u c t o r E f f e c t on Stud e n t - I n s t r u c t o r R e l a t i o n s h i p 52 6. Response Rates and Mean State Anxiety Scores of Co n t r o l and Experimental Groups 53 7. Summary of A n a l y s i s of Covariance f o r I n t e r v e n t i o n and I n s t r u c t o r E f f e c t on State Anxiety 54 8. A Comparison of Experimental and Cont r o l Subjects* Experience of S t r e s s f u l Events i n 24 Hours P r i o r to P o s t - t e s t Data C o l l e c t i o n 56 9. C l a s s i f i c a t i o n of S t r e s s f u l Events Perceived by C o n t r o l and Experimental Subjects 58 Acknowledgements The study would not have been completed without the continued i n t e r e s t and encouragement p r o v i d e d by my mother/ my aunt/ and my f r i e n d s . A s p e c i a l a p p r e c i a t i o n i s expressed t o my t h e s i s committee/ Roberta Hewat/ Chairman/ and Barbara Milne who generously gave t h e i r time/ p a t i e n c e / and valued e x p e r t i s e . In a d d i t i o n / I would l i k e to acknowledge members of the UBC S t a t i s t i c a l C o n s u l t i n g and Research L a b o r a t o r y f o r t h e i r a s s i s t a n c e w i t h the s t a t i s t i c a l aspects of the study. L a s t l y / I would l i k e t o thank the f a c u l t y and students of the Vancouver General H o s p i t a l School of Nursing who so w i l l i n g l y p a r t i c i p a t e d i n the study. T h e i r s p i r i t of c o - o p e r a t i o n was t r u l y i n s p i r a t i o n a l to a beginning r e s e a r c h e r . 1 CHAPTER ONE I n t r o d u c t i o n Background to Problem Evidence t h a t a n x i e t y i n f l u e n c e s l e a r n i n g has long been recognized by educators (Meisenhelder/ 1987; Sieber/ O'Neil/ & Tobiasr 1977; Spielberger & Sarason/ 1975). Although m i l d a n x i e t y may augment l e a r n i n g by p r o v i d i n g a motivating f o r c e / moderate to severe a n x i e t y may s e r i o u s l y i n h i b i t the l e a r n i n g process (Blainey/ 1980). Nursing research l i t e r a t u r e has c o n s i s t e n t l y i d e n t i f i e d a n x i e t y as a common response experienced by nursing students (Charlesworth/ Murphy/ & B e u t l e r / 1981; McKay/ 1978; M i l l e r / 1984). Although s e v e r a l sources of a n x i e t y have been i d e n t i f i e d / a dominant source of anxiety i s p r a c t i s e i n the c l i n i c a l s e t t i n g . Infante (1985) describes the p r o f e s s i o n a l education of the nurse as a bridge between the world of thought and the world of a c t i o n . T r a d i t i o n a l l y / education f o r the "world of a c t i o n " has occurred w i t h i n t h i s c l i n i c a l s e t t i n g . The consequences of an impaired l e a r n i n g process r e s u l t i n g from anxiety have s e r i o u s i m p l i c a t i o n s f o r t h a t p o r t i o n of the educational process of nursing which occurs i n t h i s p r a c t i s e s e t t i n g . Research f i n d i n g s have demonstrated that h i g h l y anxious l e a r n e r s have increased d i f f i c u l t y w i t h performance of psychomotor s k i l l s (Combs & 2 Taylor/ 1952; Erber/ 1984; Weinberg & Ragan/ 1978)/ w i t h l e a r n i n g of concepts/ t h e i r r e t e n t i o n and r e c a l l (Meyers & Martin/ 1974) and w i t h development of i n t e r p e r s o n a l r e l a t i o n s h i p s . Crow and Crow (1972) suggest t h a t the nurse's a b i l i t y to c o n t r o l her emotions plays a major r o l e i n the n u r s e - c l i e n t r e l a t i o n s h i p / while Brown and Fowler (1971) b e l i e v e t h a t i f a student nurse experiences d i f f i c u l t y d e a l i n g w i t h s t r e s s during the educational process the a n x i e t y generated a f f e c t s those w i t h whom she i s i n personal contact. This l a t t e r f i n d i n g i s supported by Johnson (1979) who reports t h a t increased l e v e l s of nurse a n x i e t y have a negative e f f e c t on the amount of d i s c l o s u r e between nurse and c l i e n t . Furthermore/ Infante (1985) suggests t h a t i n order to promote c r i t i c a l t h i n k i n g i n students i n the c l i n i c a l s e t t i n g the teacher must provide an environment i n which students are f r e e from anx i e t y and f e e l i n g s of inadequacy. The anxious nursing student p r a c t i c i n g w i t h i n the c l i n i c a l s e t t i n g / t h e r e f o r e / may provide l e s s than optimal care which may lead t o c l i e n t p h y s i c a l and p s y c h o s o c i a l needs being i n e f f e c t i v e l y met and standards of care j e o p a r d i z e d . In a d d i t i o n / a n x i e t y may r e s u l t i n l e a r n e r anger and depression and i n h i b i t student personal development (McMaster/ 1979). Aspy and Roebuck (1977) suggest that one method by which student anxiety can be decreased and l e a r n i n g 3 enhanced i s through the teacher's use of s t r a t e g i e s to enhance i n t e r p e r s o n a l r e l a t i o n s h i p s . Although open communication appears to decrease student a n x i e t y and enhance l e a r n i n g / evidence i n d i c a t e s that d e l i b e r a t e use of i n t e r p e r s o n a l s k i l l s i n the teacher-learner r e l a t i o n s h i p w i l l f u r t h e r f a c i l i t a t e the l e a r n i n g process and may be an area f o r f u r t h e r study (Aspy & Roebuck/ 1977). Educational research on a n x i e t y and l e a r n i n g has found the i n t e r p e r s o n a l r e l a t i o n s h i p between teacher and p u p i l s / which i s r e f l e c t e d i n c h a r a c t e r i s t i c teacher responses/ to be r e l a t e d to anxiety l e v e l s ( H i l l / 1967; McKeachie/ P o l l i e / & Speisman/ 1955; Oner/ 1977; Sarason & Davidson/ 1962; Sarason/ Davidson/ & B l a t t / 1962). Oner (1977) re p o r t s t h a t c h i l d r e n ' s a n x i e t y i s a f u n c t i o n of the way they perceive t h e i r teacher. For example/ teachers perceived as p u n i t i v e and a u t h o r i t a r i a n tend to m o b i l i z e student a n x i e t y and as a r e s u l t classroom performance d e t e r i o r a t e s . In c o n t r a s t / teachers perceived as nonpunitive/ n o n a u t h o r i t a r i a n / and i n t e r e s t e d i n g i v i n g students every opportunity t o communicate dependency and need f o r help reduce anxiety c o n s i d e r a b l y . The d e b i l i t a t i n g e f f e c t s of anxiety/ t h e r e f o r e / o f t e n r e s u l t from the nature of the s i t u a t i o n a l context and the i n d i v i d u a l ' s i n t e r p e r s o n a l r e l a t i o n s h i p s . Although the i n v e s t i g a t o r recognizes t h a t i n d i v i d u a l nursing i n s t r u c t o r s may use s t r a t e g i e s attempting to decrease student anxiety/ McKay (1978) suggests that 4 " h i s t o r i c a l l y # n u r s i n g f a c u l t y have e x e r c i s e d l i t t l e f o r e s i g h t i n p l a n n i n g l e a r n i n g experiences which w i l l a s s i s t the student i n coping with a n x i e t y " (p. 378). The i n v e s t i g a t o r b e l i e v e s t h a t d e l i b e r a t e s t r a t e g i e s implemented by n u r s i n g i n s t r u c t o r s t o e s t a b l i s h i n t e r p e r s o n a l r e l a t i o n s h i p s w i t h students may r e s u l t i n decreased student a n x i e t y i n the c l i n i c a l s e t t i n g . P r o b l e m Both n u r s i n g r e s e a r c h f i n d i n g s and the i n v e s t i g a t o r ' s o b s e r v a t i o n a l experience suggest t h a t a dominant source of an x i e t y f o r n u r s i n g students a r i s e s from p r a c t i s e i n the c l i n i c a l s e t t i n g . P e r s o n a l o b s e r v a t i o n s have a l s o r e v e a l e d t h a t a n x i e t y l e v e l s of n u r s i n g students appear t o vary among c l i n i c a l groups. Although a v a i l a b l e l i t e r a t u r e suggests t h a t an improved i n t e r p e r s o n a l r e l a t i o n s h i p between teacher and student may be h e l p f u l i n d e c r e a s i n g student a n x i e t y * few documented s t u d i e s d i r e c t l y r e l a t e the two concepts. I t i s the i n v e s t i g a t o r ' s o p i n i o n t h a t one f a c t o r t h a t may c o n t r i b u t e to the v a r i a b i l i t y i n student a n x i e t y l e v e l may be the p e r c e i v e d i n t e r p e r s o n a l r e l a t i o n s h i p with the c l i n i c a l i n s t r u c t o r . T h i s study attempts t o f i l l a r e s e a r c h v o i d by attempting t o r e l a t e the student's p e r c e p t i o n of the s t u d e n t - i n s t r u c t o r i n t e r p e r s o n a l r e l a t i o n s h i p t o student a n x i e t y l e v e l s . 5 Purpose The purpose of the study was t o t e s t the p r o p o s i t i o n t h a t nursing students' anxiety i n the c l i n i c a l s e t t i n g would be lowered by implementation of a r e l a t i o n s h i p -b u i l d i n g a c t i v i t y by the i n s t r u c t o r . In p a r t i c u l a r * three hypotheses were t e s t e d : HI: Student nurses who receive a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n w i l l r a t e t h e i r r e l a t i o n s h i p w i t h the i n s t r u c t o r higher than student nurses r e c e i v i n g a placebo i n t e r v e n t i o n . H2: Student nurses who receive a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n w i l l have l e s s s t a t e a n x i e t y than student nurses r e c e i v i n g a placebo i n t e r v e n t i o n . H3: There i s a r e l a t i o n s h i p between s t a t e anxiety l e v e l s of student nurses and t h e i r p erception of the r e l a t i o n s h i p w i t h the i n s t r u c t o r . D e f i n i t i o n of Terms State an x i e t y : "a t r a n s i t o r y emotional s t a t e or c o n d i t i o n of the human organism th a t i s c h a r a c t e r i z e d by s u b j e c t i v e * c o n s c i o u s l y perceived f e e l i n g s of te n s i o n and apprehension* and heightened autonomic nervous system a c t i v i t y . A-states may vary i n i n t e n s i t y and f l u c t u a t e over time" (Spielberger* Gorsuch* & Lushene* 1970* p. 3)* as measured by STAI Form X - l (see Appendix A). 6 T r a i t a n x i e t y : "the r e l a t i v e l y s t a b l e i n d i v i d u a l d i f f e r e n c e i n a n x i e t y proneness* that i s * the d i f f e r e n c e s between people i n the tendency to respond to s i t u a t i o n s perceived as threatening w i t h e l e v a t i o n s i n the A-state i n t e n s i t y " (Spielberger et a l . * 1970* p. 3)/ as measured by STAI Form X-2 (see Appendix B). S t u d e n t - i n s t r u c t o r r e l a t i o n s h i p ; the student's p e r c e p t i o n of the r e l a t i o n s h i p w i t h the i n s t r u c t o r as measured by the R e l a t i o n s h i p Questionnaire (adapted from Truax & Carkhuff* 1967) (see Appendix C). R e l a t i o n s h i p - b u i l d i n g a c t i v i t y ; three i n t e r a c t i o n a l episodes t h a t occur on consecutive days between one f a c u l t y member and a group of seven to e i g h t students. These episodes have been developed to have f a c u l t y demonstrate empathy* congruence* and p o s i t i v e regard during i n t e r a c t i o n w i t h students (see Appendix D). Empathy; "to sense the c l i e n t ' s world as i f i t were your own" (Rogers* 1961* p. 284). The concept i s o p e r a t i o n a l i z e d through i n s t r u c t o r v e r b a l i z a t i o n of statements which convey student understanding* r e a l i s t i c expectations* c a r i n g about students* knowledge of students* w i l l i n g n e s s to help* and r e c a l l of her previous experience as a student (Karns & Schwab* 1982). Congruence; "accurate matching of experience w i t h awareness" (Rogers* 1961* p. 282). I t i s o p e r a t i o n a l i z e d by i n s t r u c t o r statements "sharing s e l f * admitting mistakes* 7 e v a l u a t i n g s e l f as human/ acknowledging l i m i t a t i o n s / accepting c r i t i c i s m / and being honest" (Karns & Schwab/ 1982/ p. 6). P o s i t i v e regard; "a warm c a r i n g f o r the c l i e n t - a c a r i n g which i s not possessive/ which demands no personal g r a t i f i c a t i o n " (Rogers/ 1961/ p. 283). I t i s c h a r a c t e r i z e d by i n s t r u c t o r a c t i o n s " p r o v i d i n g p o s i t i v e feedback/ demonstrating w i l l i n g n e s s to l i s t e n to students/ promoting d i s c u s s i o n and questions/ t r e a t i n g students as i n t e l l i g e n t i n d i v i d u a l s / and by statements conveying t r u s t and respect of students" (Karns & Schwab/ 1982/ p. 41). C l i n i c a l s e t t i n g : "a place i n which the student i s g i v i n g d i r e c t care to r e a l c l i e n t s as p a r t of a planned l e a r n i n g a c t i v i t y " (O'Shea & Parsons/ 1979/ p. 411). In t h i s study the c l i n i c a l s e t t i n g was f i v e wards i n an acute care f a c i l i t y i n a l a r g e m e t r o p o l i t a n area. The wards s e l e c t e d were c l a s s i f i e d as e i t h e r acute s u r g i c a l areas or acute m e d i c a l - s u r g i c a l areas. Assumptions The assumptions of the study were: 1. Respondents had the a b i l i t y to assess t h e i r c u r r e n t f e e l i n g s t a t e s . 2. Respondents answered que s t i o n n a i r e s honestly and to the best of t h e i r a b i l i t y . 3. I n s t r u c t o r s implemented the treatment procedure according to the d i r e c t i o n s provided. 8 E t h i c s and Human Ri g h t s P r i o r t o commencement of the study the pr o p o s a l was submitted f o r e t h i c a l review t o both the U n i v e r s i t y of B r i t i s h Columbia b e h a v i o r a l s c i e n c e s s c r e e n i n g committee and the i n s t i t u t i o n ' s e t h i c a l review committee. Access t o the s u b j e c t pool was gained through the parent i n s t i t u t i o n of the School of Nursing* the D i r e c t o r of the School of Nursing* and the L e v e l 1 C o - o r d i n a t o r (see Appendix E ) . I n s t r u c t o r s who p a r t i c i p a t e d i n the study were pr o v i d e d with a v e r b a l and w r i t t e n e x p l a n a t i o n of t h e i r r o l e i n the study (see Appendix F ) . Implementation of the treatment package c o n s t i t u t e d consent t o p a r t i c i p a t e . Student s u b j e c t s p a r t i c i p a t i n g i n the study were a l s o p r o v i d e d w i t h a v e r b a l and w r i t t e n e x p l a n a t i o n of the study (see Appendices G and H). Completion of the q u e s t i o n n a i r e c o n s t i t u t e d consent t o p a r t i c i p a t e . Procedures f o r both the p i l o t t e s t and the study were the same. A l l s u b j e c t s and p a r t i c i p a t i n g i n s t r u c t o r s were informed t h a t t h e i r p a r t i c i p a t i o n was v o l u n t a r y and they c o u l d withdraw a t any time d u r i n g the study. They were informed t h a t t h e i r r e f u s a l or withdrawal would i n no way a f f e c t t h e i r c l a s s s t anding or employment s t a t u s . S u b j e c t s were assured t h a t q u e s t i o n n a i r e s would be destroyed a f t e r the data were analyzed. 9 S i g n i f i c a n c e to Nursing The study has s i g n i f i c a n c e f o r both n u r s i n g e d u c a t i o n and p r a c t i s e . P r e s e n t l y / programs f o r nurse educator p r e p a r a t i o n have l i t t l e content on student-teacher r e l a t i o n s h i p b u i l d i n g . I f student a n x i e t y can be s i g n i f i c a n t l y decreased through use of such t e a c h i n g s t r a t e g i e s / i t may i n d i c a t e a need f o r i n c r e a s e d emphasis on such content i n n u r s i n g c u r r i c u l a . A d d i t i o n a l l y / methods of e f f e c t i v e l y b u i l d i n g s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p s may serve as a f o cus f o r f a c u l t y development workshops. In the p r a c t i s e s e t t i n g / f i n d i n g s may suggest t h a t c h o i c e of f a c u l t y f o r c l i n i c a l t e a c h i n g take i n t o account not o n l y a candidate's t h e o r e t i c a l and p r a c t i c a l knowledge but a l s o h i s / h e r a b i l i t y t o r e l a t e e f f e c t i v e l y t o s t u d e n t s . A d d i t i o n a l l y / when i n s t r u c t o r s demonstrate e f f e c t i v e use of h e l p i n g - r e l a t i o n s h i p s k i l l s / they serve as r o l e models so t h a t students may l e a r n t h e r a p e u t i c communication s k i l l s more r e a d i l y . Students' i n t e r p e r s o n a l s k i l l s may be strengthened by such approaches and c l i e n t c a r e may b e n e f i t . Knowledge of f a c t o r s which impair l e a r n i n g w i l l h e l p us b e t t e r prepare nurses to meet the i n c r e a s i n g l y complex p h y s i c a l and p s y c h o s o c i a l needs of c l i e n t s . Knowledge of f a c t o r s which enhance l e a r n i n g w i l l make t h a t p r e p a r a t i o n process most e f f e c t i v e . 10 CHAPTER TWO C o n c e p t u a l Framework and L i t e r a t u r e R e v i e w C o n c e p t u a l Framework The t h e o r e t i c a l f r a m e w o r k u s e d t o s t r u c t u r e t h e s t u d y was d r a w n f r o m t h e o r y p r o p o s e d by C a r l R o g e r s ( 1 9 5 1 / 1 9 6 1 / 1969/ 1 9 8 3 ) . A s a p e r c e p t u a l p s y c h o l o g i s t / R o g e r s (1969) r e f e r s t o l e a r n i n g a s t h e d i s c o v e r y o f p e r s o n a l m e a n i n g . He i n t r o d u c e s t h e t e r m " s i g n i f i c a n t l e a r n i n g " w h i c h he d e f i n e s a s "more t h a n an a c c u m u l a t i o n o f f a c t s . I t i s l e a r n i n g t h a t makes a d i f f e r e n c e i n t h e i n d i v i d u a l ' s b e h a v i o r / h i s c o u r s e o f a c t i o n / h i s a t t i t u d e s / a nd h i s p e r s o n a l i t y " ( R o g e r s / 1961/ p. 2 8 0 ) . L e a r n i n g / t h e r e f o r e / i s c o n c e p t u a l i z e d a s a n a f f e c t i v e a s w e l l a s a c o g n i t i v e e x p e r i e n c e . The f i e l d o f p e r c e p t u a l p s y c h o l o g y s u g g e s t s t h a t a l l b e h a v i o r i s a f u n c t i o n o f a p e r s o n ' s p e r c e p t i o n s o r p e r s o n a l m e a n i n g s and i s d e t e r m i n e d / t h e r e f o r e / n o t by t h e o b j e c t i v e e n v i r o n m e n t b u t by a p e r s o n a l / i n d i v i d u a l way o f p e r c e i v i n g w h i c h i s u n i q u e t o t h a t i n d i v i d u a l . More s p e c i f i c a l l y / b e h a v i o r c a n be d e s c r i b e d a s a r e s u l t o f how an i n d i v i d u a l s e e s h i m s e l f / how he v i e w s t h e w o r l d a b o u t him/ a n d t h e i n t e r r e l a t i o n s h i p o f t h e t w o . A t t h e c o r e o f e a c h p e r s o n ' s p e r c e p t u a l f i e l d a r e p e r c e p t i o n s a b o u t s e l f (Combs/ D o n a l d / & P e r k e y / 1 9 7 8 ) . 11 Rogers (1961) a l s o f e e l s "a person l e a r n s s i g n i f i c a n t l y only those t h i n g s which he perceives as being involved i n the maintenance or enhancement of the s t r u c t u r e of s e l f " (p. 389) . He f u r t h e r b e l i e v e s t h a t the s t r u c t u r e and o r g a n i z a t i o n of s e l f appear to become more r i g i d under t h r e a t and more relaxed when completely f r e e from t h r e a t . He f e e l s s i g n i f i c a n t l e a r n i n g i s most e f f e c t i v e l y promoted i n a s i t u a t i o n i n which t h r e a t to the s e l f of the l e a r n e r i s reduced to a minimum and perception i s f a c i l i t a t e d (Rogers/ 1951). W i t h i n t h i s context anything that i s construed as a t h r e a t to s e l f has the p o t e n t i a l to produce a b a r r i e r to e f f e c t i v e l e a r n i n g . Two e f f e c t s of t h r e a t to s e l f are described by perceptual p s y c h o l o g i s t s . The f i r s t i s termed "tunnel v i s i o n " (Combs/ Donald/ & Perkey/ 1978/ p. 59). When the i n d i v i d u a l f e e l s threatened the perceptual f i e l d narrows and focuses on the ob j e c t of t h r e a t . I f the t h r e a t i s perceived as great/ a t t e n t i o n becomes sharply focused on the threatening event excluding a l l other perceptions. This r e s t r i c t i n g e f f e c t of t h r e a t i s i n h i b i t o r y to e f f e c t i v e l e a r n i n g . A second e f f e c t of th r e a t upon perception occurs when the i n d i v i d u a l f e e l s threatened and i s forced to defend the perceptions he already has (Combs/ Donald/ & Perkey/ 1978). This defensive stance under t h r e a t i s e x a c t l y the reverse of what provides f o r e f f e c t i v e l e a r n i n g . 12 Rogers (1951) b e l i e v e s l e a r n i n g w i l l be f a c i l i t a t e d i f students are provided the opportunity t o explore and d i s c o v e r meanings of m a t e r i a l s . E x p l o r a t i o n i s c u r t a i l e d i n an atmosphere i n which the l e a r n e r spends excessive time avoiding or reducing the experience of a n x i e t y brought about by t h r e a t t o s e l f . As a consequence* removal of t h r e a t i s seen as a s i g n i f i c a n t f a c t o r i n the r e l e a s e of the i n d i v i d u a l to perceive more adequately. Rogers (1969) b e l i e v e s t h a t f r e e i n g the i n d i v i d u a l to f a c i l i t a t e p e rception i s accomplished through p r o v i s i o n of a permissive* non-threatening r e l a t i o n s h i p . He compares the teacher-student r e l a t i o n s h i p to t h a t of the p s y c h o t h e r a p i s t - c l i e n t r e l a t i o n s h i p (Rogers* 1961). W i t h i n both these he l p i n g r e l a t i o n s h i p s * Rogers suggests that f a c i l i t a t i o n of s i g n i f i c a n t l e a r n i n g r e s t s upon c e r t a i n a t t i t u d i n a l q u a l i t i e s between f a c i l i t a t o r and l e a r n e r . The most b a s i c of these e s s e n t i a l a t t i t u d e s i s "realness or genuineness. When the f a c i l i t a t o r i s a r e a l person* being what he i s * e n t e r i n g i n t o a r e l a t i o n s h i p w i t h the l e a r n e r without presenting a f r o n t or facade* he i s much more l i k e l y to be e f f e c t i v e " (Rogers* 1969* p. 206). Rogers and Stevens (1967) used the term "congruence" to mean "the f e e l i n g s the counselor i s experiencing are a v a i l a b l e t o him* a v a i l a b l e to h i s awareness* th a t he i s 13 able to l i v e these f e e l i n g s / be them i n the r e l a t i o n s h i p / and be able to communicate them i f appropriate" (p. 90). A second a t t i t u d e Rogers and Stevens (1967) note i n s u c c e s s f u l f a c i l i t a t i o n of l e a r n i n g i s termed " p o s i t i v e regard" (p. 105). I t i s described as "a f e e l i n g which i s not p a t e r n a l i s t i c / not sentimental/ nor s p e c i f i c a l l y s o c i a l and agreeable. I t respects the other person as a separate i n d i v i d u a l and does not possess him" (p. 94). Rogers (1969) describes i t f u r t h e r as " p r i z i n g the l e a r n e r / p r i z i n g h i s f e e l i n g s / h i s opinions/ h i s person . . . I t i s a b a s i c t r u s t - a b e l i e f that t h i s other person i s somehow fundamentally trustworthy" (p. 109). The t h i r d a t t i t u d e Rogers (1969) f e e l s e s t a b l i s h e s a c l i m a t e f o r s u c c e s s f u l l e a r n i n g i s "empathic understanding" (p. I l l ) . When the teacher has the a b i l i t y to understand student r e a c t i o n s from the i n s i d e / that i s / has a s e n s i t i v e awareness of how the process of education and l e a r n i n g seem to the student/ the l i k e l i h o o d of s i g n i f i c a n t l e a r n i n g i n c r e a s e s . According to Rogers/ one of the major r e s p o n s i b i l i t i e s of the teacher i s to create a f a c i l i t a t i n g c l i m a t e i n which s i g n i f i c a n t l e a r n i n g can be accomplished. P r o v i s i o n of such a c l i m a t e minimizes t h r e a t to s e l f and r e s u l t i n g a n x i e t y . In t h i s study the e f f e c t of an i n t e r v e n t i o n designed to reduce f e e l i n g s of t h r e a t to the i n d i v i d u a l was evaluated. 14 S i n c e the experience of a n x i e t y may be p r e c i p i t a t e d by f e e l i n g s of t h r e a t t o s e l f * a c t i v i t i e s m inimizing t h r e a t may reduce a n x i e t y . The i n t e r v e n t i o n implemented was a s e r i e s of r e l a t i o n s h i p - b u i l d i n g a c t i v i t i e s i n c o r p o r a t i n g the a t t i t u d i n a l q u a l i t i e s of empathy* congruence* and p o s i t i v e r e g a r d . These t h r e e c o n s t r u c t s were used to f a c i l i t a t e development of a p o s i t i v e l y p e r c e i v e d non-t h r e a t e n i n g i n t e r p e r s o n a l r e l a t i o n s h i p . The study attempted t o r e l a t e a p o s i t i v e l y p e r c e i v e d i n t e r p e r s o n a l r e l a t i o n s h i p between i n s t r u c t o r and nu r s i n g student t o reduced student a n x i e t y l e v e l s . L i t e r a t u r e Review The l i t e r a t u r e review i s d i v i d e d i n t o three s e c t i o n s . The f i r s t s e c t i o n focuses on s t u d i e s which p r o v i d e evidence t h a t a n x i e t y i n the c l i n i c a l s e t t i n g i s a dominant source of s t r e s s f o r n u r s i n g s t u d e n t s . The second s e c t i o n reviews s t u d i e s t h a t a ssess i n t e r v e n t i o n s f o r reducing a n x i e t y i n groups of n u r s i n g s t u d e n t s . The f i n a l s e c t i o n focuses on s t u d i e s which emphasize the s i g n i f i c a n c e of i n t e r p e r s o n a l r e l a t i o n s h i p s i n c o n t r o l of a n x i e t y i n st u d e n t s . T h e c l i n i c a l s e t t i n g a s a s o u r c e o f a n x i e t y a n d s t r e s s . C l i n i c a l experience has been i d e n t i f i e d as a major s t r e s s f o r n u r s i n g students ( B i r c h * 1 9 7 9 ; E l f e r t * 1 9 7 6 ; Fox* Diamond* Walsh* Knopf* & Hodgin* 1 9 6 5 ; G a r r e t t * Manuel* & 15 Vincent/ 1976). A v a r i e t y of research methodologies/ as w e l l as a number of nursing student populations/ have been used i n s t u d i e s which have c o n t r i b u t e d to t h i s f i n d i n g . A c l a s s i c study by Fox et a l . (1965) used the c r i t i c a l i n c i d e n t technique and i d e n t i f i e d four major areas i n which nursing students may experience s t r e s s - personal/ s o c i a l / academic/ and c l i n i c a l . In t h i s study 80/000 f r e e response d e s c r i p t i o n s of s a t i s f y i n g and s t r e s s f u l i n c i d e n t s were c o l l e c t e d from 4/000 nursing students e n r o l l e d i n 23 diploma and 6 baccalaureate degree programs t h a t were randomly s e l e c t e d from the New York area. R e s u l t s revealed t h a t 71% of responses were r e l a t e d to the s t r e s s a s s ociated w i t h the c l i n i c a l aspects of nursing school experience. In another study G a r r e t t / Manuel/ and Vincent (1976) attempted to g e n e r a l i z e the f i n d i n g s of Fox et a l . One hundred and eleven sophomore/ j u n i o r / and senior nursing students between the ages of 18 and 23 years e n r o l l e d i n a c o l l e g i a t e s e t t i n g were s t u d i e d . Although s t r e s s was undefined i n the previous study/ i n t h i s study s t r e s s was defined as "a s t a t e always present i n man but that i s i n t e n s i f i e d when there i s a change or t h r e a t w i t h which the i n d i v i d u a l must cope" (p. 6). Students' r e p o r t s were independently i n t e r p r e t e d by two of three researchers who had 100% agreement on the c a t e g o r i z a t i o n of s t r e s s f u l responses. The l a r g e s t percentage of sophomore responses/ 47.8%/ were cat e g o r i z e d 16 as c l i n i c a l experience w h i l e only 22.8% of j u n i o r responses f e l l i n t h i s group. The l a r g e s t percentage of senior responses were c l a s s i f i e d as academic experiences; c l i n i c a l experiences were described i n only 16.7% of responses. Study f i n d i n g s of the d i s t r i b u t i o n of s t r e s s f u l i n c i d e n t s revealed* however* that the l a r g e s t percentage of t o t a l responses* 28.8%* were cat e g o r i z e d as c l i n i c a l experience. Using the same technique E l f e r t (1976) studied b a s i c students e n r o l l e d i n the f i r s t two years of a new baccalaureate program at the U n i v e r s i t y of B r i t i s h Columbia. Her study was l o n g i t u d i n a l and evaluated data c o l l e c t e d at the end of each of three terms over two years. Although the a c t u a l number of p a r t i c i p a n t s was not reported* the p r o p o r t i o n of respondents v a r i e d from 79% to 91% of those e n r o l l e d . Results i n d i c a t e d that the number of s t r e s s f u l episodes i n the c l i n i c a l area increased over the s i x terms. The number of s t r e s s f u l i n c i d e n t s r e l a t e d to c l i n i c a l experience* however* remained c o n s i s t e n t l y fewer than the number of s a t i s f y i n g i n c i d e n t s r e l a t e d i n the same area. In a d d i t i o n t o the c r i t i c a l i n c i d e n t technique* r a t i n g s c a l e s have a l s o been used t o study a n x i e t y i n nursing students. B i r c h (1979) stud i e d 207 nursing students e n r o l l e d i n four schools i n England. The research design included use of the P e r s o n a l i t y Testing and A b i l i t y Testing Anxiety Scale [IPAT] devised by C a t t e l l and a s e l f - d e v i s e d q u e s t i o n n a i r e t e s t i n g e x p r e s s e d a n x i e t y i n 56 a r e a s o f c l i n i c a l p r a c t i c e . The s t u d y was l o n g i t u d i n a l a n d o c c u r r e d d u r i n g t h e f i r s t two y e a r s o f h o s p i t a l e x p e r i e n c e . C a t t e l l ' s A n x i e t y S c a l e was a d m i n i s t e r e d d u r i n g t h e i n t r o d u c t o r y c o u r s e and a t t h r e e e i g h t - m o n t h l y i n t e r v a l s . The s e l f - d e v i s e d a n x i e t y q u e s t i o n n a i r e was c o m p l e t e d o n l y a t e i g h t months and two y e a r s a f t e r commencement o f t r a i n i n g . A n a l y s i s o f f i n d i n g s d e t e r m i n e d f r o m t h e IPAT r e v e a l e d t h a t o v e r 5 0 % o f s u b j e c t s s c o r e d on t h r e e o f t h e f o u r s c h e d u l e d t e s t i n g s a t l e v e l s w h i c h C a t t e l l d e s c r i b e d a s b o r d e r l i n e h i g h a n d r e q u i r i n g f o l l o w - u p f o r s t r e s s management. A l t h o u g h t h e s t u d y d i d n o t d i f f e r e n t i a t e a s t o c a u s e s o f a n x i e t y * t h e s e l f - d e v i s e d q u e s t i o n n a i r e c o n t a i n e d 56 i t e m s o f p r o f e s s i o n a l e x p e r i e n c e t h o u g h t by t h e i n v e s t i g a t o r t o l i k e l y c a u s e a n x i e t y . A r e a s o f s t r e s s i n r a n k o r d e r r e v e a l e d 9 o f t h e t o p 10 t o be a s s o c i a t e d w i t h c l i n i c a l e x p e r i e n c e and a n a l y s i s s u g g e s t e d t h a t c a u s e s o f s t r e s s d i d n o t c h a n g e s i g n i f i c a n t l y b e t w e e n 8 and 24 m o n t h s . G r a d u a t e n u r s e s a s s u m i n g a s t u d e n t r o l e h a v e a l s o b e e n d e s c r i b e d a s a n x i o u s . L i n n (1975) p r e s e n t e d d a t a on 21 s t u d e n t s i n two c o h o r t n u r s e p r a c t i t i o n e r p r o g r a m s a t t h e U n i v e r s i t y o f C a l i f o r n i a [ U C L A ] . The i n s t r u m e n t u s e d was t h e C o u r s e a nd P e r s o n a l E x p e r i e n c e I n v e n t o r y w h i c h was composed o f t h e P h y s i o l o g i c a l S t r e s s I n d e x r t h e S o c i a l 18 S t r e s s I n d e x / t h e P s y c h o l o g i c a l and t h e T o t a l S t r e s s I n d e x . B a s e l i n e d a t a w e r e a c q u i r e d on t h e f i r s t d a y o f c l a s s a n d q u e s t i o n n a i r e s w e r e c o m p l e t e d e v e r y two w e e k s d u r i n g t h e 18-week c o u r s e . A t o t a l i n d e x s c o r e was c a l c u l a t e d f o r e a c h s t u d e n t ; h i g h s c o r e s r e f l e c t e d h i g h e r s t r e s s l e v e l s . D a t a r e v e a l e d t h r e e peak p o i n t s o f s t r e s s . The f i r s t p e ak c o r r e l a t e d w i t h p r e s e n t a t i o n o f a c o n s i d e r a b l e amount o f c l a s s r o o m c o n t e n t and some c l i n i c a l e x p e r i e n c e a t t h e b e g i n n i n g o f t h e c o u r s e . The s e c o n d peak seemed t o be l i m i t e d t o i n c r e a s e d c l i n i c a l r e s p o n s i b i l i t y a n d t h e f i n a l peak r e l a t e d t o c o u r s e t e r m i n a t i o n and e x a m i n a t i o n s . F e e l i n g s o f a n x i e t y and s t r e s s a r e e x p e r i e n c e d by n u r s i n g s t u d e n t s e a r l y i n t h e p r o c e s s o f t h e i r p r o f e s s i o n a l e d u c a t i o n . G r a s s i - R u s s o and M o r r i s ( 1 9 7 8 ) / i n a s t u d y o f f r e s h m a n n u r s i n g s t u d e n t s * a s k e d p a r t i c i p a n t s t o r e c o r d two h o p e s and two f e a r s a t t h e b e g i n n i n g o f t h e i r p r o g r a m and e i g h t m o n t h s l a t e r a s k e d s u b j e c t s t o r e c o r d two p l e a s a n t and two u n p l e a s a n t e x p e r i e n c e s . The r a n k o r d e r o f f e a r s r e c o r d e d i n c l u d e d f a i l u r e / t a k i n g r e s p o n s i b i l i t y / m a k i n g a d a n g e r o u s m i s t a k e / and d e a l i n g w i t h d e a t h and s i c k p e o p l e . Two u n p l e a s a n t e x p e r i e n c e s i d e n t i f i e d w e r e o v e r - a l l s t r e s s a n d a n x i e t y a b o u t c l i n i c a l e x p e r i e n c e . A c o m p a r i s o n o f a n x i e t y l e v e l s b e t w e e n f i r s t a n d t h i r d y e a r n u r s i n g s t u d e n t s p r i o r t o c l i n i c a l e x p e r i e n c e i n a n a c c i d e n t a n d e m e r g e n c y d e p a r t m e n t and t r a u m a a r e a was 19 completed by Brunt (1984). A s e l f - d e v i s e d q u e s t i o n n a i r e was administered t o a t o t a l of nine p a r t i c i p a n t s w i t h i n one hour of a r r i v i n g i n the department and three weeks l a t e r . Two questions r e l a t e d to a n x i e t y . The f i r s t q uestion asked the students to d e s c r i b e t h e i r f e e l i n g s about working i n the area. Both l e v e l s of students expressed negative emotions such as "apprehensive/ worried/ dubious/ and nervous" (p. 37). The second question l i s t e d 26 c l i n i c a l s i t u a t i o n s and students were asked to r a t e t h e i r f e e l i n g s on a L i k e r t 4-point s c a l e . Responses v a r i e d from unworried to very worried w i t h a higher score i n d i c a t i n g a greater degree of worry. Students at both l e v e l s on both occasions scored above 40 out of a maximum t o t a l score of 60 (p. 38) confirming a n x i e t y t o be a f a c t o r i n student's l e a r n i n g experience. In an attempt to add a cross c u l t u r a l dimension to the study of nursing student s t r e s s / Davitz (1972) sought to compare s i m i l a r i t i e s and d i f f e r e n c e s i n s t r e s s reported by N i g e r i a n and American nursing students. The 37 N i g e r i a n p a r t i c i p a n t s between 18 and 19 years of age were e n r o l l e d i n a three and one-half year program. Data on the American students were acquired from the study conducted by Fox et a l . (1965). Each su b j e c t ' s recounting of a s t r e s s f u l i n c i d e n t contained an average of two d e t a i l s necessary t o understand and i n t e r p r e t the experience and c l a s s i f y i t using the o r i g i n a l four c a t e g o r i e s / personal/ s o c i a l / academic/ and c l i n i c a l / developed by Fox et a l (1965). Two coders independently rated student responses and again coder agreement was 100%. "The r e s u l t s i n terms of the four major c a t e g o r i e s were s t r i k i n g l y c o n s i s t e n t . Of the 37 students/ 36 reported s t r e s s f u l experiences concerned w i t h the c l i n i c a l area" (Davitz/ 1972/ p. 354). Areas of concern elaborated on by respondents were p h y s i c a l and emotional care of p a t i e n t s / s t r e s s of s h i f t / i n i t i a l c l i n i c a l experiences and procedure implementation. In a d d i t i o n / "ten r e p o r t s i d e n t i f i e d i n t e r p e r s o n a l r e l a t i o n s h i p s as the primary source of s t r e s s . Nine i n v o l v e d s e n i o r nurse t u t o r s and s t a f f nurses" (p. 355). Davitz (1972) noted that both American and N i g e r i a n nursing students reported t h e i r most frequent s t r e s s experience i n terms of c l i n i c a l i n t e r a c t i o n and concluded t h a t " i n t r i n s i c to the education of nurses/ regardless of the s p e c i f i c c u l t u r e i n which the t r a i n i n g occurs/ the c l i n i c a l practicum aspects of t r a i n i n g represent the primary areas of s t r e s s f o r students" (p. 356). I n t e r p e r s o n a l r e l a t i o n s h i p s as a s p e c i f i c source of s t r e s s a s s o c i a t e d w i t h c l i n i c a l experience are described by authors (Blainey/ 1980; D a v i t z / 1972). B l a i n e y (1980) i n her d i s c u s s i o n of anxiety i n m e d i c a l - s u r g i c a l students suggested that a frequent a n x i e t y t h a t students experience i s t h a t r e l a t e d t o i n t e r p e r s o n a l r e l a t i o n s h i p s . These 21 i n t e r p e r s o n a l r e l a t i o n s h i p s i n v o l v e c l i e n t s * other h e a l t h care team members* and nursing i n s t r u c t o r s . A m o d i f i c a t i o n of the c r i t i c a l i n c i d e n t technique was used by McMaster (1979) to study students i n a baccalaureate nursing program at the U n i v e r s i t y of Western Ontario. S t r e s s was defined according to Selye's d e s c r i p t i o n of d i s t r e s s ; t h a t i s * "damaging or unpleasant s t r e s s " (McMaster* 1979* p. 891). P a r t i c i p a n t s were presented w i t h p o s s i b l e b e h a v i o r a l m a n i f e s t a t i o n s of s t r e s s and were asked to r e c a l l and report i n c i d e n t s from the previous term t h a t they had perceived as s t r e s s f u l . Data were c o l l e c t e d at the end of f i r s t and second term; of the 216 students e n r o l l e d * 79% and 74% p a r t i c i p a t e d r e s p e c t i v e l y . Responses were analyzed and categorized by two independent coders and three major c a t e g o r i e s emerged: "academic* c l i n i c a l * and s o c i a l - p e r s o n a l " (McMaster* 1979* p. 89). Findings a f t e r f i r s t term Year 1 suggested t h a t the academic area was the g r e a t e s t source of s t r e s s . The i n v e s t i g a t o r f e l t t h i s was t o be expected as c l i n i c a l experience was l i m i t e d at t h i s p o i n t i n the program. The most commonly expressed concern r e l a t e d to c l i n i c a l experience was to do w i t h apprehension about f i r s t experiences i n h o s p i t a l . In c o n t r a s t * second year students at the end of f i r s t term perceived the c l i n i c a l area as the source of g r e a t e s t 22 s t r e s s w h i l e at the end of second term emphasis returned to the academic area. Responses from t h i r d year students at the end of f i r s t term i n d i c a t e d almost equal concerns r e l a t e d to academic and c l i n i c a l areas but during second term the c l i n i c a l area again took precedence. "The main c l i n i c a l concern f o r t h i s c l a s s r e l a t e d t o f a c u l t y . Many students perceived some of the teachers t o be 'threatening' and 'unhelpful' i n the c l i n i c a l area" (McMaster/ 1979r p. 94). During term one of f o u r t h year most of the concerns "arose from r e l a t i o n s h i p s w i t h f a c u l t y i n the academic area* some having a perception of teachers as ' h o s t i l e / * ' t h r e a t e n i n g / 1 and ' i n s e n s i t i v e ' " (p. 94). The study concluded t h a t major concerns r e s u l t i n g from p r o f i l e s of s t r e s s were i n the academic and c l i n i c a l area and t h a t " c l i n i c a l concerns were of p a r t i c u l a r i n t e r e s t because they focused on teacher behavior" (p. 95). McMaster*s f i n d i n g s are f u r t h e r supported by those of Zujewskyj and Davis (1985). Although workload was the most f r e q u e n t l y i d e n t i f i e d source of s t r e s s f o r t h i r d year baccalaureate students at the U n i v e r s i t y of A l b e r t a r the second most f r e q u e n t l y c i t e d source of s t r e s s was the c l i n i c a l i n s t r u c t o r . Despite the la c k of a c o n s i s t e n t d e f i n i t i o n of the concept of s t r e s s or anxi e t y / a l l s t u d i e s c l e a r l y i d e n t i f y c l i n i c a l experience as a dominant theme i n nursing students' reports of s t r e s s f u l experiences. W i t h i n t h i s 23 arena* i n t e r p e r s o n a l r e l a t i o n s h i p s as a s p e c i f i c source of s t r e s s are described by some researchers (Blainey* 1980; Da v i t z * 1972; McMaster* 1979; Zujewskyj & Davis* 1985). I n t e r v e n t i o n f o r anxie t y i n groups of nursing students. Attempts t o deal w i t h nursing student a n x i e t y have been documented i n the l i t e r a t u r e . An e a r l y d e s c r i p t i v e study reported by Rosenberg and F u l l e r (1955) described an experiment t h a t r e s u l t e d from a f e l t need of the f a c u l t y i n a diploma school of nursing "to handle a high withdrawal r a t e and emotional tensions of the students" (p. 431). The i n t e r v e n t i o n planned was a seminar i n human r e l a t i o n s f o r f i r s t year students which began the second week of the school year and terminated i n the t w e l f t h week. P s y c h i a t r i c a l l y o r i e n t e d group lea d e r s conducted the one and one-half hour weekly sessions using " s t r u c t u r e d group therapy technique which was v a r i e d t o f i t needs of adolescents" (p. 431). E v a l u a t i o n was based on students' impressions of seminars* f a c u l t y i n t e r p r e t a t i o n and r e a c t i o n s * the p s y c h o l o g i s t ' s a n a l y s i s of the meetings* and the more o b j e c t i v e observable r e s u l t s which took place on the wards and i n the classroom. S u b j e c t i v e f i n d i n g s revealed t h a t "emotional tensions of the students had been reduced and the withdrawal r a t e was obviously lower" (p. 431). A d d i t i o n a l l y * there appeared to be "fewer student expressions of anxiety t o the i n s t r u c t o r " (p. 426). 24 A l o n g i t u d i n a l study conducted by Gowell (1966) attempted to g e n e r a l i z e f i n d i n g s of Rosenberg and F u l l e r . Group work methods and process were again employed w i t h groups of 6 to 15 u n i v e r s i t y student nurses over a p e r i o d of f i v e years. Meetings were held weekly " f o r the purpose of d i s c u s s i n g common problems of student adjustment to nursing school or other d i f f i c u l t i e s they consider important" (p. 355). Study r e s u l t s were completely s u b j e c t i v e r e p o r t s and included comments such as "there are l e s s intense f e e l i n g s of a u t h o r i t y as evidenced by t h e i r a b i l i t y to d i s c u s s d i f f i c u l t i e s w i t h f a c u l t y w i t h whom they have formerly been unable to communicate" (p. 361) and "there were a l s o fewer i n c i d e n t s of psychosomatic complaints among students who had p a r t i c i p a t e d i n the s e s s i o n s " (p. 361). Although f i n d i n g s of the two c i t e d s t u d i e s suggest t h a t i n t e r v e n t i o n s were s u c c e s s f u l i n reducing s t r e s s of nursing students* methodological l i m i t a t i o n s are evident. Neither study employed v a l i d * r e l i a b l e t o o l s f o r the measurement of anxiety* attempted to measure anxi e t y l e v e l s p r i o r t o i n t e r v e n t i o n or provided comparisons w i t h appropriate c o n t r o l groups* making i t impossible to d i f f e r e n t i a t e between the e f f e c t s of the i n t e r v e n t i o n and f a c t o r s such as normal p e r s o n a l i t y development. A more rig o r o u s p r e - t e s t * p o s t - t e s t group design was used by Mancine* Lavecchia* and Clegg (1983) to i n v e s t i g a t e 25 the e f f e c t s of a s t r e s s management program [SMP] on the s t r e s s response of f u l l time graduate nursing students. The SMP c o n s i s t e d of 8 weekly one-hour sessions of demonstration and p r a c t i c e of r e l a x a t i o n / imagery/ diaphragmatic breathing/ and a commitment to reduced c a f f e i n e i n t a k e . T h i r t y female subjects between the ages of 25 to 43 years were randomly assigned to an experimental and a c o n t r o l group. A t t r i t i o n reduced the f i n a l sample to seven and nine/ r e s p e c t i v e l y . Instruments used f o r data c o l l e c t i o n were the Rahe Recent L i f e Changes Questionnaire tRLCQ]/ the A-State Anxiety Inventory/ the Palmar Sweat P r i n t [PSP]/ blood pressure readings/ and the Weekly S e l f Report [WSR] which measured SMP adherence by the experimental group and perceived s t r e s s by both groups. The PSP i n d i c a t o r demonstrated a s i g n i f i c a n t d i f f e r e n c e (p<.05) between groups. The WSR a l s o revealed t h a t the experimental group reported s i g n i f i c a n t l y fewer s t r e s s f u l experiences and used s i g n i f i c a n t l y more coping s t r a t e g i e s than the c o n t r o l group. Charlesworth et a l . (1981) conducted a s i m i l a r l y designed study to assess the e f f e c t i v e n e s s of a 10-session/ 5-week/ group-administered s t r e s s management program f o r student nurses. The i n t e r v e n t i o n c o n s i s t e d of sessions on pr o g r e s s i v e r e l a x a t i o n / deep muscle r e l a x a t i o n / autogenic t r a i n i n g / v i s u a l imagery/ and modified systematic 26 d e s e n s i t i z a t i o n conducted by the nursing i n s t r u c t o r . The experimental group was comprised of ten female nursing students w h i l e seven males and one female nursing student served as a c o n t r o l . The e f f e c t i v e n e s s of s t r e s s t r a i n i n g was assessed at three p o i n t s throughout the study: p r e t e s t * before mid-term examinations* and before f i n a l examinations. Sp i e l b e r g e r et a l . (1970) S t a t e - T r a i t Anxiety Inventory [STAI] was used to measure an x i e t y . Findings i n d i c a t e d t h a t the i n t e r v e n t i o n e f f e c t i v e l y reduced t r a i t a nxiety (p<.05)* w h i l e the c o n t r o l group's t r a i t a nxiety remained r e l a t i v e l y unchanged. In a d d i t i o n * the experimental group showed redu c t i o n i n s t a t e anxiety from mid-semester to f i n a l examinations* w h i l e the c o n t r o l group showed an increase f o r the same p e r i o d . Although both s t u d i e s demonstrated usefulness of an i n t e r v e n t i o n w i t h i n a group s e t t i n g * methodologic l i m i t a t i o n s are evident. The a b i l i t y of an i n t e r v e n t i o n employed f o r only f i v e weeks to e f f e c t i v e l y lower t r a i t a n xiety i s questionable. In a d d i t i o n * f i n d i n g s from the second study may r e f l e c t gender d i f f e r e n c e s i n groups as opposed to the e f f e c t of the i n t e r v e n t i o n . Small sample s i z e and f a i l u r e t o employ placebo i n t e r v e n t i o n s f o r c o n t r o l groups a l s o impose l i m i t a t i o n s on the f i n d i n g s of both s t u d i e s . 27 The research on group methods used to decrease a n x i e t y i n nursing students i s i n c o n c l u s i v e . Although s t u d i e s f a i l t o c o n s i s t e n t l y report s t a t i s t i c a l l y s i g n i f i c a n t e f f e c t s of such i n t e r v e n t i o n s * d e s c r i p t i v e f i n d i n g s suggest there i s a r o l e f o r such approaches to be used wi t h student nurses. The e f f e c t of i n t e r p e r s o n a l r e l a t i o n s h i p s on student  a n x i e t y l e v e l s . Research has demonstrated t h a t the f a c i l i t a t i v e c o n d i t i o n s of genuineness* non-possessive warmth* and accurate empathy are p o s i t i v e l y r e l a t e d to student emotional and i n t e l l e c t u a l f u n c t i o n i n g (Aspy & Roebuck* 1972; Reed* 1961; S t o f f e r * 1970). Reed (1961) proposed t h a t s e l e c t e d c h a r a c t e r i s t i c s of teachers had p a r t i c u l a r e f f e c t s upon students. He summarized f i n d i n g s from four e a r l i e r s t u d i e s of over one thousand grade 6 and grade 11 s u b j e c t s . R e s u l t s suggested that the r e l a t i o n s h i p s between students' perceptions of teacher behaviors that r e l a x i n t e r p e r s o n a l t e n s i o n * which he defined as warmth* and student change as measured by academic achievement gains and a t t i t u d i n a l gains measured by amounts of s e l f i n i t i a t e d school work* were c o r r e l a t e d s i g n i f i c a n t l y (p<.00D* p o s i t i v e l y and moderately (r = .20 f o r males; r = .28 f o r females) (p. 333). Aspy and Roebuck (1972) i n v e s t i g a t e d the r e l a t i o n s h i p between teachers' classroom behavior and students' l e v e l s of c o g n i t i v e f u n c t i o n i n g . Data were obtained from 40 28 f e m a l e e l e m e n t a r y t e a c h e r s who s u b m i t t e d a o n e - h o u r a u d i o t a p e r e c o r d i n g o f i n s t r u c t i o n o f r e a d i n g g r o u p s . The t e a c h e r s ' p e r f o r m a n c e was e v a l u a t e d u s i n g C a r k h u f f ' s S c a l e s f o r empathy* c o n g r u e n c e * and p o s i t i v e r e g a r d * F l a n d e r ' s I n t e r a c t i o n A n a l y s i s and t h e i r s t u d e n t s ' l e v e l s o f c o g n i t i v e f u n c t i o n i n g d e t e r m i n e d t h r o u g h u s e o f B l o o m ' s Taxonomy o f E d u c a t i o n a l O b j e c t i v e s . R a t i n g s f r o m m e a s u r e m e n t s u s i n g t h e t a x o m o n y w e r e c o l l a p s e d i n t o two c a t e g o r i e s * l e v e l 1 and l e v e l s 2-6; h i g h e r l e v e l s i n d i c a t e d h i g h e r l e v e l s o f c o g n i t i v e f u n c t i o n i n g . The t e a c h e r s ' l e v e l s o f i n t e r p e r s o n a l f u n c t i o n i n g w e r e a s s e s s e d by t h r e e t r a i n e d r a t e r s whose i n t e r - r a t e r r e l i a b i l i t y was s i g n i f i c a n t a t p<.01. An a n a l y s i s o f t h e r e l a t i o n s h i p b e t w e e n s t u d e n t l e v e l s o f c o g n i t i v e f u n c t i o n i n g and t e a c h e r c l a s s r o o m b e h a v i o r l e v e l s i n d i c a t e d t h a t t e a c h e r s whose s t u d e n t s a t t a i n e d c o g n i t i v e l e v e l s b e y o n d l e v e l one o f B l o o m ' s Taxonomy p r o v i d e d s i g n i f i c a n t l y h i g h e r l e v e l s o f p o s i t i v e r e g a r d t h a n t h o s e who r e m a i n e d a t l e v e l one t h r o u g h o u t t h e h o u r . S i g n i f i c a n t f i n d i n g s r e l a t e d t o t h e c o n s t r u c t s o f empathy a n d c o n g r u e n c e w e r e n o t o b t a i n e d i n t h e s t u d y . S t o f f e r (1970) s t u d i e d t h e e f f e c t s o f g e n u i n e n e s s * n o n - p o s s e s s i v e warmth* a n d e m p a t h i c u n d e r s t a n d i n g on c h i l d r e n who w e r e e x p e r i e n c i n g b e h a v i o r a l a n d a c a d e m i c d i f f i c u l t y i n g r a d e s one t h r o u g h s i x . T h i r t y - f i v e a d u l t f e m a l e s w o r k e d i n d i v i d u a l l y w i t h one o f 35 c h i l d r e n t w i c e 29 per week f o r th r e e months. The a d u l t h e l p e r s were i n s t r u c t e d o n l y t o e s t a b l i s h a good r e l a t i o n s h i p w i t h each c h i l d by choosing t h e i r own a c t i v i t i e s and s t r u c t u r i n g the r e l a t i o n s h i p i n d i v i d u a l l y . Interviews between a d u l t h e l p e r and c h i l d were taped near the i n i t i a t i o n and t e r m i n a t i o n of the r e l a t i o n s h i p and were r a t e d on th r e e s c a l e s measuring empathy* congruence* and p o s i t i v e r e gard. A r e l a t i o n s h i p i n v e n t o r y was used to measure the c h i l d ' s and h e l p e r ' s p e r c e p t i o n of the l e v e l s of t h e r a p e u t i c c o n d i t i o n s o f f e r e d . Each c h i l d was examined be f o r e and a f t e r treatment and i n d i c e s of b e h a v i o r a l change were determined by combining s c o r e s from i n d i v i d u a l i n t e l l i g e n c e t e s t s * gains i n achievement* r e d u c t i o n i n t e a c h e r - r a t e d behavior problems and gains i n m o t i v a t i o n . An outcome index was d e r i v e d from t o t a l l i n g s c o r e s from the i n d i v i d u a l t e s t s . P r o v i s i o n of hi g h l e v e l s of non-possessive warmth and a c c u r a t e empathy were s i g n i f i c a n t l y r e l a t e d t o gains i n achievement* r e d u c t i o n i n t e a c h e r - r a t e d behavior problems* and g a i n s r e f l e c t e d by the t o t a l outcome index. Lack of agreement between judges r e s u l t e d i n e x c l u s i o n of the v a r i a b l e of genuineness from a n a l y s i s . F u r t h e r f i n d i n g s i n d i c a t e d t h a t the c h i l d ' s p e r c e p t i o n of the r e l a t i o n s h i p w i t h the a d u l t h e l p e r was s i g n i f i c a n t l y r e l a t e d t o r e d u c t i o n i n t e a c h e r - r a t e d b e h a v i o r a l problems and g a i n s as measured by the t o t a l outcome index. 30 The above r e s e a r c h f i n d i n g s p r o v i d e e v i d e n c e t h a t s u g g e s t s f a c i l i t a t i v e t e a c h e r b e h a v i o r s a re r e l a t e d t o b e h a v i o r a l changes i n s t u d e n t s . The b e h a v i o r a l changes examined r e l a t e d o n l y i n d i r e c t l y t o a n x i e t y and u t i l i z e d s u b j e c t s i n the s c h o o l age y e a r s . Study d e s i g n s which employed i n t e r v e n t i o n t rea tments d i d not i n c l u d e c o n t r o l groups and f a i l e d t o c l e a r l y d e f i n e the i n t e r v e n t i o n used f o r s u b j e c t s . A more r i g o r o u s s tudy d e s i g n was used by Dye (1974) who used an e x p e r i m e n t a l d e s i g n and r a t i n g s c a l e s to examine the e f f e c t s of human r e l a t i o n s t r a i n i n g upon the measured s e l f - c o n c e p t * a n x i e t y l e v e l * and group awareness of 56 a s s o c i a t e degree n u r s i n g f reshmen. V o l u n t e e r s were randomly a s s i g n e d t o one o f t h r e e t rea tment g roups* a p l a c e b o - t y p e group* or a c o n t r o l g r o u p . The e x p e r i m e n t a l group r e c e i v e d one o f t h r e e t y p e s of human r e l a t i o n s t r a i n i n g f o r one and o n e - h a l f hours weekly f o r seven weeks. The human r e l a t i o n s t r a i n i n g c o n s i s t e d o f e i t h e r a l e a d e r l e s s s t r u c t u r e d group e x p e r i e n c e which f o c u s e d on l e a r n i n g th rough d i r e c t e x p e r i e n c e * a s e n s i t i v i t y e x p e r i e n c e w i t h an a f f e c t - o r i e n t e d growth o p p o r t u n i t y * or a communicat ion e x p e r i e n c e w i t h t r a i n i n g i n c o g n i t i v e l y o r i e n t e d v e r b a l and n o n - v e r b a l i n t e r a c t i o n . Group f o u r ( p l a c e b o - t y p e ) members m a i n t a i n e d j o u r n a l r e c o r d i n g s o f c r i t i c a l i n c i d e n t s i n t h e i r l i v e s as n u r s i n g s t u d e n t s and* l i k e group f i v e ( c o n t r o l ) * r e c e i v e d no human r e l a t i o n s t r a i n i n g . 31 Anxiety l e v e l was measured by the Manifest Anxiety Scale* S t a t e - T r a i t Anxiety Inventory* and A f f e c t A d j e c t i v e Check L i s t - G . I n v e n t o r i e s were administered pre- and post-treatment and a f t e r a one month p o s t - t e s t i n t e r v a l . F i n d i n g s on a l l a n x i e t y i n v e n t o r i e s " i n d i c a t e d a decrease i n mean scores f o r a l l groups across time" (p. 305). I n v e s t i g a t o r s f e l t the instruments "measured r e l a t i v e l y s t a b l e i n d i v i d u a l d i f f e r e n c e s i n anxiety l e v e l rather than the e f f e c t s of environmentally i n f l u e n c e d a n x i e t y " (p. 305). Data i m p l i e d t h a t "the s i g n i f i c a n t decrease i n measured a n x i e t y r e f l e c t e d a change over time f o r a l l groups rather than a change r e s u l t i n g from a p a r t i c u l a r type of human r e l a t i o n s treatment" (p. 305). Absence of treatment e f f e c t was f e l t to be "a n a t u r a l consequence of greater f a m i l i a r i t y w i t h the p r o f e s s i o n a l demands of nursing and w i t h the h o s p i t a l as a c l i n i c a l l a b o r a t o r y " (p. 305). Forsythe and Layton (1985) completed a c o r r e l a t i o n a l study which examined anxiety i n nursing students and teacher empathy. They s t u d i e d 130 nursing students from two p r i v a t e schools i n t h e i r f i n a l two years of nursing education. Students rated both the empathy of t h e i r c l i n i c a l i n s t r u c t o r s using the Empathy Construct Rating Scale and t h e i r own anxiety using the s t a t e s e c t i o n of the S t a t e - T r a i t Anxiety Inventory. R e s u l t s i n d i c a t e d a s t a t i s t i c a l l y s i g n i f i c a n t (p<.01) negative c o r r e l a t i o n (r = -.42) between student a n x i e t y and i n s t r u c t o r empathy. 32 E v i d e n c e s u g g e s t s t h a t f a c i l i t a t i v e t e a c h e r b e h a v i o r i s r e l a t e d p o s i t i v e l y t o d e s i r a b l e c h a n g e s i n s t u d e n t s * a nd l i m i t e d e v i d e n c e s u g g e s t s n u r s i n g s t u d e n t a n x i e t y i s r e l a t e d t o s e l e c t e d f a c i l i t a t i v e c o n d i t i o n s d e m o n s t r a t e d by f a c u l t y . A t h o r o u g h r e v i e w o f l i t e r a t u r e f a i l s t o r e v e a l * h o w e v e r * a n y r e s e a r c h t h a t d i r e c t l y r e l a t e s t h e p e r c e i v e d i n t e r p e r s o n a l r e l a t i o n s h i p b e t w e e n s t u d e n t a nd t e a c h e r t o s t u d e n t a n x i e t y l e v e l s . I n summary* r e s e a r c h c o n s i s t e n t l y i d e n t i f i e s e x p e r i e n c e i n t h e c l i n i c a l s e t t i n g a s a m a j o r s o u r c e o f a n x i e t y f o r n u r s i n g s t u d e n t s . W i t h i n t h i s s e t t i n g * t h e i n t e r p e r s o n a l r e l a t i o n s h i p w i t h t h e c l i n i c a l i n s t r u c t o r h a s b e e n d e s c r i b e d a s a s p e c i f i c s o u r c e o f a n x i e t y f o r t h e s t u d e n t . G r o u p m e t h o d s d e s i g n e d t o a s s i s t n u r s i n g s t u d e n t s i n d e a l i n g w i t h a n x i e t y h a v e b e e n s t u d i e d w i t h i n c o n s i s t e n t r e s u l t s . F i n a l l y * a l i m i t e d number o f s t u d i e s i n d i c a t e t h a t t e a c h e r f a c i l i t a t i v e b e h a v i o r i s p o s i t i v e l y c o r r e l a t e d w i t h p o s i t i v e c h a n g e i n s t u d e n t b e h a v i o r s a nd n e g a t i v e l y c o r r e l a t e d w i t h n u r s i n g s t u d e n t a n x i e t y . T h i s s t u d y a t t e m p t s t o f i l l a r e s e a r c h v o i d b y a t t e m p t i n g t o r e l a t e t h e s t u d e n t ' s p e r c e p t i o n o f t h e s t u d e n t - i n s t r u c t o r i n t e r p e r s o n a l r e l a t i o n s h i p t o s t u d e n t a n x i e t y l e v e l s . I t i s h y p o t h e s i z e d t h a t s t u d e n t n u r s e s who r e c e i v e a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n w i l l r a t e t h e i r r e l a t i o n s h i p w i t h t h e i n s t r u c t o r h i g h e r t h a n s t u d e n t n u r s e s r e c e i v i n g a p l a c e b o i n t e r v e n t i o n a n d t h a t s t u d e n t n u r s e s 33 who r e c e i v e a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n w i l l h a v e l e s s s t a t e a n x i e t y t h a n s t u d e n t n u r s e s r e c e i v i n g p l a c e b o i n t e r v e n t i o n . The i n t e r v e n t i o n p l a n n e d was d e s i g n e d t o h a v e t h e i n s t r u c t o r d e m o n s t r a t e t h e f a c i l i t a t i v e c o n d i t i o n s o f empathy* c o n g r u e n c e * and p o s i t i v e r e g a r d and was t o be i m p l e m e n t e d w i t h i n a g r o u p s e t t i n g . 34 CHAPTER THREE Methodology Research Design An experimental pre-test/ post-test group design was used to tes t the three study hypotheses. A convenience sample of f i r s t year nursing students was randomly assigned to ten groups. Of the ten groups/ f i v e constituted the control group and f i v e constituted the experimental group. Control of variables. Each of f i v e instructors had assigned to her two groups of students; one group formed the control group and the second the experimental group. Having one instructor work with both a control and an experimental group decreased the chance of inherent i n d i v i d u a l instructor c h a r a c t e r i s t i c s influencing study r e s u l t s . In order to prevent study contamination instructors worked with control groups f i r s t . Having the treatment intervention implemented following the placebo intervention prevented a carry-over e f f e c t which could have occurred i f the sequence of the intervention was randomized. Instructors working with control groups Week 2 would have been sensitized by the treatment carried out the previous week resulting i n decreased study v a l i d i t y . Prior to working with the experimental group the same f i v e p a r t i c i p a t i n g instructors were introduced to the 35 t r e a t m e n t i n t e r v e n t i o n p a c k a g e ( s e e A p p e n d i x D ) . I n a n a t t e m p t t o e n s u r e c o n s i s t e n c y o f i m p l e m e n t a t i o n among i n s t r u c t o r s t h e i n v e s t i g a t o r p r e s e n t e d t h e i n t e r v e n t i o n p a c k a g e t o a l l i n s t r u c t o r s i n p e r s o n . W r i t t e n i n s t r u c t i o n s f o r e a c h o f t h e a c t i v i t i e s p l a n n e d was a l s o p r o v i d e d . B a s e l i n e d a t a and p o s t p l a c e b o o r p o s t i n t e r v e n t i o n d a t a w e r e c o l l e c t e d b y t h e i n v e s t i g a t o r f r o m c o n t r o l a n d e x p e r i m e n t a l s u b j e c t s ( s e e T a b l e s 1 and 2). D a t a f r o m c o n t r o l s u b j e c t s w e r e c o l l e c t e d p r i o r t o i n s t r u c t o r i n v o l v e m e n t w i t h t h e t r e a t m e n t g r o u p . A t t e m p t s w e r e made t o c o n t r o l v a r i a b l e s w h i c h w o u l d i n f l u e n c e s t r e s s r a t i n g s b y s t u d y p a r t i c i p a n t s . The c l i n i c a l s e t t i n g s f o r t h e s t u d y w e r e f o u r a c u t e s u r g i c a l w a r d s and one a c u t e m e d i c a l - s u r g i c a l w a r d . B e c a u s e b o t h c o n t r o l a n d e x p e r i m e n t a l g r o u p s w e r e a s s i g n e d t o t h e same f i v e a r e a s * v a r i a t i o n i n c l i n i c a l s e t t i n g a n d a c u i t y o f c l i e n t s was m i n i m i z e d . V a r i a t i o n i n c l i e n t c o m p l e x i t y was p a r t l y c o n t r o l l e d by t h e n a r r o w d e f i n i t i o n o f t y p e s o f c l i e n t s w h i c h f i r s t l e v e l s t u d e n t s a r e a l l o w e d t o c a r e f o r . The s t u d e n t s b e g i n c l i n i c a l e x p e r i e n c e d u r i n g t h e s i x t h week o f t h e n u r s i n g p r o g r a m . S t u d e n t s b e g i n r o t a t i o n s d u r i n g w h i c h t h e y a r e i n t h e c l i n i c a l s e t t i n g f i v e h o u r s t h r e e c o n s e c u t i v e m o r n i n g s on a l t e r n a t e w e e k s . B e c a u s e o f t h e a l t e r n a t e week r o t a t i o n * s u b j e c t s i n t h e c o n t r o l a n d e x p e r i m e n t a l g r o u p s h a d p a r t i c i p a t e d i n t h e same number o f c l i n i c a l h o u r s p r i o r t o t h e s t u d y . Members o f b o t h t h e 36 T a b l e 1 P l a n f o r C o n t r o l G r o u p : I m p l e m e n t e d by e a c h o f 5 i n s t r u c t o r s Week 1 Monday T u e s d a y Wednesday T h u r s d a y A c t i v i t y 3 0 - m i n u t e p o s t - c o n f e r e n c e e a c h o f t h r e e d a y s i m p l e m e n t e d by i n s t r u c t o r u s i n g c o n v e n t i o n a l a g e n d a o f d i s c u s s i o n r e l a t e d t o s t u d e n t c o n c e r n s a n d c l i e n t c a r e . D a t a C o l l e c t i o n B a s e l i n e d a t a c o l l e c t i o n f r o m s u b j e c t s i n c o n t r o l g r o u p w h i c h i n c l u d e s c o m p l e t i o n o f (1) S t a t e / T r a i t A n x i e t y Q u e s t i o n n a i r e . P a t a C o l l e c t i o n D a t a c o l l e c t i o n f r o m s u b j e c t s i n c o n t r o l g r o u p w h i c h i n c l u d e s c o m p l e t i o n o f (1) S t a t e A n x i e t y Q u e s t i o n n a i r e / (2) I n s t r u c t o r -R e l a t i o n s h i p Q u e s t i o n n a i r e / (3) S t r e s s f u l E v e n t Q u e s t i o n n a i r e / a n d (4) D e m o g r a p h i c D a t a Q u e s t i o n n a i r e . 37 Table 2 Plan f o r Experimental Group: Implemented by each of 5 i n s t r u c t o r s Week 2 Monday Tuesday Wednesday Thursday / A c t i v i t y 30-minute post-conference each of three days i n c o r p o r a t i n g s t r u c t u r e d r e l a t i o n s h i p -b u i l d i n g a c t i v i t y provided by i n v e s t i g a t o r . P a t e c o l l e c t i o n B a s e l i n e data c o l l e c t i o n from subjects i n experimental group which in c l u d e s completion of (1) S t a t e / T r a i t Anxiety Questionnaire. Data C o l l e c t i o n Data c o l l e c t i o n from subjects i n experimental group which i n c l u d e s completion of (1) State Anxiety Questionnaire* (2) I n s t r u c t o r -R e l a t i o n s h i p Questionnaire* (3) S t r e s s f u l Event Questionnaire* and (4) Demographic Data Questionnaire. 38 c o n t r o l a n d e x p e r i m e n t a l g r o u p s h ad b e e n i n t h e s e l e c t e d c l i n i c a l a r e a one week b e f o r e t h e s t u d y t o o k p l a c e a n d t h e r e f o r e b o t h g r o u p s o f s u b j e c t s h a d c o n t a c t w i t h t h e p a r t i c i p a t i n g i n s t r u c t o r p r i o r t o commencement o f t h e s t u d y . S e t t i n g a n d S a m p l e The s t u d y t o o k p l a c e i n a t h r e e - y e a r d i p l o m a S c h o o l o f N u r s i n g i n a l a r g e m e t r o p o l i t a n a r e a i n B r i t i s h C o l u m b i a . The S c h o o l o f N u r s i n g was a s s o c i a t e d w i t h a l a r g e / a c u t e c a r e h o s p i t a l . The c l i n i c a l s e t t i n g s f o r t h e s t u d y w e r e f o u r a c u t e c a r e s u r g i c a l w a r d s and one a c u t e m e d i c a l - s u r g i c a l w a r d . The p l a c e b o a n d i n t e r v e n t i o n t r e a t m e n t s t o o k p l a c e i n c o n f e r e n c e rooms on e a c h o f t h e f i v e w a r d s i n t h e c l i n i c a l s e t t i n g . P a r t i c i p a n t s w e r e v o l u n t e e r s f r o m t h e f i r s t y e a r c l a s s o f n u r s i n g s t u d e n t s . The f i r s t y e a r o f t h e n u r s i n g p r o g r a m p r o v i d e s c o n c u r r e n t c l a s s r o o m i n s t r u c t i o n a n d c l i n i c a l e x p e r i e n c e . I n s t r u c t o r s p a r t i c i p a t i n g i n t h e s t u d y w e r e f i r s t y e a r n u r s i n g i n s t r u c t o r s i n t h e t h r e e - y e a r d i p l o m a p r o g r a m . I n s t r u c t o r s w e r e r e s p o n s i b l e f o r t e a c h i n g i n s p e c i f i c c l i n i c a l a r e a s and f o r c o n d u c t i n g p o s t c o n f e r e n c e s a s p a r t o f p l a n n e d l e a r n i n g e x p e r i e n c e s . Instruments Four q u e s t i o n n a i r e s were used i n the study. Two instruments were used to measure the e f f e c t of the r e l a t i o n s h i p - b u i l d i n g a c t i v i t i e s . The f i r s t was the S t a t e - T r a i t Anxiety Inventory ( S p i e l b e r g e r et a l . 1970) (see Appendices A and B) which was used t o measure student a n x i e t y . The second was an adapted v e r s i o n of the Truax and Carkhuff R e l a t i o n s h i p Q u e s t i o n n a i r e (Truax & Carkhuff* 1967) (see Appendix C) which measured the p e r c e i v e d s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p . A t h i r d and f o u r t h q u e s t i o n n a i r e were de v i s e d by the i n v e s t i g a t o r . The S t r e s s f u l Event Q u e s t i o n n a i r e (see Appendix I) was used t o determine whether or not s u b j e c t s p e r c e i v e d they had experienced a recent s t r e s s f u l event and i f so t o determine the nature of t h a t event. The f o u r t h q u e s t i o n n a i r e was used t o c o l l e c t data on s u b j e c t demographic c h a r a c t e r i s t i c s (see Appendix J ) . S t a t e - T r a i t A n x i e t y Inventory fSTAII ( S p i e l b e r g e r e t a l . * 1970). T h i s i n v e n t o r y c o n s i s t s of two s e l f - r e p o r t s c a l e s designed to measure two separate a n x i e t y concepts* s t a t e a n x i e t y and t r a i t a n x i e t y . The h i g h e r the a n x i e t y s c o r e the higher the l e v e l of a n x i e t y . The maximum ac h i e v a b l e score i s 80. I t i s hypothesized t h a t people e x h i b i t i n g high A - t r a i t w i l l a l s o e x h i b i t A - s t a t e e l e v a t i o n s more o f t e n than low 40 A - t r a i t i n d i v i d u a l s "because they tend to react to a wider range of s i t u a t i o n s as dangerous or t h r e a t e n i n g " (Spielberger et a l . / 1970/ p. 3 ) . S p i e l b e r g e r et a l . (1970) reported t h a t t e s t - r e t e s t c o r r e l a t i o n s of the A - t r a i t component are r e l a t i v e l y high ranging from .73 t o .86 (p. 9). Due t o the t r a n s i t o r y nature of a n x i e t y s t a t e s / the t e s t - r e t e s t c o r r e l a t i o n s of the A-state component are low/ ranging from .16 t o .54 (p. 9). Low c o r r e l a t i o n s appear v a l i d as A-state scores should r e f l e c t the i n f l u e n c e of unique s i t u a t i o n a l f a c t o r s e x i s t i n g at the time of t e s t i n g . I n t e r n a l r e l i a b i l i t y using Cronbach Alpha c o e f f i c i e n t s i s high/ however/ ranging from .83 to .92 (p. 9). In a d d i t i o n / c o n s t r u c t v a l i d i t y and concurrent v a l i d i t y have been e s t a b l i s h e d by t e s t developers (p. 10). R e l a t i o n s h i p Questionnaire (adapted from Truax & Carkhuff/ 1967). The R e l a t i o n s h i p Questionnaire was adapted by the i n v e s t i g a t o r . T h i r t y items measuring the c o n s t r u c t s empathy/ congruence/ and p o s i t i v e regard were s e l e c t e d from the o r i g i n a l q u e s t i o n n a i r e of 141 items. Ten items f o r each c o n s t r u c t were chosen. A L i k e r t 4-point r a t i n g s c a l e was used to have respondents r a t e t h e i r perceptions of the r e l a t i o n s h i p w i t h t h e i r i n s t r u c t o r . Subjects rated d e s c r i p t i v e statements from "very much so" to "not at a l l " . To help break response p a t t e r n b i a s / a 41 phenomenon o f t e n a s s o c i a t e d w i t h q u e s t i o n n a i r e s i n the a f f e c t i v e area* items were worded so t h a t h a l f were p o s i t i v e l y worded and h a l f were n e g a t i v e l y worded. P o s i t i v e l y worded items were given a value of 4 f o r a response of "very much so" through one f o r a response of "not at a l l " . The n e g a t i v e l y worded items were r e v e r s e l y scored w i t h a value of one f o r the response "very much so" through 4 f o r "not at a l l " . The highest score a t t a i n a b l e on the q u e s t i o n n a i r e was 120 and r e f l e c t e d a more s a t i s f y i n g i n t e r p e r s o n a l r e l a t i o n s h i p w i t h the i n s t r u c t o r . Because the R e l a t i o n s h i p Questionnaire used t o measure s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p was adapted by the i n v e s t i g a t o r / the q u e s t i o n n a i r e was p i l o t t e s t e d f o r t e s t -r e t e s t r e l i a b i l i t y and i n t e r n a l consistency. The qu e s t i o n n a i r e was t e s t e d on an a l t e r n a t e c l a s s of f i r s t year students who were i n t h e i r f i n a l month of the f i r s t year course. The a l t e r n a t e c l a s s was the r e s p o n s i b i l i t y of a separate group of i n s t r u c t o r s . Volunteers from the c l a s s were asked t o complete the qu e s t i o n n a i r e on two separate occasions one week apart. The i n v e s t i g a t o r asked volunteers to t h i n k of a teacher they had known and complete the qu e s t i o n n a i r e r a t i n g that s p e c i f i c i n d i v i d u a l . The q u e s t i o n n a i r e was completed the f i r s t time f o l l o w i n g a classroom s e s s i o n . Twenty-three volu n t e e r s submitted q u e s t i o n n a i r e s . The i n v e s t i g a t o r v i s i t e d the c l i n i c a l areas one week l a t e r and requested the 42 same 23 volu n t e e r s t o again complete the qu e s t i o n n a i r e t h i n k i n g of the same teacher. Because the students i n the a l t e r n a t e c l a s s of f i r s t year students were subjects f o r the p i l o t study* the i n v e s t i g a t o r v e r b a l l y requested the volun t e e r s completing the qu e s t i o n n a i r e to r e f r a i n from sharing i n f o r m a t i o n on the qu e s t i o n n a i r e s w i t h f e l l o w students. A s c a t t e r p l o t was constructed using the 23 p a i r e d data and showed evidence of a strong p o s i t i v e r e l a t i o n s h i p between scores on the qu e s t i o n n a i r e administered on the two occasions. Pearson's sample c o r r e l a t i o n c o e f f i c i e n t was c a l c u l a t e d t o be r = .87. According to Devore and Peck (1986)/ the r e l a t i o n s h i p i s c l a s s i f i e d as strong i f greater than .8 (p. 116). Cronbach's alpha was used to o b t a i n r e l i a b i l i t y c o e f f i c i e n t s f o r each of the three subscales. R e s u l t s of a n a l y s i s i n d i c a t e d r = .45 f o r empathy/ r = .71 f o r congruence/ and r = .80 f o r p o s i t i v e regard. S t r e s s f u l Event Questionnaire. The i n v e s t i g a t o r recognized t h a t any anxiety-producing event t h a t occurred between the measurement of s t a t e a n x i e t y p r i o r t o placebo or treatment i n t e r v e n t i o n and the measurement of s t a t e a n x i e t y post i n t e r v e n t i o n would c o n s t i t u t e an i n t e r v e n i n g v a r i a b l e . Consequently/ subjects were asked t o s t a t e whether or not they had experienced any stress-producing 43 situation during the intervening three days. Those stating "yes" were asked to describe the event in their own words (see Appendix I). Demographic Data. Demographic data on subject ager sexr and marital status were collected. In addition/ the c l i n i c a l area to which the subject was assigned was reported. Subjects were asked to report absenteeism from the c l i n i c a l area. In the event that large numbers of students had been absent in one c l i n i c a l group during the course of the study/ data from this group would have been excluded from the study. The fact that some subjects could have considerably more experience than others in dealing with client situations/ thus perhaps precipitating less anxiety/ was also recognized. Subjects/ therefore/ were asked to record their occupation prior to commencing the nursing program (see Appendix J ) . P r o c e d u r e When subjects f i r s t entered the nursing program they were randomly assigned to one of ten c l i n i c a l groups using a table of random numbers. Of the ten groups/ five were selected by a drawing process. These five groups constituted the control group and the remaining five 44 c o n s t i t u t e d t h e e x p e r i m e n t a l g r o u p . E a c h o f f i v e i n s t r u c t o r s h a d a s s i g n e d t o h e r a c o n t r o l g r o u p a nd an e x p e r i m e n t a l g r o u p . The i n t e r v e n t i o n p l a n n e d was a r e l a t i o n s h i p - b u i l d i n g a c t i v i t y d e s i g n e d b y t h e i n v e s t i g a t o r a n d a c o n s u l t a n t . The r e l a t i o n s h i p - b u i l d i n g a c t i v i t y was d e s i g n e d t o o c c u r d u r i n g p o s t c o n f e r e n c e s on t h r e e s u c c e s s i v e c l i n i c a l d a y s w h i c h w e r e T u e s d a y / Wednesday a n d T h u r s d a y m o r n i n g s . D u r i n g Week 1/ p r i o r t o r e c e i v i n g a ny i n f o r m a t i o n on t h e t r e a t m e n t p l a n n e d / t h e i n s t r u c t o r w o r k e d w i t h t h e c o n t r o l g r o u p ( s e e T a b l e 1 ) . The p l a c e b o t r e a t m e n t f o r t h e c o n t r o l g r o u p c o n s i s t e d o f a c t i v i t i e s n o r m a l l y s c h e d u l e d f o r a t h i r t y m i n u t e p o s t c o n f e r e n c e . S t u d e n t c o n c e r n s a n d d i s c u s s i o n o f c l i e n t p r o b l e m s a r i s i n g f r o m c l i n i c a l e x p e r i e n c e was a common a g e n d a f o r t h e c o n f e r e n c e . P r i o r t o w o r k i n g w i t h t h e e x p e r i m e n t a l g r o u p i n Week 2/ t h e same f i v e p a r t i c i p a t i n g i n s t r u c t o r s w e r e i n t r o d u c e d t o t h e r e l a t i o n s h i p - b u i l d i n g a c t i v i t i e s p a c k a g e ( s e e A p p e n d i x A) w h i c h c o n s t i t u t e d t h e t r e a t m e n t i n t h e s t u d y . D u r i n g Week 2/ f o l l o w i n g i n t r o d u c t i o n t o t h e r e l a t i o n s h i p - b u i l d i n g a c t i v i t i e s p a c k a g e / t h e same f i v e i n s t r u c t o r s i m p l e m e n t e d t h e a c t i v i t i e s w i t h t h e e x p e r i m e n t a l g r o u p ( s e e T a b l e 2 ) . The a c t i v i t i e s w e r e p l a n n e d t o o c c u r d u r i n g t h e r e g u l a r l y s c h e d u l e d p o s t c o n f e r e n c e t i m e . B a s e l i n e d a t a w e r e c o l l e c t e d f r o m a l l c o n t r o l g r o u p s u b j e c t s on t h e Monday p r i o r t o p l a c e b o i n t e r v e n t i o n on 45 Tuesday* Wednesday* and Thursday (see Table 1 ) . S u b j e c t s who were t o a t t e n d c l i n i c a l experience t h a t p a r t i c u l a r week and who v o l u n t e e r e d to p a r t i c i p a t e completed the STAI q u e s t i o n n a i r e . Data were c o l l e c t e d by the i n v e s t i g a t o r i n approximately 20 minutes f o l l o w i n g a classroom l e c t u r e . On Thursday a f t e r n o o n of the same week p r i o r t o a classroom l e c t u r e * members of the c o n t r o l group were asked to complete the A - s t a t e component of the STAI q u e s t i o n n a i r e * the R e l a t i o n s h i p Q u e s t i o n n a i r e * the S t r e s s f u l Event Q u e s t i o n n a i r e * and the Demographic Data Form. The A - t r a i t was not administered a g a i n as i t was used t o measure how anxious i n d i v i d u a l s g e n e r a l l y f e e l and i s t h e r e f o r e r e l a t i v e l y s t a b l e . Scores from A - t r a i t i n v e n t o r i e s were used to determine homogeneity of c o n t r o l and experimental groups. Data c o l l e c t i o n was again completed by the i n v e s t i g a t o r and took approximately 30 minutes. S u b j e c t s comprising the c o n t r o l group were requested v e r b a l l y t o r e f r a i n from s h a r i n g i n f o r m a t i o n r e l a t e d t o the q u e s t i o n n a i r e s w i t h classmates i n the experimental group. B a s e l i n e data were c o l l e c t e d from a l l experimental group s u b j e c t s on the Monday p r i o r t o treatment i n t e r v e n t i o n on Tuesday* Wednesday* and Thursday of Week 2 (see Table 2). Again data were c o l l e c t e d by the i n v e s t i g a t o r i n the same manner as i t was c o l l e c t e d from 46 c o n t r o l group s u b j e c t s . On Thursday a f t e r n o o n of the same week members of the experimental group were asked t o complete the same q u e s t i o n n a i r e as the c o n t r o l group. Data c o l l e c t i o n was conducted i n the same manner as i t was f o r c o n t r o l s u b j e c t s . At the completion of the two weeks* a c t i v i t i e s the i n v e s t i g a t o r h e l d a h a l f hour d e b r i e f i n g s e s s i o n w i t h p a r t i c i p a t i n g i n s t r u c t o r s . Informal v e r b a l comments on t h e i r f e e l i n g s about the e f f e c t s of the study and the i n t e r v e n t i o n package were s o l i c i t e d and recorded. In a d d i t i o n * comments from s u b j e c t s who had p a r t i c i p a t e d were e l i c i t e d from the i n s t r u c t o r s . Data A n a l y s i s Parametric s t a t i s t i c a l procedures were used t o analyze data r e l a t e d t o the study hypotheses. A two-way a n a l y s i s of v a r i a n c e (ANOVA) was used t o t e s t f o r s t a t i s t i c a l d i f f e r e n c e s between means on the sc o r e s obtained from the R e l a t i o n s h i p Q u e s t i o n n a i r e . A two-way a n a l y s i s of c o v a r i a n c e (ANCOVA) was used t o t e s t f o r d i f f e r e n c e s between means obtained from s t a t e a n x i e t y s c o r e s . A s i g n i f i c a n c e l e v e l equal t o or l e s s than .05 was used. A Pearson product-moment c o e f f i c i e n t c o r r e l a t i o n was computed t o t e s t f o r r e l a t i o n s h i p s between s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p s cores and s t a t e a n x i e t y s c o r e s . 47 A t - t e s t was u s e d t o d e t e r m i n e w h e t h e r a s i g n i f i c a n t d i f f e r e n c e was p r e s e n t b e t w e e n t h e mean t r a i t a n x i e t y s c o r e s o f t h e c o n t r o l and e x p e r i m e n t a l g r o u p s . The c h i s q u a r e p r o c e d u r e was u s e d t o m e a s u r e t h e d i f f e r e n c e s b e t w e e n t h e c o n t r o l and e x p e r i m e n t a l g r o u p s w i t h r e s p e c t t o t h e number o f s t r e s s f u l e v e n t s e x p e r i e n c e d i n t h e 24 h o u r s p r i o r t o p o s t - t e s t d a t a c o l l e c t i o n . D e s c r i p t i v e s t a t i s t i c s w e r e u s e d t o a n a l y z e t h e d a t a f r o m t h e S t r e s s f u l E v e n t Q u e s t i o n n a i r e and t h e D e m o g r a p h i c D a t a Form. 48 CHAPTER FOUR R e s u l t s and D i s c u s s i o n R e s u l t s The r e s u l t s o f t h e s t u d y a r e p r e s e n t e d i n t h e f o l l o w i n g manner. D e s c r i p t i v e i n f o r m a t i o n on s u b j e c t d e m o g r a p h i c s i s r e p o r t e d f i r s t . S e c o n d l y / t h e s t a t i s t i c a l f i n d i n g s r e l a t e d t o s t u d y h y p o t h e s e s a r e d e s c r i b e d . F i n a l l y / d e s c r i p t i v e i n f o r m a t i o n f r o m t h e S t r e s s Q u e s t i o n n a i r e and f r o m t h e d e b r i e f i n g s e s s i o n w i t h i n s t r u c t o r s i s i n c l u d e d . A t t r i t i o n . D a t a o b t a i n e d f r o m t h e e x p e r i m e n t a l p r e - t e s t / p o s t - t e s t g r o u p d e s i g n s t u d y r e v e a l e d t h a t 63 (90%) o f 70 s t u d e n t s i n t h e f i r s t y e a r n u r s i n g c l a s s v o l u n t e e r e d t o p a r t i c i p a t e i n t h e s t u d y . Due t o i l l n e s s d u r i n g t h e s t u d y / 61 o f t h e 63 p a r t i c i p a n t s / o r 87% o f t h e t o t a l c l a s s c o m p l e t e d t h e s t u d y . D e m o g r a p h i c c h a r a c t e r i s t i c s o f s u b j e c t s . A c o m p a r i s o n o f t h e d e m o g r a p h i c c h a r a c t e r i s t i c s o f t h e e x p e r i m e n t a l and c o n t r o l g r o u p s by age/ s e x / m a r i t a l s t a t u s / a n d o c c u p a t i o n p r i o r t o e n r o l l m e n t i n t h e n u r s i n g p r o g r a m i n d i c a t e d t h a t t h e g r o u p s w e r e s i m i l a r . T h e s e d a t a a r e c o n t a i n e d i n T a b l e 3. A c o m p a r i s o n o f t h e number o f c l i n i c a l d a y s m i s s e d b y s u b j e c t s i n t h e e x p e r i m e n t a l a nd c o n t r o l g r o u p s i n d i c a t e d 49 t h a t the m a j o r i t y of group members were present i n each group on a l l three days when e i t h e r the placebo or treatment i n t e r v e n t i o n occurred. One subject missed one experience i n the experimental group* while one subject missed one experience and one subject missed two experiences i n the c o n t r o l group. Table 3 A Comparison of Experimental and C o n t r o l Subjects by Age/Sex* M a r i t a l Status* and Occupation P r i o r to Enrollment (N = 61) Groups Experimental C o n t r o l n = 31 n = 30 Age (years) 17-20 23 (74) 21 (70) 21-25 8 (26) 7 (23) 26-29 - 1 (3) 30-35 — 1 (3) Sex Female 30 (97) 30 (100) Male 1 (3) -M a r i t a l Status S i n g l e 30 (97) 30 (100) Married 1 (3) — Occupation P r i o r to Enrollment Student 15 (48) 14 (47) Nurse Aide 4 (13) 2 (7) Other 12 (39) 14 (47) Note. Numbers i n brackets are percent. Hypothesis one; E f f e c t of i n t e r v e n t i o n on student-i n s t r u c t o r r e l a t i o n s h i p . The i n v e s t i g a t o r hypothesized t h a t 50 student nurses who received a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n would rate t h e i r r e l a t i o n s h i p w i t h the i n s t r u c t o r higher than student nurses who received a placebo i n t e r v e n t i o n . T h i r t y respondents i n the c o n t r o l group and 31 respondents i n the experimental group completed the R e l a t i o n s h i p Questionnaire (see Appendix C). The response r a t e and the mean score f o r each s t u d e n t - i n s t r u c t o r combination i s shown i n Table 4. Table 4 Response Rates and Mean Stu d e n t - I n s t r u c t o r R e l a t i o n s h i p Scores of C o n t r o l and Experimental Groups Group I n s t r u c t o r No. Response Rate Mean Score C o n t r o l 5 3/7 110.00 Co n t r o l 6 7/7 102.86 Co n t r o l 7 6/7 85.83 Co n t r o l 8 7/7 95.86 Co n t r o l 9 7/7 103.57 Experimental 5 7/7 106.57 Experimental 6 6/7 107.00 Experimental 7 7/7 93.71 Experimental 8 7/7 106.86 Experimental 9 4/7 108.25 51 A two-way a n a l y s i s of v a r i a n c e (ANOVA) procedure was used t o analyze the data; the f i r s t f a c t o r i s the i n t e r v e n t i o n e f f e c t (two l e v e l s : treatment and placeb o ) / and the second f a c t o r i s the i n s t r u c t o r e f f e c t ( f i v e l e v e l s ) . S ince t h e r e were unequal numbers of respondents i n each s t u d e n t - i n s t r u c t o r combination group* an ANOVA procedure f o r unbalanced d e s i g n was used. D i a g n o s t i c checking of the ANOVA model was based on r e s i d u a l a n a l y s i s . I t was concluded t h a t the two-way ANOVA model was a p p r o p r i a t e f o r the s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p d a t a . The r e s u l t s of the ANOVA (Table 5) showed t h a t there was a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the experimental and c o n t r o l group f o r the i n t e r v e n t i o n main e f f e c t . The experimental group r a t e d the s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p h i g h e r than the c o n t r o l group. That i s / the experimental group appeared t o have a b e t t e r student-i n s t r u c t o r r e l a t i o n s h i p than the c o n t r o l group. Data a n a l y s i s a l s o r e v e a l e d a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the two groups f o r the i n s t r u c t o r main e f f e c t . The d i f f e r e n c e between the c o n t r o l and experimental groups seemed t o be the same f o r a l l f i v e i n s t r u c t o r s / however. S i n c e the i n t e r a c t i o n e f f e c t was not s t a t i s t i c a l l y s i g n i f i c a n t / the d i f f e r e n c e between the two groups can be c o n s i d e r e d t o be due to the planned 52 i n t e r v e n t i o n . Hypothesis number one i s t h e r e f o r e supported. Table 5 Summary of A n a l y s i s of Variance f o r I n t e r v e n t i o n and I n s t r u c t o r E f f e c t on Stu d e n t - I n s t r u c t o r R e l a t i o n s h i p Source Degrees of Freedom Sum of Squares Mean Square F-s t a t i s t i c P-value I n t e r v e n t i o n 1 332.18 332.18 6.07 0.02 I n s t r u c t o r 4 2513.12 628.28 11.49 0.00 I n t e r a c t i o n 4 299.07 74.77 1.37 0.26 Err o r 51 2789.01 54.69 T o t a l 60 5912.75 Hypothesis two: E f f e c t of i n t e r v e n t i o n on s t a t e a n x i e t y . The i n v e s t i g a t o r hypothesized t h a t student nurses who received a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n would have l e s s s t a t e a n x i e t y than student nurses who received a placebo i n t e r v e n t i o n . For each subject who responded* a p r e - t e s t and a p o s t - t e s t s t a t e a n x i e t y score was derived from the STAI Form X - l qu e s t i o n n a i r e (see Appendix A). The response ra t e and the mean scores of the two t e s t s f o r each s t u d e n t - i n s t r u c t o r combination group i s shown i n Table 6. 53 Table 6 Response Rates and Mean State Anxiety Scores of C o n t r o l and Experimental Groups Group I n s t r u c t o r Number Response Rate Mean Pre-Test Score Mean Post-Test Score C o n t r o l 5 3/7 37.37 38.33 Co n t r o l 6 7/7 38.14 47.14 Cont r o l 7 6/7 42.67 48.67 Cont r o l 8 7/7 40.14 45.57 Con t r o l 9 6/7 40.50 42.00 Experimental 5 6/7 41.67 39.00 Experimental 6 6/7 41.83 41.50 Experimental 7 6/7 41.50 42.50 Experimental 8 7/7 43.86 38.29 Experimental 9 4/7 39.50 42.00 A two-way a n a l y s i s of covariance (ANCOVA) procedure was used f o r the a n a l y s i s of the data. The dependent v a r i a b l e was the p o s t - t e s t s t a t e a n x i e t y score* the f i r s t f a c t o r was the i n t e r v e n t i o n e f f e c t (two l e v e l s : treatment and placebo)t the second f a c t o r was the i n s t r u c t o r e f f e c t ( f i v e l e v e l s ) / and the c o v a r i a t e was the p r e - t e s t s t a t e - a n x i e t y score. Since there were unequal numbers of respondents i n each s t u d e n t - i n s t r u c t o r combination group* an a n a l y s i s of covariance procedure f o r unbalanced design was used. 54 D i a g n o s t i c checking of the covariance model was based on r e s i d u a l a n a l y s i s . I t was concluded t h a t the covariance model was appropriate f o r the p o s t - t e s t s t a t e a n x i e t y data. Re s u l t s of the two-way a n a l y s i s of covariance are shown i n Table 7. Table 7 Summary of A n a l y s i s of Covariance f o r I n t e r v e n t i o n and I n s t r u c t o r E f f e c t on State Anxiety Source Degrees of Freedom Sum of Squares Mean Square F-s t a t i s t i c P-value P r e - t e s t 1 2268.04 2268.04 18.76 0.00 I n t e r v e n t i o n 1 312.75 312.75 2.59 0.11 I n s t r u c t o r 4 231.91 57.98 0.48 0.75 I n t e r a c t i o n 4 193.34 48.34 0.40 0.81 E r r o r 47 5680.96 120.87 T o t a l 60 8647.52 Findings from the F - t e s t i n d i c a t e d that adjustment provided by the i n c l u s i o n of the c o v a r i a t e (the p r e - t e s t s t a t e a n x i e t y score) was necessary (p<0.00). There was no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the experimental and c o n t r o l groups i n t h e i r post-t e s t s t a t e a n x i e t y r a t i n g s . There was no s i g n i f i c a n t i n s t r u c t o r main e f f e c t * i n t e r v e n t i o n main e f f e c t * nor 55 s i g n i f i c a n t i n s t r u c t o r - i n t e r v e n t i o n i n t e r a c t i o n e f f e c t . Hypothesis number two i s t h e r e f o r e unsupported. A n a l y s i s of a s c a t t e r p l o t of post s t a t e a n x i e t y scores by treatment group shown i n F i g u r e 1 (see Appendix K) i n d i c a t e d t h a t post i n t e r v e n t i o n s t a t e a n x i e t y l e v e l s tended to be lower f o r s u b j e c t s i n the experimental group than i n the c o n t r o l group. Although d i f f e r e n c e s between groups d i d not achieve s t a t i s t i c a l s i g n i f i c a n c e / p< 0 . 1 1 / the t r e n d was i n the r i g h t d i r e c t i o n . T h i s suggests t h a t the i n t e r v e n t i o n treatment may have helped i n l o w e r i n g s t a t e a n x i e t y i n some of the s u b j e c t s / but not enough to e s t a b l i s h s t a t i s t i c a l s i g n i f i c a n c e . A n a l y s i s of a s c a t t e r p l o t of s t a t e a n x i e t y v e r s u s i n s t r u c t o r s shown i n F i g u r e 2 (see Appendix L) r e v e a l e d no obvious p a t t e r n . T h i s suggested t h a t the i n s t r u c t o r was not a major f a c t o r i n l owering s t a t e a n x i e t y l e v e l s and t h e r e f o r e the i n t e r v e n t i o n was the most s i g n i f i c a n t f a c t o r . H y p o t h e s i s t h r e e : R e l a t i o n s h i p between student- i n s t r u c t o r r e l a t i o n s h i p score and s t a t e a n x i e t y s c o r e . Pearson's product-moment c o r r e l a t i o n c o e f f i c i e n t between s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p scores and p o s t - t e s t s t a t e a n x i e t y s c o r e s was c a l c u l a t e d to be - 0 . 3 6 and - 0 . 5 0 / f o r the c o n t r o l and experimental groups r e s p e c t i v e l y . Although the t r e n d was not strong/ the r e s u l t suggests t h a t the s t r o n g e r the r e l a t i o n s h i p between the i n s t r u c t o r and the student/ the lower the s t a t e a n x i e t y f o r the student. 56 A comparison of t r a i t a nxiety scores of c o n t r o l and experimental groups. To determine i f d i f f e r e n c e s i n t r a i t a n x i e t y e x i s t e d between the c o n t r o l and experimental groups a t - t e s t was completed on t r a i t a nxiety scores. R e s u l t s revealed no s i g n i f i c a n t d i f f e r e n c e between the mean scores f o r the two groups. Data from S t r e s s Questionnaire. The e f f e c t of a perceived s t r e s s f u l event i n the 24-hour period p r i o r to data c o l l e c t i o n on post i n t e r v e n t i o n s t a t e a n x i e t y was a p o s s i b l e i n t e r v e n i n g v a r i a b l e . Therefore subjects were requested to provide data on such occurrences. Table 8 presents t h i s i n f o r m a t i o n . Using the Chi Square procedure a s t a t i s t i c a l d i f f e r e n c e was not found between the c o n t r o l and experimental groups i n r e l a t i o n s h i p to the number of s t r e s s f u l events perceived. Table 8 A Comparison of Experimental and Con t r o l Subjects Experience of S t r e s s f u l Events i n 24 Hours P r i o r to P o s t - t e s t Data C o l l e c t i o n (N = 61) Groups Experimental C o n t r o l n = 30 Experience n = 31 Yes 13 (42) 9 (30) No 18 (58) 21 (70) Note. Numbers i n brackets are percent. 57 S u b j e c t s who r e s p o n d e d p o s i t i v e l y t o h a v i n g e x p e r i e n c e d a s t r e s s f u l e v e n t w e r e a s k e d t o d e s c r i b e t h e e v e n t i n t h e i r own w o r d s . S u b j e c t s i n b o t h t h e e x p e r i m e n t a l and c o n t r o l g r o u p s d e s c r i b e d s i m i l a r t y p e s o f e v e n t s . A l t h o u g h t h e i n v e s t i g a t o r had g i v e n a c a r a c c i d e n t o r t h e d e a t h o f a f r i e n d o r f a m i l y member a s e x a m p l e s o f s t r e s s f u l e v e n t s * s u b j e c t s p e r c e i v e d and r e p o r t e d v e r y d i f f e r e n t t y p e s o f e v e n t s . Upon a n a l y s i s o f t h e d e s c r i p t i o n s t h e i n v e s t i g a t o r n o t e d t h a t a l l t h e comments c o u l d be r e a d i l y c l a s s i f i e d i n t o t h e c a t e g o r i e s o f s t r e s s f u l e v e n t s - P e r s o n a l * S o c i a l * A c a d e m i c * and C l i n i c a l - d e v e l o p e d by F o x e t a l . ( 1 9 6 5 ) . T h e s e c a t e g o r i e s w e r e u s e d * t h e r e f o r e * i n d e s c r i b i n g t h e e v e n t s . S e v e r a l s u b j e c t s d e s c r i b e d more t h a n one t y p e o f e v e n t . The f r e q u e n c y and c l a s s i f i c a t i o n o f r e s p o n s e s i s d i s p l a y e d i n T a b l e 9. Members o f b o t h t h e c o n t r o l and e x p e r i m e n t a l g r o u p s d e s c r i b e d s i m i l a r s i t u a t i o n s . S e v e r a l comments r e l a t e d t o t h e f a c t t h a t t h e f i r s t i n t r a m u s c u l a r i n j e c t i o n was g i v e n . O t h e r comments r e l a t e d t o c a r i n g f o r n a u s e a t e d c l i e n t s o r c l i e n t s w i t h a p o o r p r o g n o s i s . A c a d e m i c c o n c e r n s r e l a t e d t o i m p e n d i n g e x a m i n a t i o n s and c o m p l e t i o n o f n u r s i n g c a r e p l a n s w i t h a s s o c i a t e d t i m e r e s t r a i n t s . P e r s o n a l s t r e s s e s w e r e p r e d o m i n a n t l y r e s u l t s o f i n d i v i d u a l h e a l t h p r o b l e m s . 58 Table 9 C l a s s i f i c a t i o n of S t r e s s f u l Events Perceived by Co n t r o l and Experimental Subjects (N = 61) Groups Experimental C o n t r o l n = 31 n = 30 Stress Reported 13 (42) 9 (30) (number of subjects) T o t a l number of comments 17 12 C l a s s i f i c a t i o n of S t r e s s f u l Events Personal 2 (12) 4 (33) S o c i a l - -Academic 9 (53) 2 (17) C l i n i c a l 5 (29) 6 (50) U n c l a s s i f i e d 1 (6) — No Str e s s Reported 18 (58) 21 (70) (number of subjects) Note. Numbers i n brackets are percent. D e s c r i p t i v e i n f o r m a t i o n from a d e b r i e f i n g s e s s i o n w i t h i n s t r u c t o r s . I n s t r u c t o r s were asked to comment on t h e i r experience during an informal half-hour meeting. Comments from student subjects reported by i n s t r u c t o r s are reported f i r s t ; comments by i n s t r u c t o r s are reported l a s t . Students r e c e i v i n g the i n t e r v e n t i o n treatment s t a t e d they d i d not mind having t h e i r post-conference time f i l l e d w i t h communication e x e r c i s e s f o r one week but they would 59 not l i k e i t c o n t i n u o u s l y . Others f e l t i t would be a b e n e f i c i a l e x e r c i s e to have i n i t i a l l y i n each r o t a t i o n . Some s u b j e c t s expressed concern t h a t t h e i r answers were being taped and one student confessed she found the conferences more s t r e s s f u l than u s u a l . F i n a l l y / students e s p e c i a l l y l i k e d the f a c t t h a t i n s t r u c t o r s had to a c t i v e l y p a r t i c i p a t e i n the experience. I n i t i a l l y / i n s t r u c t o r s were questioned about t h e i r a b i l i t y t o implement the i n t e r v e n t i o n package. Only one i n s t r u c t o r s t a t e d she had been unable t o c a r r y out the e x e r c i s e s designed f o r use w i t h the experimental group on day t h r e e as students were l a t e l e a v i n g the ward. A l l other i n s t r u c t o r s s t a t e d they had c a r r i e d out the i n s t r u c t i o n s p r o v i d e d with the package and the e x e r c i s e s took from 20 to 30 minutes each day. One i n s t r u c t o r stayed l a t e one day t o ensure the e x e r c i s e s were completed. G e n e r a l l y comments from i n s t r u c t o r s were f a v o r a b l e . They found the p o s t conference more r e l a x i n g than normal as t h e r e was a pre-arranged format which d i d not a l l o w any time t o p r o v i d e negative feedback to l e a r n e r s . I n s t r u c t o r s found the e x e r c i s e s p a r t i c u l a r l y u s e f u l as i t f o r c e d a l l students to p a r t i c i p a t e and to p r o v i d e more i n f o r m a t i o n than "yes" or "no". Because of the nature of the i n f o r m a t i o n shared/ i n s t r u c t o r s f e l t they l e a r n e d more about students and o f t e n t h e i r f i r s t p e r c e p t i o n s of the l e a r n e r were not confirmed. They a l l f e l t they gained i n s i g h t i n t o the i n d i v i d u a l nature of t h e i r s t u d e n t s . 60 I n t e r e s t i n g l y / one new i n s t r u c t o r w i t h l i m i t e d t e a c h i n g e x p e r i e n c e s t a t e d t h a t s h e f e l t much more a t e a s e w i t h h e r s t u d e n t g r o u p on t h e s e c o n d d a y . She a t t r i b u t e d t h e s e f e e l i n g s t o u s e o f t h e i n t e r v e n t i o n on d a y o n e . D i s c u s s i o n I n t e r v e n t i o n e f f e c t on s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p . The f a c t t h a t t h e e x p e r i m e n t a l g r o u p r a t e d t h e i r r e l a t i o n s h i p w i t h t h e i n s t r u c t o r s i g n i f i c a n t l y h i g h e r t h a n t h e c o n t r o l g r o u p i s i m p o r t a n t . S c h w e e r and G e b b i e (1976) s u g g e s t t h a t t h e e f f e c t i v e n e s s o f t h e t o t a l c l i n i c a l n u r s i n g p r o g r a m i s d i r e c t l y p r o p o r t i o n a l t o t h e k i n d o f r e l a t i o n s h i p t h e i n s t r u c t o r e s t a b l i s h e s w i t h s t u d e n t s . A u t h o r s h a v e c o n s i s t e n t l y i d e n t i f i e d t h e a b i l i t y t o e s t a b l i s h e f f e c t i v e i n t e r p e r s o n a l r e l a t i o n s h i p s a s an i n t e g r a l b e h a v i o r a l c omponent o f e f f e c t i v e c l i n i c a l i n s t r u c t o r s (Barham* 1 9 6 5 ; Brown* 1 9 8 1 ; K a r n s & Schwab* 19 8 2 ; K i k e r * 1 9 7 3 ) . S i n c e a l a r g e p a r t o f n u r s i n g s k i l l a n d b e h a v i o r l e a r n e d by n u r s i n g s t u d e n t s i s d i r e c t l y r e l a t e d t o t h e b e h a v i o r t h e y o b s e r v e i n t h e i r n u r s i n g i n s t r u c t o r ( K i k e r * 1 9 7 3 ; Rauen* 1974 ; S t u e b b e * 1 9 8 1 ) * an i n s t r u c t o r who d e m o n s t r a t e s t h e a b i l i t y t o r e l a t e w e l l t o s t u d e n t s p r o v i d e s a p a t t e r n and s e r v e s a s a r o l e m o d e l i n t h e a r e a o f i n t e r p e r s o n a l r e l a t i o n s h i p s . S e v e r a l a u t h o r s h a v e s u g g e s t e d t h a t t h e i n t e r p e r s o n a l r e l a t i o n s h i p w i t h t h e i n s t r u c t o r i s a s o u r c e o f s t r e s s f o r 61 n u r s i n g students (Blainey/ 1980; D a v i t z * 1972; McMaster/ 1979). Rogers (1961) suggested t h a t l e a r n i n g was most e f f e c t i v e l y promoted i n a s i t u a t i o n where t h r e a t to s e l f was minimized and advocated measures to enhance i n t e r p e r s o n a l r e l a t i o n s h i p s . S i g n i f i c a n t l e a r n i n g i s more l i k e l y t o occur/ t h e r e f o r e / i n s i t u a t i o n s where a student experiences a p o s i t i v e i n t e r p e r s o n a l r e l a t i o n s h i p with h i s / h e r i n s t r u c t o r . Furthermore/ s i n c e the s e l f concept i s understood to develop through an i n d i v i d u a l ' s r e l a t i o n s h i p w i t h s i g n i f i c a n t others/ i n c l u d i n g f a c u l t y members/ students e x p e r i e n c i n g p o s i t i v e i n t e r p e r s o n a l r e l a t i o n s h i p s w i t h i n s t r u c t o r s are p r o v i d e d an o p p o r t u n i t y f o r development of a p o s i t i v e s e l f concept (Rogers/ 1961). I n s t r u c t o r e f f e c t on student s t a t e a n x i e t y . Although the i n t e r v e n t i o n treatment f a i l e d t o lower s t a t e a n x i e t y i n the experimental group to s t a t i s t i c a l l y s i g n i f i c a n t l e v e l s / the t r e n d f o r post i n t e r v e n t i o n s t a t e a n x i e t y scores to be h i g h e r i n the c o n t r o l group than the experimental group i s meaningful. A number of p o s s i b l e e x p l a n a t i o n s f o r the study r e s u l t s are o f f e r e d . The f a c t t h a t one i n s t r u c t o r was unable t o c a r r y out the i n t e r v e n t i o n planned on day t h r e e may have r e s u l t e d i n h i g h e r mean s t a t e a n x i e t y scores i n the experimental group/ thus d e c r e a s i n g the chance f o r s c o r e s to be s t a t i s t i c a l l y s i g n i f i c a n t . In a d d i t i o n / r e s e a r c h treatment e f f e c t s o f t e n 62 do not occur u n t i l w e l l a f t e r the i n t e r v e n t i o n . Expected change may occur over a period of time and at d i f f e r e n t i n d i v i d u a l r a t e s . M u l t i p l e measurements of v a r i a b l e s may have produced d i f f e r e n t f i n d i n g s . Furthermore* numerous sources of s t r e s s f o r nursing students have been i d e n t i f i e d . D e s c r i p t i v e data from the St r e s s Questionnaire suggested t h a t s t r e s s was due predominantly t o c l i n i c a l and academic concerns. This was c o n s i s t e n t w i t h f i n d i n g s of E l f e r t (1976)* Fox et a l . (1965)* and McMaster (1979). W i t h i n the c l i n i c a l s e t t i n g * however* some researchers have suggested that the i n t e r p e r s o n a l r e l a t i o n s h i p between i n s t r u c t o r and nursing student i s not as important a source of s t r e s s as other i d e n t i f i e d f a c t o r s (McMaster* 1979; Zujewskyj & Davis* 1985). Davitz (1972) and McMaster (1979) both noted that i n i t i a l experiences evoke a n x i e t y . This f i n d i n g i s supported by data acquired i n t h i s study i n which students f r e q u e n t l y i d e n t i f i e d the a d m i n i s t r a t i o n of intramuscular i n j e c t i o n s f o r the f i r s t time t o be s t r e s s f u l . The l a c k of s t a t i s t i c a l s i g n i f i c a n c e achieved when determining the e f f e c t of the i n t e r v e n t i o n on post s t a t e a n x i e t y scores may i n d i c a t e the i n t e r v e n t i o n was s u c c e s s f u l i n d e a l i n g only w i t h s e l e c t e d sources of s t r e s s . The i n t e r v e n t i o n may be u s e f u l i n decreasing s t r e s s r e s u l t i n g from n e g a t i v e l y perceived i n t e r p e r s o n a l r e l a t i o n s h i p s w i t h 63 i n s t r u c t o r s but unsuccessful i n d e a l i n g w i t h s t r e s s from other sources such as those associated w i t h i n i t i a l experiences/ personal h e a l t h problems/ or academic concerns. C o r r e l a t i o n between scores of s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p s and a n x i e t y . Although the f i n d i n g s c o r r e l a t i n g the higher rated i n s t r u c t o r - s t u d e n t r e l a t i o n s h i p w i t h lower r a t i n g s of s t a t e a n x i e t y were not strong/ they were i n the a n t i c i p a t e d d i r e c t i o n and were supported by f i n d i n g s of Forsyth and Layton (1985). A l a r g e r sample s i z e and an i n t e r v e n t i o n which occurs over a longer p e r i o d of time may have strengthened the c o r r e l a t i o n s . L i m i t a t i o n s The l i m i t a t i o n s of the study are: 1. Factors other than the treatment i n t e r v e n t i o n may have i n f l u e n c e d the perceived s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p . 2. Fa c t o r s other than the treatment i n t e r v e n t i o n may have i n f l u e n c e d s t a t e a n x i e t y . 3. The dependent v a r i a b l e s used i n the study r e l y on s e l f - r e p o r t measures and th e r e f o r e are subject to the l i m i t a t i o n s of t h i s measurement technique. 64 4. Sample s i z e was small* confined t o one i n s t i t u t i o n and c o n s i s t e d of only one l e v e l of student as s u b j e c t s ; t h e r e f o r e * r e s u l t s are not g e n e r a l i z a b l e except to a popu l a t i o n w i t h s i m i l a r c h a r a c t e r i s t i c s . 5. Having the treatment group second i n a l l cases r a i s e s the p o s s i b i l i t y that d i f f e r e n c e s may be due to order e f f e c t . 6. The inherent v a r i a b i l i t y of i n s t r u c t o r s to c a r r y out the treatment package may have a f f e c t e d r e s u l t s . 7. The a b i l i t y of the developed STAI q u e s t i o n n a i r e to a c c u r a t e l y measure the type of anxi e t y experienced by student nurses must be considered. 8. Use of a r a t i n g s c a l e i n the R e l a t i o n s h i p Questionnaire t o measure the phenomena of empathy* congruence* and p o s i t i v e regard suggests they can be reduced to q u a n t i f i a b l e elements. Stewart (1956) argues t h a t empathy cannot be stud i e d by the use of t r a d i t i o n a l methods and suggests a more h o l i s t i c p e r s p e c t i v e t o measurement. This view i s supported by Hackney (1978) who suggests no instrument may be able to measure the p r o j e c t i o n of an i n d i v i d u a l ' s own f e e l i n g s i n t o another. Cronbach's alpha performed on the R e l a t i o n s h i p Questionnaire revealed i n t e r n a l consistency f o r the co n s t r u c t of empathy t o be only .45. 65 CHAPTER FIVE Summary^ Conclusions/ and Recommendations f o r Further Research Summary o f t h e s t u d y The purpose of the study was to determine i f an i n t e r v e n t i o n designed to enhance the i n t e r p e r s o n a l r e l a t i o n s h i p between the nursing i n s t r u c t o r and a group of nursing students would lower students' anx i e t y i n the c l i n i c a l s e t t i n g . I t was hypothesized that student nurses who received a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n would r a t e t h e i r r e l a t i o n s h i p w i t h the i n s t r u c t o r higher than student nurses who received a placebo i n t e r v e n t i o n / and that student nurses who received a r e l a t i o n s h i p - b u i l d i n g i n t e r v e n t i o n would have l e s s s t a t e anxiety than student nurses r e c e i v i n g a placebo i n t e r v e n t i o n . A secondary purpose of the study was to determine the r e l a t i o n s h i p between the v a r i a b l e s of i n t e r e s t / s t a t e anxiety and s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p . The t h e o r e t i c a l underpinnings of the study were drawn from the work of C a r l Rogers (1951/ 1961/ 1969/ 1983). He suggests t h a t l e a r n i n g i s an a f f e c t i v e as w e l l as a c o g n i t i v e experience and that a n x i e t y r e s u l t i n g from f e e l i n g s of t h r e a t t o s e l f could be minimized by e s t a b l i s h i n g a p o s i t i v e i n t e r p e r s o n a l r e l a t i o n s h i p between teacher and l e a r n e r . He f u r t h e r suggests that three 66 c o n s t r u c t s / empathy/ congruence/ and p o s i t i v e regard/ f a c i l i t a t e development of such a r e l a t i o n s h i p . A review of s e l e c t e d l i t e r a t u r e r e v e a l s t h a t p r a c t i s e i n the c l i n i c a l s e t t i n g i s a dominant source of a n x i e t y f o r nu r s i n g s t u d e n t s . A s p e c i f i c source of a n x i e t y w i t h i n t h i s c l i n i c a l s e t t i n g i s noted t o be a student's r e l a t i o n s h i p w i t h the i n s t r u c t o r . Authors a l s o suggest t h a t the i n t e r p e r s o n a l r e l a t i o n s h i p e s t a b l i s h e d between teacher and l e a r n e r can be r e l a t e d to student a n x i e t y and t h a t group methods designed t o d e a l w i t h a n x i e t y i n n u r s i n g students have been e f f e c t i v e . F i n d i n g s from l i t e r a t u r e and c u r i o s i t y a r i s i n g from p e r s o n a l o b s e r v a t i o n s p r o v i d e d the impetus f o r an experimental p r e - t e s t / p o s t - t e s t group d e s i g n t o be used t o t e s t t hree hypotheses. The experimental i n t e r v e n t i o n i n the study was designed t o have nu r s i n g i n s t r u c t o r s demonstrate empathy/ congruence/ and p o s i t i v e regard d u r i n g t h r e e s u c c e s s i v e post conferences with n u r s i n g s t u d e n t s . The placebo i n t e r v e n t i o n was normally scheduled post conference d i s c u s s i o n . The study took p l a c e over a two-week p e r i o d and i n v o l v e d p a r t i c i p a n t s i n a three-year diploma n u r s i n g program. The 30 member c o n t r o l group p a r t i c i p a t e d i n the study b e f o r e the 31 member experimental group. B a s e l i n e and post i n t e r v e n t i o n data were c o l l e c t e d from each group p r i o r t o and f o l l o w i n g the r e s p e c t i v e i n t e r v e n t i o n s . Data c o l l e c t i o n t o o l s were: a demographic q u e s t i o n n a i r e / a 67 S t r e s s f u l Event Questionnaire/ the S t a t e - T r a i t Anxiety Inventory (Spielberger et a l . / 1970)/ and the R e l a t i o n s h i p Questionnaire (adapted from Truax and Carkhuff/ 1967). D e s c r i p t i v e i n f o r m a t i o n from i n s t r u c t o r s and students was gathered i n f o r m a l l y at study end. A n a l y s i s of data i n d i c a t e d t h a t members of both groups were s i m i l a r i n demographic c h a r a c t e r i s t i c s and t r a i t a n x i e t y r a t i n g s . A n a l y s i s of data from the R e l a t i o n s h i p Questionnaire i n d i c a t e d a treatment and i n s t r u c t o r main e f f e c t were s t a t i s t i c a l l y s i g n i f i c a n t . Members of the experimental group rated the perceived r e l a t i o n s h i p w i t h the i n s t r u c t o r s t a t i s t i c a l l y s i g n i f i c a n t l y higher than members of the c o n t r o l group. There was no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between the c o n t r o l and the experimental groups i n t h e i r r a t i n g s of s t a t e a n x i e t y . There was a trend/ however/ f o r those i n the experimental group to have lower s t a t e anxiety r a t i n g s than those i n the c o n t r o l group. While c o r r e l a t i o n s c i t e d between the perceived student-i n s t r u c t o r i n t e r p e r s o n a l r e l a t i o n s h i p and anxiety were low/ they were i n the a n t i c i p a t e d d i r e c t i o n and suggested important r e l a t i o n s h i p s . The d i f f e r e n c e s between c o n t r o l and experimental groups were not s t a t i s t i c a l l y s i g n i f i c a n t i n r e l a t i o n s h i p to the number of r e c e n t l y experienced s t r e s s f u l events nor were they d i f f e r e n t i n the types of events perceived as 68 s t r e s s f u l . The types of events i d e n t i f i e d were c o n s i s t e n t w i t h f i n d i n g s of other r e s e a r c h e r s . Informal data from i n s t r u c t o r s and students i n d i c a t e d t h a t the i n t e r v e n t i o n was p o s i t i v e l y r e c e i v e d and determined t o be u s e f u l . C o n c l u s i o n s 1. Experimental s u b j e c t s rated the s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p h i g h e r than c o n t r o l s u b j e c t s . I t can be concluded* t h e r e f o r e * t h a t a planned i n t e r v e n t i o n implemented i n a group of n u r s i n g students may r e s u l t i n an improved i n t e r p e r s o n a l r e l a t i o n s h i p between n u r s i n g i n s t r u c t o r and student. T h i s r e l a t i o n s h i p i s i n t e g r a l t o the success of the c l i n i c a l component of n u r s i n g e d u c a t i o n . I n c l u s i o n of l e a r n i n g a c t i v i t i e s designed t o f o s t e r t h i s r e l a t i o n s h i p seem v a l u a b l e . 2. Experimental s u b j e c t s d i d not r e p o r t l e s s s t a t e a n x i e t y than c o n t r o l s u b j e c t s . Therefore* i t cannot be concluded t h a t a p o s i t i v e l y p e r c e i v e d r e l a t i o n s h i p w i t h a n u r s i n g i n s t r u c t o r w i l l r e s u l t i n decreased student a n x i e t y . 3. The c o r r e l a t i o n between s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p s c o r e s and s t a t e a n x i e t y s c o r e s were negative and g r e a t e r f o r the experimental group than the c o n t r o l group. I t can be concluded* t h e r e f o r e * t h a t t h e r e i s an i n v e r s e r e l a t i o n s h i p between n u r s i n g student a n x i e t y and the p e r c e i v e d r e l a t i o n s h i p w i t h the i n s t r u c t o r . 69 4. The f i n d i n g s of t h i s study support the theory proposed by C a r l Rogers (1957/ 1961/ 1969/ 1983). The c o n s t r u c t s of empathy/ congruence/ and p o s i t i v e regard are s i g n i f i c a n t components f o r developing a p o s i t i v e l y p e r c e i v e d i n t e r p e r s o n a l r e l a t i o n s h i p between teacher and l e a r n e r . 5. In t h i s p a r t i c u l a r study/ aspects of Roger's theory which suggest l e a r n e r s w i l l be l e s s anxious i f the r e l a t i o n s h i p t o the teacher i s p o s i t i v e l y p e r c e i v e d i s not supported. I m p l i c a t i o n s f o r Nursing Education Because c l i n i c a l i n s t r u c t o r s cannot t o t a l l y manipulate the c l i n i c a l s i t u a t i o n t o promote l e a r n i n g / they should i n c l u d e as p a r t of c l i n i c a l i n s t r u c t i o n l e a r n i n g experiences which w i l l f a c i l i t a t e development of p o s i t i v e i n t e r p e r s o n a l r e l a t i o n s h i p s with s t u d e n t s . The d e l i b e r a t e placement of a r e l a t i o n s h i p - b u i l d i n g a c t i v i t y at the beginning of a c l i n i c a l r o t a t i o n or a group of s t r a t e g i c a l l y p l a c e d a c t i v i t i e s throughout a r o t a t i o n may be most u s e f u l . B u i l d i n g of r e l a t i o n s h i p s with students may h e l p decrease t h e i r a n x i e t y i n the s t r e s s f u l environment of c l i n i c a l p r a c t i s e . As a r e s u l t of decreased anxiety/ l e a r n i n g should be enhanced and c l i e n t c a r e may b e n e f i t . 70 I n c o r p o r a t i o n of such l e a r n i n g experiences depends l a r g e l y on the r e p e r t o i r e of t e a c h i n g s t r a t e g i e s c l i n i c a l i n s t r u c t o r s have a v a i l a b l e to them. Current programs p r e p a r i n g nurse educators f o r the r o l e of c l i n i c a l i n s t r u c t o r have l i m i t e d content on methods c o n t r i b u t i n g to the development of s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p s . C u r r i c u l a of such programs c o u l d be expanded to ensure t h a t content a d d r e s s i n g t h i s e s s e n t i a l area i s i n c l u d e d . Furthermore* f a c u l t y development workshops focused on the theme of s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p s c o u l d be o f f e r e d . C l i n i c a l i n s t r u c t o r s should be aware of the s i g n i f i c a n t e f f e c t s t h e i r p a t t e r n s of communication have on n u r s i n g students and s t r i v e to p r a c t i s e empathy* congruence* and p o s i t i v e r e gard. They should be encouraged to r e g u l a r l y e v a l u a t e t h e i r own use of such c r i t i c a l communication s k i l l s and seek a s s i s t a n c e w i t h development or m o d i f i c a t i o n of such s k i l l s . In a d d i t i o n * the s e n s i t i v i t y of f a c u l t y to i n d i c a t o r s of i n c r e a s i n g a n x i e t y w i t h i n groups of students f o r whom they are r e s p o n s i b l e i s important. E v a l u a t i n g t h e i r own behavior as a p o s s i b l e source of the emotion and i n c l u s i o n of an a c t i v i t y t o d e a l with the response may be i n d i c a t e d . C r i t e r i a f o r s e l e c t i o n of f a c u l t y f o r c l i n i c a l t e a c h i n g r o l e s should i n c l u d e those r e l a t e d not only t o t h e o r e t i c a l and p r a c t i c a l knowledge but a l s o those r e l a t e d to t h e i r a b i l i t y t o r e l a t e e f f e c t i v e l y to s t u d e n t s . Students o f t e n 71 are not the most important p r i o r i t y i n n u r s i n g e d u c a t i o n . Pressure t o be p r o d u c t i v e i n s c h o l a r l y a c t i v i t i e s / such as r e s e a r c h and p u b l i c a t i o n or involvement i n community s e r v i c e s / o f t e n takes precedence over l e a r n e r s i n the academic s e t t i n g . Furthermore/ c l i n i c a l i n s t r u c t o r s o f t e n work i n i s o l a t i o n with l i m i t e d o p p o r t u n i t y f o r peer support and r e c o g n i t i o n . C l i n i c a l i n s t r u c t o r s need to be rewarded f o r e x c e l l e n c e i n t e a c h i n g and/ s p e c i f i c a l l y / f o r demonstration of f a c i l i t a t i v e i n t e r p e r s o n a l s k i l l s . F a c u l t y e v a l u a t i o n t o o l s should r e f l e c t assessment of these valued q u a l i t i e s . I f h i g h a n x i e t y s i t u a t i o n s e x i s t i n n u r s i n g / as r e s e a r c h f i n d i n g s suggest/ s t r a t e g i e s f o r coping with them are e s s e n t i a l both i n the i n t e r e s t of enhancing l e a r n i n g and i n p r o v i d i n g f u t u r e h e a l t h p r o f e s s i o n a l s w i t h techniques they can use w i t h c l i e n t s . Student nurses v a l u i n g a p o s i t i v e i n t e r p e r s o n a l r e l a t i o n s h i p w i t h i n s t r u c t o r s may s t r i v e towards development of such r e l a t i o n s h i p s w i t h c l i e n t s / thus p r o v i d i n g c l i e n t s w i t h one source of d e a l i n g with t h e i r p a r t i c u l a r a n x i e t i e s . Recommendations f o r F u r t h e r Research The R e l a t i o n s h i p Q u e s t i o n n a i r e adapted by the i n v e s t i g a t o r r e q u i r e s f u r t h e r development and refinement t o improve i n t e r n a l c o n s i s t e n c y of the c o n s t r u c t empathy. I n c r e a s i n g the number of responses r a t i n g the c o n s t r u c t of 72 empathy f r o m t h e p r e s e n t 10 t o 20 and t e s t i n g t h e i n s t r u m e n t on a more h e t e r o g e n o u s p o p u l a t i o n may r e s u l t i n h i g h e r c o r r e l a t i o n r e a d i n g s . F u r t h e r r e s e a r c h i s n e e d e d t o t e s t t h e s t u d y ' s g e n e r a l i z a b i l i t y t o n u r s i n g s t u d e n t s whose c h a r a c t e r i s t i c s * g e o g r a p h i c s e t t i n g * and a c a d e m i c c o n d i t i o n s d i f f e r f r o m t h e s a m p l e i n t h i s s t u d y . O t h e r s a m p l e s s h o u l d i n c l u d e c l i n i c a l g r o u p s f r o m b a c c a l a u r e a t e p r o g r a m s and t w o - y e a r d i p l o m a p r o g r a m s a s w e l l a s s t u d e n t s a t o t h e r l e v e l s w i t h i n t h e t h r e e - y e a r d i p l o m a p r o g r a m . F i n d i n g s f r o m t h e S t r e s s Q u e s t i o n n a i r e i n d i c a t e d a v a r i e t y o f s o u r c e s o f s t u d e n t a n x i e t y w i t h i n t h e c l i n i c a l s e t t i n g . A c o m p a r i s o n o f r e s e a r c h f i n d i n g s i n t h i s a r e a t h a t w e r e a c q u i r e d u s i n g q u a l i t a t i v e m e t h o d o l o g y w o u l d be i n t e r e s t i n g . S t u d e n t a n x i e t y c o u l d be i n f l u e n c e d by f a c t o r s s u c h a s t y p e o f c l i n i c a l s e t t i n g and i n t e r a c t i o n s w i t h o t h e r h e a l t h t e a m members. I d e n t i f i c a t i o n o f t h e s e f a c t o r s w o u l d p r o v i d e c l i n i c a l i n s t r u c t o r s w i t h k n o w l e d g e t o p l a n a p p r o p r i a t e i n t e r v e n t i o n . The s t u d y t e s t e d t h e e f f e c t i v e n e s s o f an i n t e r v e n t i o n w h i c h was e m p l o y e d o v e r a t h r e e - d a y p e r i o d . S t u d e n t a n x i e t y l e v e l s w e r e n o t l o w e r e d s u f f i c i e n t l y t o r e a c h s t a t i s t i c a l s i g n i f i c a n c e . A r e p l i c a t e s t u d y u s i n g a l a r g e r s a m p l e s i z e and e m p l o y i n g a s i m i l a r i n t e r v e n t i o n p a c k a g e o v e r a l o n g e r p e r i o d o f t i m e may i m p r o v e r e s u l t s . 73 In a d d i t i o n / the study assumed t h a t the i n s t r u c t o r was p r i m a r i l y r e s p o n s i b l e f o r the l e v e l of f a c i l i t a t i v e i n t e r p e r s o n a l c o n d i t i o n s present i n the r e l a t i o n s h i p w i t h s t u d e n t s . There i s c o n s i d e r a b l e evidence which suggests the l e v e l of c o n d i t i o n s i s a r e s u l t of dynamic i n t e r a c t i o n between teacher and student. T h i s i n t e r a c t i o n deserves f u r t h e r i n v e s t i g a t i o n . F i n a l l y / t h i s study employed on l y one method to d e a l w i t h student a n x i e t y i n the c l i n i c a l s e t t i n g . Research i n t o the e f f e c t i v e n e s s of other group methods i s i n d i c a t e d . In c o n c l u s i o n / the i n v e s t i g a t o r b e l i e v e s t h a t the i n t e r p e r s o n a l r e l a t i o n s h i p e s t a b l i s h e d between c l i n i c a l i n s t r u c t o r and n u r s i n g student i s s i g n i f i c a n t . Teaching s t r a t e g i e s a v a i l a b l e t o c l i n i c a l i n s t r u c t o r s have demonstrated e f f e c t i v e n e s s i n improving t h i s r e l a t i o n s h i p and should be i n c o r p o r a t e d i n t o the i n s t r u c t o r ' s r e p e r t o i r e of t e a c h i n g t e c h n i q u e s . The consequences of an improved s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p may be h e l p f u l i n both m i n i m i z i n g student a n x i e t y and enhancing the e f f e c t i v e n e s s of the v alued c l i n i c a l l e a r n i n g experience. References American P s y c h o l o g i c a l A s s o c i a t i o n . (1983). 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I n v e s t i g a t i o n of p o s i t i v e b e h a v i o r a l change as a f u n c t i o n of genuineness/ nonpossessive warmth/ and empathic understanding. The J o u r n a l of E d u c a t i o n a l Research/ £1 (5)/ 226-228. Stuebbe* B. (1981). Student and f a c u l t y p e r s p e c t i v e on the r o l e of nursing i n s t r u c t o r s . J o u r n a l of Nursing Education* 2 (9)* 4-9. Truax* C. B.* & Carkhuff* R. R. (1967). Toward e f f e c t i v e counseling and psychotherapy: T r a i n i n g and p r a c t i c e . Chicago: A l d i n e . Weinberg* R.* & Ragan* J . (1978). Motor performance under three l e v e l s of t r a i t anxiety and s t r e s s . J o u r n a l of Motor, B e h a v i o r * i d * 169-176. Zujewskyj* T.* & Davis* L. (1985). Sources and e f f e c t s of anxiety i n videotape l e a r n i n g experience. Nursing P a p e r s * 12 (3)* 75-85. APPENDIX A S e l f - E v a l u a t i o n Q u e s t i o n n a i r e STAI FORM X - l S e l f - E v a l u a t i o n Questionnaire STAI FORM X - l Questionnaire Number: Student Number Date DIRECTIONS: A number of statements which people have used t o des c r i b e themselves are given below. Read each statement and then c i r c l e to the r i g h t of the statement the number which i n d i c a t e s how you f e e l r i g h t now* that ^ i s * at t h i s moment. There are no n r i g h t or wrong answers. Do not spend too much time on any one statement but ^ giv e the answer which seems to > describe your present f e e l i n g s best. ^ 1. I 2. I 3. I 4. I 5. I 6. I 7. I am p r e s e n t l y worrying over 8. I 9. I 10. I 11. I 12. I 13. I 14. I 15. I g o a w o w 1-3 w £ O i-3 > s w 1-3 M F S! K > a tr1 > cn tr< i-3 O 16. I f e e l content 1 2 3 17. I am worried 1 2 3 18. I f e e l o v e r - e x c i t e d and " r a t t l e d " . . 1 2 3 19. I f e e l j o y f u l 1 2 3 20. I f e e l pleasant 1 2 3 Note: From STAI manual f o r the s t a t e - t r a i t a n x i e t y  inventory by C. D. S p i e l b e r g e r / R. L. Gorsuch/ & R. E. Lushene/ 1970/ Palo A l t o / CA: Consulting P s y c h o l o g i s t s Press. Copyright 1968 by C. D. S p i e l b e r g e r . 84 APPENDIX B S e l f - E v a l u a t i o n Q u e s t i o n n a i r e STAI FORM X-2 S e l f - E v a l u a t i o n Questionnaire STAI FORM X-2 Questionnaire Number: Student Number Date DIRECTIONS: A number of statements which people have used t o describe themselves are given below. Read each statement and then c i r c l e to the r i g h t > of the statement the number which § i n d i c a t e s how you g e n e r a l l y f e e l . ° There are no r i g h t or wrong answers. 1-3 Do not spend too much time on any one g statement but give the answer which £3 seems to d e s c r i b e how you g e n e r a l l y w f e e l . * 21. I f e e l pleasant 1 22. I t i r e q u i c k l y 1 23. I f e e l l i k e c r y i n g 1 24. I wish I could be as happy as others seem to be 1 25. I am l o s i n g out on things because I can't make up my mind soon enough .. 1 26. I f e e l rested 1 27. I am "calm* coolr and c o l l e c t e d " ... 1 28. I f e e l t h a t d i f f i c u l t i e s are p i l i n g up so t h a t I cannot overcome them .. 1 29. I worry too much over something that r e a l l y doesn't matter 1 30. I am happy 1 31. I am i n c l i n e d to take t h i n g s hard ... 1 32. I lack s e l f - c o n f i d e n c e 1 33. I f e e l secure 1 34. I t r y t o avoid f a c i n g a c r i s i s or d i f f i c u l t y 1 > K O cn cn o 2 i-3 O W H tr] < S H3 W W W CO 2 35. I f e e l blue 1 2 3 36. I am content 1 2 3 37. Some unimportant thought runs through my mind and bothers me 1 2 3 38. I take disappointments so keenly t h a t I can't put them out of my mind .... 1 2 3 39. I am a steady person 1 2 3 40. I get i n a s t a t e of t e n s i o n or t u r m o i l as I think over my recent concerns and i n t e r e s t s 1 2 3 Note-. From STAI manual f o r the s t a t e - t r a i t a nxiety inventory by C. D. Sp i e l b e r g e r * R. L. Gorsuch* & R. E. Lushene* 1970* Palo A l t o * CA: Consulting P s y c h o l o g i s t s Press. Copyright 1968 by C. D. S p i e l b e r g e r . 86 > g cn > I cn 4 4 APPENDIX C R e l a t i o n s h i p Questionnaire R e l a t i o n s h i p Q u e s t i o n n a i r e Q u e s t i o n n a i r e Number: S t u d e n t Number D a t e DIRECTIONS: P e o p l e f e e l d i f f e r e n t l y a b o u t some p e o p l e t h a n t h e y do a b o u t o t h e r s . T h e r e a r e a number o f s t a t e m e n t s b e l o w t h a t d e s c r i b e a v a r i e t y o f ways t h a t one p e r s o n may f e e l a b o u t a n o t h e r p e r s o n * o r ways t h a t one p e r s o n may a c t t o w a r d a n o t h e r p e r s o n . C o n s i d e r e a c h s t a t e m e n t § c a r e f u l l y a n d d e c i d e how c l o s e l y i t ^ d e s c r i b e s y o u r p r e s e n t r e l a t i o n s h i p > w i t h y o u r i n s t r u c t o r . C i r c l e t h e 1-3 number t o t h e r i g h t o f e a c h s t a t e m e n t > w h i c h b e s t d e s c r i b e s y o u r r e s p o n s e . F 1. She seems t o l i k e me no m a t t e r w h a t I s a y t o h e r 1 2. She n e v e r s a y s a n y t h i n g t h a t makes h e r s o u n d l i k e a r e a l p e r s o n 1 3. She u n d e r s t a n d s e x a c t l y how I s e e t h i n g s 1 4. I f I made m i s t a k e s o r m i s s a c l a s s * s h e r e a l l y g i v e s me t r o u b l e a b o u t i t 1 5. She i s i m p a t i e n t w i t h me 1 6. She u s u a l l y knows e x a c t l y w h a t I mean* s o m e t i m e s e v e n b e f o r e I f i n i s h s a y i n g i t 1 7. She d o e s n ' t l i k e me a s a p e r s o n * b u t c o n t i n u e s t o s e e me a s a s t u d e n t anyway 1 8. She a p p r e c i a t e s me 1 9. E v e n i f I were t o c r i t i c i z e h e r * she w o u l d s t i l l l i k e me 1 1 0 . She l i k e s me b e t t e r when I a g r e e w i t h h e r 1 89 8 < O b d O W K i-a cn > O r g g > 2 td C i-3 H f O S ! K SS > SS tr1 > cn co f i-3 O O 11. I o f t e n cannot understand what she i s t r y i n g to t e l l me 1 2 3 4 12. Often she makes me f e e l s t u p i d / the way she uses strange words 1 2 3 4 13. I am j u s t another student to her ... 1 2 3 4 14. I can l e a r n a l o t about myself from t a l k i n g w i t h her 1 2 3 4 15. She l i k e s to see me 1 2 3 4 16. I f e e l she i s being genuine w i t h me 1 2 3 4 17. She f e e l s i n d i f f e r e n t about me 1 2 3 4 18. Sometimes I f e e l what she says to me i s very d i f f e r e n t from the way she r e a l l y f e e l s 1 2 3 4 19. She sometimes seems more i n t e r e s t e d i n what she h e r s e l f says than i n what I say 1 2 3 4 20. She ignores some of my f e e l i n g s .... 1 2 3 4 21. I would not be a f r a i d to ask her f o r h e lp 1 2 3 4 22. She a c t s too p r o f e s s i o n a l 1 2 3 4 23. She r e a l l y l i s t e n s to everything I say 1 2 3 4 24. She ignores some of my f e e l i n g s .... 1 2 3 4 25. I f e e l I can t r u s t her to be honest w i t h me 1 2 3 4 26. She seems w i l l i n g to share her own experiences as a student 1 2 3 4 90 B < D M 2! H 5S O W * H W t> O H3 g > 2 W c! H3 H f n a K K > EC F > cn cn 27. She sometimes pretends to ^ understand me when she r e a l l y does not 1 2 3 4 28. She i s u s u a l l y not very i n t e r e s t e d i n what I have t o say 1 2 3 4 29. I am a f r a i d of her 1 2 3 4 30. I f e e l I can count on her t o t e l l me what she r e a l l y t h i n k s or f e e l s .... 1 2 3 4 Notet Adapted from Toward e f f e c t i v e counseling and psychotherapy.- T r a i n i n g and p r a c t i c e by C. B. Truax & R. R. Carkhuffr 1967* Chicago: A l d i n e . Copyright 1963 by C. B. Truax. APPENDIX D R e l a t i o n s h i p - b u i l d i n g A c t i v i t i e s Package T h i s packet c o n t a i n s an o u t l i n e of a c t i v i t i e s which I'd l i k e you to complete w i t h your i n d i v i d u a l groups next week. There are three " i n t e r a c t i o n a l e pisodes". P lease complete number one on Tuesday d u r i n g post conference/ number two on Wednesday d u r i n g post conference/ and number three on Thursday duri n g post conference. Thank you f o r your c o o p e r a t i o n . The teacher as a person i s more important than the teacher as a t e c h n i c i a n . What he i s has more e f f e c t than anything he does. Jack C a n f i e l d 93 I n t e r a c t i o n a l E p i s o d e I D u r i n g y o u r p o s t c l i n i c t i m e * r a t h e r t h a n c a r r y i n g o u t y o u r r e g u l a r d i s c u s s i o n / p l e a s e c a r r y o u t t h e f o l l o w i n g e x e r c i s e s . E x p l a i n t o y o u r c l i n i c a l g r o u p t h a t * r a t h e r t h a n t h e c o n v e n t i o n a l p o s t c o n f e r e n c e * t h i s week a d i f f e r e n t f o r m a t f o c u s e d on c o m m u n i c a t i o n w i l l be f o l l o w e d . The e x e r c i s e s s h o u l d t a k e a p p r o x i m a t e l y 30 m i n u t e s . E x e r c i s e 1 D i v i d e t h e g r o u p i n t o two g r o u p s o f f o u r * o r one g r o u p o f t h r e e a n d one g r o u p o f f o u r . The i n s t r u c t o r i s i n c l u d e d i n one o f t h e g r o u p s . Have t h e two g r o u p s s i t f a c i n g e a c h o t h e r (one p e r s o n may n o t h a v e a p a r t n e r i n i t i a l l y ) . E a c h member o f t h e p a i r f i l l s i n t h e f o l l o w i n g p h r a s e : "When I s e e * I f e e l " ( I n s t r u c t o r c a n w r i t e t h e p h r a s e on t h e b o a r d . ) A l l o w t i m e f o r t h o u g h t f o r m u l a t i o n . A f t e r e a c h p a i r h a s c o m p l e t e d t h e e x e r c i s e * one row o f f o u r moves one s e a t a l o n g s o two new p a r t n e r s a r e f a c i n g e a c h o t h e r . The p h r a s e w i l l t h e n be c o m p l e t e d b y e a c h p e r s o n u s i n g new w o r d s . The row k e e p s c h a n g i n g u n t i l t h e o r i g i n a l p a i r a r e f a c i n g e a c h o t h e r . E x e r c i s e 2 Each group member ( i n c l u d i n g the i n s t r u c t o r ) w i l l complete the statement: "I am " Complete the statement u s i n g f i v e a d j e c t i v e s d e s c r i b i n g y o u r s e l f and then rank order them i n terms of importance t o you as an i n d i v i d u a l . Record your answers independently. Go around the group and each group member shares t h e i r a d j e c t i v e s i n rank order with the most s i g n i f i c a n t r e p o r t e d l a s t . E x e r c i s e 3 The i n s t r u c t o r shares with the group an anecdote about themselves as a student or an amusing episode i n v o l v i n g themselves as an i n s t r u c t o r . E x e r c i s e 4 C l o s u r e e x e r c i s e . I n s t r u c t o r t o w r i t e on board: I thin k I f e e l I l e a r n e d Each student and i n s t r u c t o r f i l l s i n one of the blanks and v e r b a l l y shares i t with the group. Complete i n one go-round. 95 Every person needs r e c o g n i t i o n . I t i s expressed c o g e n t l y by the l a d who says* "Mother* l e t ' s p l a y d a r t s . I ' l l throw the d a r t s and you say 'wonderful.'" M. Dale Baughman* Educator's Handbook of S t o r i e s * Quotes* and Humour 96 I n t e r a c t i o n a l Episode I I During your post c l i n i c timer r a t h e r than c a r r y i n g out your r e g u l a r d i s c u s s i o n / p l e a s e c a r r y out the f o l l o w i n g e x e r c i s e s . The e x e r c i s e s should take approximately 30 minutes. E x e r c i s e 1 D i v i d e the group i n t o two groups of f o u r / or one group of t hree and one group of f o u r . The i n s t r u c t o r i s i n c l u d e d i n one of the groups. Have the two groups s i t f a c i n g each other (one person may not have a p a r t n e r i n i t i a l l y ) . Each member of the p a i r answers the f o l l o w i n g t h r e e q u e s t i o n s : "What do you f e e l ? " "What do you want?" "What are you a f r a i d o f ? " I n s t r u c t o r can w r i t e q u e s t i o n s on the board. Allow time f o r thought f o r m u l a t i o n . A f t e r each member of the p a i r has answered the qu e s t i o n s / one row of four moves one seat along so two new p a r t n e r s are f a c i n g each other. The q u e s t i o n s w i l l then be completed by each person using new words. The row keeps changing u n t i l the o r i g i n a l p a i r are f a c i n g each o t h e r . 97 E x e r c i s e 2 Students share w i t h the i n s t r u c t o r and other students t h e i r e x p e c t a t i o n s of the i n s t r u c t o r as a p r o f e s s i o n a l and c l i n i c a l i n s t r u c t o r . For example* i n s t r u c t o r b e h a v i o r s they l i k e or f i n d h e l p f u l and those they d i s l i k e or f i n d u n h e l p f u l . E x e r c i s e 3 C l o s u r e e x e r c i s e . I n s t r u c t o r t o w r i t e on board: I t h i n k I f e e l I l e a r n e d Each student and i n s t r u c t o r f i l l s i n one of the blanks and v e r b a l l y shares i t w i t h the group. Complete i n one go-round. I f f a c t s are the seeds t h a t l a t e r produce knowledge and wisdom* then the emotions and the impressions of the senses are the f e r t i l e s o i l i n which the seeds must grow. Rachel Carson* The  Sense of Wonder 98 I n t e r a c t i o n a l Episode I I I During your post c l i n i c time* r a t h e r than c a r r y i n g out your r e g u l a r d i s c u s s i o n * p l e a s e c a r r y out the f o l l o w i n g e x e r c i s e s . The e x e r c i s e s should take approximately 30 minutes. E x e r c i s e 1 Students and i n s t r u c t o r to s i t i n a c i r c l e . Each group member ( i n c l u d i n g the i n s t r u c t o r ) shares w i t h the group two p o s i t i v e experiences i n which they were i n v o l v e d d u r i n g the past week. Ask t h a t p a r t i c i p a n t s choose at l e a s t one experience t h a t p e r t a i n s t o c l i n i c a l work. Allow a few minutes f o r thought f o r m u l a t i o n . Have each group member ( i n c l u d i n g the i n s t r u c t o r ) share v e r b a l l y t h e i r two ex p e r i e n c e s . E x e r c i s e 2 Students and i n s t r u c t o r t o share with the group one nega t i v e experience they i d e n t i f i e d d u r i n g the week. For example* a statement might begin: "One t h i n g I had t r o u b l e w i t h " or "One t h i n g I d i d n ' t l i k e E x e r c i s e 3 Group members and i n s t r u c t o r t o g i v e one response t o "Thi s week I e s p e c i a l l y a p p r e c i a t e d " E x e r c i s e 4 Group t o share f e e l i n g s about i n t e r a c t i o n a l episodes wit h each o t h e r . The End With thanks f o r your c o o p e r a t i o n . 100 APPENDIX E Explanatory L e t t e r D i r e c t o r ^ L e v e l 1 C o - o r d i n a t o r 101 Dear D i r e c t o r / C o - o r d i n a t o r : In order to complete a Master's Degree i n Nursing a t the U n i v e r s i t y of B r i t i s h Columbia I have e l e c t e d t o do a t h e s i s . My r e s e a r c h i s i n the area of i n t e r p e r s o n a l r e l a t i o n s h i p s and t h e i r e f f e c t on student a n x i e t y i n the c l i n i c a l s e t t i n g . I would l i k e t o conduct an experimental study i n v o l v i n g one c l a s s of f i r s t l e v e l students and t h e i r c l i n i c a l i n s t r u c t o r s . I propose to have each of the f i v e i n s t r u c t o r s work w i t h both a c o n t r o l and an experimental group. The treatment i n v o l v e d c o n s i s t s of t h r e e " i n t e r a c t i o n a l e pisodes" designed to f a c i l i t a t e p o s i t i v e i n t e r p e r s o n a l r e l a t i o n s h i p s between i n s t r u c t o r and s t u d e n t s . The study would take p l a c e over a two-week p e r i o d . During the f i r s t week the i n s t r u c t o r would implement the " c o n t r o l " package and d u r i n g the second week would implement the "treatment" package. The amount of i n s t r u c t o r time i n v o l v e d would be about one to two hours i n a d d i t i o n t o her r e g u l a r l y scheduled c l i n i c a l hours. During the one to two hour p e r i o d / o r i e n t a t i o n t o the "package" would occur. T h i s would be completed by myself. I propose t o have students r a t e both a n x i e t y and i n s t r u c t o r - s t u d e n t r e l a t i o n s h i p s . T h e i r p a r t i c i p a t i o n i s e n t i r e l y v o l u n t a r y . I would l i k e t o have approximately 102 one h a l f hour f o r data c o l l e c t i o n on Monday and Thursday of two consecutive weeks at 1300 hours. In a d d i t i o n * i t i s necessary f o r me to p r e t e s t my instrument to measure i n s t r u c t o r - s t u d e n t r e l a t i o n s h i p s . I would l i k e to do t h i s w i t h a group of twenty f i r s t l e v e l students who would not be i n v o l v e d i n the study. I would l i k e to have them complete the q u e s t i o n n a i r e on two occasions i n order to e s t a b l i s h t e s t - r e t e s t r e l i a b i l i t y . The q u e s t i o n n a i r e could be completed i n approximately twenty minutes. I look forward to hearing from you and working w i t h you. Sharon Sundberg* BSN APPENDIX F Explanatory L e t t e r P a r t i c i p a t i n g F i r s t Year I n s t r u c t o r s 104 Dear C o l l e a g u e : In order to complete a Master's Program i n Nursing at The U n i v e r s i t y of B r i t i s h Columbia I have s e l e c t e d t o do a t h e s i s . My r e s e a r c h i s i n the area of i n t e r p e r s o n a l r e l a t i o n s h i p s and t h e i r e f f e c t on student a n x i e t y i n the c l i n i c a l s e t t i n g . I would l i k e t o conduct an experimental study which would i n v o l v e both y o u r s e l f and your two groups of students. Your involvement would e n t a i l implementing three groups of a c t i v i t i e s w i t h the experimental group. The t h r e e a c t i v i t i e s f o r the experimental group would take p l a c e d u r i n g p o s t conference Tuesday* Wednesday* and Thursday of t h e i r second week on your ward. The o b j e c t i v e s and i n s t r u c t i o n s f o r the a c t i v i t i e s would be p r o v i d e d by myself p r i o r t o implementation. O r i e n t a t i o n to the " a c t i v i t i e s package" w i l l probably take one hour and time f o r q u e s t i o n s w i l l be allowed. Your p a r t i c i p a t i o n i n the study i s e n t i r e l y v o l u n t a r y and w i l l i n no way r e f l e c t on your employment s t a t u s . I f at any time d u r i n g the study you wish to withdraw* your a c t i o n s are a c c e p t a b l e . Students w i l l be asked to complete q u e s t i o n n a i r e s as a p a r t of the study. F i n d i n g s from these q u e s t i o n n a i r e s w i l l be grouped t o ensure anonymity. Q u e s t i o n n a i r e s w i l l be shredded once data i s coded. 105 Implementation of the planned a c t i v i t i e s with your students w i l l c o n s t i t u t e consent to p a r t i c i p a t e i n the study. Thank you f o r your c o o p e r a t i o n . I look forward to working w i t h you. Sharon Sundberg* BSN APPENDIX G Explanatory L e t t e r S u b j e c t s f o r Instrument V a l i d a t i o n Test 107 My name i s Sharon Sundberg and I am a graduate student i n the Master's Degree Program i n Nursing a t The U n i v e r s i t y of B r i t i s h Columbia. I am p l a n n i n g to conduct a study t i t l e d "The E f f e c t of a R e l a t i o n s h i p - B u i l d i n g A c t i v i t y on Nursing Student A n x i e t y i n the C l i n i c a l S e t t i n g " . The purpose of t h i s study i s to examine through the use of q u e s t i o n n a i r e s students* a n x i e t y i n the c l i n i c a l s e t t i n g . F i n d i n g s of the study w i l l be of b e n e f i t t o both f a c u l t y and students i n enhancing l e a r n i n g w i t h i n t h i s s e t t i n g . The study has been approved by the e t h i c a l review committee of t h i s agency and by the School of Nursing. Your p a r t i c i p a t i o n i n t h i s study i s e n t i r e l y v o l u n t a r y . I f you choose not to p a r t i c i p a t e * no untoward a c t i o n s w i l l ensue. P a r t i c i p a t i o n i n v o l v e s completion of a q u e s t i o n n a i r e which w i l l take approximately 15 minutes. I would l i k e you t o complete the q u e s t i o n n a i r e on two o c c a s i o n s approximately one week a p a r t . The purpose of t h i s t e s t i n g i s t o e s t a b l i s h t e s t - r e t e s t r e l i a b i l i t y . Q u e s t i o n n a i r e s are anonymous/ but i f on completion of the q u e s t i o n n a i r e you p r e f e r not t o submit i t / your a c t i o n s are a c c e p t a b l e . Data from q u e s t i o n n a i r e s w i l l be used s o l e l y f o r the purpose of t h i s study. F i n d i n g s w i l l be grouped to ensure anonymity of respondents. Q u e s t i o n n a i r e s w i l l be shredded once data i s coded. 108 Grouped f i n d i n g s of the study may be shared w i t h the f a c u l t y of t h i s School of Nursing and with the members of the p a r t i c i p a t i n g c l a s s of s t u d e n t s . Completion of the q u e s t i o n n a i r e w i l l c o n s t i t u t e your consent f o r p a r t i c i p a t i o n i n the study. Thank you f o r your a s s i s t a n c e . Sharon Sundberg* BSN APPENDIX H Explanatory L e t t e r C o n t r o l and Experimental S u b j e c t s 110 My name i s Sharon Sundberg and I am a graduate student i n the Master*s Degree Program i n Nursing at The U n i v e r s i t y of B r i t i s h Columbia. I am planning to conduct a study t i t l e d "The E f f e c t of a R e l a t i o n s h i p - B u i l d i n g A c t i v i t y on Nursing Student Anxiety i n the C l i n i c a l S e t t i n g " . The purpose of t h i s study i s to examine through the use of q u e s t i o n n a i r e s students' a n x i e t y i n the c l i n i c a l s e t t i n g . F i n d i n g s of the study w i l l be of b e n e f i t t o both f a c u l t y and students i n enhancing l e a r n i n g w i t h i n t h i s s e t t i n g . The study has been approved by the e t h i c a l review committee of t h i s agency and by the School of Nursing. Your p a r t i c i p a t i o n i n t h i s study i s e n t i r e l y v o l u n t a r y . I f you choose not to p a r t i c i p a t e / no untoward a c t i o n s w i l l ensue. P a r t i c i p a t i o n i n v o l v e s completion of q u e s t i o n n a i r e s which w i l l take approximately 30 minutes. Questionnaires are anonymous/ but i f on completion of the q u e s t i o n n a i r e you p r e f e r not to submit i t / your a c t i o n s are acceptable. Data from q u e s t i o n n a i r e s w i l l be used s o l e l y f o r the purpose of t h i s study. Findings w i l l be grouped to ensure anonymity of respondents. Questionnaires w i l l be shredded once data i s coded. Grouped f i n d i n g s of the study may be shared w i t h the f a c u l t y of t h i s School of Nursing and w i t h the members of the p a r t i c i p a t i n g c l a s s of students. Completion of the q u e s t i o n n a i r e w i l l c o n s t i t u t e your consent f o r p a r t i c i p a t i o n i n the study. Thank you f o r a s s i s t a n c e . Sharon Sundberg* BSN 112 APPENDIX I S t r e s s f u l Event Q u e s t i o n n a i r e S t r e s s f u l Event 113 Q u e s t i o n n a i r e Number: Do you f e e l you have experienced an u n u s u a l l y s t r e s s f u l event d u r i n g the p a s t 24 hours? Yes • No • I f yes* p l e a s e d e s c r i b e i n your own words the nature of the s t r e s s f u l event. For example* a car a c c i d e n t * death of a f a m i l y member or f r i e n d . APPENDIX J Demographic Data Form 115 Demographic Data Form Questionnaire Number: Please complete the f o l l o w i n g questions by f i l l i n g i n the c o r r e c t box. Age 17-20 • Sex Male • M a r i t a l S i n g l e Q 21-25 Q Female Q s t a t u s Married Q 26-29 • Divorced 30-39 • Separated • Occupation p r i o r t o enrolment i n the VGH Nursing program: Student • P r a c t i c a l Nurse Q Nurse aide Q Other • During the past week your c l i n i c a l experience was on: A3 • E7 • W7 • E9 • E10 • Were you i n attendance on a l l three c l i n i c a l days? Yes • No • I f nor d i d you miss: 1. • 2. • 3. • 116 APPENDIX K F i g u r e 1: P l o t of S t a t e A n x i e t y Scores by Treatment Group 118 APPENDIX L Figure 2: P l o t of S t a t e A n x i e t y Scores by I n s t r u c t o r s 119 Figure 2 Plot of State Anxiety Scores by Instructors 30 40 SO 60 Pre-test State Anxiety Score 

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