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The effect of preceptorship on role transition of novice staff nurses MacDonald, Bernadette 1990

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THE EFFECT OF PRECEPTORSHIP  ON ROLE TRANSITION  OF NOVICE STAFF NURSES By BERNADETTE MACDONALD B.N.  Dalhousie  University,  198G  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (SCHOOL OF NURSING) We accept t h i s t h e s i s as to the r e q u i r e d  conforming  standard  The U n i v e r s i t y of B r i t i s h Columbia May  1990  @ Bernadette MacDonald  In  presenting  this  thesis in  degree at the University of  partial  fulfilment of  the  requirements  for  an advanced  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  department  or  by  his  or  scholarly purposes may be granted her  representatives.  It  is  by the head of  understood  that  copying  my or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of The University of British Columbia Vancouver, Canada  DE-6 (2/88)  Abstract T h i s study i n v e s t i g a t e d  the e f f e c t  of a p r e c e p t o r s h i p  program on r o l e t r a n s i t i o n of novice s t a f f A quasi-experimental, design was used. participated  orientation  T h i r t y - f o u r novice s t a f f  (control)  (2)  (1)  demonstrate  Three r e s e a r c h hypotheses  demonstrate of  nurses  traditional  novice  in a preceptorship  level  post-test,  preceptorship  to determine whether  r e p o r t a higher  staff  group.  who p a r t i c i p a t e d  program would:  20 i n the  group, and 14 i n the  were i n v e s t i g a t e d nurses  c o n t r o l group p r e t e s t  i n the study;  (experimental)  nurses.  easier role  staff  orientation transition,  job performance,  and  l e s s r o l e d e p r i v a t i o n , than those  (3)  novice  nurses who p a r t i c i p a t e d i n a t r a d i t i o n a l  o r i e n t a t i o n program.  Role t r a n s i t i o n was measured  using  the Six Dimension Scale of Nursing Performance (Schwirian, (Corwin,  1978)  1961).  d u r i n g the  first  and the Nursing Role Conception Scale P a r t i c i p a n t s completed week of the o r i e n t a t i o n  programs and again one-month l a t e r . significant either  differences  or  Results  preceptorship i n d i c a t e d no  (p<0.05) between the groups on  the Nursing Role Conception Scale or the  Dimension Scale of Nursing Performance.  i i l  the two s c a l e s  Six  Table of  Contents Page ii iii v vi  Abstract Table of Contents L i s t of Tables L i s t of F i g u r e s Acknowledgements Chapter One -  vii  Introduction  Background to the Problem Problem Statement Purpose T h e o r e t i c a l Framework S o c i a l i z a t i o n and R e a l i t y Shock P r e c e p t o r s h i p Programs and S o c i a l i z a t i o n D e f i n i t i o n of Terms Research Hypotheses Assumptions Limitations Delimitations S i g n i f i c a n c e of the Study Scope of the study Chapter Two -  1 3 4 4 10 12 14 16 18 19 19 19 20  Review of the L i t e r a t u r e  Development of P r e c e p t o r s h i p Programs B e n e f i t s of P r e c e p t o r s h i p Research on P r e c e p t o r s h i p Summary  22 24 25 32  Chapter Three - Methods and Procedures Des ign Setting Sample C r i t e r i a and S e l e c t i o n P r o t e c t i o n of Human R i g h t s Measurement of V a r i a b l e s Instruments Data A n a l y s i s Summary Chapter Four - P r e s e n t a t i o n  :  33 33 34 ..37 38 39 44 45  of Data  D e s c r i p t i v e C h a r a c t e r i s t i c s of Sample R e s u l t s i n R e l a t i o n to Research Hypotheses Hypothesis Two iii  46 ...50  Hypothesis Hypothesis Summary  Page 57 64 64  Three One  Chapter F i v e - D i s c u s s i o n of F i n d i n g s D i s c u s s i o n i n R e l a t i o n to Research Hypotheseis Hypothesis Two . 68 Hypothesis Three 73 Hypothesis One 76 Comparison of Present Study R e s u l t s to Other S t u d i e s . . . 8 2 Summary. 84 Chapter S i x - Summary, Conclusions  and  Implications  Summary Conclus ions Limitations Implications: Nursing P r a c t i c e Nursing Education Nursing Research References Appendices: Appendix A. P r e c e p t o r s h i p Program Schedule Appendix B. Preceptor Development Program Appendix C. T r a d i t i o n a l O r i e n t a t i o n Schedule H o s p i t a l (A) Appendix D. T r a d i t i o n a l O r i e n t a t i o n Schedule H o s p i t a l (B) Appendix E . L e t t e r of I n t r o d u c t i o n Appendix F . Demographic Data Sheet Appendix G. Six Dimension Scale of Nursing Performance Appendix H. Nursing Role Conception Scale  iv  85 88 90 ....91 95 99 102 108 110 112 114 117 120 122 126  L i s t of  Tables Page  Table 1. Demographic Characteristics  of Sample  Table 2. Pretest Scores on the Six Dimension Scale of Nursing Performance for Experimental and Control Groups  48  53  Table 3. Comparison of Pretest to Post-test Scores on the Six Dimension Scale of Nursing Performance for the Experimental Group... 54 Table 4. Comparison of Pretest to Post-test Scores on the Six Dimension Scale of Nursing Performance for the Control Group 55 Table 5. Comparison of Post-test Scores on the Six Dimension Scale of Nursing Performance for Experimental and Control Groups 57 Table 6. Comparison of Pretest to Post-test Nursing Role Conception Scale Scores for Experimental (Preceptorship) Group 60 Table 7. Comparison of Pretest to Post-test Nursing Role Conception Scale Scores for Control (Traditional Orientation) Group ..61 Table 8. Comparison of Pretest to Post-test Nursing Role Conception Scale Scores for Both Groups 63  v  Table of Figures Page Figure 1. Diagram of Hypothesized Role Transition Process Occurring Post Work-Entry with Versus Traditional Orientation Programs  vi  Preceptorship 18  Acknowledgements I extend  s i n c e r e g r a t i t u d e t o my t h e s i s  Sonia Acorn  and D r . S h a r o n A n d e r s e n ,  contributions throughout  in directing,  advising,  the research process.  supervision  enhanced  Completion  of t h i s  the q u a l i t y  for their and c h a l l e n g i n g me  The q u a l i t y of t h i s  the cooperation of p a r t i c i p a t i n g  without  the the p a r t i c i p a t i o n  study.  My t h a n k s  I also and  gave o f t h e i r  i s extended  t o take  part  who in this  to a l l .  a c k n o w l e d g e my f a m i l y f o r t h e c o n t i n u i n g s u p p o r t  encouragement which t h e y extended  of s t u d y .  possible  a g e n c i e s , and  of novice nurses  own t i m e  of t h e i r  research.  s t u d y would n o t have been  without  willingly  committee, Dr.  Although  were a l w a y s c l o s e  t h e two y e a r s  t h e y were f a r away i n m i l e s ,  i n thought  e n c o u r a g e m e n t when n e e d e d . memory o f my f a t h e r ,  over  and t h e r e w i t h words o f I dedicate this  Stephen  they  MacDonald.  vii  thesis  to the  1 CHAPTER ONE INTRODUCTION Background to the Problem Nurse leaders in education and practice settings have long been concerned about the role t r a n s i t i o n required if-  for  the beginning nurse practitioner (Goldenberg,  1987/1988; Talarczyk & Milbrant, 1988).  While Benner and  Benner (1979) described the change from student  to  practitioner as "a troubled passage at best" (p.  15),  Meir-Hamilton and Keifer (1986) depicted i t as "one of life's  most challenging role transitions" (p. 3).  In  essence, beginning practice in nursing can be the best of times or the worst of times. Varied approaches have been u t i l i z e d in an effort  to  ease the problem of troubled t r a n s i t i o n s (Goldenberg, 1987/1988; Talarczyk & Milbrant, 1988).  The most  prevalent is the use of preceptorship programs (Morrow, 1984).  In a preceptorship progam, a preceptor is "a  person, generally a staff nurse, who teaches,  counsels,  i n s p i r e s , role models and supports the growth and development of an individual (the novice)  for a fixed and  limited amount of time with the s p e c i f i c purpose of s o c i a l i z a t i o n into a new role" (Morrow, 1984, p. 4).  While the l i t e r a t u r e provides abundant anecdotal descriptions of the benefits of preceptorship programs (Chickerella & Lutz, 1981; Davis & Barham, 1989; Donius, 1988; Goldenberg, 1987/1988; Jennings, C o s t e l l o , Durkin, & Rotkovitch, 1986;  Metzger, 1986; Spears, 1986; S t u l l  1987) there is an obvious s c a r c i t y of research studies confirming the effectiveness of preceptorships in easing role t r a n s i t i o n experiences  of novice staff  nurses.  Studies of preceptorships have been conducted, (Allanach & Jennings, 1990; Clayton, Broome, & E l l i s , 1989; Dobbs, 1988; Giles & Moran, 1989; Huber,  1981;  Itano, Warren & Ishida, 1987; McLean, 1987; Sheetz, Shogan, Prior & K o l s k i , 1985).  1989  Among these, studies by  Giles and Moran; McLean; and Shogan, P r i o r , and K o l s k i ; essentially surveys. al.;  have been program evaluation,  satisfaction  Studies by Clayton et a l . ; Dobbs; and Itano et  investigated  t r a n s i t i o n in terms of the effects of  preceptorship on role mastery and role conceptions when preceptorship programs were used as part of student preparatory education.  Studies by Huber (1981) and  Allanach and Jennings (1990), examined the effect of preceptorship programs on the role t r a n s i t i o n of novice staff  nurse orientees;  however, only Huber's study  compared the effects of different types of  orientations  3 (internship versus preceptorship) on the role t r a n s i t i o n of novice staff  nurses.  Spears (1986) has called for research on the effect of preceptorship programs on newly graduated nurses. P a r t i c u l a r l y , for pre- and post-preceptorship measurements of novice nurse performance and s e l f concept,  to determine i f changes actually do occur as a  result of the preceptorship experience.  Myrick (1988)  concurs that research in this area is required.  "While  the underlying assumption for the use of preceptorship programs is that one-to-one learning furnishes an effective method of learning, there is limited empirical evidence to substantiate 1988, p.  i t s effectiveness"  (Myrick,  136). Problem Statement  It is presumed that preceptorship is indeed a useful orientation strategy which eases the role t r a n s i t i o n of novice staff  nurses; however, evidence necessary  substantiate  this b e l i e f  is lacking.  to  Research is needed  to examine the actual effect of preceptorships on the role t r a n s i t i o n of novice staff  nurses.  Specifically,  research is needed comparing the t r a n s i t i o n which occurs in orientations without preceptorships to the t r a n s i t i o n that occurs with preceptorships.  This comparison is  needed in order to determine whether differences t r a n s i t i o n of novice staff  in role  nurses can be attributed to  preceptorship programs. Purpose The purpose of this study was to examine the effect of preceptorship programs, used in hospital-based orientations,  on the role t r a n s i t i o n of novice  staff  nurses. Theoretical Framework Kramer's (1974) theory of r e a l i t y shock provided the theoretical framework for this study.  The r e a l i t y shock  concept is borrowed from the l i t e r a t u r e and the experience of culture shock.  Culture shock is the  surprise and imbalance f e l t when one moves from his/her accustomed culture to an unfamiliar culture that has different meanings and requires adjustment to previously familiar events (Kramer & Schmalenberg, 1977a).  Moving  from school to practice is comparable to moving into a new c u l t u r a l system in which ideals, rewards, and sanctions d i f f e r from those received in school. The term r e a l i t y shock is used predominantly in r e l a t i o n to the response of neophytes upon entry into a professional f i e l d (Kramer and Schmalenberg, 1977a).  It  characterizes the shock-like response of neophytes when  confronted with work experiences  for which they presumed  they would be prepared, but, find they are not prepared. The t y p i c a l shock-like response occurs when the novice senses professional ideals acquired at school are not appreciated in the work s e t t i n g .  The discrepancy in  values of the work and school cultures, which neophytes confront upon work entry, leaves them in a state of values c o n f l i c t , and thus, susceptible  to r e a l i t y shock.  In the theory of r e a l i t y shock, Kramer (1974) suggested the t r a n s i t i o n from student to novice nurse w i l l follow a predictable pattern. four phases: (4)  This t r a n s i t i o n process consists of  (1) honeymoon, (2) shock,  (3) recovery, and  resolution.  During the honeymoon phase, the novice usually perceives the world through rose-colored glasses.  In  this phase, one focuses on two primary concerns: (1) mastery of s k i l l s , and (2) s o c i a l integration into the work group (Kramer, 1974).  Since neophytes during  this phase are so absorbed'with the novel features of their work, they are l i k e l y to be i n e f f i c i e n t accurately appraising the work s i t u a t i o n .  in  "The sudden  r e a l i z a t i o n that nursing i s n ' t what one thought i t would be and the d i s s a t i s f y i n g  feeling that this evokes is  precursor to the shock phase" (Kramer & Schmalenberg,  the  6  1977a, p. 10).  When the novice experiences obstacles to  goal achievement, either due to lack of personal competency or due to system r e s t r i c t i o n s , the shock phase begins (Kramer, 1974). Characteristic features of the shock phase are: (1) moral outrage, (2) r e j e c t i o n , (3) fatigue, and (4) perceptual d i s t o r t i o n (Kramer, 1974).  Moral outrage is  the anger experienced at finding out things are not as they ought to be (Kramer & Schmalenberg, 1977a).  The  rejection component can either be a rejection of values acquired in school or a rejection of workforce norms/expectations.  Moral outrage and rejection are  draining and result in physical symptoms.  Often,  depression is the f i r s t indication that one is experiencing the shock phase.  In contrast to the  honeymoon phase, perception is distorted in the shock phase to the extent that everything has a g l o b a l l y negative outlook. fortunately,  The shock phase is depleting and  i t is time l i m i t e d .  Eventually, recovery or  resolution must occur. The recovery phase is i d e n t i f i e d by the return of a more r e a l i s t i c appraisal of the work s i t u a t i o n and by a return of one's sense of humor.  Tension and anxiety  levels decrease and there is a new sense of balance.  Accompanying this new balance is an i n i t i a l a b i l i t y to competently predict actions and reactions of others and an a b i l i t y to see more than one's own perspective. recovery phase is c r u c i a l to constructive  "The  conflict  resolution, because in this phase the newcomer  realizes  that previous perspectives and strategies probably w i l l not work and that new ones are c a l l e d for" (Kramer & Schmalenberg, 1977a, P.  17).  In the resolution phase, there are various ways in which r e a l i t y shock may be resolved; some are constructive,  while others are more detrimental.  Examples of various less functional means of resolving r e a l i t y shock include: (1) r e s t r i c t i n g involvement by performing at a minimally acceptable  level;  (2) transferring jobs frequently in an effort elusive perfect  to find the  job; or (3) withdrawing completely from  the profession to start a new career, or withdrawing temporarily from the profession only to return years later. The most constructive resolution is a b i c u l t u r a l adaptation,  in which the neophyte reevaluates school  learned values,  maintaining those that are beneficial and  meshing them with the r e a l i t i e s Constructive resolutions  of the work s i t u a t i o n .  are growth producing and enable  8 the person to integrate work values with school The interweaving of the two perspectives functional than either perspective  values.  is more  independently (Kramer,  1974). Kramer's (1974) description of r e a l i t y shock brought the d i f f i c u l t i e s ,  that new graduates have in making the  adjustment to p r a c t i c e , to the attention of the nursing profession. setting  Kramer found the f i r s t year in a hospital  is often marked by dramatically c o n f l i c t i n g value  systems, s p e c i f i c a l l y ,  the idealism of education and the  r e a l i t y of nursing p r a c t i c e .  Studies by Stewart-Dedmon  (1988) and Horsburgh (1989) concur with Kramer's finding that,the discrepancy between the ideal mode learned in their education program and the r e a l i t y of the bureaucratic mode practiced and enforced in the work setting  is the primary cause of r e a l i t y shock for new  graduates. Kramer and Schmalenberg (1977a) i d e n t i f i e d students are usually presented with the r e a l i t y of the nursing u n i t .  "front-stage"  This front-stage  the appearance that the unit staff audiences  that  portrays for  r e a l i t y is specific  (students, faculty, and administration).  "Following employment the new graduate discovers or uncovers the "back-stage" r e a l i t y , the things that go on  9 everyday when everyone's guard is down and they are not putting their best foot forward.  It causes a great deal  of anger because these new graduate nurses had not been prepared for the back-stage r e a l i t y " (p.  11).  The manner in which a neophyte reconciles this  conflict  greatly determines whether the person w i l l remain in the profession (Ahmadi, Speedling & Kuhn-Weissman, 1987; Kinney, 1985; Kramer, 1974 ). dissatisfied  Many new graduates,  and frustrated, opt to leave the profession  within the f i r s t year of graduation (Fisher & Connelly, 1989; Jennings et a l . , 1986; McLean, 1987).  Experiencing  r e a l i t y shock, the novice s t a f f nurse has d i f f i c u l t y in practicing nursing in the work environment. Health care organizations have established the need for the nursing role and have instituted demands about a c t i v i t i e s that ought to occur in the role (Rubin, 1988). The nurse must perform a c t i v i t i e s demanded by the organization to successfully  fulfill  the nursing r o l e .  The novice staff nurse's f a i l u r e to function immediately as a seasoned and competent professional nurse has been attributed to inadequate s o c i a l i z a t i o n to the  realities  of the professional r o l e , rather than to inadequate theoretical knowledge (Benner & Benner, 1979).  10 According to Watson (1983) professional  socialization  is the complex process by which a person acquires the knowledge, s k i l l s , and the sense of identity that are c h a r a c t e r i s t i c of a member of that  profession.  S o c i a l i z a t i o n is aimed at learning new values, attitudes,  beliefs,  and behaviours; and in resynthesizing  previously learned material in resolving  conflicts  between and among various role expectations which comprise the role complex (total roles a person occupies). S o c i a l i z a t i o n and Reality Shock S o c i a l i z a t i o n into an occupational role  entails:  s h i f t i n g focus from broad professional goals to work tasks,  specific  i n t e r n a l i z i n g values of the occupational  group, and adopting prescribed behaviours (Leddy & Pepper, 1985).  The l a t t e r refers to the behaviors one  must display according to the norms of the group.  reference  Professional role expectations are transmitted  and maintained through education and regulatory processes (Corwin & Taves, 1962). experiences  Thus, through s o c i a l i z a t i o n  one learns the expectations of a p a r t i c u l a r  role. Prior to entering p r a c t i c e , much of the knowledge nurses acquire in terms of the professional nursing role  is provided by the faculty of their preparatory education program (Conway, 1983).  Frequently, however, the role  expectations of educators are incongruent with those of practitioners.  Yet, "it is the culture of the p r a c t i c i n g  nurse whose role expectations" novice nurses w i l l encounter and have to reconcile when they begin practice (Clayton, Broome & E l l i s ,  1989, p.  72).  Deficient role s o c i a l i z a t i o n can lead to role (Hardy & Conway, 1988).  conflicts  According to Rendon (1988) role  incongruence creates role c o n f l i c t s which interfere with efficient  role performance.  Beginning nurses are  inexperienced in dealing with role c o n f l i c t s created by the clashing of bureaucratic goals with the professional ideals learned at school. Dobbs (1988) identified that successful  role  t r a n s i t i o n , from student to practitioner in nursing, requires an integration of the three nursing role conceptions  (professional,  bureaucratic, and s e r v i c e ) .  This integration is necessary in order that the novice nurse may "accomplish bureaucratic goals while maintaining professional standards and q u a l i t y care" (Dobbs, 1988, p. 167).  The orientation process is an  important factor affecting role development and role t r a n s i t i o n (DiMauro & Mack, 1989).  According to Itano et a l . (1987) novice nurses need guidance in developing competence in practice while preserving professional conceptions emphasized in education.  Several authors suggest preceptorship  programs provide such guidance (Clayton et a l . ,  1989;  Dobbs, 1988; Goldenberg, 1987/1988; Itano et a l . , Patton, Grace & Rocca, 1981).  1987;  These programs a s s i s t  neophytes to reconcile c o n f l i c t s between values acquired in school with those of the c l i n i c a l practice environment. Preceptorship Programs and S o c i a l i z a t i o n The primary goals of preceptorship programs are (1)  to  a s s i s t novice nurses with s o c i a l i z a t i o n to professional and bureaucratic nursing roles and (2) to a s s i s t with s k i l l a c q u i s i t i o n needed for successful  role performance.  Preceptors serve as role models and resource persons for novice nurses.  Preceptors are oriented to the roles  and functions of the preceptor. such topics as:  objectives  Their orientation covers  of the preceptorship program,  functions of the preceptor r o l e , adult learning p r i n c i p l e s , stages of adjustment of novice staff  nurses,  and methods of formative and summative evaluation (Modic & Bowman, 1989).  The preparation of preceptors for the  role and the preceptorship program's one-to-one  arrangement distinguishes orientation program.  i t from a t r a d i t i o n a l  The l a t t e r  where various experienced nurses,  is a "buddy system" none of whom receive  preparation for the r o l e , are "buddied with" the  neophyte  during the orientation period (Morrow,.1984). Preceptors provide guidance to neophytes in role s o c i a l i z a t i o n and in gaining competence in role performance in the practice setting (Clayton, 1989; Dobbs, 1988).  The preceptor provides the neophyte with a  model of performance to emulate in order to f u l f i l l  the  performance expectations of p r a c t i c e .  In turn,  the  neophyte internalizes role conceptions  that are congruent  with the role of practicing professional nurses. preceptors f a c i l i t a t e  Thus,  role t r a n s i t i o n of novice nurses by  promoting role s o c i a l i z a t i o n and role performance. Dobbs (1988) contends when new graduates are not assisted with the t r a n s i t i o n into the work role they frequently resolve the c o n f l i c t of r e a l i t y shock in negative rather than constructive ways.  For example,  (1) values associated with professional practice are diminished or rejected,  or (2) values appreciating  attainment of bureaucratic goals are discarded and active practice is abandoned.  Orientation programs and  preceptorship programs have been used in f a c i l i t a t i n g  the  14 t r a n s i t i o n from school to p r a c t i c e .  It is suggested that  preceptorship programs are the most effective vehicles  to  f a c i l i t a t e role s o c i a l i z a t i o n of novice nurses. In summary, preceptorship programs offer a means of easing the t r a n s i t i o n from student to novice staff practitioner.  nurse  This is accomplished through assistance  provided to the neophyte in the areas of s k i l l mastery and s o c i a l integration.  In addition, preceptorships are  believed to reduce the effects of r e a l i t y shock experienced by novice nurses. Definition of Terms For the purpose of this study the following d e f i n i t i o n s were used: Novice Staff Nurse is an individual beginning his/her f i r s t employment as a s t a f f  nurse.  Preceptor is an experienced registered nurse with a particular area of nursing expertise who can teach and guide the preceptee  (novice staff  nurse) and who has  received preparation prior to assuming the function of preceptor. Preceptorship program is a formal type of hospital orientation in which novice staff nurses are assigned to designated nurse preceptors.  Novice staff  nurses receive  individual guidance from their preceptors with whom they  rotate s h i f t s  over the course of the preceptorship  program. Traditional Orientation Program is a formal period in which the novice s t a f f nurse receives teaching and guidance in unit routine from a variety of experienced staff nurses.  These s t a f f nurses who provide guidance do  not receive educational preparation to assume this teaching r o l e . Role "is a set of expectations  about how a person in a  given position in a p a r t i c u l a r s o c i a l system should.act and how others in r e c i p r o c a l positions should act" (Kramer, 1974, p.  52).  Role Transition is the a l t e r a t i o n in expectations  related  to actions and reactions demanded by a change in role from student to novice staff  nurse.  Role t r a n s i t i o n was  measured by Schwirian's Six Dimension Scale of Nursing Performance and Corwin's Nursing Role Conception Scale. Role Conception is the internal representation of role expectations  held by an individual at a s p e c i f i c time  (Corwin, 1961). integration.  Role conception is a measure of s o c i a l  Corwin categorized nursing role conceptions  into three categories:  (1) professional role conception  (PRC) which indicates prime l o y a l t y to the nursing profession;  (2) bureaucratic role conception (BRC) which  indicates prime l o y a l t y to hospital administration; and (3) service role conception (SRC) which indicates prime l o y a l t y to the  patient.  Role Deprivation is the internal response f e l t by a nurse when circumstances  in the work environment r e s t r i c t role  portrayal such that the nurse perceives an ideal role conception to be non-functional in practice (Itano et al.,  1987; Dobbs, 1988).  Job Performance is the a b i l i t y to competently carry out nursing actions while in the practice s e t t i n g . important component of job performance is s k i l l  An mastery.  Job performance was measured using Schwirian's Six Dimension Scale of Nursing Performance. Research Hypotheses The research hypotheses examined in t h i s study were: 1. Role t r a n s i t i o n w i l l be perceived to be easier by novice staff  nurses who participate in a preceptorship  program than by novice staff  nurses who participate in a  t r a d i t i o n a l orientation program. 2. Job performance levels reported by novice staff  nurses  who participate in a preceptorship program w i l l be higher than those reported by novice staff  nurses who  participate in a t r a d i t i o n a l orientation program.  17 3. Perceived role deprivation reported by novice  staff  nurses who participate in a preceptorship program w i l l be less than that reported by novice staff  nurses who  participate in a t r a d i t i o n a l orientation program. Based on the hypotheses of this study, a diagram of the hypothesized role t r a n s i t i o n process occurring post workentry with preceptorship versus t r a d i t i o n a l oreintation programs is presented in Figure 1.  Upon leaving  educational programs, neophyes have p a r t i c u l a r role conceptions  and s k i l l l e v e l s .  When they enter the work  s e t t i n g , neophytes recognize that their role  conceptions  and s k i l l levels must be adjusted to the demands of the work environment.  This adjustment creates the values  c o n f l i c t associated with r e a l i t y shock.  Two possible  strategies to ease r e a l i t y shock ( t r a d i t i o n a l  orientation  programs and preceptorship programs) with the proposed impact of each on role t r a n s i t i o n are presented.  18  Role Conceptions Performance  Work  <r—Education Program  Level  Entry  Role T r a n s i t i o n Process  j  Socialization Traditional Orientation ^ Role T r a n s i t i o n  Preceptorship Orientation •T Role T r a n s i t i o n  F i g u r e 1. Hypothesized Role T r a n s i t i o n Process O c c u r r i n g Post Work-entry with P r e c e p t o r s h i p versus T r a d i t i o n a l O r i e n t a t i o n Programs.  Assumptions In t h i s study the f o l l o w i n g assumptions were a c c e p t e d : 1.  Beginning p r a c t i c e as a novice s t a f f  successful role 2.  Participants  nurse r e q u i r e s a  transition. w i l l p r o v i d e frank and honest r a t i n g s  of  t h e i r s e l f - p e r c e i v e d performance and r o l e c o n c e p t i o n on pre and p o s t - t e s t s . 3.  Role t r a n s i t i o n  can be assessed u s i n g C o r w i n ' s  Nursing Role Conception S c a l e and S c h w i r i a n ' s 6-D S c a l e . 4.  P r e c e p t o r s in the p r e c e p t o r s h i p program have  p r e p a r a t i o n p r i o r to assuming the preceptor  role.  received  19 Limitations and Delimitations The recognized limitations and delimitation of this study were: Limitations 1.  Random selection  or random assignment  into the  t r a d i t i o n a l orientation and preceptorship groups was not feasible. 2.  There are some factors that could not c o n t r o l l e d .  These included: (a) hospital staffing needs, (b) assignments of orientees and preceptees,  and (c)  multiple unit and hospital v a r i a t i o n s . Delimitation 1.  The length of time to complete the study was  circumscribed, so i t was not possible to measure longterm role adjustment.  The adjustment during the  first  month of orientation was examined. Significance of the Study In the present climate of economic restraints and nursing shortages,  the orientation of nurses is a  s i g n i f i c a n t aspect of a nursing department's program and budget (Plewellyn & Gosnell, 1987; Hoffman, 1985; Mooney, Diver, & Schnackel, 1988).  According to Flewellyn and  Gosnell the cost of orientating one nurse i s estimated be between 1500 and 3000 d o l l a r s .  to  Flewellyn and Gosnell  20 note that to j u s t i f y the investment  in orientation  programs, nursing departments must be able to outcomes.  identify  That i s , the relationship among the  orientation method, performance in the c l i n i c a l area, and retention of nurses.  Increasingly, nursing departments  w i l l be c a l l e d on to j u s t i f y expenditures such as those associated with preceptorship programs used to orient novice staff  nurses.  To be able to j u s t i f y the need f o r ,  and the appropriateness of such resource a l l o c a t i o n , research on the effect of preceptorship programs is essential. Furthermore, given the problems associated with retaining nurses in the profession,  and the contention  that preceptorship programs ease role t r a n s i t i o n difficulties,  i t is important that their effectiveness in  this area be substantiated through research.  Scope of the Study This thesis is organized into six chapters.  Included  in Chapter One are the study problem, the purpose,  its  significance and the research hypotheses. In addition, the theoretical framework is explained and i t s  link to  s o c i a l i z a t i o n and role t r a n s i t i o n is i l l u s t r a t e d . Chapter Two selected l i t e r a t u r e on preceptorships  In is  21  reviewed.  In Chapter Three research methods and  procedures are described.  In Chapter Four findings are  presented.  In Chapter Five analysis of findings  discussed.  In Chapter Six the summary, conclusions, and  implications are presented.  is  CHAPTER TWO REVIEW OF THE LITERATURE Selected l i t e r a t u r e relevant to preceptorships reviewed in this chapter.  is  Factors instrumental in  motivating nurse administrators to use preceptorship programs for orientation of novice nurses are discussed. Review of l i t e r a t u r e on preceptorships covers anecdotal and research l i t e r a t u r e , but focuses on the  latter.  Development of Preceptorship Programs H i s t o r i c a l l y , a standard orientation has been provided by the inservice education department. anywhere from one to two weeks.  It usually lasted  This general hospital  orientation focused on global topics such as hospital philosophy, p o l i c i e s and procedures.  Subsequent to the  hospital-wide orientation, the new employee participated in an informal orientation to the nursing u n i t . Different nurses were buddied with the novice nurse to advise her/him in the unit routine, and to provide informal help and guidance (Shamian & Inhaber, 1985). However, these orientation programs were inadequate in providing structured learning of the unit routine, and in a s s i s t i n g with s o c i a l i z a t i o n to the staff  nurse r o l e .  This d e f i c i t resulted in increased anxiety levels in new graduates.  The deficiencies  of this buddy system for  orientation of novice nurses, raised concern among nurse managers.  Its  i n e f f i c i e n c y in orienting neophytes to  the unit routine, and in a s s i s t i n g them with role s o c i a l i z a t i o n , was associated with high staff  turnover,  r e a l i t y shock, early burnout, and low morale among both novice and experienced nurses (Shamian & Inhaber, 1985). In order to reduce the anxiety resulting from adjustment to the new work m i l i e u , preceptorship programs were developed.  These programs range from two weeks to four  months in duration (Shamian & Inhaber, 1985). According to Shamian and Inhaber (1985) implementation of the preceptorship model appears to be in response  to  the i d e n t i f i e d needs of both nursing service and nursing education personnel.  However, Backenstose  (1983)  contends preceptorship is not a t o t a l l y new concept in nursing; from i t s  inception nursing has used a type of  apprenticeship or preceptorship model in which practicing nurses educated students and novice nurses.  Although  preceptorships take advantage of apprenticing neophytes with experienced nurses, there is an important d i s t i n c t i o n between apprenticeship and preceptorship. The difference  is that, while apprenticeship is synonmous  with an informal buddy system; preceptorship,  is  apprenticeship but with an "enlightened guide" who is  24  prepared for the formal and informal teaching function. The underlying assumption of preceptorship programs is that the one-to-one learning experience with an seasoned role model, (1) eases t r a n s i t i o n of neophytes into the staff  nurse r o l e ; and (2)  facilitates  neophytes into the work group.  integration of  This is based on the  assumption that the experienced preceptor orients  the  neophyte to norms and expectations of the reference peer work group to which the novice wishes to become an accepted member.  In the preceptorship model "integration  of the new employee into the unit is f a c i l i t a t e d by someone who is close to the scene of a c t i v i t y and there is good reason to believe that a peer relationship better able to affect Inhaber, 1985,  p. 80).  is  the required learning" (Shamian & In this model, the preceptor  provides an immediate resource person for the novice nurse during the t r a n s i t i o n period (Metzger, 1986). Benefits of Preceptorship Many anecdotal a r t i c l e s have been written on the benefits of preceptorship programs for anticipatory s o c i a l i z a t i o n whereby students,  as part of their  education program, work with hospital preceptors (Chickerella & Lutz, 1981; Davis & Barham, 1989; Donius, 1988; Estey & Ferguson, 1985; Fisher & Connolly, 1989;  25 Jennings et a l . , 1986; Limon, B a r g a g l i o t t i , & Spencer, 1982; Rodzwick, 1984; Spears, 1986; Wheeler, 1984).  In  addition, many anecdotal a r t i c l e s have also been written on the benefits of preceptorship programs for orientation of new employees, p a r t i c u l a r l y new graduates  (Friesen &  Conohan, 1980; Goldenberg, 1987/1988; Marchette, 1985; McGrath & Koewing, 1978; Modic & Bowman, 1989; Patton, Grace & Rocca, 1981; Schempp & Rompre, 1985; Shogan et al.,  1985).  The use of preceptorship programs both in  education and practice settings is strongly endorsed by a l l cited authors.  Benefits of preceptorship programs  can be summarized to include the following: (1) helping novice staff  nurses to develop s k i l l  mastery;  (2) f a c i l i t a t i n g the role t r a n s i t i o n of novice staff nurses by a s s i s t i n g them to link educational and practice experience;  (3) reducing problems associated with r e a l i t y  shock; (4) s o c i a l i z i n g and integrating the novice  staff  nurse within the unit; and (5) enhancing professional growth and job s a t i s f a c t i o n  for staff  nurses who function  as preceptors (Shamian & Inhaber, 1985). Research on Preceptorship Despite the evident interest in preceptorship,  there  has been limited research on the effect of preceptorship programs on novice staff  nurses in terms of role  t r a n s i t i o n or performance outcomes.  Huber (1981)  conducted a study to investigate the effect of preceptorship and internship orientation programs on graduate nurse performance.  According to Huber (1981)  internship orientation programs, d i f f e r  from  preceptorship. programs in that they are less i n d i v i d u a l l y monitored and r e l y on various non-designated guide the novice.  nurses  to  The internship orientation in Huber's  study is synonymous to the orientation provided by the t r a d i t i o n a l orientation programs of the present  study.  The focus of Huber's study was to determine i f graduate nurses completing a hospital-based  preceptorship  orientation perceived their performance more p o s i t i v e l y than graduate nurses completing a hospital-based internship orientation program.  Participants in the  preceptorship orientation program group each had a designated nurse preceptor to guide them and to act as a role model.  The internship orientation group did not  have designated preceptors.  Study participants  their performance a b i l i t y before and after respective  orientations.  evaluated  their  Performance a b i l i t y was  measured using the Six Dimension Scale of Nursing Performance (6-D Scale) at pre and post orientation. Analysis of the differences  between the groups f a i l e d to  27 show any s i g n i f i c a n t  differences.  Olsen, Gresley, and Heater (1984) examined an eight week undergraduate c l i n i c a l course to determine i f  it  would strengthen nursing students* perception of competence and self-concept.  The study sample was  composed of 48 students which included eight interns, five non-interns, and 36 c o n t r o l . design was employed.  A pretest,  post-test  Instruments used in the study were  the Tennessee Self-Concept Scale and the 6-D Scale.  Data  analysis using ANOVA with a 0.05 significance level found no s i g n i f i c a n t difference between the groups. however, the numbers in the intern and  Since  non-intern groups  were so small, power to detect s i g n i f i c a n t  differences  between the groups was low. A study conducted in Canada by Shamian and Lemieux (1984) evaluated whether there was any difference in the effectiveness of two teaching methods in enhancing the knowledge base of p a r t i c i p a t i n g nurses.  The two teaching  models that were evaluated were the preceptor teaching model and the formal teaching model.  The study sample  was composed of a l l nurses (registered nurses and nursing assistants) who worked on 14 designated units within a 600-bed h o s p i t a l .  The participants completed two scales:  the f i r s t , immediately following teaching sessions; and  28 the second, after a three month time i n t e r v a l .  The  findings of this study were that the preceptorship model of teaching resulted in better outcomes in terms of knowledge attainment, s k i l l s , educational program attendance, and assessment c a p a b i l i t i e s when compared to the t r a d i t i o n a l teaching method.  Despite the fact that  this study concluded that the preceptorship model of teaching was superior to the t r a d i t i o n a l methods,  its  findings cannot be generalized as the study was limited to one hospital in eastern Canada, and potential for bias arises out of. the heterogeneous sample used in the study. Itano et a l . (1987) studied whether there was a difference  in role conceptions and role deprivation in  students who participated in a preceptorship program and those students who did not.  The study included 118  students of a baccalaureate nursing program.  Role  conceptions and role deprivation were measured using Corwin's Nursing Role Conception Scale. study demonstrated no differences  Results of t h i s  between the groups in  role conceptions or role deprivation; In 1988 Dobbs conducted a study to investigate  the  effect of a preceptorship program used in the senior year of baccalaureate nursing education program as a method of providing students with anticipatory s o c i a l i z a t i o n to the  29 work role of professional nurses.  The study measured  role conceptions and role deprivation immediately before and after a preceptorship program using Corwin's Nursing Role Conception Scale.  The study sample consisted of 103  generic baccalaureate students.  Results of this study  indicated a s i g n i f i c a n t difference at p <.01 role deprivation.  in perceived  The author suggests that this  result  supports the effectiveness of a preceptorship program in promoting anticipatory s o c i a l i z a t i o n to the work role of professional nursing.  However, since a l l subjects in  four different groups received the same treatment (preceptorship) one needs to question the degree to which preceptorship, as opposed to another teaching strategy, accounts for the change in the measures over the two testing periods. Clayton et a l . (1989) examined the effect of a preceptorship experience on role s o c i a l i z a t i o n of graduate nurses.  The sample consisted of two groups,, one  having a preceptorship experience in the f i n a l quarter of the baccalaureate program (n=33) and one group having a faculty member providing a "traditional" c l i n i c a l learning experience  (n=33).  Schwirian's 6-D Scale was  completed by each group three times: prior to the course, immediately following the course, and six months after  graduation.  Results of the study only p a r t i a l l y  supported the hypothesis that there would be s i g n i f i c a n t differences between the groups on the six subscales.  At  six months follow-up there was a s i g n i f i c a n t difference between the groups with the preceptor group scoring higher on the: (a) leadership (p.004); (b) teaching/collaboration (p.01);  (c) interpersonal  relations /communications (p.008); and (d) planning/ evaluation (p.009) subscales.  However there was no  s i g n i f i c a n t difference between the groups on the professional development (p.11) and c r i t i c a l care (p.21) subscales. Sheetz (1989) investigated the effect of nursing student preceptorship programs on the development of nursing student competence among 72 senior baccalaureate students.  A non-equivalent comparison group, pretest,  post-test design was used.  The sample consisted of a  treatment group of 36 students who participated in nursing student preceptorship programs and a comparison group of 36 students who worked as nursing assistants in a non-instructional c l i n i c a l s e t t i n g .  Head nurses on the  units to which the subjects were assigned observed the subjects on each of the f i r s t three days of the second (pretest) and tenth (post-test) weeks of the  preceptorship or nursing assistant experience.  At the  end of the t h i r d day of observation, head nurses rated the student's c l i n i c a l competence using the C l i n i c a l Competence Rating Scale.  Results indicated students who  participated in summer preceptorship programs gained greater levels of c l i n i c a l competence,  than did students  who worked as nursing assistants in non-instructional c l i n i c a l settings. Giles and Moran (1989) compared the orientation satisfaction  outcomes of nurses oriented by a buddy  system with those nurses oriented by the preceptorship program.  Results indicated nurses oriented by the  preceptorship program method were more s a t i s f i e d  than  those nurses who were oriented by the buddy system (p<0.01).  However, caution must be used since concurrent  and retrospective comparisons of subject experiences orientation may have biased  with  results.  Allanach and Jennings (1990) investigated  whether an  eight week preceptorship program at one m i l i t a r y medical center eased the t r a n s i t i o n process of new graduates (N=44).  A repeated measures design was used to assess  changes in preceptees affective  states over time.  Participants completed the Multiple Adjective Affect Checklist and the I-E Scale (which measures  32 internal/external locus of control) at: one week prior to the preceptorship program; at the end of the program; and at f i v e , and 16 weeks after completion of the preceptorship program.  Although the results f a i l e d to  support the contention that the t r a n s i t i o n from student to staff  nurse did generate anxiety, participants did  verbalize feelings of psychological tension.  Allanach  and Jennings suggest a possible explanation for this result is that the preceptorship program i t s e l f in the more positive affective  resulted  states of p a r t i c i p a n t s .  They identify that a control comparison group who had not had a preceptorship experience would have been b e n e f i c i a l in terms of interpreting the effect of preceptorship on transition  experiences. Summary  In summary, the various studies on preceptorship have resulted in inconsistent  findings.  More research on  preceptorship is needed to substantiate  the b e l i e f  preceptorship is a useful orientation strategy.  that  This  study investigated the effect of preceptorship on role t r a n s i t i o n of novice staff used as an orientation  nurses when preceptorship was  strategy.  33 CHAPTER THREE METHODS AND PROCEDURES Reseach design, methods and procedures are presented in this chapter. Design A quasi-experimental, control group pretest design was used.  post-test  This design was appropriate in that  random selection and assignment Were not  feasible.  Whether novice staff nurses participated in a preceptorship program depended completely on the type of orientation program used by the employing agency. Setting The study was conducted in three t e r t i a r y hospitals in lower mainland B r i t i s h Columbia, one of which uses a preceptorship program and two others which do not use preceptorship programs for orientation of new nursing staff.  These hospitals range in size from 575 to 875  beds. The preceptorship program consisted of a three day central nursing orientation and one-half day general hospital-wide orientation (Appendix A ) . t h i s central o r i e n t a t i o n , novice staff  Subsequent to nurses were  assigned to designated preceptors by the head nurse of their respective wards.  Novice staff  nurses were  34 preceptored for two to three weeks. Head nurses of the respective  units are responsible, for  assigning the preceptors to work with novice nurses.  staff  Experienced nurses who are selected to be  preceptors participate in a four-hour Preceptor Development Program prior to assuming the preceptor role (Appendix B). One of the t r a d i t i o n a l orientation programs consisted of three and one-half days central nursing orientation followed by up to a maximum of 11.5 s h i f t s in which novice staff staff  nurses are buddied with various  nurses on their respective  experienced  wards : (Appendix C ) .  The other t r a d i t i o n a l orientation program included four days of central orientation, one-half day central hospital-wide  orientation, and one day unit  orientation (Appendix D).  specific  Following t h i s central  o r i e n t a t i o n , novice nurses on average received an additional two days of unit s p e c i f i c  orientation.  Sample C r i t e r i a and Selection A convenience  sample (N=34) of novice staff  their f i r s t - t i m e employment as staff from three t e r t i a r y hospitals Columbia.  nurses in  nurses was obtained  in lower mainland B r i t i s h  Although role t r a n s i t i o n is required with a l l  role changes, t h i s study focused on the role t r a n s i t i o n  35  of novice nurses.  Accordingly, the sample selected was  limited to novice s t a f f nurses in their employment as staff  first-time  nurses, a l l of whom, were undergoing  a similar role change; student to novice s t a f f  nurse.  I n i t i a l contact with three potential p a r t i c i p a t i n g agencies was made to determine the f e a s i b i l i t y of obtaining the needed study sample.  Because limited  s t a t i s t i c s were kept on the preceptorship and orientation progams, i t was not always possible to extrapolate the number of participants who were novice s t a f f nurses in their f i r s t - t i m e employment.  However, one hospital that  used a t r a d i t i o n a l orientation program indicated on average over the last two years i t had s i x new graduates per month on o r i e n t a t i o n .  This same hospital indicated  that 42 percent of the nurses they employ annually are new graduates.  In descending order, t h i s hospital had  the greatest numbers in orientation during the months of September, January, and June. Another hospital that used a t r a d i t i o n a l orientation program orientated 177 nurses during the previous year, but was unable to determine of that number how many were novice s t a f f nurses.  The months with the highest,  proportion in orientation were January, October, September, and June respectively.  36 The t h i r d h o s p i t a l used a p r e c e p t o r s h i p program and employed 240 novice s t a f f year.  The months with the l a r g e s t  graduates June.  nurses during, the, p r e v i o u s  i n o r i e n t a t i o n were January, September, and  Based on i n i t i a l c o n t a c t  three a g e n c i e s , study sample.  requested  and d i s c u s s i o n with these  i t appeared f e a s i b l e  to o b t a i n the  needed  Agency approval to conduct the study was  obtained from the three A letter  p r o p o r t i o n of new  institutions.  (Appendix B) which e x p l a i n e d the study and p a r t i c i p a t i o n was d i s t r i b u t e d to  study p a r t i c i p a n t s  (novice  staff  time employment i n n u r s i n g ) . from v o l u n t e e r s  contacted  nurses  potential  in their  first  The sample was selected..  through v i s i t s by the  r e s e a r c h e r to the p a r t i c i p a t i n g a g e n c i e s ' o r i e n t a t i o n or p r e c e p t o r s h i p program d u r i n g the f i r s t respective  programs.  the  The r e s e a r c h e r e x p l a i n e d the  addressed any questions requested  week of  from p o t e n t i a l  study,  p a r t i c i p a n t s and  their participation.  Persons who met the sample c r i t e r i a and those agreeing to p a r t i c i p a t e completed three s c a l e s : a Demographic Data Sheet (Appendix F ) , S c h w i r i a n ' s S i x Dimension Scale of Nursing Performance (Appendix G ) , and Corwin's Nursing Role Conception Scale  (Appendix H ) .  Completion of these s c a l e s r e q u i r e d approximately 20  37 minutes.  Participants supplied their names and addresses  to the researcher to use for the mailout of questionnaires  for the second data c o l l e c t i o n .  One month l a t e r , the 6-D Scale and the Nursing Role Conception Scale with an accompanying l e t t e r , to participants for completion.  were sent  Two weeks after  the  second set of questionnaires were mailed, reminder l e t t e r s encouraging reply to the follow-up scales were sent to participants who had not to date returned questionnaires. u n t i l February,  Data were collected from October, 1989 1990.  Protection of Human Subjects E t h i c a l approval to conduct this study was granted by the University of B r i t i s h Columbia Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects and by E t h i c a l Review Committees in p a r t i c i p a t i n g agencies. Participants in the study were given a l e t t e r explaining the purpose of the study and the requirements involved in p a r t i c i p a t i o n .  In addition, they were given  an opportunity to question the researcher about the study.  They were informed that individual responses to  the study would be kept c o n f i d e n t i a l , that they could withdraw from the study at any time, and completion of  38 the q u e s t i o n n a i r e s  i m p l i e d consent by the respondent  p a r t i c i p a t i o n i n the  study.  To maintain c o n f i d e n t i a l i t y , assigned  each p a r t i c i p a n t was  a code number so t h a t names of s u b j e c t s d i d not  appear on the completed q u e s t i o n n a i r e s . assigned the  to  Previously  code numbers with an added "A" were a f f i x e d  f o l l o w - u p s c a l e s to maintain c o n f i d e n t i a l i t y  to  and to  a l l o w comparison of s u b j e c t ' s p r e t e s t and p o s t - t e s t scores. Measurement of V a r i a b l e s The independent  v a r i a b l e was the type of  orientation.  Subjects  i n the experimental  hospital  where the p r e c e p t o r s h i p program was in  and, t h u s ,  were assigned  group were those i n the  to a designated  effect  preceptor(s)  the d u r a t i o n of the p r e c e p t o r s h i p program and the  for  study.  The assignment of the preceptor was p a r t of t h a t  agency's  p r e c e p t o r s h i p program and under the d i r e c t i o n of  the  agency not the  investigator.  the presence of designated  The treatment  effect  nurse preceptors  i n the  p r e c e p t o r s h i p group and a lack of designated  was  preceptors  i n the t r a d i t i o n a l o r i e n t a t i o n group.  The dependent  v a r i a b l e s t u d i e d was r o l e t r a n s i t i o n .  T h i s v a r i a b l e was  measured by two s c a l e s : S c h w i r i a n ' s Six Dimension of Nursing Performance  Scale  (1978) and Corwin's Nursing Role  39 Conception Scale  (1961). Instruments  Data were c o l l e c t e d  using two instruments:  Schwirian's  Six Dimension Scale of Nursing Performance ( 6 - S c a l e ) and Corwin's Nursing Role Conception S c a l e . Six Dimension Scale of Nursing Performance The Six Dimension Scale of Nursing Performance (6-D Scale)  c o n s i s t s of 52 items c a t e g o r i z e d  into  six  dimensions of n u r s i n g performance: t e a c h i n g / collaboration,  critical  interpersonal relations development,  care,  planning/evaluation,  /communications,  and l e a d e r s h i p  (Appendix G ) .  professional Subscale  items  i n the  i n t e r p e r s o n a l r e l a t i o n s / c o m m u n i c a t i o n s dimension  relate  to n u r s e ' s  behavior i n the realm of communication  and i n t e r p e r s o n a l r e a l t i o n s h i p s with c l i e n t s colleagues.  T h i s subscale  and  i n c l u d e d such items as h e l p i n g  a p a t i e n t communicate with o t h e r s ,  and c o n t r i b u t i n g to  p r o d u c t i v e working r e l a t i o n s h i p s with other h e a l t h team members. actions  L e a d e r s h i p subscale dimensions r e l a t e  to  that the nurse would employ i n e n a c t i n g a  leadership function.  T h i s subscale  i n c l u d e d such  items  as the a b i l i t y to guide other h e a l t h team members and to delegate e f f e c t i v e l y . into nursing a c t i v i t i e s  The c r i t i c a l associated  care subscale with care of  taps  c r i t i c a l l y i l l patients.  It includes such items as  functioning calmly in emergency s i t u a t i o n s , and recognizing and meeting the emotional needs of a dying patient.  The teaching and collaboration subscale  depicts  behaviors in which the nurse teaches the c l i e n t / f a m i l y , as well as, behaviors indicative of the collaborative role of nurses with patients, professionals.  families, and other health  It includes such items as teaching  preventive health measures and encouraging the family to participate in the c l i e n t ' s  care.  The planning and  evaluation subscale comprises behaviors involved in planning and evaluating the c l i e n t ' s professional development subscale  nursing care.  The  describes  c h a r a c t e r i s t i c s of professionalism, such as> using learning opportunities for ongoing personal and professional growth. The Six Dimension Scale of Nursing Performance was designed to be used for s e l f - a p p r a i s a l of performance, supervisor evaluation of performance and/or for nurse graduates' ranking of the adequacy of their nursing education program (Schwirian, 1978).  Approval to use  this scale was obtained from the copyright holder. Respondents use a four point Likert type rating scale .,to .indicate how well or how frequently they engage in  described behaviours.  On the f i r s t 42 items,  rate how well they perform on the i d e n t i f i e d  subjects activities  (l=not very well, 2=satisfactorily,  3=well, 4=very well,  X=not expected  On the f i n a l 10 items  in my current job).  on professional development,  subjects rate the frquency  with which they engage in specified behaviors (l=seldom, 2=occasionally,  3=frequently,  4=consistently).  Each  of the six subscales of the Six Dimension Scale of Nursing Performance is comprised of a different number of items: leadership (5); c r i t i c a l care (5); collaboration (11);  planning/evaluation  teaching/ (7);  interpersonal relationships/communication (12); and professional development difference  (10).  Because of  this  in number of subscale items the scoring  formula was:  X....Xn n -m  where X . . . X n = the numerical rating for each behavior in the subscale;  n= the t o t a l number of items in the  subscale; m= the t o t a l number of items in the for job".  which the subject rated "not expected  subscale  in my current  Use ..of this formula ensured the elimination of any  scoring penalty for those items which were not  expected  in the current job (Schwirian, 1978). Content and construct v a l i d i t y of this scale was established during i t s development.  Following an  extensive l i t e r a t u r e review of concepts, constructs, and measures to describe nursing performance, deans and directors of 151 schools of nursing were asked to provide operational d e f i n i t i o n s of effective  nursing performance.  These same i n d i v i d u a l s , along with experienced nurse educators, researchers, and administrators served as p i l o t respondents to review and c r i t i q u e the developing scale.  Respondents were consistently asked to consider  whether any of the items were biased in favour of, or against, any of the three types of nursing programs. bias was evident (Schwirian, 1978).  No  From an i n i t i a l pool  of 76 nursing behaviours, following factor analysis, 52 items loading on the six sub-scales were retained. R e l i a b i l i t y was calculated using Chronbach's alpha for each of the subscales.  The alpha coefficients  ranged in  value from 0.84 for the leadership subscale to 0.98 for professional development subscale (Schwirian, 1978).  In  a study by Clayton et a l (1989) r e l i a b i l i t y measures for this scale using a sample of 66, ranged from a low of 0.73 for the leadership subscale to a high of 0.96 for the professional development subscale. Nursing Role Conception Scale Corwin's (1961) Nursing Role Conception Scale (Appendix H) was developed to measure role conceptions and role  deprivation. hospital  It  b u r e a u c r a c y , the  patient.  The s c a l e  situations. agree, the  l=strongly  Six  eight  ought  principles  to  role  that  profession.  job  of  the  nursing  (5=strongly indicate  way i t  the  way  actually  professional  rules  role  Differences  to  and  and  the  to  conception  the  to  which d e p i c t  organization  nursing administration. n u r s i n g as  a primary  loyalty  to  the  the  The a calling  patient.  " a c t u a l " and " i d e a l " s c o r e s yield  use  the  this  total  the  and s u g g e s t s  to  added t o  nursing  refers  refers  role  s c a l e was  for  deprivation  granted  by  the  holder.  C o n t e n t v a l i d i t y was the  occupational  conception  Permission to  copyright  to  loyalty  and r e g u l a t i o n s  between t h e  item are  refers  primary  in a specific  and s u g g e s t s  during  the  the  bureaucratic subscale,  conception  suggest  primary a l l e g i a n c e  score.  be and a l s o  each  and  22 h y p o t h e t i c a l  respondents  Bureaucratic role  administrative  service  of  to  subscales.  Professional  each  disagree),  items comprise  nurse's  allegiance  nursing profession,  consists  i t e m s make up t h e  service  respondents'  Using a L i k e r t - t y p e r a t i n g ,  situation  is.  assesses  development  demonstrated  construct  established of  the  by C o r w i n  scale.  and p r e d i c t i v e  Kramer  (1961) (1970)  v a l i d i t y at  the  0.01 level of confidence. coefficients 0.86 s e r v i c e , professional.  The t e s t - r e t e s t r e l i a b i l i t y  for the role conception subscale were: (b) 0.89 bureaucratic, and (c)  (a)  0.88  Other nurse researchers have used this  scale in recent studies but have not reported any new information in terms of the r e l i a b i l i t y of t h i s  scale  (Dobbs, 1988; Itano et a l . , 1987). In a series of studies u t i l i z i n g Corwin's Nursing Role Conception Scale (1961), i t has been found that the mean role deprivation score of graduate nurses working for at least one year is 23.  The shock phase of r e a l i t y shock  is associated with scores greater than 30 (Kramer,  1974,  p.102). Data Analysis Descriptive s t a t i s t i c s  were used to describe the groups  in terms of such demographics as: sex,  age, academic  preparation, and previous c l i n i c a l experience in the employing agency prior to employment as s t a f f  nurses.  Because these demographic data were of a nominal l e v e l , chi-square analysis was conducted. statistic  The chi-square  tests whether observed proportions d i f f e r  s i g n i f i c a n t l y from expected (Glass & Hopkins, 1984). In addition, groups were compared on pretest scores of the Nursing Role Conception Scale and the Six Dimension  45 Scale of Nursing Performance to assess for homogeneity of variance between the groups.  The o v e r a l l change within  the groups from pre-test to post-test in each dimension of the 6-D Scale were analyzed using paired t - t e s t s . Using the same s t a t i s t i c a l t e s t , the o v e r a l l change within the groups from pre-test to post-test on the Nursing Role Conception Scale was also analyzed. Differences between the groups on post-test scores of each of the scales was assessed using pooled t - t e s t s . The significane l e v e l for the study was set at p <0.05. The SPSS-X ( S t a t i s t i c a l Packages for the Social Sciences) a computer analysis system package was used for data analysis. Summary In this chapter, the methods and procedures for the study were outlined.  A quasi-experimental, control  group, pretest post-test design Was used.  Sample  c r i t e r i a and selection procedures were presented. Instruments used in the study were discussed and procedures for data analysis were explained.  Ethical  considerations in conducting the study were addressed.  CHAPTER FOUR PRESENTATION OF DATA The results  from the data analysis procedures are  provided in t h i s chapter.  Findings in r e l a t i o n to the  research hypotheses and supplemental findings are presented. Descriptive Characteristics of the Sample Thirty four novice staff study sample.  I n i t i a l l y , 50 novice staff  completed the pretest; (experimental)  nurses comprised the f i n a l nurses  30 in the preceptorship  group and 20 in the t r a d i t i o n a l  orientation (control) group.  Since the purpose of  this  study was to investigate the effect of a preceptorship program on role t r a n s i t i o n of novice staff  nurses,  the  study design required that role t r a n s i t i o n from pretest to post-test be compared.  Thus, 13 p a r t i c i p a n t s , who  completed the pretest but did not complete the one-month follow-up portion of the study, were eliminated from the f i n a l study sample.  One participant in the t r a d i t i o n a l  orientation group had to withdraw from the study due to resigning from the hospital prior to the one month follow-up portion of the study.  Two participants  returned their one-month follow-up questionnaires  after  the cut-off date for inclusion in the study, and were  47 therefore not included in the f i n a l study sample.  The  one month follow-up response rate was 70% for the experimental group and was 75% for the control group. The o v e r a l l response rate was 72.5%. A l l participants were female.  The sample ranged in age  from 21 to 34 years with the mean age 24.5 years.  The  majority of the study sample (94 %) were diploma graduates.  P a r t i c i p a n t ' s previous experience in the  employing agency ranged from zero weeks to three years (those with three years experience were graduates of the school of nursing of the hospital to which they were employed).  The experimental group's c l i n i c a l experience  in the employing agency prior to employment ranged from zero to three years with a mean of 63.3 weeks.  The  control group's experience in the employing agency ranged from zero to 64 weeks with a mean of 21.8 weeks. Additional demographic c h a r a c t e r i s t i c s of the sample are presented in Table 1.  48 Table 1 Demographic Characteristics of Sample (N=34) Characteristic  Experimental (n=14) # /  Basic Nursing Education Diploma (2 year) Diploma (3 year) Baccalaureate Other Post Secondary Education Yes No  %  5/25 14/ 70 1/5  Control (n=20) # / %  12/ 86 1/ 7 1/7  12/ 60 8/ 40  9/ 64 5/ 36  12/ 60 8/ 40  11/ 79 3/ 21  10/ 50 7/ 35  14/ 100 0/ 0  Hospital Employment Prior to Education Program none nurse's aide other  10/ 50 4/ 20 6/ 30  7/50 4/ 29 3/ 21  Work Experience * (Non-hospital) yes no  18/ 90 2/ 10  13/ 93 0/ 0  C l i n i c a l Experience in Employing Agency * yes no Duration < three years 3 years  * demographic c h a r a c t e r i s t i c s with less than t o t a l sample size because some subjects did not respond to a l l items. Chi-square analysis was used to compare the groups in terms of p a r t i c u l a r demographic charateristics.... analysis is used to determine whether observed  This  proportions d i f f e r s i g n i f i c a n t l y from expected proportions (Glass & Hopkins, 1984).  Demographic  c h a r a t e r i s t i c s subjected to chi-square analysis were: (1) basic nursing education; (2)  post-secondary  education; (3) c l i n i c a l experience (4) length of c l i n i c a l experience  in employing agency; in employing agency;  (5) hospital work experience other than during education program; (6) past non-hospital work experience; and (7) age. Results of chi-square analysis on demographic c h a r a c t e r i s t i c s demonstrated s i g n i f i c a n t differences  in  expected and observed proportions on basic nursing education and c l i n i c a l experience prior to employment.  in the employing agency  In terms of basic nursing  education, 86% of the t r a d i t i o n a l orientation group were from a two year diploma program; while 70 % of the preceptorship group were from a three year diploma program.  The chi-square s t a t i s t i c on basic education was  s i g n i f i c a n t at 0.0012.  This highly s i g n i f i c a n t  finding  i l l u s t r a t e s that the groups were skewed such that the preceptorship group consisted predominantly of three year diploma graduates, whereas the control group consisted predominantly of two year diploma graduates.  This  s i g n i f i c a n t discrepancy in observed and expected  porportions could be an important factor in role t r a n s i t i o n experiences of the groups. In r e l a t i o n to length of c l i n c a l experience  in the  employing agency, there was a s i g n i f i c n t difference group proportions analysed using chi-square. significance  in  The  of the chi-square s t a t i s t i c on t h i s  c h a r a c t e r i s t i c was 0.0216.  The experimental group had a  large porportion of members who had s u b s t a n t i a l l y more c l i n i c a l experience  in the employing agency prior to  employment as novice staff group.  nurses than did the control  The s i g n i f i c a n t difference  in observed and  expected porportions of t h i s demographic variable may be an i n f l u e n t i a l factor in the t r a n s i t i o n experiences of the two groups. Results in Relation to Research Hypotheses Three research hypotheses were evaluated in t h i s study.  statistically  For c l a r i t y , results in r e l a t i o n to  research hypothesis two are presented f i r s t ,  followed by  results in r e l a t i o n to hypothesis three, and then results In r e l a t i o n to hypothesis one are presented. HYPOTHESIS TWO: JOB PERFORMANCE LEVELS REPORTED BY NOVICE STAFF NURSES WHO PARTICIPATE IN A PRECEPTORSHIP PROGRAM WILL BE SIGNIFICANTLY MORE IMPROVED THAN THOSE REPORTED BY NOVICE STAFF NURSES WHO PARTICIPATE IN A TRADITIONAL  51 ORIENTATION PROGRAM. Hypothesis two was measured by the Six Dimension Scale of Nursing Preformance.  Pretest scores were compared to  evaluate whether the two groups were similar in terms of job performance levels at the beginning of the study, and therefore,  whether making comparisons over time to assess  the treatment effect were appropriate.  Pretest scores of  the experimental and control groups on the Six Dimension Scale of Nursing Performance are presented in Table 2. On the four point scale,  the mean scores for the  control group on the Six Dimension Scale of Nursing Performance ranged from a low of 2.41 on the teaching/ collaboration subscale to a high of 3.37 on the professional development subscale.  The means scores for  the experimental group ranged from 2.55 on the teaching/ collaboration subscale to 3.46 on the professional development subscale. leadership subscale,  However, with the exception of the at pretest the experimental group  scored themselves higher in a l l other subscales of the Six Dimension Scale of Nursing Performance than did the control group. Group pretest mean scores were compared using pooled t - t e s t s , and results  indicate 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 differences  between the groups in any of the  52 six subscales of the Six Dimension Scale of Nursing Performance.  Group variances were also compared and  demonstrated homogeneity of variance.  In addition, since  the control group consisted of participants from two separate s i t e s , pretest scores for respondents within the control group who were from separate s i t e s , were analysed separately. differences variance.  Pooled t - t e s t s yielded no s i g n i f i c a n t in means.  There was also homogeneity of  These results supported combining responses  from subjects at the two separate s i t e s and treating them as one control group. The s t a t i s t i c a l analysis thus indicates that since the groups were not s i g n i f i c a n t l y different on pretest scores,  i t is reasonable to compare the experimental  group's performance outcomes associated with the treatment effect  (presence of a preceptor) to those of  the control group.  53 Table 2 Pretest Scores on the Six Dimension Scale of Nursing Performance for Experimental and Control Groups (N=34) Experimental (n=20) X  S.D.  Control (n=14) X  S.D.  t- value  p  LEADERSHIP  2.74  0.51  2.84  0.50  0.54  0.59  CRITICAL CARE  2.71  0.47  2.49  0.47  -1.35  0.19  2.55  0.40  2.41  0.53  -0.88  0.39  PLANNING/ EVALUATION 2.81 INTERPERSONAL RELATIONSHIPS/  0.52  2.76  0.37  -0.25  0.81  COMMUNICATION  3.23  0.39  3.16  0.32  -0.52  0.61  3.46  0.32  3.37  0.35  -0.79  0.44  TEACHING/ COLLABORATION  PROFESSIONAL DEVELOPMENT p<0.05 The within-group change from pretest to post-test on the Six Dimension Scale of Nursing Performance was assessed for each group using paired t - t e s t s .  A  comparison of pretest to post-test scores for the experimental group on the Six dimension Scale of Nursing Performance is presented in Table 3.  The within-group  change from pretest to post-test for the experimental group was s i g n i f i c a n t  in the planning/evaluation  subscale.  Although the mean scores of the experimental  group on a l l the other subscales increased from pretest to post-test, the change was not s i g n i f i c a n t . Table 3 Comparison of Pretest to Post-test Scores on the Six Dimension Scale of Nursing Performance for the Experimental Group. (n=20) Pretest  Post-test  X  X  S.D.  S.D.  t-values  p  LEADERSHIP  2.77  0.51  2.84  0.53  -0.55  0.59  CRITICAL CARE  2.71  0.47  2.77  0.55  -0.71  0.49  2.55  0.40  2.60  0.52  -0.37  0.72  PLANNING/ EVALUATION 2.81 INTERPERSONAL RELATIONSHIPS/  0.52  2.98  0.43  -2.26  0.04*  COMMUNICATION  3.23  0.39  3.33  0.38  -1.03  0.32  3.46  0.32  3.49  0.33  -0.77  0.45  TEACHING/ COLLABORATION  PROFESSIONAL DEVELOPMENT  * indicates s i g n i f i c a n t difference at p<.05. A comparison of scores on the Six Dimension Scale of Nursing Performance from pre-test to post-test for the control group is presented in Table 4.  Results  demonstrate that the mean scores of the control group consistently increased in a l l subscales,  from pretest to  post-test, with these changes d i f f e r i n g s i g n i f i c a n t l y in only the c r i t i c a l care, teaching/collaboration, and interpersonal relationships/communication subscales. Thus, performance ratings reported by both groups revealed discrepancies in the dimensions of performance in which each group exhibited s i g n i f i c a n t improvement from pretest to post-test.  The question is whether these  discrepancies are due to orientation program differences. Table 4 Comparison of Pretest to Post-test Scores on the Six Dimension Scale of Nursing Performance for the Control Group (n=14) Pretest X  S.D.  Post -test X  S.D.  t-values  p  LEADERSHIP  2 .84  0.50  2.93  0.53  -1.07  0.30  CRITICAL CARE  2 .49  0.47  2.93  0.31  -5.09  0.00***  TEACHING/ COLLABORATION 2 .41  0.53  2.72  0.55  -2.55  0.02*  PLANNING/ EVALUATION  2 .76  0.37  2.98  0.55  -1.87  0.08  INTERPERSONAL RELATIONSHIPS/ COMMUNICATION 3 .16  0.32  3.41  0.43  -3.52  0.004**  PROFESSIONAL DEVELOPMENT  0.35  3.36  0.40  0.15  3 .37  * indicates s i g n i f i c a n t difference at p<.05. ** indicates s i g n i f i c a n t difference at p<.01. *** indicates s i g n i f i c a n t difference at p<.001.  0.88  56 Performance ratings of the two groups at post-test as measured by the Six Dimension Scale of Nursing Performance were compared using pooled t - t e s t s .  Scores  on the Six Dimension Scale of Nursing Performance, at the one month follow-up for the experimental and control groups are presented in Table 5 . s i g n i f i c a n t differences  Results indicate no  between the groups.  there were no s i g n i f i c a n t differences  Thus,  since  between the groups'  scores on the Six Dimension Scale of Nursing Performance, the second research hypothesis; that job performance levels reported by novice staff  nurses who participate in  a preceptorship program w i l l be s i g n i f i c a n t l y more improved than those reported by novice staff  nurses who  participate in a t r a d i t i o n a l orientation program, was not supported.  In other words, in comparing the performance  of the two groups, as reported on the Six Dimension Scale of Nursing Performance, analysis shows that the preceptorship experience with the presence of a designated preceptor did not have the i d e n t i f i e d on performance outcomes that was anticipated.  effect  57 Table 5 Comparison of Post-test Scores on the Six Dimension Scale of Nursing Performance for Experimental and Control Groups (n=34) Experimental (n=20) X  Control (n=14)  S.D.  X  S.D.  t-values  p  LEADERSHIP  2.84  0.53  2.93  0.53  0.48  0.63  CRITICAL CARE  2.77  0.55  2.93  0.31  0.95  0.35  2.60  0.52  2.72  0.55  0.69  0.50  PIANNING/ EVALUATION 2.98 INTERPERSONAL RELATIONSHIPS/  0.43  2.98  0.55  -0.04  0.97  COMMUNICATION  3.33  0.38  3.41  0.43  0.61  0.54  PROFESSIONAL DEVELOPMENT _____  3.49  0.33  3.36  0.40  -1.04  0.30  TEACHING/ COLLABORATION  HYPOTHESIS THREE: PERCEIVED ROLE DEPRIVATION REPORTED BY NOVICE STAFF NURSES WHO PARTICIPATE IN A PRECEPTORSHIP PROGRAM WILL BE LESS THAN THAT REPORTED BY NOVICE STAFF NURSES WHO PARTICIPATE IN A TRADITIONAL ORIENTATION PROGRAM. The Nursing Role Conception Scale was used to evaluate the t h i r d research hypothesis.  In completing this  scale  subjects were asked to rate 22 hypothetical nursing,.  58 situations  in terms of how the s i t u a t i o n i d e a l l y ought to  be in nursing, and also how the s i t u a t i o n actually is in nursing.  Scores for both the responses (ideal  versus  actual) are given. Pretest mean scores of the control and experimental groups on the Nursing Role Conception Scale were compared using pooled t - t e s t s .  This analysis was carried out to  establish whether groups were similar at the beginning of the study in r e l a t i o n to role  conceptions/role^  deprivation, and thus, whether comparisons of role conception/deprivation outcomes in r e l a t i o n to the treatment effect were appropriate.  Group variances were  compared to determine whether there was homogeneity of variance between the groups.  Results of both these  comparisons indicate no s i g n i f i c a n t differences the groups.  between  In addition, since the control group was  drawn from two separate s i t e s , responses of participants from these two s i t e s were compared separately. indicated no s i g n i f i c a n t differences  Results  in means and also  indicated homogeneity of variance within the responses of participants from the two separate s i t e s .  This supported  joining these subject's responses to be considered as one control group.  This o v e r a l l analysis of pretest scores  demonstrated that the groups were not s i g n i f i c a n t l y  59 different  i n r e l a t i o n to r o l e c o n c e p t i o n s /  the s t a r t  of the s t u d y ,  appropriateness treatment  and t h u s ,  supported  of making comparisons  effect  d e p r i v a t i o n at the  i n l i g h t of  the  at the one-month p o s t - t e s t .  A comparison of p r e t e s t to p o s t - t e s t Nursing Role Conception Scale s c o r e s f o r the (preceptorship) i n Table 6. change,  experimental  group, using p a i r e d t - t e s t s ,  R e s u l t s demonstrate  t h a t the  is  presented  within-group  from p r e t e s t to p o s t - t e s t on the Nursing Role  Conception S c a l e , professional decreased  was s i g n i f i c a n t  o n l y on the  r o l e conception subscale;  While mean s c o r e s  from p r e t e s t to p o s t - t e s t on a l l the  (BRC, PRC, SRC, RD), o n l y on the p r o f e s s i o n a l conception significant.  (ideal)  subscale  This r e s u l t  was t h i s  subcales role  decrease  suggests that  for  the  experimental group there was a decrease i n PRC ( i d e a l ) f o l l o w i n g a preceptored o r i e n t a t i o n . however an accompanying i n c r e a s e expect.  There was not  i n BRC as one might  60 Table 6 COMPARISON OF PRETEST TO POST-TEST NURSING ROLE CONCEPTION SCALE SCORES FOR EXPERIMENTAL (PRECEPTORSHIP) GROUP (n=20? : Pretest X  Post-test  S.D.  X  S.D.  t-values  p  BRC (ideal) (actual)  17. 50 18. 80  3 .90 2 .75  17. 10 19. 15  2.75 0.60 2.48 -0.49  0. 56 0. 63  PRC (ideal) (actual)  26. 80 23. 70  3 .43 2 .54  25. 10 22. 75  4.39 3.14  2.72 1.32  0. 01* 0. 20  SRC (ideal) (actual)  27. 90 24. 30  3 .24 2 .76  27. 70 23. 10  2.64 3.96  0.36 1.35  0. 73 0. 19  5. 40  6 .35  4. 80  RD  6.96  0.38  0 .71  * indicates s i g n i f i c a n t difference at p<.05. BRC= bureaucratic role conception. PRC= professional role conception. SRC= service role conception. RD= role deprivation.  A comparison of Nursing Role Conception Scale scores from pretest to post-test for the control ( t r a d i t i o n a l orientaion) group, using paired t - t e s t s , Table 7.  is presented in  While the control group's mean scores stayed  the same or decreased s l i g h t l y from pretest to post-test, the within group change from pretest to post-test was not s i g n i f i c a n t on any of the subscales (BRC, PRC, SRC, RD). Analysis indicates for the control group the t r a d i t i o n a l orientation program at one month did not show a  significant  impact on role conceptions/role deprivation.  Table 7 COMPARISON OF PRETEST TO POST-TEST NURSING ROLE CONCEPTION SCALE SCORES FOR CONTROL (TRADITIONAL ORIENTATION) GROUP. (n=14) Pretest Post-test X  S • D.  X  S.D.  t-values  P  BRC (ideal) (actual)  16. 36 18. 71  2 .98 2 .59  16. 36 18. 93  1.99 2.17  0.00 -0.24  1 .00 0 .17  PRC (ideal) (actual)  28. 36 22. 86  2 .10 2 .35  27. 21 23. 86  3.19 3.76  1.45 -1.16  0 .89 0 .27  SRC (ideal) (actual)  28. 43 24. 57  3 .52 2 .21  28. 29 23. 93  2.05 2.70  0.14 1.09  0 .89 0 .30  7. 00  5 .88  5. 14  6.49  0.99  0 .34  RD  BRC=bureaucratic role conception. PRC= professional role conception. SRC= service role conception. RD= role deprivation. p<0.05 A comparison of pretest to post-test Nursing Role Conception Scale scores for both groups using pooled t tests is presented in Table 8.  Results indicate no  s i g n i f i c a n t difference between the groups from pretest to post-test on any subscales of the Nursing Role Conception Scale.  Thus, research hypothesis  supported.  three was not  This analysis suggests that despite a  s i g n i f i c a n t within-group decrease in PRC (ideal)  for the  experimental group; t h i s difference was not enough to  cause a s i g n i f i c a n t difference  in o v e r a l l post-test  scores on the Nursing Role Conception Scale.  In other  words, despite some discrepancy in within-group role conception scores from pre-test to post-test, the groups* post-test role conception and role deprivation scores were not s i g n i f i c a n t l y different even though they participated in different types of orientation programs.  63 Table 8 COMPARISON OF PRETEST TO POST-TEST NURSING ROLE CONCEPTION SCALE SCORES FOR BOTH GROUPS Experimental (n=20) X  S. D.  Control (n=14) X  S. D.  t-values  P  Pretest BRC ( i d e a l ) (actual)  17. 50 18. 80  3 .90 2 .75  16 .36 18 .71  2 .98 2 .59  -0.92 -0.09  0.36 0.93  PRC ( i d e a l ) (actual)  26. 80 23. 70  3 .43 2 .54  28 .36 22 .86  2 .10 2 .35  1.51 -0.98  0.14 0.33  SRC ( i d e a l ) (actual)  27. 90 24. 30  3 .24 2 .76  28 .43 24 .57  3 .52 2 .21  0.45 0.31  0.66 0.76  5. 40  6 .35  7. 00  5 .88  0.74  0.46  BRC ( i d e a l ) (actual)  17. 10 19. 15  2 .75 2 . 48  16 .36 18 .93  1 .99 2 .17  -0.86 -0.27  0.39 0.79  PRC ( i d e a l ) (actual)  25. 10 22. 75  4 .39 3 .14  27 .21 23 .86  3 .19 3 .76  1.54 0.93  0.13 0.36  SRC ( i d e a l ) (actual)  27. 70 23. 10  2 .64 3 .96  28 .29 23 .93  2 .05 2 .70  0.70 0.68  0.49 0. 50  4. 80  6 .96  5 .14  6 .49  0.15  0.89  RD Post-test  RD  BRC= b u r e a u c r a t i c r o l e c o n c e p t i o n . PRC= p r o f e s s i o n a l role conception. SRC= s e r v i c e r o l e c o n c e p t i o n . RD= r o l e d e p r i v a t i o n s c a l e . p<0.05  HYPOTHESIS 1. ROLE TRANSITION WILL BE PERCEIVED TO BE EASIER BY NOVICE STAFF NURSES WHO PARTICIPATE IN A PRECEPTORSHIP PROGRAM THAN BY NOVICE STAFF NURSE WHO PARTICIPATE IN A TRADITIONAL ORIENTATION PROGRAM. Role t r a n s i t i o n is the a l t e r a t i o n in expectations related to actions and reactions demanded by a change in role.  Role t r a n s i t i o n from student to novice staff  requires adjustments conceptions/role  nurse  in s k i l l mastery and role  deprivation.  In order for hypothesis  one to be supported, pretest to post-test scores reported by the experimental  (preceptorship)  group, had to reveal  s i g n i f i c a n t l y less role deprivation on the Nursing Role Conception Scale and s i g n i f i c a n t l y higher -performance ratings on the Six Dimension Scale of Nursing Performance than those reported by the control orientation)  group.  (traditional  Comparisons of group scores at post-  test on both instruments using pooled t - t e s t s (Table 5 and Table 8) demonstrate no s i g n i f i c a n t between group post-test scores. result,  differences  Since t h i s was the  the f i r s t research hypothesis was not supported. Summary  Results of of the data analysis were presented in t h i s chapter.  Demographic charateristies  of the sample were  evaluated using chi-square analysis and, showed that the  65 groups d i f f e r e d on two v a r i a b l e s : b a s i c n u r s i n g education and amount of c l i n i c a l experience  i n the employing  p r i o r to beginning employment as s t a f f differences  may have been i n f l u e n t i a l f a c t o r s  t r a n s i t i o n experiences Pretest  nurses.  of  agency  These i n the  role  participants.  scores i n r e l a t i o n to performance l e v e l s  as  measured by the Six Dimension Scale of Nursing Performance,  and r o l e c o n c e p t i o n / r o l e  d e p r i v a t i o n scores  as measured by the Nursing Role Conception Scale were compared.  Results  i n d i c a t e no s i g n i f i c a n t  between the groups at the s t a r t  differences  of the s t u d y .  This  f i n d i n g supported the s u i t a b i l i t y of comparing performance r a t i n g s and r o l e c o n c e p t i o n s / r o l e  deprivation  over the time of the study to assess the e f f e c t treatment  (presence of a designated  preceptor for  experimental group, and lack of a designated for the c o n t r o l group) on these  of the  preceptor  outcomes.  Within-group changes i n performance r a t i n g s  from  p r e t e s t to p o s t - t e s t for each group were a s s e s s e d . Results  of t h i s  dimensions  analysis  revealed discrepancies  i n the  of performance i n which each group showed  significantly  improved performance r a t i n g s .  experimental group showed s i g n i f i c a n t  The  improvement i n only  the p l a n n i n g / e v a l u a t i o n dimension, while the c o n t r o l  66 group e x h i b i t e d care,  improved performance i n the  teaching/collaboration,  relationships/communication question  and  dimensions of performance.  o r i e n t a t i o n program d i f f e r e n c e s  compared. between measured  interpersonal  i s whether t h e s e d i s c r e p a n c i e s  Post-test  critical  a r e due  or o t h e r  A  to  factors.  p e r f o r m a n c e r a t i n g s o f b o t h g r o u p s were Analysis  i n d i c a t e d no s i g n i f i c a n t d i f f e r e n c e s  t h e g r o u p s on a n y d i m e n s i o n s o f p e r f o r m a n c e by t h e S i x D i m e n s i o n S c a l e  Performance.  Thus, d e s p i t e  of N u r s i n g  discrepancies  i n the  d i m e n s i o n s of performance i n which each group performance gains from p r e t e s t discrepancies  to post-test;  exhibited these  were n o t enough t o r e s u l t i n s i g n i f i c a n t l y  d i f f e r e n t p e r f o r m a n c e r a t i n g s between  the groups a t  post-  test . W i t h i n - g r o u p changes deprivation the  in role  conception/role  s c o r e s were c o m p a r e d .  Analysis  showed  that  e x p e r i m e n t a l g r o u p had a s i g n i f i c a n t d e c r e a s e i n PRC  (ideal)  from p r e t e s t  accompanying  increse  t o p o s t t e s t , b u t i t d i d n o t have an i n BRC  ( i d e a l ) as one m i g h t e x p e c t .  The c o n t r o l g r o u p d i d n o t e x h i b i t a n y s i g n i f i c a n t differences test .  i n role conceptions/role  deprivation  at  post-  67  Results indicate  that there were no s i g n i f i c a n t  d i f f e r e n c e s between the groups on e i t h e r Conception  the Nursing  Role  Scale or the S i x Dimension Scale of Nursing  Performance.  Thus, n e i t h e r group's r o l e  experiences d i f f e r e d Consequently, t h i s study was  transition  s i g n i f i c a n t l y over the o t h e r .  none of the three r e s e a r c h hypotheses supported.  of  68 CHAPTER FIVE DISCUSSION OF FINDINGS In this chapter study findings and interpretation of s t a t i s t i c a l data presented in the preceding,chapter are discussed.  Study results  in r e l a t i o n to each of the  research hypotheses and factors that may have influenced these results are discussed.  Results of this study are  compared to the findings of other studies of preceptorships. Discussion in Relation to Research Hypotheses, For c l a r i t y , discussion of results  in r e l a t i o n to each  of the research hypothesis w i l l deal f i r s t with hypothesis two, followed by discussion of results of hypothesis three, and w i l l conclude with discussion of results related to hypothesis  one.  HYPOTHESIS TWO: JOB PERFORMANCE LEVELS REPORTED BY NOVICE STAFF NURSES WHO PARTICIPATE IN A PRECEPTORSHIP PROGRAM WILL BE HIGHER THAN THOSE REPORTED BY NOVICE STAFF NURSES WHO PARTICIPATE IN A TRADITIONAL ORIENTATION PROGRAM. Pretest performance scores reported by the experimental group were consistently higher than those of the control group in a l l subscales of the Six Dimension Scale of Nursing Performance, but the leadership subscale.  This  suggests that s u b j e c t s i n the experimental their  group began  p r e c e p t o r s h i p program with a predominantly more  p o s i t i v e s e l f - p e r c e p t i o n of t h e i r In comparing the w i t h i n - g r o u p ratings,  performance  change i n performance  the c o n t r o l group had a s i g n i f i c a n t  from p r e t e s t performance  to p o s t - t e s t (critical  ability.  improvement  i n three dimensions of  care,  interpersonal  relationships  /communication, and t e a c h i n g / c o l l a b o r a t i o n ) . experimental significant  group from p r e t e s t improvement  to p o s t - t e s t had a  i n o n l y the  dimension of performance.  planning/evaluation  However, at p o s t - t e s t  was no s i g n i f i c a n t d i f f e r e n c e s  i n the  performance scores between the groups. that the higher p r e t e s t experimental  The  there  post-test It  is possible  performance r a t i n g s of  group were balanced out by the  the  control  g r o u p ' s improved performance i n more dimensions of performance than that of the experimental balancing e f f e c t  group.  may e x p l a i n why there were no  s i g n i f i c a n t d i f f e r e n c e s between the groups in performance outcomes.  performance outcomes?  post-test  One must q u e s t i o n what f a c t o r s  might e x p l a i n the unexpected d i s c r e p a n c y i n  within-group  Possible explanations r e l a t e  demographic v a r i a b l e s of study p a r t i c i p a n t s , factors,  This  and study d e s i g n  limitations.  program  to  70 Demographic V a r i a b l e s A n a l y s i s of demographic v a r i a b l e s u s i n g  chi-square  a n a l y s i s r e v e a l e d t h a t t h e g r o u p p r o p o r t i o n s were s i g n i f i c a n t l y d i f f e r e n t on two d e m o g r a p h i c v a r i a b l e s : b a s i c n u r s i n g e d u c a t i o n and ( 2 ) c l i n i c a l the employing novice s t a f f  agency p r i o r nurses.  to their  experience i n  present  The e x p e r i m e n t a l  (1)  employment a s  group had a  s i g n i f i c a n t l y h i g h e r p o r p o r t i o n o f s u b j e c t s , who were educated  i n a three year  diploma  compared t o t h e t r a d i t i o n a l  program ( 7 0 % ) , as  o r i e n t a t i o n g r o u p , who had a  s i g n i f i c a n t l y h i g h e r p o r p o r t i o n o f p a r t i c i p a n t s who were educated The  i n a two y e a r d i p l o m a  experimental  program  g r o u p had a g r e a t e r p r o p o r t i o n o f  s u b j e c t s who had been g r a d u a t e s n u r s i n g of the employing  of the h o s p i t a l school of  agency.  s u b s t a n t i a l l y more c l i n i c a l agency p r i o r  (85.7%).  T h e y t h e r e f o r e had  experience  i n the  employing  t o t h i s employment t h a n d i d t h e c o n t r o l  group (Table 2 ) . Participants  i n the experimental  a l r e a d y had more c l i n i c a l  experience  l o n g e r e d u c a t i o n a l program. more c l i n i c a l  experience  t h e y a r e now e m p l o y e d . factors,  group a t p r e t e s t by v i r t u e o f t h e  They a l s o has s i g n i f i c a n t l y  i n the p r a c t i c e s e t t i n g With  the combination  where  of these  i n a d d i t i o n t o t h e p r e c e p t o r s h i p p r o g r a m , one  71  might expect that t h e i r performance would continue improve and be s i g n i f i c a n t l y c o n t r o l group.  Despite  higher than t h a t of  the a p p a r e n t l y  advantages i n demographic v a r i a b l e s ,  explanations design  from that  the  experimental differ  of the c o n t r o l group.  for t h i s r e l a t e  the  favorable  group p o s t - t e s t performance r a t i n g s d i d not significantly  to  Probable  to program f a c t o r s  or study  limitations.  Program F a c t o r s The d i f f e r e n c e  i n focus of the c e n t r a l n u r s i n g  o r i e n t a t i o n aspects of the p r e c e p t o r s h i p and t r a d i t i o n a l o r i e n t a t i o n programs i s  one program f a c t o r  c o n t r i b u t e d to t h i s study not f i n d i n g any significant the groups.  difference  t h a t may have statistically  i n performance outcomes between  The t r a d i t i o n a l o r i e n t a t i o n program at  s i t e s was q u i t e s k i l l  o r i e n t e d as compared to  the  p r e c e p t o r s h i p program (Appendices B, C , and D). f a c t o r may have been i n s t r u m e n t a l improvement e x h i b i t e d orientation) Performance.  i n the  by the c o n t r o l  both  This  performance  (traditional  group on the Six Dimension Scale of Nursing T h i s group had a s i g n i f i c a n t  improvement i n three s u b s c a l e s teaching/collaboration, /communication),  (critical  and i n t e r p e r s o n a l  performance  care, relationships  (Table 4 ) ; while the p r e c e p t o r s h i p group  had s i g n i f i c a n t subscale  improvement  (planning/evaluation),  Study Design  researcher  influenced  subjects  could  experimental  made  assign  and c o n t r o l  may have  differed  which  t o randomly  experimental  i t impossible  i s another  the performance  n o t be r a n d o m l y  or c o n t r o l  Whether  experimental  or c o n t r o l  investigator's  Without  perception,  since  this  control  factors  and/or  time.  in their  in their  was under  nursing  there  such as i n d i v i d u a l performance  Although pretest  i s no means t o  participants  ability  gains within  the agency's  of subjects t o the  t h e s t u d y , and (2) u n e q u a l a b i l i t y  over  Since  were i n t h e  random a s s i g n m e n t  performance  that  g r o u p was beyond t h e  and e x p e r i m e n t a l g r o u p s  recognize  factor  g r o u p s , s u b j e c t s may have  control  (1) u n e q u a l a c t u a l  to the  assigned to the  individuals  control  f o r the  results.  t o a c c u r a t e l y a p p r e c i a t e changes  performance.  of  5).  (Table  participants  groups  i n areas of s e l f  control.  on o n l y one  Limitations  A study l i m i t a t i o n  ability  i n performance  having:  at the beginning to accurately  their  mean s c o r e s  own  performance  and v a r i a n c e s  were a s s e s s e d and were n o t f o u n d t o be s i g n i f i c a n t l y different, present.  this  does  n o t mean t h a t  d i f f e r e n c e s were n o t  N e i t h e r , do t h e s e a s s e s s m e n t s  address  potential  73 differences  in participants' a b i l i t i e s to recognize  performance gains over time.  HYPOTHESIS THREE:  PERCEIVED ROLE DEPRIVATION REPORTED BY  NOVICE STAFF NURSES WHO PARTICIPATE IN A PRECEPTORSHIP PROGRAM WILL BE LESS THAN THAT REPORTED BY NOVICE STAFF NURSES WHO PARTICIPATE IN A TRADITIONAL ORIENTATION PROGRAM. Results indicate that there were no s i g n i f i c a n t differences  between the groups in pretest role  conceptions and role deprivation scores.  In comparing  the within-group change in role conceptions/  role  deprivation, the experimental group had a s i g n i f i c a n t decrease in professional role conception (ideal)  but  there was no accompanying increase in bureaucratic role cojnception as one might expect.  Possible reasons  that  may be posed for this result are: (1) The experimental group who were precepted may have received increased pressure from preceptors to conform to bureaucratic r u l e s .  Based on their experience,  have perceived i t necessary,  they may  in order to gain approval  from their peer preceptors, to adjust downward their ideal professional role conception ratings. despite decreasing their PRC ( i d e a l ) ,  However,  post-test scores  i n d i c a t e t h e y were n o t y e t r e a d y increase their identified nurses  BRC.  Kramer and S c h m a l e n b e r g  (1977b)  t h a t c e r t a i n t e s t i n g t a k e s p l a c e when  are attempting  u n i t work g r o u p . nurses  to s i g n i f i c a n t l y  t o become a c c e p t e d  In essence the f i r s t  novice  members o f t h e  job f o r novice  i s a p r o v i n g g r o u n d where t h e n o v i c e must p r o v e  her/himself  i n the s t a f f  nurse  role.  Participants  p r e c e p t o r s h i p g r o u p may h a v e p e r c e i v e d t h a t t h e i r  i n the PRC  n e e d e d t o be a d j u s t e d t o more c l o s e l y m a t c h t h e PRC o f t h e r e f e r e n c e g r o u p t o w h i c h t h e y a s p i r e d t o become accepted  members.  T h i s may a c c o u n t  f o r the decrease i n  PRC ( i d e a l ) a t p o s t - t e s t m e a s u r e m e n t .  Given  the fact  t h a t t h e c o n t r o l g r o u p had v a r i o u s e x p e r i e n c e d buddied  as c l o s e l y w i t h t h e r e f e r e n c e group t o  which t h e y d e s i r e d membership. experimental  Thus, u n l i k e t h e  group, the c o n t r o l group d i d not r e p o r t a  i n PRC ( i d e a l ) a t p o s t - t e s t .  (2) A s e c o n d p o s s i b i l i t y  i s that the experimental  may h a v e r e c e i v e d n e g a t i v e h o l d i n g such to these  who  w i t h them, s u b j e c t s i n t h e c o n t r o l g r o u p may n o t  have i d e n t i f i e d  decrease  nurses  feedback  group  (sanctions) f o r  h i g h i d e a l PRC and f o r a t t e m p t s  to live  up  ideal p r o f e s s i o n a l r o l e conceptions i n  professional practice.  I f t h i s were t h e c a s e , a t p o s t -  t e s t t h e y may have a d j u s t e d t h e i r r a t i n g s ( d e c r e a s e d  PRC-  75 ideal) (3)  in l i g h t  of such  Another p o s s i b i l i t y  i d e a l may r e f l e c t  feedback. i s that t h i s decrease i n PRC  a realistic  demands of p r a c t i c e .  positive  adjustment  Perhaps the l e v e l  high f o r the demands of the p r a c t i c e s e t t i n g . identified  that r o l e conceptions  school do not grasp the f u l l experience.  complexities  Corwin  of the work  practice.  r e a l i t y shock  is a b i c u l t u r a l adaptation,  neophyte r e e v a l u a t e s  school  those that are b e n e f i c i a l ,  r e s o l u t i o n of  maintaining  and meshing them with As s u c h , t h i s  the decrease  r e p o r t e d by the experimental group may  indicate a positive role  movement toward r e a l i s m necessary  for  transition.  Despite the d i f f e r e n c e s p r e t e s t to p o s t - t e s t statistically  to  i n which the  learned v a l u e s ,  of the work s i t u a t i o n .  i n PRC ( i d e a l )  adjunct  Kramer and Schmalenberg  (1977a) i d e n t i f i e d t h a t the most s u c c e s s f u l  i n w i t h i n - g r o u p changes from  i n the PRC ( i d e a l ) ,  significant  differences  in post-test r o l e conception/role possible  too  acquired in  i s almost an inescapable  beginning p r o f e s s i o n a l  successful  is  Consequently, the r e f i n i n g and a d j u s t i n g of  these i d e a l standards  realities  the  of  p r o f e s s i o n a l i s m that neophytes a c q u i r e i n school  (1961)  to  there were no  between the  groups  deprivation scores.  e x p l a n a t i o n for t h i s might be t h a t d u r i n g  A  this  76 f i r s t one month both programs may have concentrated more on mastery of s k i l l s and organizational a b i l i t i e s , opposed to dealing with s o c i a l integration. the s i t u a t i o n ,  as  If this were  this would account for the study results  f a i l i n g to find any differences role conceptions  between the groups on  and role deprivation.  HYPOTHESIS ONE: ROLE TRANSITION WILL BE PERCEIVED TO BE EASIER BY NOVICE STAFF NURSES WHO PARTICIPATE IN A PRECEPTORSHIP PROGRAM THAN BY NOVICE STAFF NURSES WHO PARTICIPATE IN A TRADITIONAL ORIENTATION PROGRAM. In order for this hypothesis to be supported the experimental group had to report higher performance scores and lower role deprivation scores at post-test than those reported by the control group.  Since this was  not the result this hypothesis was not supported. Several possible reasons may account for t h i s  result.  Program Factors The assignment of preceptors for the experimental group is a program factor that may have influenced  the  performance and role deprivation results of t h i s study. Head nurses of the respective  wards to which novice  nurses were hired were responsible  for  preceptors to work with novice nurses.  staff  assigning On occasions,  nurses assigned to function as preceptors with the novice  77 nurses,  had not attended  the Preceptor  Development  Program which prepares p r e c e p t o r s to f u n c t i o n i n role.  In these s i t u a t i o n s ,  called preceptors,  these s t a f f  staff  nurses  assigned  Moreover, novice  d i l u t e the expected  the groups on performance r a t i n g s ; or r o l e t r a n s i t i o n  Nevertheless,  nurses  role  experiences.  Recent l i t e r a t u r e has i d e n t i f i e d t h i s  Murray, Lindholm,  the  difficulties, experienced  experience  role.  problem ( C a n t w e l l ,  Griepp,  1989;  Hamilton,  & Myers,1989; Lewis, 1990).  (1989) noted s e v e r a l  between  conceptions/  of having enough  1989;  of  instrumental  prepared to f u n c t i o n i n the preceptor  Kahn, Lacey & McLaughlin,  effect  differences  one needs to recognize  with the n u r s i n g s h o r t a g e ,  these  o v e r a l l treatment  i n there being no s i g n i f i c a n t  deprivation;  frequently  In essence,  a p r e c e p t o r s h i p program, and may have been factors  "buddy" of  i n the p r e c e p t o r s h i p program were  more than one p r e c e p t o r .  practices  nurses who are  were r e a l l y more l i k e the  the t r a d i t i o n a l o r i e n t a t i o n program.  this  Griepp  instances of nurses with l i m i t e d  ( l e s s than one year)  being assigned  "by  d e f a u l t " to f u n c t i o n as preceptors because u n i t s d i d not have enough experienced requirements.  staff  nurses  for i t s  preceptor  78 Job f a c t o r s and i n d i v i d u a l c h a r a c t e r i s t i c s of  the  p r e c e p t o r s s e l e c t e d for the preceptor r o l e , may i n f l u e n c e the q u a l i t y of the feedback, given to the novice s t a f f 1988).  s u p e r v i s i o n , and guidance  nurse by p r e c e p t o r s  These f a c t o r s may a l s o have i n f l u e n c e d the  findings.  responsibilities p.229).  make t h i s  these e x i s t ,  impossible"  job ( C a n t w e l l , et  al.,  T h i s i s p a r t i c u l a r l y a problem with the  nursing shortage.  influence  study  One needs to q u e s t i o n whether "the preceptor  t r u l y a c t [ s ] as a preceptor or do other  1989,  (Sheetz,  When problems and p r a c t i c e s such as  they n e u t r a l i z e the expected  positive  of p r e c e p t o r s f o r novice nurse t r a n s i t i o n to  practice. Another c o n s i d e r a t i o n was i d e n t i f i e d by Sheetz  (1989).  She found that r e g i s t e r e d nurses who buddied with students who were not i n a p r e c e p t o r s h i p program assumed the informal r o l e of preceptor to s t u d e n t s ,  even though  the r o l e was not f o r m a l l y recognized by the o r g a n i z a t i o n . If s t a f f  nurses  i n the c o n t r o l ( t r a d i t i o n a l  orientation)  program followed t h i s p r a c t i c e , even though they had not r e c e i v e d p r e p a r a t i o n for the r o l e , guidance to the novice s t a f f  they may have provided  nurses of the c o n t r o l group,  s i m i l a r to that which was provided by the p r e c e p t o r s novice s t a f f  nurses  i n the p r e c e p t o r s h i p  to  (experimental)  group.  As such, the expected difference in treatment  between the experimental and control group would not have occurred.  If this were the case, i t would account for  the lack of s i g n i f i c a n t differences between the groups in terms of t r a n s i t i o n experiences. Study Design Limitations Whether novice staff nurses in the study had participated in a preceptorship program as part of their educational program is a factor that was not assessed, and which might have contributed to the r e s u l t s .  These  programs are included in some c u r r i c u l a as a means to provide students with anticipatory s o c i a l i z a t i o n to the novice s t a f f  nurse role (Chickerella & Lutz, 1981).  could surmise, i f subjects had such an experience,  One they  might be sensitized to the issues surrounding the t r a n s i t i o n from student to beginning p r a t i t i o n e r , and this may influence their adjustment to p r a c t i c e .  As  such, consideration of this factor in the study design would have helped in interpreting possible reasons for study r e s u l t s . The time frame for the study is another factor that may have affected the results of this study.  Participants  may not have moved beyond the honeymoon phase of r e a l i t y shock.  During the honeymoon phase, the new nurse's  80 appraisal of her/his job is t y p i c a l l y very positiveThere is a tendancy to view situations through rosecolored glasses (Kramer, 1974), and as such, during this stage "problems are not recognized, they're not even perceived" (Kramer & Schmalenberg, 1977a, p. 6). Accordingly, i f subjects in this study had not moved beyond the. honeymoon phase, c o n f l i c t s which new nurses are expected to have to face, may not have yet surfaced from their perspectives.  As such, i t would be useful  to  study the groups over a longer time frame, and investigate whether changes in any of these parameters (performance r a t i n g s , role conceptions/ deprivation, role transition) w i l l be exhibited with time. A t h i r d study design factor that may have contributed to the unexpected results of this study was the small sample s i z e .  When sample size is small this l i m i t s the  power to detect s i g n i f i c a n t differences differences  should  actually exist (Burns & Grove, 1987).  Individual Factors Many  individual factors may have been i n f l u e n t i a l in  the role t r a n s i t i o n outcomes of the two groups. According to Spickerman (1988) many factors mediate the severity of r e a l i t y shock.  S k i l l s , knowledge  levels,  81 and attitudes  associated  with c l i n i c a l practice are  influential.  Other factors such as s e l f  interpersonal relationship s k i l l s , abilities,  concept,  organizational  and compatability between personal and  professional goals also contribute to one's adjustment when entering professional p r a c t i c e . groups had persons who were confident,  Accordingly, i f the had s o l i d  knowledge bases, strong interpersonal relationship and organizational s k i l l s ; these factors alone, as opposed to the p a r t i c u l a r orientation program that the individuals received, may have made these individuals more l i k e l y to be accepted into the reference work group of nurses.  experienced  This is l i k e l y to be the case since these are  the types of s k i l l s that experienced nurses tend to highly value.  Kramer and Schmalenberg (1977b) noted that  experienced nurses are continually testing the neophyte with informal tests and judging the neophyte's performance based on their own standards of performance, without consideration of the neophyte's lack of experience.  Given t h i s ,  i t is reasonable to suggest that  i f participants possessed c h a r a c t e r i s t i c s such as these described, they would be more l i k e l y to be accepted as f u l l members of the unit work group of professional nurses.  82 Comparison of Present Study Results to Other Studies It had been expected that the preceptorship group, as a result of the preceptorship program, would demonstrate s i g n i f i c a n t l y greater performance gains than the t r a d i t i o n a l orientation group.  This study f a i l e d to  support the hypothesis that job performance levels reported by novice staff  nurses who participate in a  preceptorship orientation program w i l l be higher than those reported by novice staff  nurses who participate in  a t r a d i t i o n a l orientation program.  This is similar to  the findings of Clayton, Broome and E l l i s  (1989); Huber  (1981); and Olsen, Gresley, and Heater, 1984.  Huber  (1981) found that graduate nurses who completed a hospital-based  preceptorship orientation program  preceived their performance to be no different graduate nurses completing a hospital-based orientation program.  than  internship  Huber also used the Six Dimension  Scale of Nursing Performance to measure performance by graduate  self-perceived  nurses.  Olsen, Gresely and Heater (1984) found that nursing students who completed an eight week undergraduate c l i n i c a l course did not perceive their performance, as rated on the Six Dimension Scale of Nursing Performance, to be different  from that of students who had not  83 completed the course. Clayton et a l . (1989) used measures of performance, as self-evaluated  by participants on the Six Dimension Scale  of Nursing Performance, to determine the effect of a preceptorship experience on role s o c i a l i z a t i o n of graduate nurses.  The study only p a r t i a l l y supported the  hypothesis that there would be s i g n i f i c a n t  differences  between the groups on the six subscales of the Six Dimension Scale of Nursing Performance. s i g n i f i c a n t differences  There were  between the groups on the  leadership, teaching/collaboration,  interpersonal  relationships/communication and planning/evaluation subscales,  but not on the professional development and  c r i t i c a l care  subscales.  Like other studies that have investigated  role  conceptions/role deprivation (Dobbs, 1988; Itano et a l . , 1987), results of this study did not find any s i g n i f i c a n t effect of a preceptorship program on role conception or role deprivation as compared to a t r a d i t i o n a l orientation program.  At post-test measurement there were no  s i g n i f i c a n t differences  between the preceptorship and  t r a d i t i o n a l orientation groups' role conception and role deprivation scores.  Thus, the study hypothesis,  that  participants in the preceptorship program would report  less role deprivation than participants in the t r a d i t i o n a l orientation program was not supported. Participants in this study did not have differences  significant  in performance ratings or role  conceptions/role  deprivation at post-test  Thus, novice staff  measurement.  nurses' role t r a n s i t i o n experiences  were not found to be s i g n i f i c a n t l y different whether they participated in the preceptorship or the t r a d i t i o n a l orientation program.  As such, the treatment effect of  presence of a preceptor for the preceptorship group was not as strong an influence on role t r a n s i t i o n of novice staff  nurses as had been expected. Summary  The results of this study f a i l e d to support any of the study hypotheses that suggested novice staff  nurses who  participated in a preceptorship program would (1) report higher performance ratings,  (2) less role deprivation,  and (3) easier role t r a n s i t i o n than novice staff  nurses  who participate in a t r a d i t i o n a l orientation program. Results of the study and factors that may be posed to explain the study findings were discussed.  Results of  this study were compared to results of other studies on preceptorship.  85  CHAPTER SIX SUMMARY, CONCLUSIONS, AND IMPLICATIONS A summary of study findings and conclusions presented  in this chapter.  are  In addition, limitations of  the study, study implications, and recommendations  for  future study are provided. Summary The t r a n s i t i o n from student to beginning practitioner in nursing has been i d e n t i f i e d as a p a r t i c u l a r l y difficult transition.  Preceptorship programs have been  used as orientation strategies in a effort to ease this t r a n s i t i o n from student to practitioner in nursing.  The  purpose of this study was to investigate the effect of a preceptorship program on the role t r a n s i t i o n of novice staff  nurses.  The three research hypotheses that were  tested in t h i s study were: 1. Role t r a n s i t i o n w i l l be perceived to be easier by novice staff  nurses who participate in a preceptorship  program than by novice staff  nurses who participate in a  t r a d i t i o n a l orientation program. 2. Job performance levels reported by novice staff  nurses  who participate in a preceptorship program w i l l be higher than those reported by novice staff  nurses who  participate in a t r a d i t i o n a l orientation program.  86  3. Perceived role deprivation reported by novice  staff  nurses who participate in a preceptorship program w i l l be less than that reported by novice staff  nurses who  participate in a t r a d i t i o n a l orientation program. Demographic c h a r a c t e r i s t i c s of the groups were assessed using chi-square analysis.  Results revealed that the  experimental and control groups differed s i g n i f i c a n t l y on two variables: (1) basic nursing education, and (2) amount of c l i n i c a l experience  in the employing agency  prior to their present employment as novice staff These differences  nurses.  in proportions may have been important  influencing factors on the role t r a n s i t i o n  experiences  reported by the groups. In r e l a t i o n to hypothesis two, results s i g n i f i c a n t differences performance outcomes.  indicated no  between the groups in post-test There were discrepancies  from  pretest to post-test in the areas of performance in which the groups reported s t a t i s t i c a l l y s i g n i f i c a n t withingroup performance gains.  The control group reported  improvements in three dimensions of performance ( c r i t i c a l care, teaching/collaboration, and interpersonal relationships/communication).  The experimental group  reported improved performance in only the planning/ evaluation dimension of performance.  Despite these  87 within-group d i f f e r e n c e s , scores  comparison of o v e r a l l p o s t - t e s t  r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s  between  the  groups i n any dimensions of performance as measured by the Six Dimension Scale of Nursing Performance. possible  reasons were presented  for these  (demographic v a r i a b l e s , program f a c t o r s ,  Many  results and study design  1 imitations). Role c o n c e p t i o n and r o l e d e p r i v a t i o n s c o r e s , measured by the Nursing Role Conception S c a l e , t e s t e d to evaluate hypothesis t h r e e . in r e l a t i o n to hypothesis w i t h i n - g r o u p decrease  as were  A n a l y s i s of  results  three r e v e a l e d a s i g n i f i c a n t  i n PRC ( i d e a l )  from p r e t e s t  to  p o s t - t e s t for the experimental group; but not an accompanying i n c r e a s e i n BRC as one might Several possible introduced.  explanations  for t h i s  r e s u l t were  On the remaining subscales  Role Conception Scale  expect.  of the Nursing  (BRC, SRC, RD), the experimental  group e x h i b i t e d no s i g n i f i c a n t w i t h i n - g r o u p d i f f e r e n c e s between p r e t e s t  and p o s t - t e s t s c o r e s .  By comparison, the  c o n t r o l group r e p o r t e d no s i g n i f i c a n t w i t h i n - g r o u p differences  from p r e t e s t  to p o s t - t e s t  the Nursing Role Conception Scale  i n any s u b s c a l e s  (PRC, BRC, SRC, RD).  P o s t - t e s t r o l e c o n c e p t i o n and r o l e d e p r i v a t i o n scores of both groups were compared.  R e s u l t s i n d i c a t e d no  of  88  s t a t i s t i c a l l y s i g n i f i c a n t differences on these scores.  between the groups  Thus, at one month the preceptorship  program had less of an affect  on role deprivation than  had been anticipated. Since the experimental group did not report higher performance ratings or lower role deprivation scores than those reported by the control group, the f i r s t research hypothesis, easier  that suggested role t r a n s i t i o n would be  for the experimental group, was not supported.  Role t r a n s i t i o n experiences  of the groups were not found  to be s i g n i f i c a n t l y d i f f e r e n t .  Results suggest that at  one month there was no difference exhibited in either program a s s i s t i n g novice staff  nurses to make the  t r a n s i t i o n from student to beginning p r a c t i t i o n e r . Conclus ions Conclusions which can be drawn from analysis of the study data are: 1. Participants in both programs (preceptorship and t r a d i t i o n a l orientation)  showed s i g n i f i c a n t  performance  gains in d i s t i n c t l y different aspects of performance as measured by the Six Dimension Scale of Nursing Performance.  While the control ( t r a d i t i o n a l  orientation)  group exhibited performance gains on three dimensions of performance ( c r i t i c a l care, teaching/collaboration, and  89  interpersonal relationships/conununication);  the  experimental group r e p o r t e d improved performance on o n l y one dimension of performance However, p a r t i c i p a n t s significantly  (planning/evaluation).  i n n e i t h e r group gained  i n terms of o v e r a l l performance a b i l i t y  over the o t h e r .  Thus,  i t can be concluded t h a t  programs p r o v i d e b e n e f i t s , with d i f f e r e n t  areas of  but i n d i f f e r e n t  both  directions,  focus.  2. Role c o n c e p t i o n scores of the groups at p o s t - t e s t were not s i g n i f i c a n t l y d i f f e r e n t . (preceptorship)  However, the  group r e p o r t e d a s i g n i f i c a n t  decrease i n PRC ( i d e a l ) .  within-group  The c o n t r o l group r e p o r t e d no  significant  within-group differences  conceptions  from p r e t e s t to p o s t - t e s t .  i n any r o l e  concluded that the w i t h i n - g r o u p change conceptions  experimental  I t can be in role  r e p o r t e d by the groups demonstrates  groups had d i f f e r e n t  experiences i n t h e i r  that  the  orientation  programs. 3. P a r t i c i p a n t s i n the p r e c e p t o r s h i p program d i d not demonstrate  l e s s r o l e d e p r i v a t i o n than p a r t i c i p a n t s  the t r a d i t i o n a l o r i e n t a t i o n program.  Thus,  in  i t can be  concluded that p r e c e p t o r s h i p program p a r t i c i p a n t s d i d not p e r c e i v e themselves as having l e s s c o n f l i c t dilemmas about how s i t u a t i o n s  in resolving  i d e a l l y ought to be i n  90  nursing, versus preceptorship  how t h e y  p r o g r a m had l e s s  deprivation  t h a n was  4.  the  Overall,  employment, assisting  actually  staff  Thus  c a n be c o n c l u d e d  less  role  beginning  of  practice  a factor  transition  was shown  nurses  to  was  an e f f e c t  suggest t h a t ,  ho d i f f e r e n c e  student it  of  in p r a c t i c e . on  The  role  anticipated.  findings  novice  are  in  that  to  at  one-month  in either  make t h e  post-  program  transition  from  in professional  nursing.  the  preceptors  presence  influencing  t h a n had been  of  novice  staff  nurse  anticipated.  Limitations Recognized  limitations  1. Random s e l e c t i o n  of  (preceptorship)  orientation)  groups  of  the  on t h e  of  administered a time  was  time at  interval  there  This  subjects  into  (traditional depended was  out  control. the  post-test  T h i s may have  i n which to  detect  novice  of  and t h e r e f o r e ,  one month.  p r o g r a m were o f t e n addition,  precluded.  constraints,  transition differences 3. I n p r a c t i c e  include:  and c o n t r o l  employing agency,  investigators's  2. B e c a u s e  study  or random a s s i g n m e n t  experimental  entirely  this  between t h e staff  assigned  were s e v e r a l  nurses  been  significant  was too  short  role  groups. i n the  more t h a n one occasions  preceptorship preceptor.  when  In  experienced  91 nurses,  who  prepare  them f o r t h e p r e c e p t o r  preceptors  had n o t had t h e e d u c a t i o n a l p r o g r a m t o  to novice s t a f f  have l i m i t e d program.  role,  nurses.  were a s s i g n e d as These  the e f f e c t i v e n e s s of t h i s  Particularly,  in offsetting  factors  preceptorship benefits attributed  t o p r e c e p t o r s h i p programs, such  a s , one-to-one  with  i s prepared  an " e n l i g h t e n e d g u i d e "  preceptor 4.  5.  differences  F a c t o r s such  novice  staff  agencies  learning,  f o r the  role.  The sample s i z e  detect  who  may  was  s m a l l , thus  limiting  should d i f f e r e n c e s  as s t a f f i n g  nurses,  actually  exist.  needs, assignments g i v e n t o  and work m i l i e u  were f a c t o r s  t h e power t o  in participating  t h a t were n o t c o n t r o l l e d  in this  study. Implications Findings  of the study  have i m p l i c a t i o n s  practice,  e d u c a t i o n , and r e s e a r c h .  presented  individually  Nursing The nurses  Each of these i s  i n the f o l l o w i n g s e c t i o n s .  Practice  p e r i o d of b e g i n n i n g is critical  long term  of n u r s e s .  during this  satisfaction  employment as n o v i c e  to the p r o f e s s i o n a l  adjustment  experienced their  for nursing  time  and l a t e r  The  staff  d e v e l o p m e n t and  socialization  e s t a b l i s h e s the b a s i s f o r loyalty  t o b u r e a u c r a t i c and  92  professional  standards  s e t t i n g s need to f o s t e r facilitate  (Ahmadi et a l . , positive  novice nurses'  1987).  environments  Practice that  t r a n s i t i o n from s c h o o l  to  practice. The a b i l i t y of n u r s i n g p r a c t i c e s e t t i n g s to provide a s u p p o r t i v e environment to beginning s t a f f becoming more d i f f i c u l t given t o d a y ' s  nurses  is  changing h e a l t h  care environment.  According to T a l a r c z y k and M i l b r a n t  (1988) the present  h e a l t h care environment, with  on "high tech" and c o s t containment, demands on n u r s e s . provide competent  and s e n s i t i v e n u r s i n g care to Moreover,  it  experienced  (1989)  o r i e n t a t i o n programs have e s s e n t i a l l y  is,  focused  in role  i n a c q u i s i t i o n of a t t r i b u t e s  c h a r a c t e r i s t i c of the p r o f e s s i o n a l  in  hospital on the  and p r o t o c o l s  and have u s u a l l y f a i l e d to attend  p r o v i d i n g guidance to the novice that  factors  practice.  f a m i l i a r i z i n g new nurses to the p o l i c i e s institution;  they  by novice nurses  making the t r a n s i t i o n from s c h o o l to According to Hamilton et a l .  These  to  patients  r e q u i r e s that  care i n a f a s t paced manner.  add to the pressures  the  increased  I t r e q u i r e s nurses who are able  with i n c r e a s e d a c u i t y . deliver this  places  emphasis  to  development,  that  are  nursing r o l e .  of  Kramer and Schmalenberg (1977b) d e s c r i b e d how the job of novice nurses i s a p r o v i n g ground.  first  In t h i s  p r o v i n g p e r i o d the novice i s put through many formal and informal t e s t s by the r e f e r e n t work group. for neophytes with these t e s t s ambiguous, and the c r i t e r i a clear.  The problem  i s t h a t they are  for p a s s i n g the t e s t s are not  Another problem with these t e s t s  of the r e f e r e n t work group tend to judge  i s that members neophytes'  performance from the l e v e l of performance they have a t t a i n e d by experience without regard f o r the lack of e x p e r i e n c e .  I t would be worthwhile for p r a c t i c e  s e t t i n g s to a p p r a i s e the t e s t i n g , testing,  Clearly,  particularly  that takes p l a c e and to d i s c u s s  this testing  on t r a n s i t i o n experiences  of  informal  the impact of neophytes.  when such p r a c t i c e s are d i s c u s s e d there  greater l i k e l i h o o d that t e s t i n g ,  if  it  could be adjusted so that e x p e c t a t i o n s reflect  neophyes  the d i f f e r e n t experience  and seasoned  professionals.  is a  i s to c o n t i n u e , i n t e s t i n g could  l e v e l s between  novice  Conseguently, expert  of performance would not be expected  levels  from beginning  practitioners. Based on the present study f i n d i n g s , both of  the  o r i e n t a t i o n programs ( p r e c e p t o r s h i p and t r a d i t i o n a l o r i e n t a t i o n ) were equal i n t h a t there were no s i g n i f i c a n t  94 differences novice s t a f f traditional benefits  in role t r a n s i t i o n  experiences,  nurses p a r t i c i p a t e d orientation  program.  i n a p r e c e p t o r s h i p or a T h i s suggests that  of p r e c e p t o r s h i p programs over  orientation  whether  the  traditional  programs, that have been c i t e d i n  the  l i t e r a t u r e , may not be borne out as s t r o n g l y as was anticipated. greater  If  benefit  the t r a n s i t i o n  p r e c e p t o r s h i p programs are to be of i n a s s i s t i n g novice s t a f f  nurses to make  from students to beginning  practitioners,  a t t e n t i o n needs to be given to p r e c e p t o r s h i p program development and monitoring of t h e i r Difficulties  a r i s e with preceptor programs having  enough experienced s t a f f preceptors.  effectiveness.  prepared to f u n c t i o n as  The impact of the n u r s i n g s h o r t a g e ,  complicates the a b i l i t y  of p r a c t i c e s e t t i n g s to have  enough experienced nurses to provide p r e c e p t o r s novice n u r s e s .  for  Changing preceptor assignments i n  the  middle of the program or a s s i g n i n g s e v e r a l p r e c e p t o r s each novice nurse d e s t r o y s the c o n t i n u i t y neophyte  (Goldenberg, 1987/1988).  are to reap the g r e a t e s t  benefits  If  for  practice  the settings  that have been a s c r i b e d  to p r e c e p t o r s h i p programs, mechanisms to i n c r e a s e the number of p r e c e p t o r s prepared to f u l f i l l needed.  for  that r o l e  are  95 A t t e n t i o n a l s o needs to be given to the s e l e c t e d for the preceptor r o l e . competence; skills;  interpersonal  nurses chosen  important i n g r e d i e n t s  The c l i n i c a l  relationship/communication  teaching a b i l i t i e s ;  experienced  person's  and w i l l i n g n e s s  of  for the preceptor r o l e are a l l  i n ensuring the q u a l i t y of  the  t e a c h i n g and guidance given to noephytes by p r e c e p t o r s . In t h i s  p r e c e p t o r s h i p program s t u d i e d there were no  formal standards preceptors.  i n terms of the q u a l i t i e s  required in  As w e l l there was no f o r m a l i z e d ongoing  f o l l o w - u p with p r e c e p t o r s and o r i e n t e e s .  These  might l i m i t the degree to which the program i s c o n s i s t e n t with i t s address  purpose.  factors operating  Nursing p r a c t i c e needs to  i s s u e s of commitment to the p r e c e p t o r s h i p program  as a means to a s s i s t novice nurses with the t r a n s i t i o n practice used.  if  it  to  i s to be used as i t was intended to be  If these programs are to be  successful  o r g a n i z a t i o n a l commitment to the o b j e c t i v e s p r e c e p t o r s h i p program i s  of  the  essential.  Nursing E d u c a t i o n Nursing education prepares p r a c t i t i o n e r s discipline,  and as s u c h , must be a l e r t to the  of c l i n i c a l p r a c t i c e settings.  for a p r a c t i c e  in today's  realities  nursing p r a c t i c e  Nursing education must prepare students  for  96 the  transition  beginning  to p r a c t i c e  practitioners  and  face.  programs must p r o v i d e c o n t e n t anticipatory socialization professional To  be  nursing  "real  Role  As  typical such,  in reality  educators  situation  become more c o n g r u e n t . prepare  shock  to the r e a l i t y  of  the  must be  and  Moreover,  students  anticipatory knowledgable  i f educators  for professional  are c l i n i c a l l y  thus  proficient,  nursing students  and  f o r the r e a l and  closely  that students  the  technical,  skills  i n order  nursing Given  to handle  will, skills  in  educators to  of n u r s i n g .  nursing practice begin  the r e a l i t i e s  to  need  to  practice and  of  be with  conceptual  beginning  practice. t h e p a c e of change  have some means t o m a i n t a i n provide  world  interpersonal relationship,  necessary  are  are q u a l i f i e d ,  Thus, n u r s i n g e d u c a t i o n linked  must  practice  to ensure t h a t  instruction  and  upon g r a d u a t i o n , to competently  i n nursing, educators competence  i n order  s u p e r v i s i o n to students provide  begin  them w i t h  practice  of  settings.  practitioners  n u r s i n g , mechanisms a r e needed  prepare  and  in nursing practice  e x p e c t a t i o n s of e d u c a t o r s  adequately  that  role.  programs,  world"  problems  education  s u c c e s s f u l i n p r o v i d i n g adequate  socialization the  the  the  must to that  requisite  in nursing.  Many  97 i s s u e s need t o be a d d r e s s e d university setting. teaching  particularly  i n the  According to Myrick  (1988)  in university settings  i s subordinate  c l a s s r o o m t e a c h i n g , r e s e a r c h , and  clinical to  publication.  Nursing  o u g h t t o q u e s t i o n what i s t h e i d e a l c o m b i n a t i o n , nursing faculty expertise learning  i n terms of c l i n i c a l  for  proficiency,  i n the a p p l i c a t i o n of sound t e a c h i n g  and  and  principles.  Another  i s s u e t h a t n e e d s t o be a d d r e s s e d  educational standards education  i s whether  a r e a p p r o p r i a t e , or whether n u r s i n g  i s a d v o c a t i n g and  t e a c h i n g p e r f e c t i o n i s m as  opposed t o p r o f e s s i o n a l i s m ?  Nursing education  and  nursing service personnel should c o l l a b o r a t e i n e s t a b l i s h i n g appropriate curriculum content e d u c a t i o n programs. n u r s i n g e d u c a t i o n and  for nursing  T h e r e must be a g r e e m e n t b e t w e e n n u r s i n g s e r v i c e on what  a p p r o p r i a t e b a s i c e n t r y - l e v e l s k i l l s o f new  constitutes  graduates.  T h e r e h a v e been f r e q u e n t d e b a t e s c o n c e r n i n g t h e b e t w e e n n u r s i n g p r a c t i c e and (Schempp & Rompre, 1 9 8 6 ) . often complain prepare  nursing education  Nursing service  As a r e s u l t ,  s e t t i n g s must s p e n d i n o r d i n a t e t i m e graduates  personnel  personnel  t h a t s c h o o l s of n u r s i n g f a i l  students for practice.  gap  to  adequately  practice  in orienting  new  b e f o r e t h e y a r e r e a d y t o assume f u l l p a t i e n t  98 care  responsibilities.  Educators defend that i t i s  impossible t o prepare a f i n i s h e d product practice  i n any s e t t i n g .  settings  fail  They a l s o c o n t e n d t h a t p r a c t i c e  t o t r e a t t h e new g r a d u a t e i n a manner t h a t  fosters successful transition The  novice  ready f o r  nurse,  from s c h o o l  to practice.  caught i n t h e middle of t h i s  between n u r s i n g e d u c a t i o n  debate  and n u r s i n g p r a c t i c e  personnel,  frequently feels personally responsible f o r her/his inadequate preparation & Rompre, 1 9 8 6 ) .  f o r the s t a f f  nurse r o l e  A resolution to this  long  b l a m i n g game i s needed s o t h a t p r a c t i c e and personnel  (Schempp  standing education  work c o l l a b o r a t i v e l y t o p r o v i d e p o s i t i v e  c o n d i t i o n s f o r smoother t r a n s i t i o n s o f neophytes  into  professional practice. Another  i s s u e t h a t n e e d s t o be a d d r e s s e d b y n u r s i n g  education  r e l a t e s t o the nursing shortage  effects.  Educators,  nursing bodies are w i l l i n g  practice personnel,  need t o c o n s i d e r  be  the l i m i t s t o which  Given the c r i t i c a l  they  nursing  and t h e p r o m i s e o f i n c r e a s i n g p r e s s u r e  compromises and  and p r o f e s s i o n a l  t o compromise p r o f e s s i o n a l e x p e c t a t i o n s f o r  bureaucratic standards. shortage  and i t s  ( i . e . , decrease standards  nursing education), addressed.  Nursing  i ti s crucial  t o make  i n nursing practice that these  issues  n e e d s t o c l e a r l y and p r o a c t i v e l y  d e l i n e a t e the l i m i t s to which i t w i l l submit i n decreasing  standards.  contingencies  This w i l l  ensure t h a t  with accompanying r a t i o n a l e are developed  so t h a t n u r s i n g education  standards  and  not  unduely  jeopardized. C l e a r l y , n u r s i n g p r a c t i c e i s the r a i s o n d ' e t r e of the nursing p r o f e s s i o n .  Nursing  education  i s charged  p r e p a r i n g p r a c t i t i o n e r s f o r the p r a c t i c e of Educators  must be p r o f i c i e n t  p r o f e s s i o n a l n u r s i n g , and  with  nursing.  i n the p r a c t i c e of  thus, cannot be separate  from  nursing p r a c t i c e . Nursing  Research  Preceptorship  programs are e x t e n s i v e l y used f o r  o r i e n t a t i o n of novice s t a f f nurses to n u r s i n g p r a c t i c e . While many b e n e f i t s of p r e c e p t o r s h i p programs f o r t h i s purpose are noted i n the anecdotal s u b j e c t , the r e s e a r c h which has of p r e c e p t o r s h i p programs has More r e s e a r c h  l i t e r a t u r e on  the  i n v e s t i g a t e d the  found c o n f l i c t i n g  effect results.  i s needed to i n v e s t i g a t e the e f f e c t  p r e c e p t o r s h i p programs.  I t i s recommended t h a t  this  study be r e p l i c a t e d with a l a r g e r sample s i z e and p a r t i c i p a n t s be  followed over a longer  of  that  time frame i n  order to determine whether changes i n r o l e t r a n s i t i o n novice s t a f f nurses over time can be a t t r i b u t e d to the  of  100  effects of the preceptorship program. In addition, future research could address: (1) Whether preceptorship programs, as opposed to t r a d i t i o n a l orientation programs, have any differences terms of effects on job s a t i s f a c t i o n ,  in  and retention of  nurses. (2) Whether prior c l i n i c a l experience in the employing agency as part of their education program teaches neophytes the "back stage" r e a l i t y and the day-to-day p o l i t i c s of the bureaucratic organizations in which novice nurses begin p r a c t i c e .  (This data would be useful  in determining whether this information can be deleted or condensed in orientation programs). (3) Whether differences  in novice staff  correlate to level of preceptor (4) Whether there are differences  nurse outcomes  competence. in effects of  preceptorship programs when preceptors  receive  orientation to the preceptor role versus programs where preceptors do not receive preparation for the preceptor role. (5) Whether retention of nurses is increased when they begin professional practice in a place of employment where they received substantial c l i n i c a l experience during their preparatory education program.  101  ( 6 ) Whether orientation programs which focus on s k i l l mastery as opposed to s o c i a l integration foster  positive  role t r a n s i t i o n . C l e a r l y preceptorship programs are frequently used in nursing education programs and nursing practice settings. More study is needed to validate whether these programs are t r u l y as effective as they have been declared to be.  102 REFERENCES Ahmadi, K. S., Speedling, E . J . , & Kuhn-Weissman, G. 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Occupational Health Nursing, 32(8), 410-411.  108 Appendix A.  109 P r e c e p t o r s h i p Program Schedule Monday 0800-0830 0830-0915 0915-0930 0930-1000 1000-1030 1030-1100 1100-1200 1200-1300 1300-1600  Welcome, I n t r o d u c t i o n , Meet I n s t r u c t o r s C h a r t i n g R e s p o n s i b i l i t i e s and A c c o u n t a b i l i t y " L i f t and T r a n s f e r Techniques" video Break Nursing Personnel P o l i c i e s "Restraint/Non R e s t r a i n t " video Blood Glucose M o n i t o r i n g Lunch C l i n i c a l Area- Complete: P o l i c y and Procedure Module,Pharmacy Module, P r e - r e a d i n g M a t e r i a l , Search and F i n d and L i f t i n g and T r a n s f e r r i n g Return Demonstration,  Tuesday 0800-1200 1200130013301345141514451530-  H o s p i t a l Wide O r i e n t a t i o n (by Employee Relations) Lunch Communications Systems I n t r o d u c t i o n t o Competency Based E d u c a t i o n Computers i n Nursing Break Philosophy Overview of Nursing D i v i s i o n O r g a n i z a t i o n  1300 1330 1345 1415 1445 1530 1600  Wednesday 0800-0840 0840-0910 0910-0930 0930-1000 1000-1100 1100-1200 1200-1300 1300-1600  E d u c a t i o n and Research Q u a l i t y Assurance, Standards and P r o t o c a l s Break P a s t o r a l Care Infection Control R e s p i r a t o r y Therapy Lunch P a r e n t e r a l Therapy  Thursday 0800-1100 1100-1200 1200-1600 0700-1100 1100-1200 1200-1500  OR  Code Blue (General Areas) Lunch C l i n i c a l Area C l i n i c a l Area Lunch Code Blue (General Areas)  Appendix B.  Ill  Preceptor Development Program Purpose: This half day program is designed to a s s i s t participants (registered nurses who w i l l be acting as preceptors) to develop the knowledge, s k i l l s and attitudes necessary to e f f e c t i v e l y quide a new employee through o r i e n t a t i o n . Program Objectives: At the end of the program the participant w i l l be able to: 1.  Describe the purposes and benefits program for orientation.  of a preceptorship  2.  Outline roles of the orientee, preceptor and head nurse or delegate in the Hospital Preceptorship Program.  3.  Identify methods of assessing an orientee's learning needs.  4.  Outline competency areas required of the  5.  Develop teaching strategies to a s s i s t orientees to meet their learning needs and competencies.  orientees.  Give constructive feedback in response to an observed performance or case study.  112 A p p e n d i x C.  Traditional Orientation Schedule Hospital (A) Tuesday 0800--0830 0830--0835 0835--0840 0840 -0900 0900--0930 0930 -0945 0945--1015 1015 -1040 1040- -1100 1100 -1120 1120- -1200 1200- -1230 1230 -1300 1300- -1530  Introduction Pastoral Care S p i r i t u a l Aspects Personnel Services Union Reps: HSA HEU BCNU Coffee Infection Control F i r e Safety Disaster Plan Employee Health Services Lunch Nursing Department Philosophy & Objectives Nursing Personnel Information Back Care Program  Wednesday 0730 -0815 0815 -0900 0900 -0915 0915 -0930 0930 -1045 1045 -1145 1145 -1215 1215 -1245 1245 -1400 1400 -1415 1415 -1530 Thursday 1200 -1315 1315 -1530  Computerized Medication System I.V. Therapy R.N.A.B.C. Coffee T.P.N. Unit Orientation (Complete seek and f i n d , review unit orientation) Lunch Care of the Surgical Patient Charting Coffee Equipment Workshop Emergency Equipment Care of the Person with AIDS Summary and Evaluation  Extended Orientation (For New Graduates) Friday E: 0800 -0830 0830 -0900 0900 -1000 1000 -1100 1100 -1200 1200 -1315 1315 -1400 1400 -1415 1415 -1600  Introduction Coffee AIDS Update Registered Nurse and Charge Nurse Roles Lunch Processing Orders Physician Coverage Coffee Equipment Workshop  114 Appendix D.  115 Traditional Orientation Schedule Hospital (B) Tuesday 0800-1200  1200-1300 1300-1330 1300-1600  Central Orientation (Welcome from Education Services and Administration, Slide tapes "Welcome to Hospital", "Fundamentals of Back Care", F i r e Safety, Tour of Hospital, Union Reps, Benefits Presentation and Completion of Benefits Forms). Lunch Introduction to Acute Care Nursing Orientation Independent Study: Respiratory Therapy, Support Services Modules, Videotape- Oxygen Delivery Systems, Demonstration and Practice: Oxygen Delivery Systems  Wednesday 0800-0815 0830-0845 0845-0915 0915-0945 0945-1000 1000-1045 1045-1200 1200-1300 1300-1315 1315-1415 1430-1600  C l i n i c a l Nurse S p e c i a l i s t Welcome from Nursing Department Video- "Chest Tubes" Demonstration/Practice "Pleurevac" Break Independent Study- Chest Tubes and Support Services Modules Demonstration & Return Demo "Accuchek II" Lunch Home Care Liaison Nurse Independent Study of Modules: Emergency Cart, Cardiac and Respiratory Arrest, and Catheterization Demonstration/Practice: Emergency Cart, Cardiac and Respiratory Arrest, and Catheterization  Thursday 0800-0900 0900-0930  0930-1000 1000-1015 1015-1030 1030-1045 1045-1200 1200-1300  Independent Study: Infection Control Multiple Choice Post Quiz: Emergency Cart, Cardiac and Respiratory Arrest, Support Services, Catheterization, Infection Control, Respiratory Therapy, Chest Tubes Review Quiz Tour (ICU, C . S . D . , Pharmacy) Break Lecture/Discussion Medicus System Independent Study- Medicus System Lunch  116 Traditional Orientation Schedule Hospital (B) Thursday (Con't) 1300-1600 1300-1600  Return Demonstrations: Chest Tubes, Catheterization, Respiratory Therapy Independent Study: Medicus, Medications, Nursing Department, Pharmaceutical Math Questions Handout, I . V . Therapy and Direct I.V. Medications  Fr iday 0800-0900 0900-0915 0915-1030 1030-1130 1130-1200 1200-1230 1230-1300 1300-1600  Demonstration/Practice I . V . Therapy, Direct I . V . Medications Break Independent Study: I . V . Therapy, Direct I . V . Medications Multiple Choice Quiz- Medications, I . V . Therapy, and Direct I . V . Medications Review Quiz Lecture/Discussion Charting L e g a l i t i e s Lunch Independent Study: Patient Chart, Equipment, Return Demos: I . V . Therapy, Direct I . V . Medications Quiz- Medicus Evaluation  Monday ( a l l Day) Unit Orientation Tuesday 0800-1230 1300-1400 1400-1530  CPR Basic Level 1 (only i f c e r t i f i c a t i o n necessary) or Unit Orientation Transfer Techniques Mock Arrest (Emergency Cart, Cardiac and Respiratory Arrest  Appendix E.  118 Letter of Introduction The University of B r i t i s h Columbia School of Nursing Vancouver, B r i t i s h Columbia Dear Colleague: I am a graduate student in the University of B r i t i s h Columbia School of Nursing. For my thesis, I am conducting a study to examine the effect of orientation programs on the role t r a n s i t i o n of new graduates in their f i r s t - t i m e employment as registered nurses. To date there has been limited research done which has investigated the effectiveness of orientation programs. In order for nursing departments to make decisions on particular types of programs and to j u s t i f y expenditure, i t is important that their effectiveness be evaluated. The purpose of t h i s study is to compare the effectiveness of two types of orientation programs. Your voluntary p a r t i c i p a t i o n is requested to provide information regarding orientation. This information may be helpful in improving future orientation programs. Each participant w i l l be asked to complete two questionnaires at the start of orientation and again one month l a t e r . These include: a s e l f - a p p r a i s a l of nursing performance using Schwirian's Six Dimension Scale of Nursing Performance and a s e l f - a p p r a i s a l of role conception using Corwin's Nursing Role Conception Scale. Completion of these scales is estimated to take approximately 15 and 20 minutes respectively. Finally, each participant w i l l be asked to complete a Demographic Data Sheet. Follow-up scales w i l l be mailed to participants with prepaid postal return envelopes. A l l information provided w i l l be used in confidence by this researcher. Individual responses w i l l be kept confidential and they w i l l not be shared with hospital personnel. In order to preserve the identity of participants in the study, each participant in the study w i l l be assigned a code number. Only code numbers, not names of p a r t i c i p a n t s , w i l l be appear on the completed questionnaires. A separate l i s t of study participants w i l l be kept by t h i s researcher. A l l data w i l l be maintained in safekeeping by t h i s researcher. The completed study w i l l not disclose the i d e n t i t y of individual p a r t i c i p a n t s .  119 Your p a r t i c i p a t i o n in this study would be appreciated. P a r t i c i p a t i o n in t h i s study is on a voluntary basis, and you are free to withdraw from the study at any time. There is no penalty associated should you choose not to participate in the study. If the questionnaires are completed i t w i l l be assumed that consent to participate in the study has been given. F i n a l l y , whether or not you participate in this study w i l l not influence how you are evaluated by hospital personnel during your orientation period. This thesis study is being supervised by Dr. Sonia Acorn, Assistant Professor, University of B r i t i s h Columbia School of Nursing. Office phone number for Dr. Acorn i s : If you have any questions about the study please contact me at the University of B r i t i s h Columbia School of Nursing or at my home address: Bernadette MacDonald address Phone Sincerely; Bernadette MacDonald R.N. B.N. (MSN student)  120  Appendix F .  121 Demographic Data Sheet Please use a check mark to indicate which of the following categories apply to you. 1.  Sex:  male female  2.  Type of program: orientation preceptorship  3.  Basic Nursing Education: Diploma (two year program) Diploma (three year program) Baccalaureate program  4. Other post-secondary education (besides nursing) yes no i f yes please specify 5. Did you have c l i n i c a l experience in employing agency during your education program? yes no i f yes please specify number of weeks 6. Past experience working in a hospital:(does not include c l i n i c a l experience in question 4) none nurse's aide other (please specify) 7. Length of past experience working in a h o s p i t a l : please specify number of months or years 8. Past work experience other than in a hospital yes no  i f yes please specify  ,  9. Age:  Code Number  A p p e n d i x G.  \  123 SIX-DIMENSION SCALE OF NURSING PERFORMANCE (6-D SCALE) (Schwirian)  P E R F O R M A N C E OF NURSING BEHAVIORS Instructions; This section contains a list of a c t i v i t i e s in which nurses engage with varying degrees of frequency and s k i l l . F o r these a c t i v i t i e s that you do perform in your current job, please indicate how well you perform them by using numbers from the following k e y : 1234X -  N o t very well Satisfactorily Well Very w e l l N o t expected in my current job  TC  Teach a patient's family members about the patient's needs.  PE  Coordinate the plan of nursing care with the medical plan of c a r e .  L  G i v e praise and recognition for achievement of those under your direction.  TC  Teach preventive health measures to patients and their f a m i l i e s .  TC  Identify and use community resources in developing a plan of care for a patient and his family. Identify and include in nursing care plans anticipated changes in patient's  PE  condition. PE  Evaluate results of nursing c a r e .  IPR  Promote the inclusion of the patient's decisions and desires concerning his c a r e .  PE  Develop a plan of nursing care for a patient.  PE  Initiate planning and evaluation of nursing care with others.  CC  PE  P e r f o r m technical procedures: e.g., oral suctioning, tracheostomy c a r e , intravenous therapy, catheter c a r e , dressing changes, e t c . Adapt teaching methods and materials to the understanding of the particular audience: e.g., age of patient, educational background, and sensory deprivations. Identify and include immediate patient needs in the plan of nursing c a r e .  TC  Develop innovative methods and materials for teaching patients.  TC  Communicate a feeling of acceptance of each patient and a concern for the patient's welfare. Seek assistance when necessary. Help a patient communicate with others. Use mechanical devices: e.g., suction machines, Gomco, cardiac monitor, respirator, etc. Give emotional support to family of dying patient. Verbally communicate facts, ideas, and feelings to other health team members. Promote the patient's right to privacy. Contribute to an atmosphere of mutual trust, acceptance, and respect among other health team members. Delegate responsibility for care based on assessment of priorities of nursing care needs and the abilities and limitation of available health care personnel. Explain nursing procedures to a patient prior to performing them. Guide other health team members in planning for nursing c a r e . A c c e p t responsibility for the level of care provided by those under your direction. P e r f o r m appropriate measures in emergency situations. Promote the use of interdisciplinary resource persons. Use teaching aids and resource materials in teaching patients and their families. P e r f o r m nursing care required by critically ill patients. Encourage the family to participate in the care of the patient. Identify and use resources within your health care agency in developing a plan of care for a patient and his family. Use nursing procedures as opportunities for interaction with patients. Contribute to productive working relationships with other health team members. Help a patient meet his emotional needs. Contribute to the plan of nursing care for the patient. Recognize and meet the emotional needs of a dying patient.  125 TC  C o m m u n i c a t e facts, ideas, and professional opinions in writing to patients and their families.  TC  Plan for the integration of patient needs with family needs.  CC  Functions c a l m l y and competently in emergency situations.  L  R e m a i n in open to the suggestions of those under your direction and use them when appropriate. Use opportunities for patient teaching when they arise.  IPR  P E R F O R M A N C E OF PROFESSIONAL D E V E L O P M E N T BEHAVIORS Instructions; Using the following key, please indicate on the line at the left of each item the number that best describes the frequency with which you engage in the following behaviors. 1- Seldom or never 2 - Occasionally 3 - Frequently 4 - Consistently PD  Use learning opportunities for on-going personal and professional growth.  PD  Display s e l f - d i r e c t i o n .  PD  A c c e p t responsibility for own actions.  PD  Assume new responsibilities within the limit of capabilities.  PD  Maintain high standards of self-performance.  PD  Demonstrate self-confidence.  PD  Display a generally positive attitude.  PD  Demonstrate knowledge of the legal boundaries of nursing.  PD  Demonstrate knowledge of the ethics of nursing.  PD  A c c e p t and use constructive c r i t i c i s m .  K e y To Subscales: L CC TC PE IPR PD  -  Leadership Critical Care Teaching/Collaboration Planning/Evaluation IPR/Communications Professional Development  126  A p p e n d i x H.  127  NURSING R O L E CONCEPTION  SCALE  INSTRUCTIONS  This consists of a list of 22 hypothetic situations in which as nurse might find herself. You are asked to indicate both: A)  the extent to which you think the situation should be the ideal nursing.  B)  the extent to which you have observed the situation in your hospital.  Notice the two (2) questions must be answered for each situation. Consider the questions of what ought to be the case and what is really the case separately; try not to let your answer to one question influence your anwser to the other question. Give your opinions; there are no "wrong" answers. Indicate the degree to which you agree or disagree with the statement by checking one of the alternative answers, ranging from: S T R O N G L Y A G R E E , A G R E E , U N D E C I D E D , D I S A G R E E , and S T R O N G L Y D I S A G R E E .  S T R O N G L Y A G R E E indicates that you agree with the statement with almost no exceptions; A G R E E indicates that you agree with the statement with some exceptions. U N D E C I D E D indicates that you could either "agree" or "disagree" with the statement with about an equal number of exceptions in either case. D I S A G R E E indicates that you disagree with the statement with some exceptions. S T R O N G L Y D I S A G R E E indicates that you disagree with the statement with almost no exception.  Some graduate nurses in New York hospitals believe that doctors are more professional than nurses. A.  On the basis of the facts graduate nurses should believe doctors are more professional.  B.  Graduate nurses at my hospital actually do believe that doctors are more professional.  Suppose that, almost without exception, you agree that nurses she>uld reg ard doc tors as more professional. Then check (V) the first column (STRONGLY A kGREE) for que stion A Suppose that, with some exceptions, you disagree that nurses in y<3ur hosp>ital do believe that doctors are more professional. Then check (^ column four (C)ISAGR EE) afttsr question B. Be sure you place a check mark {/) after both questions A and B.  Bureaucratic Items 1.  2.  3.  One graduate nurse, who is an otherwise excellent nurse except that she is frequently late for work, is not being considered for promotion, even though she seems to get the important work done. A.  Do you think this is the way it should be in nursing?  B.  Js_this the way things are at your hospital?  A head nurse at one hospital insists that the rules be followed in detail at all times, even if some of them do seem impractical. A.  Do you think this is the way head nurses and supervisors should act?  B.  _Is_this the way head nurses and supervisors at your hospital actually do act when the occasion arises?  A graduate staff nurse observes another graduate staff nurse, licensed practical nurse, or aide who has worked In the hospital for months violating a very important hospital rule or policy and mentions it to the head nurse or supervisor. A.  Do you think that this is what graduate nurses should do?  B.  Is this what graduate nurses at your hospital actually do when the occasion arises?  STRONGLY DISAGREE  DISAGREE  UNDECIDED  AGREE  Here is an example:  STRONGLY AGREE  128  4.  5.  6.  When a supervisor at one hospital considered a graduate for promotion, one of the most important factors is the length of experience on the job. A.  Do you think this is what supervisors should regard as important?  B.  Js this what supervisors at your hospital actually do regard as important?  In talking to acquaintances who aren't in nursing, a graduate nurse gives her opinions about things she disagrees with in the hospital. A.  Do you think this is what graduate nurses should do?  B.  J s this what graduate nurses at your hospital actually do when the occasion arises?  A graduate nurse is influenced mainly by the opinions of the hospital authorities and doctors when she considers what truly "good", nursing is. A.  Do you think this is what graduate nurses should consider in forming their opinions?  B.  Is this what graduate nurses at your hospital actually do consider in forming their opinions?  P R O F E S S I O N A L ITEMS 7.  8.  One graduate nurses tries to put her standards and ideals about good nursing into p r a c t i c e even if hospital rules and procedures prohibit it. A.  Do you think that this is what graduate nurses should do?  B.  J s this what graduate nurses at your hospital actually do when the occasion arises?  One graduate nurse does not do anything which she is told to do unless she is satisfied that it is best for the welfare of the patient. A.  Do you think that this is what graduate nurses should do?  B.  Js this what graduate nurses at your hospital actually do when the occasion arises?  STRONGLY DISAGREE  DISAGREE  UNDECIDED  AGREE  STRONGLY AGREE  129  9.  10.  11.  12.  13.  A l l graduate nurses in a hospital are a c t i v e members in professional nursing associations, attending most conferences and meetings of the association. A.  Oo you think this should be true of a l l nurses?  B.  _Is this true of nurses at your hospital?  A l l graduate nurses in a hospital spend, on the average, at least six hours a week reading professional journals and taking refresher courses. A.  Do you think this should be true of all nurses?  B.  Is this true of nurses at your hospital?  Some nurses try to live up to what they think are the standards of their profession, even if other nurses on the ward or supervisors don't seem to like it. A.  Do you think that this is what graduate nurses should do?  B.  J s this what graduate nurses at your hospital actually do when the occasion arises?  Some graduate nurses believe that they can get along very well without a lot of formal education, such as required for a B.S., M.S., or M . A . college degree. A.  Do you think that this is what graduate nurses should believe?  B.  _ this what graduate nurses at your hospital actually do believe?  A t some hospitals when a graduate nurse is considered for promotion, one of the most important factors considered by the supervisor is her knowledge of, and ability to use, judgement about nursing c a r e procedures. A.  Dp you think this is what supervisors should regard as important?  B.  Is this what supervisors at your hospital actually do regard as important?  STRONGLY DISAGREE  DISAGREE  UNDECIDED •  AGREE  STRONGLY AGREE  130  131  14.  Some hospitals try to hire only graduate nurses who took their training in colleges and universities which are equipped to teach the basic t h e o r e t i c a l knowledge of nursing science. A.  Do you think this is the way it should be in nursing?  B.  J s this the way things are at your hospital?  S E R V I C E ITEMS 15.  16.  17.  18.  A t one hospital graduate nurses spend more time at bedside nursing than any other nursing task. A.  Do you think this is the way it should be in nursing?  B.  J s this the way things are at your hospital?  Head nurses and doctors at one hospital allow the graduate nurse to tell patients as much about their physical and emotional condition as the nurse thinks is best for the patient. A.  Do you think this is the way it should be in nursing?  B.  Js_this the way things are at your hospital?  A doctor orders a patient to sit up in a wheel c h a i r twice a day, but a graduate nurse believes that he is not emotionally ready to sit up; the doctor respects her opinion and changes the t r e a t m e n t . A.  Do you think this is the way it should be in nursing?  B.  Is this the way things are at your hospital?  Doctors and head nurses at the hospital respect and reward nurses who spend time talking with patients in an attempt to understand the hostilities, fear, and doubts which may e f f e c t the patient's recovery. A.  Do you think this is what doctors and head nurses should regard as important?  B.  Js_this what doctors and head nurses at your hospital actually do regard as important?  19.  20.  21.  22.  A graduate nurse believes that a patient ought to be referred to a psychologist or a public health nurse and tries to convince the doctor of this, even though he is doubtful. A.  Do you think this is what a graduate nurse should do?  B.  J s this what graduate nurses at your hospital actually do when the occasion arises?  A t one hospital the nurse's ability to understand the psychological and social factors in the patient's background is regarded as more important then her knowledge of such other nursing skills as how to give enemas, IVs, or how to chart a c c u r a t e l y . A.  Do you think this is the way it should be in nursing?  B.  Is this the way things are at your hospital?  Some graduate nurses believe that the professional nurses who should be rewarded most highly are the ones who regard nursing as a c a l l i n g in which one's religious beliefs can be put into p r a c t i c e . A.  Do you think that is is what graduate nurses should believe?  B.  J s this what graduate nurses at your hospital actually do believe?  A t some hospitals the graduate nurses who are most successful are the ones who are realistic and p r a c t i c a l about their jobs, rather than the ones who attempt to live according to idealistic principles about serving humanity. A.  Do you think this is the way it should be in nursing? _  B.  Is this the way things are at your hospital?  •  STRONGLY DISAGREE  DISAGREE  UNDECIDED  AGREE  STRONGLY AGREE  132  

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