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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 U n i v e r s i t y , 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 th i s thes is as conforming to the required standard The Univers i ty of B r i t i s h Columbia May 1990 @ Bernadette MacDonald In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada Department of DE-6 (2/88) Abstract This study invest igated the effect of a preceptorship program on ro le t r a n s i t i o n of novice s ta f f nurses. A quasi-experimental , contro l group pretest pos t - tes t , design was used. T h i r t y - f o u r novice s t a f f nurses par t i c ipa ted in the study; 20 in the preceptorship (experimental) group, and 14 in the t r a d i t i o n a l or i enta t ion (control) group. Three research hypotheses were invest igated to determine whether novice s t a f f nurses who par t i c ipa ted in a preceptorship or ienta t ion program would: (1) demonstrate easier ro l e t r a n s i t i o n , (2) report a higher l e v e l of job performance, and (3) demonstrate less ro le depr iva t ion , than those novice s ta f f nurses who par t i c ipa ted in a t r a d i t i o n a l or i enta t ion program. Role t r a n s i t i o n was measured using the Six Dimension Scale of Nursing Performance (Schwirian, 1978) and the Nursing Role Conception Scale (Corwin, 1961). Par t i c ipant s completed the two scales during the f i r s t week of the or ienta t ion or preceptorship programs and again one-month l a t e r . Results indicated no s i g n i f i c a n t di f ferences (p<0.05) between the groups on e i ther the Nursing Role Conception Scale or the Six Dimension Scale of Nursing Performance. i i l Table of Contents Page Abstract i i Table of Contents i i i L i s t of Tables v L i s t of Figures v i Acknowledgements v i i Chapter One - Introduction Background to the Problem 1 Problem Statement 3 Purpose 4 Theoret ica l Framework 4 S o c i a l i z a t i o n and R e a l i t y Shock 10 Preceptorship Programs and S o c i a l i z a t i o n 12 D e f i n i t i o n of Terms 14 Research Hypotheses 16 Assumptions 18 Limitat ions 19 Del imitat ions 19 S igni f icance of the Study 19 Scope of the study 20 Chapter Two - Review of the L i t e r a t u r e Development of Preceptorship Programs 22 Benefits of Preceptorship 24 Research on Preceptorship 25 Summary 32 Chapter Three - Methods and Procedures Des ign 33 Set t ing 33 Sample C r i t e r i a and Se lect ion 34 Protect ion of Human Rights . .37 Measurement of Variables : 38 Instruments 39 Data Analys is 44 Summary 4 5 Chapter Four - Presentation of Data Descr ipt ive C h a r a c t e r i s t i c s of Sample 46 Results in Relat ion to Research Hypotheses Hypothesis Two . . .50 i i i Page Hypothesis Three 57 Hypothesis One 64 Summary 6 4 Chapter Five -Discuss ion of Findings Discussion in Relat ion to Research Hypotheseis Hypothesis Two . 68 Hypothesis Three 73 Hypothesis One 76 Comparison of Present Study Results to Other S tud ie s . . . 82 Summary. 8 4 Chapter Six - Summary, Conclusions and Implications Summary 85 Conclus ions 88 Limitat ions 9 0 Implicat ions: Nursing Prac t i ce . . . . 9 1 Nursing Education 95 Nursing Research 99 References 102 Appendices: Appendix A. Preceptorship Program Schedule 108 Appendix B. Preceptor Development Program 110 Appendix C. T r a d i t i o n a l Orientat ion Schedule Hospi ta l (A) 112 Appendix D. T r a d i t i o n a l Orientat ion Schedule Hospi ta l (B) 114 Appendix E . Let ter of Introduction 117 Appendix F . Demographic Data Sheet 120 Appendix G. Six Dimension Scale of Nursing Performance 122 Appendix H. Nursing Role Conception Scale 126 iv List of Tables Page Table 1. Demographic Characteristics of Sample 48 Table 2. Pretest Scores on the Six Dimension Scale of Nursing Performance for Experimental and Control Groups 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 Preceptorship Versus Traditional Orientation Programs 18 vi Acknowledgements I extend s i n c e r e g r a t i t u d e to my t h e s i s committee, Dr. Sonia Acorn and Dr. Sharon Andersen, f o r t h e i r c o n t r i b u t i o n s i n d i r e c t i n g , a d v i s i n g , and c h a l l e n g i n g me throughout the r e s e a r c h p r o c e s s . The q u a l i t y of t h e i r s u p e r v i s i o n enhanced the q u a l i t y of t h i s r e s e a r c h . Completion of t h i s study would not have been p o s s i b l e without the c o o p e r a t i o n of p a r t i c i p a t i n g agencies, and without the the p a r t i c i p a t i o n of novice nurses who w i l l i n g l y gave of t h e i r own time to take p a r t i n t h i s study. My thanks i s extended to a l l . I a l s o acknowledge my f a m i l y f o r the c o n t i n u i n g support and encouragement which they extended over the two years of study. Although they were f a r away i n m i l e s , they were always c l o s e i n thought and there with words of encouragement when needed. I d e d i c a t e t h i s t h e s i s to the memory of my f a t h e r , Stephen MacDonald. v i i 1 CHAPTER ONE INTRODUCTION Background to the Problem Nurse leaders in education and practice settings have long been concerned about the role transit ion 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 l i f e ' 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 ut i l ized in an effort to ease the problem of troubled transitions (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, inspires, role models and supports the growth and development of an individual (the novice) for a fixed and limited amount of time with the specific purpose of social ization into a new role" (Morrow, 1984, p. 4). While the l i terature provides abundant anecdotal descriptions of the benefits of preceptorship programs (Chickerella & Lutz, 1981; Davis & Barham, 1989; Donius, 1988; Goldenberg, 1987/1988; Jennings, Costello, Durkin, & Rotkovitch, 1986; Metzger, 1986; Spears, 1986; Stul l 1987) there is an obvious scarcity of research studies confirming the effectiveness of preceptorships in easing role transit ion 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, 1989 Shogan, Prior & Kolski , 1985). Among these, studies by Giles and Moran; McLean; and Shogan, Pr ior , and Kolski; essentially have been program evaluation, satisfaction surveys. Studies by Clayton et a l . ; Dobbs; and Itano et a l . ; investigated transition 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 transit ion 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 transition of novice staff nurses. Spears (1986) has called for research on the effect of preceptorship programs on newly graduated nurses. Part icularly , for pre- and post-preceptorship measurements of novice nurse performance and self-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 its effectiveness" (Myrick, 1988, p. 136). Problem Statement It is presumed that preceptorship is indeed a useful orientation strategy which eases the role transition of novice staff nurses; however, evidence necessary to substantiate this belief is lacking. Research is needed to examine the actual effect of preceptorships on the role transit ion of novice staff nurses. Specif ical ly , research is needed comparing the transition which occurs in orientations without preceptorships to the transition that occurs with preceptorships. This comparison is needed in order to determine whether differences in role transit ion of novice staff 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 transition of novice staff nurses. Theoretical Framework Kramer's (1974) theory of rea l i ty shock provided the theoretical framework for this study. The rea l i ty shock concept is borrowed from the l i terature and the experience of culture shock. Culture shock is the surprise and imbalance felt 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 cultural system in which ideals, rewards, and sanctions differ from those received in school. The term real i ty shock is used predominantly in relation to the response of neophytes upon entry into a professional f ie ld (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 typical shock-like response occurs when the novice senses professional ideals acquired at school are not appreciated in the work setting. The discrepancy in values of the work and school cultures, which neophytes confront upon work entry, leaves them in a state of values conf l ic t , and thus, susceptible to rea l i ty shock. In the theory of rea l i ty shock, Kramer (1974) suggested the transition from student to novice nurse w i l l follow a predictable pattern. This transition process consists of four phases: (1) honeymoon, (2) shock, (3) recovery, and (4) 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) social 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 ike ly to be inefficient in accurately appraising the work situation. "The sudden real ization that nursing isn't what one thought i t would be and the dissatisfying feeling that this evokes is the precursor to the shock phase" (Kramer & Schmalenberg, 6 1977a, p. 10). When the novice experiences obstacles to goal achievement, either due to lack of personal competency or due to system restr ict ions , the shock phase begins (Kramer, 1974). Characteristic features of the shock phase are: (1) moral outrage, (2) rejection, (3) fatigue, and (4) perceptual distortion (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 globally negative outlook. The shock phase is depleting and fortunately, i t is time limited. Eventually, recovery or resolution must occur. The recovery phase is identified by the return of a more rea l i s t i c appraisal of the work situation 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. "The recovery phase is crucial to constructive confl ict 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 called for" (Kramer & Schmalenberg, 1977a, P. 17). In the resolution phase, there are various ways in which rea l i ty shock may be resolved; some are constructive, while others are more detrimental. Examples of various less functional means of resolving rea l i ty shock include: (1) restr ict ing involvement by performing at a minimally acceptable level; (2) transferring jobs frequently in an effort to find the elusive perfect 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 bicultural adaptation, in which the neophyte reevaluates school learned values, maintaining those that are beneficial and meshing them with the rea l i t i es of the work situation. Constructive resolutions are growth producing and enable 8 the person to integrate work values with school values. The interweaving of the two perspectives is more functional than either perspective independently (Kramer, 1974). Kramer's (1974) description of rea l i ty shock brought the d i f f i c u l t i e s , that new graduates have in making the adjustment to practice, to the attention of the nursing profession. Kramer found the f i r s t year in a hospital setting is often marked by dramatically confl ict ing value systems, spec i f ica l ly , the idealism of education and the rea l i ty of nursing practice. 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 rea l i ty of the bureaucratic mode practiced and enforced in the work setting is the primary cause of rea l i ty shock for new graduates. Kramer and Schmalenberg (1977a) identified that students are usually presented with the "front-stage" rea l i ty of the nursing unit. This front-stage rea l i ty is the appearance that the unit staff portrays for specific audiences (students, faculty, and administration). "Following employment the new graduate discovers or uncovers the "back-stage" rea l i ty , 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 reality" (p. 11). The manner in which a neophyte reconciles this confl ict greatly determines whether the person w i l l remain in the profession (Ahmadi, Speedling & Kuhn-Weissman, 1987; Kinney, 1985; Kramer, 1974 ). Many new graduates, dissatisf ied 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 rea l i ty shock, the novice staff 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 act iv i t ies that ought to occur in the role (Rubin, 1988). The nurse must perform act iv i t ies demanded by the organization to successfully f u l f i l l the nursing role . The novice staff nurse's fai lure to function immediately as a seasoned and competent professional nurse has been attributed to inadequate social ization to the rea l i t i es of the professional role , rather than to inadequate theoretical knowledge (Benner & Benner, 1979). 10 According to Watson (1983) professional social ization is the complex process by which a person acquires the knowledge, s k i l l s , and the sense of identity that are characteristic of a member of that profession. Socialization is aimed at learning new values, bel iefs , attitudes, 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). Socialization and Reality Shock Socialization into an occupational role entails: shift ing focus from broad professional goals to specific work tasks, internalizing values of the occupational group, and adopting prescribed behaviours (Leddy & Pepper, 1985). The latter refers to the behaviors one must display according to the norms of the reference group. Professional role expectations are transmitted and maintained through education and regulatory processes (Corwin & Taves, 1962). Thus, through social ization experiences one learns the expectations of a particular role. Prior to entering practice, 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 practit ioners. Yet, "it is the culture of the practicing 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 social ization can lead to role conflicts (Hardy & Conway, 1988). According to Rendon (1988) role incongruence creates role conflicts which interfere with eff icient role performance. Beginning nurses are inexperienced in dealing with role conflicts created by the clashing of bureaucratic goals with the professional ideals learned at school. Dobbs (1988) identified that successful role transit ion, from student to practitioner in nursing, requires an integration of the three nursing role conceptions (professional, bureaucratic, and service). This integration is necessary in order that the novice nurse may "accomplish bureaucratic goals while maintaining professional standards and quality care" (Dobbs, 1988, p. 167). The orientation process is an important factor affecting role development and role transit ion (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 . , 1987; Patton, Grace & Rocca, 1981). These programs assist neophytes to reconcile conflicts between values acquired in school with those of the c l i n i c a l practice environment. Preceptorship Programs and Socialization The primary goals of preceptorship programs are (1) to assist novice nurses with social izat ion to professional and bureaucratic nursing roles and (2) to assist with s k i l l acquisition 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. Their orientation covers such topics as: objectives of the preceptorship program, functions of the preceptor role , adult learning principles , 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 i t from a tradit ional orientation program. The latter is a "buddy system" where various experienced nurses, none of whom receive preparation for the role , are "buddied with" the neophyte during the orientation period (Morrow,.1984). Preceptors provide guidance to neophytes in role social ization 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 practice. In turn, the neophyte internalizes role conceptions that are congruent with the role of practicing professional nurses. Thus, preceptors fac i l i ta te role transit ion of novice nurses by promoting role social ization and role performance. Dobbs (1988) contends when new graduates are not assisted with the transition into the work role they frequently resolve the confl ict of rea l i ty 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 fac i l i ta t ing the 14 transition from school to practice. It is suggested that preceptorship programs are the most effective vehicles to fac i l i ta te role social ization of novice nurses. In summary, preceptorship programs offer a means of easing the transition from student to novice staff nurse practit ioner. This is accomplished through assistance provided to the neophyte in the areas of s k i l l mastery and social integration. In addition, preceptorships are believed to reduce the effects of rea l i ty shock experienced by novice nurses. Definition of Terms For the purpose of this study the following definitions were used: Novice Staff Nurse is an individual beginning his/her f i r s t employment as a staff 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 shifts over the course of the preceptorship program. Traditional Orientation Program is a formal period in which the novice staff nurse receives teaching and guidance in unit routine from a variety of experienced staff nurses. These staff nurses who provide guidance do not receive educational preparation to assume this teaching role . Role "is a set of expectations about how a person in a given position in a particular social system should.act and how others in reciprocal positions should act" (Kramer, 1974, p. 52). Role Transition is the alteration in expectations related to actions and reactions demanded by a change in role from student to novice staff nurse. Role transition 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 specific time (Corwin, 1961). Role conception is a measure of social integration. Corwin categorized nursing role conceptions into three categories: (1) professional role conception (PRC) which indicates prime loyalty to the nursing profession; (2) bureaucratic role conception (BRC) which indicates prime loyalty to hospital administration; and (3) service role conception (SRC) which indicates prime loyalty to the patient. Role Deprivation is the internal response fe l t by a nurse when circumstances in the work environment res tr ic t role portrayal such that the nurse perceives an ideal role conception to be non-functional in practice (Itano et a l . , 1987; Dobbs, 1988). Job Performance is the a b i l i t y to competently carry out nursing actions while in the practice setting. An important component of job performance is s k i l l mastery. Job performance was measured using Schwirian's Six Dimension Scale of Nursing Performance. Research Hypotheses The research hypotheses examined in this study were: 1. Role transit ion wi 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 tradit ional orientation program. 2. Job performance levels reported by novice staff nurses who participate in a preceptorship program wi l l be higher than those reported by novice staff nurses who participate in a tradit ional orientation program. 17 3. Perceived role deprivation reported by novice staff nurses who participate in a preceptorship program wi l l be less than that reported by novice staff nurses who participate in a tradit ional orientation program. Based on the hypotheses of this study, a diagram of the hypothesized role transition process occurring post work-entry with preceptorship versus tradit ional oreintation programs is presented in Figure 1. Upon leaving educational programs, neophyes have particular role conceptions and s k i l l levels. When they enter the work setting, 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 confl ict associated with rea l i ty shock. Two possible strategies to ease rea l i ty shock (traditional orientation programs and preceptorship programs) with the proposed impact of each on role transition are presented. 18 Role Conceptions <r—Education Program Performance Level Work Entry j Role T r a n s i t i o n Process S o c i a l i z a t i o n T r a d i t i o n a l Or ientat ion ^ Role T r a n s i t i o n Preceptorship Or ienta t ion •T Role T r a n s i t i o n Figure 1. Hypothesized Role T rans i t ion Process Occurring Post Work-entry with Preceptorship versus T r a d i t i o n a l Or ientat ion Programs. In t h i s study the fol lowing assumptions were accepted: 1. Beginning prac t ice as a novice s t a f f nurse requires a successfu l ro le t r a n s i t i o n . 2. Pa r t i c ipan ts w i l l provide frank and honest ra t ings of the i r s e l f - p e r c e i v e d performance and ro le conception 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 using Corwin's Nursing Role Conception Scale and Schwir ian 's 6-D Sca le . 4. Preceptors in the preceptorship program have received preparat ion p r io r to assuming the preceptor r o l e . Assumptions 19 Limitations and Delimitations The recognized limitations and delimitation of this study were: Limitations 1. Random selection or random assignment into the tradit ional orientation and preceptorship groups was not feasible. 2. There are some factors that could not controlled. These included: (a) hospital staffing needs, (b) assignments of orientees and preceptees, and (c) multiple unit and hospital variations. Delimitation 1. The length of time to complete the study was circumscribed, so i t was not possible to measure long-term role adjustment. The adjustment during the f i r s t 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 significant 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 is estimated to be between 1500 and 3000 dol lars . Flewellyn and Gosnell 20 note that to just i fy the investment in orientation programs, nursing departments must be able to identify outcomes. 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 wi l l be called on to just i fy expenditures such as those associated with preceptorship programs used to orient novice staff nurses. To be able to just i fy the need for, and the appropriateness of such resource al location, 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 transit ion d i f f i c u l t i e s , 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 its link to social izat ion and role transit ion is i l lus trated . In Chapter Two selected l iterature on preceptorships is 21 reviewed. In Chapter Three research methods and procedures are described. In Chapter Four findings are presented. In Chapter Five analysis of findings is discussed. In Chapter Six the summary, conclusions, and implications are presented. CHAPTER TWO REVIEW OF THE LITERATURE Selected l i terature relevant to preceptorships is reviewed in this chapter. Factors instrumental in motivating nurse administrators to use preceptorship programs for orientation of novice nurses are discussed. Review of l i terature on preceptorships covers anecdotal and research l i terature , but focuses on the la t ter . Development of Preceptorship Programs His tor ica l ly , a standard orientation has been provided by the inservice education department. It usually lasted anywhere from one to two weeks. This general hospital orientation focused on global topics such as hospital philosophy, policies and procedures. Subsequent to the hospital-wide orientation, the new employee participated in an informal orientation to the nursing unit . 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 assisting with social izat ion to the staff nurse role . This def ic 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 inefficiency in orienting neophytes to the unit routine, and in assisting them with role social izat ion, was associated with high staff turnover, rea l i ty 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 milieu, 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 identified needs of both nursing service and nursing education personnel. However, Backenstose (1983) contends preceptorship is not a total ly new concept in nursing; from its 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 dist inct ion 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 transition of neophytes into the staff nurse role; and (2) fac i l i tates integration of neophytes into the work group. 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 fac i l i tated by someone who is close to the scene of act iv i ty and there is good reason to believe that a peer relationship is better able to affect the required learning" (Shamian & Inhaber, 1985, p. 80). In this model, the preceptor provides an immediate resource person for the novice nurse during the transition period (Metzger, 1986). Benefits of Preceptorship Many anecdotal art ic les have been written on the benefits of preceptorship programs for anticipatory social ization 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, Bargagliott i , & Spencer, 1982; Rodzwick, 1984; Spears, 1986; Wheeler, 1984). In addition, many anecdotal art ic les have also been written on the benefits of preceptorship programs for orientation of new employees, part icularly 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 a l . , 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 ac i l i t a t ing the role transit ion of novice staff nurses by assisting them to link educational and practice experience; (3) reducing problems associated with rea l i ty shock; (4) social iz ing and integrating the novice staff nurse within the unit; and (5) enhancing professional growth and job satisfaction 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 transition 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, differ from preceptorship. programs in that they are less individually monitored and rely on various non-designated nurses to guide the novice. The internship orientation in Huber's study is synonymous to the orientation provided by the tradit ional 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 posit ively 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 evaluated their performance a b i l i t y before and after their respective orientations. 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 fai led to 27 show any significant differences. Olsen, Gresley, and Heater (1984) examined an eight week undergraduate c l i n i c a l course to determine i f i t 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 control . A pretest, post-test design was employed. 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 significant difference between the groups. Since however, the numbers in the intern and non-intern groups were so small, power to detect significant 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 participating 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 hospital . The participants completed two scales: the f i r s t , immediately following teaching sessions; and 28 the second, after a three month time interval . 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 capabil i t ies when compared to the tradit ional teaching method. Despite the fact that this study concluded that the preceptorship model of teaching was superior to the tradit ional methods, i ts 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. Results of this study demonstrated no differences 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 social izat ion 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 significant difference at p <.01 in perceived role deprivation. The author suggests that this result supports the effectiveness of a preceptorship program in promoting anticipatory social ization 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 social ization of graduate nurses. The sample consisted of two groups,, one having a preceptorship experience in the f inal 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 part ia l ly supported the hypothesis that there would be significant differences between the groups on the six subscales. At six months follow-up there was a significant 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 significant 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 setting. 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 third day of observation, head nurses rated the student's c l i n i c a l competence using the C l in i ca 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 satisf ied 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 with orientation may have biased results . Allanach and Jennings (1990) investigated whether an eight week preceptorship program at one mil i tary medical center eased the transition 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 ive, and 16 weeks after completion of the preceptorship program. Although the results fai led to support the contention that the transition 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 se l f resulted in the more positive affective states of participants. They identify that a control comparison group who had not had a preceptorship experience would have been beneficial in terms of interpreting the effect of preceptorship on transit ion experiences. Summary In summary, the various studies on preceptorship have resulted in inconsistent findings. More research on preceptorship is needed to substantiate the belief that preceptorship is a useful orientation strategy. This study investigated the effect of preceptorship on role transition of novice staff nurses when preceptorship was used as an orientation strategy. 33 CHAPTER THREE METHODS AND PROCEDURES Reseach design, methods and procedures are presented in this chapter. Design A quasi-experimental, control group pretest post-test design was used. 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 tert iary hospitals in lower mainland Bri t i sh 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). Subsequent to this central orientation, novice staff 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 staff nurses. 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 tradit ional orientation programs consisted of three and one-half days central nursing orientation followed by up to a maximum of 11.5 shifts in which novice staff nurses are buddied with various experienced staff nurses on their respective wards : (Appendix C). The other tradit ional orientation program included four days of central orientation, one-half day central hospital-wide orientation, and one day unit specific orientation (Appendix D). Following this central orientation, novice nurses on average received an additional two days of unit specific orientation. Sample Cr i ter ia and Selection A convenience sample (N=34) of novice staff nurses in their f irst-time employment as staff nurses was obtained from three tert iary hospitals in lower mainland Bri t i sh Columbia. Although role transition is required with a l l role changes, this study focused on the role transit ion 35 of novice nurses. Accordingly, the sample selected was limited to novice staff nurses in their f irst-t ime employment as staff nurses, a l l of whom, were undergoing a similar role change; student to novice staff nurse. I n i t i a l contact with three potential participating agencies was made to determine the f eas ib i l i ty of obtaining the needed study sample. Because limited s tat i s t ics were kept on the preceptorship and orientation progams, i t was not always possible to extrapolate the number of participants who were novice staff nurses in their f irst-time employment. However, one hospital that used a tradit ional orientation program indicated on average over the last two years i t had six new graduates per month on orientation. This same hospital indicated that 42 percent of the nurses they employ annually are new graduates. In descending order, this hospital had the greatest numbers in orientation during the months of September, January, and June. Another hospital that used a tradit ional orientation program orientated 177 nurses during the previous year, but was unable to determine of that number how many were novice staff nurses. The months with the highest, proportion in orientation were January, October, September, and June respectively. 36 The t h i r d hosp i ta l used a preceptorship program and employed 240 novice s t a f f nurses during, the, previous year. The months with the larges t proportion of new graduates in or i en ta t ion were January, September, and June. Based on i n i t i a l contact and d iscuss ion with these three agencies, i t appeared feas ib le to obta in the needed study sample. Agency approval to conduct the study was obtained from the three i n s t i t u t i o n s . A l e t t e r (Appendix B) which explained the study and requested 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 p o t e n t i a l study p a r t i c i p a n t s (novice s t a f f nurses in the ir f i r s t time employment i n nurs ing) . The sample was selected.. from volunteers contacted through v i s i t s by the researcher to the p a r t i c i p a t i n g agencies' or i enta t ion or preceptorship program during the f i r s t week of the respect ive programs. The researcher explained the study, addressed any questions from potent ia l par t i c ipant s and requested t h e i r p a r t i c i p a t i o n . 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 sca les : a Demographic Data Sheet (Appendix F ) , Schwirian's Six Dimension Scale of Nursing Performance (Appendix G) , and Corwin's Nursing Role Conception Scale (Appendix H). Completion of these scales required approximately 20 37 minutes. Participants supplied their names and addresses to the researcher to use for the mailout of questionnaires for the second data col lect ion. One month later , the 6-D Scale and the Nursing Role Conception Scale with an accompanying let ter , were sent to participants for completion. Two weeks after the second set of questionnaires were mailed, reminder letters encouraging reply to the follow-up scales were sent to participants who had not to date returned questionnaires. Data were collected from October, 1989 unt i l February, 1990. Protection of Human Subjects Ethical approval to conduct this study was granted by the University of Br i t i sh Columbia Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects and by Ethical Review Committees in participating agencies. Participants in the study were given a letter explaining the purpose of the study and the requirements involved in participation. 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 confidential , that they could withdraw from the study at any time, and completion of 38 the questionnaires implied consent by the respondent to p a r t i c i p a t i o n in the study. To maintain c o n f i d e n t i a l i t y , each par t i c ipant was assigned a code number so that names of subjects d id not appear on the completed quest ionnaires . Previous ly assigned code numbers with an added "A" were af f ixed to the follow-up scales to maintain c o n f i d e n t i a l i t y and to allow comparison of subject ' s pretest and post - tes t scores . Measurement of Variables The independent var iab le was the type of o r i e n t a t i o n . Subjects in the experimental group were those in the hosp i ta l where the preceptorship program was in ef fect and, thus, were assigned to a designated preceptor(s) for the durat ion of the preceptorship program and the study. The assignment of the preceptor was part of that agency's preceptorship program and under the d i r e c t i o n of the agency not the inves t iga tor . The treatment ef fect was the presence of designated nurse preceptors in the preceptorship group and a lack of designated preceptors in the t r a d i t i o n a l or i en ta t ion group. The dependent var iab le studied was ro le t r a n s i t i o n . This var iab le was measured by two sca les : Schwirian's Six Dimension Scale of Nursing Performance (1978) and Corwin's Nursing Role 39 Conception Scale (1961). Instruments Data were co l l ec ted using two instruments: Schwirian's Six Dimension Scale of Nursing Performance (6-Scale) and Corwin's Nursing Role Conception Scale . Six Dimension Scale of Nursing Performance The Six Dimension Scale of Nursing Performance (6-D Scale) consists of 52 items categorized into s ix dimensions of nursing performance: teaching/ c o l l a b o r a t i o n , c r i t i c a l care , p lanning/eva luat ion , interpersonal r e la t ions /communications, profess ional development, and leadership (Appendix G) . Subscale items in the interpersonal relations/communications dimension re la te to nurse's behavior in the realm of communication and interpersonal rea l t i onsh ips with c l i e n t s and col leagues. This subscale included such items as helping a patient communicate with others, and contr ibut ing to productive working re la t ionsh ips with other health team members. Leadership subscale dimensions re la te to actions that the nurse would employ in enacting a leadership funct ion . This subscale included such items as the a b i l i t y to guide other health team members and to delegate e f f e c t i v e l y . The c r i t i c a l care subscale taps into nursing a c t i v i t i e s associated with care of c r i t i c a l l y i l l patients. It includes such items as functioning calmly in emergency situations, 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 ient / family , as well as, behaviors indicative of the collaborative role of nurses with patients, families, and other health professionals. It includes such items as teaching preventive health measures and encouraging the family to participate in the c l ient 's care. The planning and evaluation subscale comprises behaviors involved in planning and evaluating the c l ient 's nursing care. The professional development subscale describes characteristics 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 self-appraisal 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, subjects rate how well they perform on the identified act iv i t ies (l=not very well, 2=satisfactorily, 3=well, 4=very well, X=not expected in my current job). On the f inal 10 items 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); teaching/ collaboration (11); planning/evaluation (7); interpersonal relationships/communication (12); and professional development (10). Because of this difference in number of subscale items the scoring formula was: X . . . . X n n - m where X . . . X n = the numerical rating for each behavior in the subscale; n= the total number of items in the subscale; m= the total number of items in the subscale for which the subject rated "not expected in my current job". 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 va l id i ty of this scale was established during i ts development. Following an extensive l i terature review of concepts, constructs, and measures to describe nursing performance, deans and directors of 151 schools of nursing were asked to provide operational definitions of effective nursing performance. These same individuals, along with experienced nurse educators, researchers, and administrators served as pi lot respondents to review and crit ique 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. No bias was evident (Schwirian, 1978). 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. Re l i ab 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 d e p r i v a t i o n . I t a s sesses r e s p o n d e n t s ' a l l e g i a n c e to h o s p i t a l b u r e a u c r a c y , the n u r s i n g p r o f e s s i o n , and the p a t i e n t . The s c a l e c o n s i s t s of 22 h y p o t h e t i c a l n u r s i n g s i t u a t i o n s . U s i n g a L i k e r t - t y p e r a t i n g , (5=s trong ly a g r e e , l = s t r o n g l y d i s a g r e e ) , respondents i n d i c a t e the way the s i t u a t i o n ought to be and a l s o the way i t a c t u a l l y i s . S i x items make up the b u r e a u c r a t i c s u b s c a l e , and e i g h t items comprise each of the p r o f e s s i o n a l and the s e r v i c e s u b s c a l e s . P r o f e s s i o n a l r o l e c o n c e p t i o n r e f e r s to o c c u p a t i o n a l p r i n c i p l e s t h a t suggest p r i m a r y l o y a l t y to the n u r s i n g p r o f e s s i o n . 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 r e f e r s to the a d m i n i s t r a t i v e r u l e s and r e g u l a t i o n s which d e p i c t the n u r s e ' s job i n a s p e c i f i c o r g a n i z a t i o n and sugges ts p r i m a r y a l l e g i a n c e to n u r s i n g a d m i n i s t r a t i o n . The s e r v i c e r o l e c o n c e p t i o n r e f e r s to n u r s i n g as a c a l l i n g and sugges ts a p r i m a r y l o y a l t y to the p a t i e n t . D i f f e r e n c e s between the " a c t u a l " and " i d e a l " s c o r e s f o r each i tem are added to y i e l d the t o t a l r o l e d e p r i v a t i o n s c o r e . P e r m i s s i o n to use t h i s s c a l e was granted by the c o p y r i g h t h o l d e r . Content v a l i d i t y was e s t a b l i s h e d by Corwin (1961) d u r i n g the development of the s c a l e . Kramer (1970) demonstrated c o n s t r u c t and p r e d i c t i v e v a l i d i t y at the 0.01 level of confidence. The test-retest r e l i a b i l i t y coefficients for the role conception subscale were: (a) 0.86 service, (b) 0.89 bureaucratic, and (c) 0.88 professional. 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 this 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 rea l i ty shock is associated with scores greater than 30 (Kramer, 1974, p.102). Data Analysis Descriptive s tat i s t ics 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 staff nurses. Because these demographic data were of a nominal level , chi-square analysis was conducted. The chi-square s ta t i s t i c tests whether observed proportions differ s ignif icantly 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 overall change within the groups from pre-test to post-test in each dimension of the 6-D Scale were analyzed using paired t-tests . Using the same s ta t i s t i ca l test, the overall 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-tests . The significane level for the study was set at p <0.05. The SPSS-X (Stat is t ical 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 this chapter. Findings in relation to the research hypotheses and supplemental findings are presented. Descriptive Characteristics of the Sample Thirty four novice staff nurses comprised the f inal study sample. I n i t i a l l y , 50 novice staff nurses completed the pretest; 30 in the preceptorship (experimental) group and 20 in the tradit ional orientation (control) group. Since the purpose of this study was to investigate the effect of a preceptorship program on role transit ion of novice staff nurses, the study design required that role transition from pretest to post-test be compared. Thus, 13 participants, who completed the pretest but did not complete the one-month follow-up portion of the study, were eliminated from the f inal study sample. One participant in the tradit ional 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 inal study sample. The one month follow-up response rate was 70% for the experimental group and was 75% for the control group. The overall 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. Participant'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 characteristics of the sample are presented in Table 1. 48 Table 1 Demographic Characteristics of Sample (N=34) Experimental Control Characteristic (n=14) (n=20) # / % # / % Basic Nursing Education Diploma (2 year) 5 /25 12/ 86 Diploma (3 year) 14/ 70 1/ 7 Baccalaureate 1 / 5 1 / 7 Other Post Secondary  Education Yes 12/ 60 9/ 64 No 8/ 40 5/ 36 C l i n i c a l Experience in Employing Agency * yes 12/ 60 11/ 79 no 8/ 40 3/ 21 Duration < three years 10/ 50 14/ 100 3 years 7/ 35 0/ 0 Hospital Employment Prior to Education Program none 10/ 50 7/50 nurse's aide 4/ 20 4/ 29 other 6/ 30 3/ 21 Work Experience * (Non-hospital) yes 18/ 90 13/ 93 no 2/ 10 0/ 0 * demographic characteristics with less than total 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 particular demographic charateristics.... This analysis is used to determine whether observed proportions differ s ignif icant ly from expected proportions (Glass & Hopkins, 1984). Demographic charateristics subjected to chi-square analysis were: (1) basic nursing education; (2) post-secondary education; (3) c l i n i c a l experience in employing agency; (4) length of c l i n i c a l experience 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 characteristics demonstrated significant differences in expected and observed proportions on basic nursing education and c l i n i c a l experience in the employing agency prior to employment. In terms of basic nursing education, 86% of the tradit ional 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 ta t i s t i c on basic education was significant at 0.0012. This highly significant finding i l lustrates 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 significant discrepancy in observed and expected porportions could be an important factor in role transit ion experiences of the groups. In relation to length of c l inca l experience in the employing agency, there was a s ignif icnt difference in group proportions analysed using chi-square. The significance of the chi-square s ta t i s t i c on this characteristic was 0.0216. The experimental group had a large porportion of members who had substantially more c l i n i c a l experience in the employing agency prior to employment as novice staff nurses than did the control group. The significant difference in observed and expected porportions of this demographic variable may be an inf luential factor in the transition experiences of the two groups. Results in Relation to Research Hypotheses Three research hypotheses were evaluated s t a t i s t i c a l l y in this study. For c l a r i t y , results in relation to research hypothesis two are presented f i r s t , followed by results in relation to hypothesis three, and then results In relation 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. However, with the exception of the leadership subscale, 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-tests, and results indicate no s t a t i s t i c a l l y significant 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 tes , pretest scores for respondents within the control group who were from separate s i tes , were analysed separately. Pooled t-tests yielded no significant differences in means. There was also homogeneity of variance. These results supported combining responses from subjects at the two separate sites and treating them as one control group. The s ta t i s t i ca l analysis thus indicates that since the groups were not s ignif icantly 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 Control (n=20) (n=14) X S.D. 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 TEACHING/ COLLABORATION 2.55 0.40 2.41 0.53 -0.88 0.39 PLANNING/ EVALUATION 2.81 0.52 2.76 0.37 -0.25 0.81 INTERPERSONAL RELATIONSHIPS/ COMMUNICATION 3.23 0.39 3.16 0.32 -0.52 0.61 PROFESSIONAL DEVELOPMENT 3.46 0.32 3.37 0.35 -0.79 0.44 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-tests . 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 significant 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 ignif icant. 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 S.D. X 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 TEACHING/ COLLABORATION 2.55 0.40 2.60 0.52 -0.37 0.72 PLANNING/ EVALUATION 2.81 0.52 2.98 0.43 -2.26 0.04* INTERPERSONAL RELATIONSHIPS/ COMMUNICATION 3.23 0.39 3.33 0.38 -1.03 0.32 PROFESSIONAL DEVELOPMENT 3.46 0.32 3.49 0.33 -0.77 0.45 * indicates significant 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 differing s ignif icantly 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 significant 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 Post -test X S.D. 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 3 .37 0.35 3.36 0.40 0.15 0.88 * indicates significant difference at p<.05. ** indicates significant difference at p<.01. *** indicates significant difference at p<.001. 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-tests. 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. Results indicate no significant differences between the groups. Thus, since there were no significant differences 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 wi l l be s ignif icant ly more improved than those reported by novice staff nurses who participate in a tradit ional 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 identified effect on performance outcomes that was anticipated. 57 Table 5 Comparison of Post-test Scores on the Six Dimension Scale  of Nursing Performance for Experimental and Control  Groups (n=34) Experimental Control (n=20) (n=14) X 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 TEACHING/ COLLABORATION 2.60 0.52 2.72 0.55 0.69 0.50 PIANNING/ EVALUATION 2.98 0.43 2.98 0.55 -0.04 0.97 INTERPERSONAL RELATIONSHIPS/ 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 _____ 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 third research hypothesis. In completing this scale subjects were asked to rate 22 hypothetical nursing,. 58 situations in terms of how the situation ideally ought to be in nursing, and also how the situation 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-tests . This analysis was carried out to establish whether groups were similar at the beginning of the study in relation to role conceptions/role^ deprivation, and thus, whether comparisons of role conception/deprivation outcomes in relation 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 significant differences between the groups. In addition, since the control group was drawn from two separate s i tes , responses of participants from these two sites were compared separately. Results indicated no significant differences in means and also indicated homogeneity of variance within the responses of participants from the two separate s i tes . This supported joining these subject's responses to be considered as one control group. This overall analysis of pretest scores demonstrated that the groups were not s ignif icant ly 59 d i f f e r e n t in r e l a t i o n to ro le conceptions/ depr ivat ion at the s t a r t of the study, and thus, supported the appropriateness of making comparisons in l i g h t of the treatment e f fect at the one-month pos t - t e s t . A comparison of pretest to post - test Nursing Role Conception Scale scores for the experimental (preceptorship) group, using paired t - t e s t s , is presented in Table 6. Results demonstrate that the within-group change, from pretest to post - test on the Nursing Role Conception Scale , was s i g n i f i c a n t only on the profess ional ro le conception subscale; While mean scores decreased from pretest to post - tes t on a l l the subcales (BRC, PRC, SRC, RD), only on the profess ional ro le conception ( ideal ) subscale was th i s decrease s i g n i f i c a n t . This r e s u l t suggests that for the experimental group there was a decrease in PRC ( ideal ) fol lowing a preceptored o r i e n t a t i o n . There was not however an accompanying increase in BRC as one might expect. 60 Table 6 COMPARISON OF PRETEST TO POST-TEST NURSING ROLE  CONCEPTION SCALE SCORES FOR EXPERIMENTAL (PRECEPTORSHIP)  GROUP (n=20? : Pretest Post-test X S.D. X S.D. t-values p BRC (ideal) 17. 50 3 .90 17. 10 2.75 0.60 0. 56 (actual) 18. 80 2 .75 19. 15 2.48 -0.49 0. 63 PRC (ideal) 26. 80 3 .43 25. 10 4.39 2.72 0. 01* (actual) 23. 70 2 .54 22. 75 3.14 1.32 0. 20 SRC (ideal) 27. 90 3 .24 27. 70 2.64 0.36 0. 73 (actual) 24. 30 2 .76 23. 10 3.96 1.35 0. 19 RD 5. 40 6 .35 4. 80 6.96 0.38 0 .71 * indicates significant 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 (traditional orientaion) group, using paired t-tests, is presented in Table 7. While the control group's mean scores stayed the same or decreased s l ight ly from pretest to post-test, the within group change from pretest to post-test was not significant on any of the subscales (BRC, PRC, SRC, RD). Analysis indicates for the control group the tradit ional 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) 16. 36 2 .98 16. 36 1.99 0.00 1 .00 (actual) 18. 71 2 .59 18. 93 2.17 -0.24 0 .17 PRC (ideal) 28. 36 2 .10 27. 21 3.19 1.45 0 .89 (actual) 22. 86 2 .35 23. 86 3.76 -1.16 0 .27 SRC (ideal) 28. 43 3 .52 28. 29 2.05 0.14 0 .89 (actual) 24. 57 2 .21 23. 93 2.70 1.09 0 .30 RD 7. 00 5 .88 5. 14 6.49 0.99 0 .34 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 significant difference between the groups from pretest to post-test on any subscales of the Nursing Role Conception Scale. Thus, research hypothesis three was not supported. This analysis suggests that despite a significant within-group decrease in PRC (ideal) for the experimental group; this difference was not enough to cause a significant difference in overall 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 ignif icant ly 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 C o n t r o l (n=20) (n=14) X S. D. X S. D. t-v a l u e s P P r e t e s t BRC ( i d e a l ) 17. 50 3 .90 16 .36 2 .98 -0.92 0.36 ( a c t u a l ) 18. 80 2 .75 18 .71 2 .59 -0.09 0.93 PRC ( i d e a l ) 26. 80 3 .43 28 .36 2 .10 1.51 0.14 ( a c t u a l ) 23. 70 2 .54 22 .86 2 .35 -0.98 0.33 SRC ( i d e a l ) 27. 90 3 .24 28 .43 3 .52 0.45 0.66 ( a c t u a l ) 24. 30 2 .76 24 .57 2 .21 0.31 0.76 RD 5. 40 6 .35 7. 00 5 .88 0.74 0.46 P o s t - t e s t BRC ( i d e a l ) 17. 10 2 .75 16 .36 1 .99 -0.86 0.39 ( a c t u a l ) 19. 15 2 . 48 18 .93 2 .17 -0.27 0.79 PRC ( i d e a l ) 25. 10 4 .39 27 .21 3 .19 1.54 0.13 ( a c t u a l ) 22. 75 3 .14 23 .86 3 .76 0.93 0.36 SRC ( i d e a l ) 27. 70 2 .64 28 .29 2 .05 0.70 0.49 ( a c t u a l ) 23. 10 3 .96 23 .93 2 .70 0.68 0. 50 RD 4. 80 6 .96 5 .14 6 .49 0.15 0.89 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 r o l e c o n c e p t i o n . 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 transition is the alteration in expectations related to actions and reactions demanded by a change in role . Role transition from student to novice staff nurse requires adjustments in s k i l l mastery and role conceptions/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 ignif icant ly less role deprivation on the Nursing Role Conception Scale and s ignif icantly higher -performance ratings on the Six Dimension Scale of Nursing Performance than those reported by the control (traditional orientation) group. Comparisons of group scores at post-test on both instruments using pooled t-tests (Table 5 and Table 8) demonstrate no significant differences between group post-test scores. Since this was the result , the f i r s t research hypothesis was not supported. Summary Results of of the data analysis were presented in this 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 var iab le s : basic nursing education and amount of c l i n i c a l experience in the employing agency pr ior to beginning employment as s t a f f nurses. These di f ferences may have been i n f l u e n t i a l factors in the ro l e t r a n s i t i o n experiences of p a r t i c i p a n t s . Pretest scores in r e l a t i o n to performance l eve l s as measured by the Six Dimension Scale of Nursing Performance, and ro le concept ion/role depr ivat ion scores as measured by the Nursing Role Conception Scale were compared. Results indicate no s i g n i f i c a n t di f ferences between the groups at the s t a r t of the study. This f inding supported the s u i t a b i l i t y of comparing performance rat ings and ro le concept ions /role depr ivat ion over the time of the study to assess the effect of treatment (presence of a designated preceptor for the experimental group, and lack of a designated preceptor for the contro l group) on these outcomes. Within-group changes in performance rat ings from pretest to post - test for each group were assessed. Results of th i s analys is revealed discrepancies in the dimensions of performance in which each group showed s i g n i f i c a n t l y improved performance r a t i n g s . The experimental group showed s i g n i f i c a n t improvement in only the planning/evaluat ion dimension, while the contro l 66 group e x h i b i t e d improved performance i n the c r i t i c a l c a r e , t e a c h i n g / c o l l a b o r a t i o n , and i n t e r p e r s o n a l r e l a t i o n s h i p s / c o m m u n i c a t i o n d i m e n s i o n s of performance. A q u e s t i o n i s whether t h e s e d i s c r e p a n c i e s a r e due t o o r i e n t a t i o n program d i f f e r e n c e s or o t h e r f a c t o r s . P o s t - t e s t performance r a t i n g s of both groups were compared. A n a l y s i s 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 between t h e groups on any d i m e n s i o n s of performance measured by the S i x Dimension S c a l e of N u r s i n g Performance. Thus, d e s p i t e d i s c r e p a n c i e s i n the d i m e n s i o n s of performance i n which each group e x h i b i t e d performance g a i n s from p r e t e s t t o p o s t - t e s t ; t h e s e d i s c r e p a n c i e s were not 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 performance r a t i n g s between t h e groups a t p o s t -t e s t . W i t h i n - g r o u p changes i n 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 s c o r e s were compared. A n a l y s i s showed t h a t the e x p e r i m e n t a l group had a s i g n i f i c a n t d e c r e a s e i n PRC ( i d e a l ) from p r e t e s t t o p o s t t e s t , but i t d i d not have an accompanying i n c r e s e i n BRC ( i d e a l ) as one might e x p e c t . The c o n t r o l group d i d not e x h i b i t any s i g n i f i c a n t d i f f e r e n c e s i n r o l e c o n c e p t i o n s / r o l e d e p r i v a t i o n a t p o s t -t e s t . 6 7 Results indicate that there were no s i g n i f i c a n t differences between the groups on either the Nursing Role Conception Scale or the Six Dimension Scale of Nursing Performance. Thus, neither group's role t r a n s i t i o n experiences d i f f e r e d s i g n i f i c a n t l y over the other. Consequently, none of the three research hypotheses of thi s study was supported. 68 CHAPTER FIVE DISCUSSION OF FINDINGS In this chapter study findings and interpretation of s ta t i s t i ca l data presented in the preceding,chapter are discussed. Study results in relation 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 relation 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 subjects in the experimental group began the i r preceptorship program with a predominantly more pos i t i ve s e l f - p e r c e p t i o n of the i r performance a b i l i t y . In comparing the within-group change in performance r a t i n g s , the contro l group had a s i g n i f i c a n t improvement from pretest to pos t - tes t in three dimensions of performance ( c r i t i c a l care , interpersonal re la t ionsh ips /communication, and t e a c h i n g / c o l l a b o r a t i o n ) . The experimental group from pretest to pos t - tes t had a s i g n i f i c a n t improvement in only the p lanning/evaluat ion dimension of performance. However, at pos t - tes t there was no s i g n i f i c a n t d i f fe rences in the p o s t - t e s t performance scores between the groups. It i s poss ib le that the higher pretest performance ra t ings of the experimental group were balanced out by the contro l group's improved performance in more dimensions of performance than that of the experimental group. This balancing e f fec t may explain why there were no s i g n i f i c a n t d i f fe rences between the groups in post - tes t performance outcomes. One must question what factors might explain the unexpected discrepancy in within-group performance outcomes? Possib le explanations re la te to demographic var iab les of study p a r t i c i p a n t s , program f a c t o r s , and study design l i m i t a t i o n s . 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 c h i - s q u a r e a n a l y s i s r e v e a l e d t h a t t h e group 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 demographic v a r i a b l e s : (1) 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 e x p e r i e n c e i n the employing agency p r i o r t o t h e i r p r e s e n t employment as n o v i c e s t a f f n u r s e s . The e x p e r i m e n t a l 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 of s u b j e c t s , who were educated i n a t h r e e year d i p l o m a program ( 7 0 % ) , as compared t o t h e t r a d i t i o n a l o r i e n t a t i o n group, 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 of p a r t i c i p a n t s who were educated i n a two year d i p l o m a program ( 8 5 . 7 % ) . The e x p e r i m e n t a l group had a g r e a t e r p r o p o r t i o n of s u b j e c t s who had been g r a d u a t e s of the h o s p i t a l s c h o o l of n u r s i n g of t h e employing agency. They t h e r e f o r e had s u b s t a n t i a l l y more c l i n i c a l e x p e r i e n c e i n the employing agency p r i o r t o t h i s employment than d i d t h e c o n t r o l group ( T a b l e 2 ) . P a r t i c i p a n t s i n t h e e x p e r i m e n t a l group a t p r e t e s t a l r e a d y had more c l i n i c a l e x p e r i e n c e by v i r t u e of the l o n g e r e d u c a t i o n a l program. They a l s o has s i g n i f i c a n t l y more c l i n i c a l e x p e r i e n c e i n the p r a c t i c e s e t t i n g where t h e y a r e now employed. With t h e c o m b i n a t i o n of t h e s e f a c t o r s , i n a d d i t i o n t o the p r e c e p t o r s h i p program, one 71 might expect that the i r performance would continue to improve and be s i g n i f i c a n t l y higher than that of the contro l group. Despite the apparently favorable advantages in demographic v a r i a b l e s , the experimental group post- test performance rat ings d id not d i f f e r s i g n i f i c a n t l y from that of the contro l group. Probable explanations for th i s re la te to program factors or study design l i m i t a t i o n s . Program Factors The d i f ference in focus of the centra l nursing or i en ta t ion aspects of the preceptorship and t r a d i t i o n a l or i en ta t ion programs is one program factor that may have contributed to th i s study not f inding any s t a t i s t i c a l l y s i g n i f i c a n t di f ference in performance outcomes between the groups. The t r a d i t i o n a l or i enta t ion program at both s i t e s was quite s k i l l oriented as compared to the preceptorship program (Appendices B, C, and D). This factor may have been instrumental in the performance improvement exhibited by the contro l ( t r a d i t i o n a l or ientat ion) group on the Six Dimension Scale of Nursing Performance. This group had a s i g n i f i c a n t performance improvement in three subscales ( c r i t i c a l care , t each ing /co l laborat ion , and interpersonal re la t ionsh ips /communication), (Table 4); while the preceptorship group had s i g n i f i c a n t improvement i n performance on o n l y one subsc a l e ( p l a n n i n g / e v a l u a t i o n ) , (Table 5). Study Design L i m i t a t i o n s A study l i m i t a t i o n which made i t impossible f o r the re s e a r c h e r to randomly a s s i g n p a r t i c i p a n t s to the experimental and c o n t r o l groups i s another f a c t o r that may have i n f l u e n c e d the performance r e s u l t s . Since s u b j e c t s could not be randomly assigned to the experimental or c o n t r o l groups, s u b j e c t s may have d i f f e r e d i n areas of s e l f p e r c e p t i o n , and/or i n t h e i r a b i l i t y to a c c u r a t e l y a p p r e c i a t e changes i n t h e i r n u r s i n g performance. Whether i n d i v i d u a l s were i n the experimental or c o n t r o l group was beyond the i n v e s t i g a t o r ' s c o n t r o l s i n c e t h i s was under the agency's c o n t r o l . Without random assignment of s u b j e c t s t o the c o n t r o l and experimental groups there i s no means to c o n t r o l f a c t o r s such as i n d i v i d u a l p a r t i c i p a n t s having: (1) unequal a c t u a l performance a b i l i t y at the beginning of the study, and (2) unequal a b i l i t y to a c c u r a t e l y r e c o g n i z e performance gains w i t h i n t h e i r own performance over time. Although p r e t e s t mean scores and v a r i a n c e s were assessed and 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 , t h i s does not mean th a t d i f f e r e n c e s were not present. N e i t h e r , do these assessments address p o t e n t i a l 73 differences in participants' ab 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 significant 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 significant 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 rules. Based on their experience, they may have perceived i t necessary, in order to gain approval from their peer preceptors, to adjust downward their ideal professional role conception ratings. However, despite decreasing their PRC (ideal), post-test scores i n d i c a t e t h e y were not y e t ready to s i g n i f i c a n t l y i n c r e a s e t h e i r BRC. Kramer and Schmalenberg (1977b) i d e n t i f i e d 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 n o v i c e nurses a r e a t t e m p t i n g t o become a c c e p t e d members of t h e u n i t work group. In essence the f i r s t j o b f o r n o v i c e nurses i s a p r o v i n g ground where the n o v i c e must prove h e r / h i m s e l f i n t h e s t a f f nurse r o l e . 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 group may have p e r c e i v e d t h a t t h e i r PRC needed t o be a d j u s t e d t o more c l o s e l y match the PRC of the r e f e r e n c e group t o which t h e y a s p i r e d t o become ac c e p t e d members. T h i s may account f o r the d e c r e a s e i n PRC ( i d e a l ) a t p o s t - t e s t measurement. Gi v e n the f a c t t h a t the c o n t r o l group had v a r i o u s e x p e r i e n c e d nurses who buddied 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 group may not have i d e n t i f i e d as c l o s e l y w i t h the 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. Thus, u n l i k e t h e e x p e r i m e n t a l group, the c o n t r o l group d i d not r e p o r t a d e c r e a s e i n PRC ( i d e a l ) a t p o s t - t e s t . (2) A second p o s s i b i l i t y i s t h a t the e x p e r i m e n t a l group may have r e c e i v e d n e g a t i v e feedback ( s a n c t i o n s ) f o r h o l d i n g such h i g h i d e a l PRC and f o r at t e m p t s t o l i v e up t o t h e s e i d e a l p r o f e s s i o n a l r o l e c o n c e p t i o n s i n p r o f e s s i o n a l p r a c t i c e . I f t h i s were the 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) in l i g h t of such feedback. (3) Another p o s s i b i l i t y i s that th i s decrease in PRC ideal may r e f l e c t a r e a l i s t i c pos i t ive adjustment to the demands of p r a c t i c e . Perhaps the l e v e l of profess ional ism that neophytes acquire in school is too high for the demands of the pract i ce s e t t i n g . Corwin (1961) i d e n t i f i e d that ro le conceptions acquired in school do not grasp the f u l l complexities of the work experience. Consequently, the r e f i n i n g and adjust ing of these idea l standards i s almost an inescapable adjunct to beginning profess ional p r a c t i c e . Kramer and Schmalenberg (1977a) i d e n t i f i e d that the most successful r e so lu t ion of r e a l i t y shock 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 b e n e f i c i a l , and meshing them with the r e a l i t i e s of the work s i t u a t i o n . As such, th i s decrease in PRC ( ideal) reported by the experimental group may indicate a pos i t ive movement toward rea l i sm necessary for successful ro le t r a n s i t i o n . Despite the dif ferences in within-group changes from pretest to post - test in the PRC ( i d e a l ) , there were 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 di f ferences between the groups in post- test ro le concept ion/role depr ivat ion scores . A poss ible explanation for th i s might be that during th i s 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 , as opposed to dealing with social integration. If this were the situation, this would account for the study results fa i l ing to find any differences between the groups on role conceptions 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 this 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 this study. Head nurses of the respective wards to which novice staff nurses were hired were responsible for assigning preceptors to work with novice nurses. On occasions, nurses assigned to function as preceptors with the novice 77 nurses, had not attended the Preceptor Development Program which prepares preceptors to function in th i s r o l e . In these s i t u a t i o n s , these s ta f f nurses who are c a l l e d preceptors , were r e a l l y more l i k e the "buddy" of the t r a d i t i o n a l or i en ta t ion program. Moreover, novice s t a f f nurses in the preceptorship program were frequently assigned more than one preceptor. In essence, these pract ices d i l u t e the expected o v e r a l l treatment effect of a preceptorship program, and may have been instrumental factors in there being no s i g n i f i c a n t d i f ferences between the groups on performance ra t ings ; ro le conceptions/ depr iva t ion; or ro le t r a n s i t i o n experiences. Nevertheless, one needs to recognize the d i f f i c u l t i e s , with the nursing shortage, of having enough experienced nurses prepared to function in the preceptor r o l e . Recent l i t e r a t u r e has i d e n t i f i e d th i s problem (Cantwell , Kahn, Lacey & McLaughlin, 1989; Griepp, 1989; Hamilton, Murray, Lindholm, & Myers,1989; Lewis, 1990). Griepp (1989) noted several instances of nurses with l imi ted experience ( less than one year) being assigned "by default" to function as preceptors because units d id not have enough experienced s t a f f nurses for i t s preceptor requirements. 78 Job factors 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 preceptors selected for the preceptor r o l e , may influence the q u a l i t y of the feedback, superv i s ion , and guidance given to the novice s t a f f nurse by preceptors (Sheetz, 1988). These factors may also have influenced the study f ind ings . One needs to question whether "the preceptor t r u l y act[s] as a preceptor or do other job r e s p o n s i b i l i t i e s make th i s impossible" (Cantwell , et a l . , 1989, p.229). This is p a r t i c u l a r l y a problem with the nursing shortage. When problems and pract ices such as these ex i s t , they neutra l i ze the expected pos i t ive influence of preceptors for novice nurse t r a n s i t i o n to p r a c t i c e . Another considerat ion was i d e n t i f i e d by Sheetz (1989). She found that reg is tered nurses who buddied with students who were not in a preceptorship program assumed the informal ro le of preceptor to students, even though the ro le was not formally recognized by the organizat ion . If s t a f f nurses in the contro l ( t r a d i t i o n a l or ientat ion) program followed th i s p r a c t i c e , even though they had not received preparation for the r o l e , they may have provided guidance to the novice s t a f f nurses of the contro l group, s i m i l a r to that which was provided by the preceptors to novice s t a f f nurses in the preceptorship (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 significant differences between the groups in terms of transition 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 results. These programs are included in some curricula as a means to provide students with anticipatory social ization to the novice staff nurse role (Chickerella & Lutz, 1981). One could surmise, i f subjects had such an experience, they might be sensitized to the issues surrounding the transition from student to beginning pratit ioner, and this may influence their adjustment to practice. As such, consideration of this factor in the study design would have helped in interpreting possible reasons for study results. 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 rea l i ty shock. During the honeymoon phase, the new nurse's 80 appraisal of her/his job is typical ly very positive-There is a tendancy to view situations through rose-colored 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, conflicts 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 ratings, role conceptions/ deprivation, role transition) wi l l be exhibited with time. A third study design factor that may have contributed to the unexpected results of this study was the small sample size. When sample size is small this l imits the power to detect significant differences should differences actually exist (Burns & Grove, 1987). Individual Factors Many individual factors may have been inf luential in the role transition outcomes of the two groups. According to Spickerman (1988) many factors mediate the severity of real i ty shock. S k i l l s , knowledge levels, 81 and attitudes associated with c l i n i c a l practice are inf luent ia l . Other factors such as self concept, interpersonal relationship s k i l l s , organizational a b i l i t i e s , and compatability between personal and professional goals also contribute to one's adjustment when entering professional practice. Accordingly, i f the groups had persons who were confident, had sol id knowledge bases, strong interpersonal relationship and organizational s k i l l s ; these factors alone, as opposed to the particular orientation program that the individuals received, may have made these individuals more l ike ly to be accepted into the reference work group of experienced nurses. This is l ike ly 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 this , i t is reasonable to suggest that i f participants possessed characteristics such as these described, they would be more l ike ly 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 ignif icantly greater performance gains than the tradit ional orientation group. This study failed to support the hypothesis that job performance levels reported by novice staff nurses who participate in a preceptorship orientation program wi l l be higher than those reported by novice staff nurses who participate in a tradit ional 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 than graduate nurses completing a hospital-based internship orientation program. Huber also used the Six Dimension Scale of Nursing Performance to measure self-perceived performance by graduate 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 social ization of graduate nurses. The study only part ia l ly supported the hypothesis that there would be significant differences between the groups on the six subscales of the Six Dimension Scale of Nursing Performance. There were significant differences 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 significant effect of a preceptorship program on role conception or role deprivation as compared to a tradit ional orientation program. At post-test measurement there were no significant differences between the preceptorship and tradit ional 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 tradit ional orientation program was not supported. Participants in this study did not have significant differences in performance ratings or role conceptions/role deprivation at post-test measurement. Thus, novice staff nurses' role transition experiences were not found to be s ignif icantly different whether they participated in the preceptorship or the tradit ional orientation program. As such, the treatment effect of presence of a preceptor for the preceptorship group was not as strong an influence on role transition of novice staff nurses as had been expected. Summary The results of this study failed 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 transition than novice staff nurses who participate in a tradit ional 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 are presented in this chapter. In addition, limitations of the study, study implications, and recommendations for future study are provided. Summary The transit ion from student to beginning practitioner in nursing has been identified as a part icularly d i f f i c u l t transit ion. Preceptorship programs have been used as orientation strategies in a effort to ease this transition from student to practitioner in nursing. The purpose of this study was to investigate the effect of a preceptorship program on the role transit ion of novice staff nurses. The three research hypotheses that were tested in this study were: 1. Role transition wi 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 tradit ional orientation program. 2. Job performance levels reported by novice staff nurses who participate in a preceptorship program wi l l be higher than those reported by novice staff nurses who participate in a tradit ional orientation program. 86 3. Perceived role deprivation reported by novice staff nurses who participate in a preceptorship program wi l l be less than that reported by novice staff nurses who participate in a tradit ional orientation program. Demographic characteristics of the groups were assessed using chi-square analysis. Results revealed that the experimental and control groups differed s ignif icantly 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 nurses. These differences in proportions may have been important influencing factors on the role transition experiences reported by the groups. In relation to hypothesis two, results indicated no significant differences between the groups in post-test performance outcomes. 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 significant within-group 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 erences , comparison of o v e r a l l post - test scores revealed no s i g n i f i c a n t di f ferences between the groups in any dimensions of performance as measured by the Six Dimension Scale of Nursing Performance. Many possible reasons were presented for these resu l t s (demographic v a r i a b l e s , program fac tors , and study design 1 imi ta t ions ) . Role conception and ro le depr ivat ion scores , as measured by the Nursing Role Conception Scale , were tested to evaluate hypothesis three . Analys is of r e su l t s in r e l a t i o n to hypothesis three revealed a s i g n i f i c a n t within-group decrease in PRC ( ideal) from pretest to post - test for the experimental group; but not an accompanying increase in BRC as one might expect. Several poss ible explanations for th i s re su l t were introduced. On the remaining subscales of the Nursing Role Conception Scale (BRC, SRC, RD), the experimental group exhibited no s i g n i f i c a n t within-group di f ferences between pretest and post- test scores . By comparison, the contro l group reported no s i g n i f i c a n t within-group dif ferences from pretest to post- test in any subscales of the Nursing Role Conception Scale (PRC, BRC, SRC, RD). Post- test ro le conception and ro le depr ivat ion scores of both groups were compared. Results indicated no 88 s t a t i s t i c a l l y significant differences between the groups on these scores. 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, that suggested role transition would be easier for the experimental group, was not supported. Role transit ion experiences of the groups were not found to be s ignif icantly different. Results suggest that at one month there was no difference exhibited in either program assisting novice staff nurses to make the transition from student to beginning practit ioner. Conclus ions Conclusions which can be drawn from analysis of the study data are: 1. Participants in both programs (preceptorship and tradit ional orientation) showed significant performance gains in d i s t inc t ly different aspects of performance as measured by the Six Dimension Scale of Nursing Performance. While the control (traditional 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 reported improved performance on only one dimension of performance (p lanning/evaluat ion) . However, par t i c ipant s in neither group gained s i g n i f i c a n t l y in terms of o v e r a l l performance a b i l i t y over the other. Thus, i t can be concluded that both programs provide benef i t s , but in d i f f eren t d i r e c t i o n s , with d i f f e r e n t areas of focus. 2. Role conception scores of the groups at post - tes 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 . However, the experimental (preceptorship) group reported a s i g n i f i c a n t within-group decrease in PRC ( i d e a l ) . The contro l group reported no s i g n i f i c a n t within-group di f ferences in any ro le conceptions from pretest to pos t - tes t . It can be concluded that the within-group change in ro le conceptions reported by the groups demonstrates that the groups had d i f f e r e n t experiences in the i r or i enta t ion programs. 3. Par t i c ipant s in the preceptorship program did not demonstrate less ro le depr ivat ion than par t i c ipants in the t r a d i t i o n a l or i enta t ion program. Thus, i t can be concluded that preceptorship program par t i c ipant s d id not perceive themselves as having less c o n f l i c t in reso lv ing dilemmas about how s i tua t ions i d e a l l y ought to be in 90 nurs ing , v e r s u s how they a c t u a l l y are i n p r a c t i c e . The p r e c e p t o r s h i p program had l e s s of an e f f e c t on r o l e d e p r i v a t i o n than was a n t i c i p a t e d . 4. O v e r a l l , the f i n d i n g s suggest t h a t , at one-month p o s t -employment, ho d i f f e r e n c e was shown i n e i t h e r program a s s i s t i n g n o v i c e s t a f f nurses to make the t r a n s i t i o n from s t u d e n t to b e g i n n i n g p r a c t i c e i n p r o f e s s i o n a l n u r s i n g . Thus i t can be conc luded t h a t the presence of p r e c e p t o r s was l e s s of a f a c t o r i n i n f l u e n c i n g n o v i c e s t a f f nurse r o l e t r a n s i t i o n than had been a n t i c i p a t e d . L i m i t a t i o n s Recognized l i m i t a t i o n s of t h i s s t u d y i n c l u d e : 1. Random s e l e c t i o n or random assignment of s u b j e c t s i n t o e x p e r i m e n t a l ( p r e c e p t o r s h i p ) and c o n t r o l ( t r a d i t i o n a l o r i e n t a t i o n ) groups was p r e c l u d e d . T h i s depended e n t i r e l y on the employing agency , and t h e r e f o r e , was out of the i n v e s t i g a t o r s ' s c o n t r o l . 2. Because of t ime c o n s t r a i n t s , the p o s t - t e s t was a d m i n i s t e r e d a t one month. T h i s may have been too s h o r t a t ime i n t e r v a l i n which to d e t e c t s i g n i f i c a n t r o l e t r a n s i t i o n d i f f e r e n c e s between the g r o u p s . 3. In p r a c t i c e n o v i c e s t a f f nurses i n the p r e c e p t o r s h i p program were o f t e n a s s i g n e d more than one p r e c e p t o r . In a d d i t i o n , t h e r e were s e v e r a l o c c a s i o n s when e x p e r i e n c e d 91 nurses, who had not had the e d u c a t i o n a l program to prepare them f o r the preceptor r o l e , were assigned as pr e c e p t o r s to novice s t a f f nurses. These f a c t o r s may have l i m i t e d the e f f e c t i v e n e s s of t h i s p r e c e p t o r s h i p program. P a r t i c u l a r l y , i n o f f s e t t i n g b e n e f i t s a t t r i b u t e d to p r e c e p t o r s h i p programs, such as, one-to-one l e a r n i n g , with an "e n l i g h t e n e d guide" who i s prepared f o r the preceptor r o l e . 4. The sample s i z e was s m a l l , thus l i m i t i n g the power to d e t e c t d i f f e r e n c e s should d i f f e r e n c e s a c t u a l l y e x i s t . 5. F a c t o r s such as s t a f f i n g needs, assignments given to novice s t a f f nurses, and work m i l i e u i n p a r t i c i p a t i n g agencies were f a c t o r s t h a t were not c o n t r o l l e d i n t h i s study. I m p l i c a t i o n s F i n d i n g s of the study have i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , e d u c a t i o n , and r e s e a r c h . Each of these i s presented i n d i v i d u a l l y i n the f o l l o w i n g s e c t i o n s . Nursing P r a c t i c e The p e r i o d of beginning employment as novice s t a f f nurses i s c r i t i c a l to the p r o f e s s i o n a l development and long term adjustment of nurses. The s o c i a l i z a t i o n experienced d u r i n g t h i s time e s t a b l i s h e s the b a s i s f o r t h e i r s a t i s f a c t i o n and l a t e r l o y a l t y to b u r e a u c r a t i c and 92 profess ional standards (Ahmadi et a l . , 1987). Pract i ce set t ings need to foster pos i t i ve environments that f a c i l i t a t e novice nurses' t r a n s i t i o n from school to p r a c t i c e . The a b i l i t y of nursing pract i ce set t ings to provide a supportive environment to beginning s t a f f nurses is becoming more d i f f i c u l t given today's changing health care environment. According to Talarczyk and Milbrant (1988) the present health care environment, with emphasis on "high tech" and cost containment, places increased demands on nurses. It requires nurses who are able to provide competent and sens i t ive nursing care to patients with increased acu i ty . Moreover, i t requires that they de l i ver th i s care in a fast paced manner. These factors add to the pressures experienced by novice nurses in making the t r a n s i t i o n from school to p r a c t i c e . According to Hamilton et a l . (1989) hosp i ta l or i en ta t ion programs have e s s e n t i a l l y focused on the 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 and protocols of the i n s t i t u t i o n ; and have usual ly f a i l e d to attend to providing guidance to the novice in ro le development, that i s , in a c q u i s i t i o n of a t t r ibutes that are c h a r a c t e r i s t i c of the profess ional nursing r o l e . Kramer and Schmalenberg (1977b) described how the f i r s t job of novice nurses i s a proving ground. In th i s proving period the novice is put through many formal and informal tests by the referent work group. The problem for neophytes with these tests is that they are ambiguous, and the c r i t e r i a for passing the tests are not c l e a r . Another problem with these tests is that members of the referent work group tend to judge neophytes' performance from the l e v e l of performance they have attained by experience without regard for the neophyes lack of experience. It would be worthwhile for pract ice set t ings to appraise the t e s t i n g , p a r t i c u l a r l y informal t e s t i n g , that takes place and to discuss the impact of th i s t e s t ing on t r a n s i t i o n experiences of neophytes. C l e a r l y , when such pract ices are discussed there is a greater l i k e l i h o o d that t e s t i n g , i f i t i s to continue, could be adjusted so that expectations in te s t ing could r e f l e c t the d i f f eren t experience leve ls between novice and seasoned profess iona l s . Conseguently, expert leve ls of performance would not be expected from beginning p r a c t i t i o n e r s . Based on the present study f ind ings , both of the or i enta t ion programs (preceptorship and t r a d i t i o n a l or ientat ion) were equal in that there were no s i g n i f i c a n t 94 d i f fe rences in ro le t r a n s i t i o n experiences, whether novice s t a f f nurses par t i c ipa ted in a preceptorship or a t r a d i t i o n a l o r ien ta t ion program. This suggests that the benef i ts of preceptorship programs over t r a d i t i o n a l o r ien ta t ion programs, that have been c i t e d in the l i t e r a t u r e , may not be borne out as s t rongly as was a n t i c i p a t e d . If preceptorship programs are to be of greater benef i t in a s s i s t i n g novice s t a f f nurses to make the t r a n s i t i o n from students to beginning p r a c t i t i o n e r s , a t tent ion needs to be given to preceptorship program development and monitoring of the i r e f f ec t i veness . D i f f i c u l t i e s a r i se with preceptor programs having enough experienced s t a f f prepared to funct ion as preceptors. The impact of the nursing shortage, complicates the a b i l i t y of p rac t ice se t t ings to have enough experienced nurses to provide preceptors for novice nurses. Changing preceptor assignments in the middle of the program or assigning severa l preceptors for each novice nurse destroys the cont inu i ty for the neophyte (Goldenberg, 1987/1988). If p rac t ice se t t ings are to reap the greatest benef i ts that have been ascr ibed to preceptorship programs, mechanisms to increase the number of preceptors prepared to f u l f i l l that ro le are needed. 95 Attent ion also needs to be given to the person's selected for the preceptor r o l e . The c l i n i c a l competence; interpersonal relationship/communication s k i l l s ; teaching a b i l i t i e s ; and wi l l ingness of experienced nurses chosen for the preceptor ro le are a l l important ingredients in ensuring the q u a l i t y of the teaching and guidance given to noephytes by preceptors. In th i s preceptorship program studied there were no formal standards in terms of the q u a l i t i e s required in preceptors . As well there was no formalized ongoing follow-up with preceptors and orientees . These factors might l i m i t the degree to which the program is operating consistent with i t s purpose. Nursing prac t i ce needs to address issues of commitment to the preceptorship 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 to pract i ce i f i t i s to be used as i t was intended to be used. If these programs are to be successful organizat ional commitment to the object ives of the preceptorship program is e s s e n t i a l . Nursing Education Nursing education prepares p r a c t i t i o n e r s for a prac t i ce d i s c i p l i n e , and as such, must be a l e r t to the r e a l i t i e s of c l i n i c a l pract ice in today's nursing prac t i ce s e t t ings . Nursing education must prepare students for 96 the t r a n s i t i o n to p r a c t i c e and the t y p i c a l problems that beginning p r a c t i t i o n e r s f a c e . As such, education programs must provide content i n r e a l i t y shock and a n t i c i p a t o r y s o c i a l i z a t i o n to the r e a l i t y of the p r o f e s s i o n a l n u r s i n g r o l e . To be s u c c e s s f u l i n p r o v i d i n g adequate a n t i c i p a t o r y s o c i a l i z a t i o n programs, educators must be knowledgable of the " r e a l world" s i t u a t i o n i n n u r s i n g p r a c t i c e s e t t i n g s . Role e x p e c t a t i o n s of educators and p r a c t i t i o n e r s must become more congruent. Moreover, i f educators are to adequately prepare students f o r p r o f e s s i o n a l p r a c t i c e i n n u r s i n g , mechanisms are needed to ensure t h a t educators are c l i n i c a l l y p r o f i c i e n t , and thus are q u a l i f i e d , to prepare n u r s i n g students f o r the r e a l world of n u r s i n g . Thus, n u r s i n g education and n u r s i n g p r a c t i c e need to be c l o s e l y l i n k e d i n order t h a t students begin p r a c t i c e with the t e c h n i c a l , i n t e r p e r s o n a l r e l a t i o n s h i p , and conceptual s k i l l s n e cessary to handle the r e a l i t i e s of beginning n u r s i n g p r a c t i c e . Given the pace of change i n n u r s i n g , educators must have some means to maintain competence i n order to provide i n s t r u c t i o n and s u p e r v i s i o n to students t h a t w i l l , upon g r a d u a t i o n , provide them with the r e q u i s i t e s k i l l s to competently begin p r a c t i c e i n n u r s i n g . Many 97 i s s u e s need t o be a d d r e s s e d p a r t i c u l a r l y i n the u n i v e r s i t y s e t t i n g . A c c o r d i n g t o M y r i c k (1988) c l i n i c a l t e a c h i n g i n u n i v e r s i t y s e t t i n g s i s s u b o r d i n a t e t o 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 p u b l i c a t i o n . N u r s i n g ought t o q u e s t i o n what i s the i d e a l c o m b i n a t i o n , f o r n u r s i n g f a c u l t y i n terms of c l i n i c a l p r o f i c i e n c y , and e x p e r t i s e 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 l e a r n i n g p r i n c i p l e s . Another i s s u e t h a t needs t o be a d d r e s s e d i s whether e d u c a t i o n a l s t a n d a r d s a r e a p p r o p r i a t e , or whether n u r s i n g e d u c a t i o n 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 ? N u r s i n g e d u c a t i o n and n u r s i n g s e r v i c e p e r s o n n e l s h o u l d 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 a p p r o p r i a t e c u r r i c u l u m c o n t e n t f o r n u r s i n g e d u c a t i o n programs. There must be agreement between n u r s i n g e d u c a t i o n and n u r s i n g s e r v i c e on what c o n s t i t u t e s 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 of new g r a d u a t e s . There have been f r e q u e n t debates c o n c e r n i n g t h e gap between n u r s i n g p r a c t i c e and n u r s i n g e d u c a t i o n p e r s o n n e l (Schempp & Rompre, 1986). N u r s i n g s e r v i c e p e r s o n n e l o f t e n c o m p l a i n t h a t s c h o o l s of n u r s i n g f a i l t o a d e q u a t e l y p r e p a r e s t u d e n t s f o r p r a c t i c e . As a r e s u l t , p r a c t i c e s e t t i n g s must spend i n o r d i n a t e time i n o r i e n t i n g new g r a d u a t e s 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 c a r e r e s p o n s i b i l i t i e s . E d u c a t o r s defend t h a t i t i s i m p o s s i b l e t o p r e p a r e a f i n i s h e d p r o d u c t r e a d y f o r p r a c t i c e i n any s e t t i n g . They a l s o contend t h a t p r a c t i c e s e t t i n g s f a i l t o t r e a t t h e new grad u a t e i n a manner t h a t f o s t e r s s u c c e s s f u l t r a n s i t i o n from s c h o o l t o p r a c t i c e . The n o v i c e n u r s e , caught i n t h e mi d d l e of t h i s debate between n u r s i n g e d u c a t i o n and n u r s i n g p r a c t i c e p e r s o n n e l , f r e q u e n t l y f e e l s p e r s o n a l l y r e s p o n s i b l e f o r h e r / h i s i n adequate p r e p a r a t i o n f o r the s t a f f nurse r o l e (Schempp & Rompre, 1986). A r e s o l u t i o n t o t h i s l o n g s t a n d i n g b l a m i n g game i s needed so t h a t p r a c t i c e and e d u c a t i o n p e r s o n n e l 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 of neophytes i n t o p r o f e s s i o n a l p r a c t i c e . Another i s s u e t h a t needs t o be addressed by n u r s i n g e d u c a t i o n r e l a t e s t o t h e n u r s i n g s h o r t a g e and i t s e f f e c t s . E d u c a t o r s , p r a c t i c e p e r s o n n e l , and p r o f e s s i o n a l n u r s i n g b o d i e s need t o c o n s i d e r the l i m i t s t o which t h e y are w i l l i n g 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 b u r e a u c r a t i c s t a n d a r d s . G i v e n t h e c r i t i c a l n u r s i n g s h o r t a g e and the promise of i n c r e a s i n g p r e s s u r e t o make compromises ( i . e . , d e c r e a s e s t a n d a r d s i n n u r s i n g p r a c t i c e and n u r s i n g e d u c a t i o n ) , i t i s c r u c i a l t h a t t h e s e i s s u e s be a d d r e s s e d . N u r s i n g needs t o c l e a r l y and p r o a c t i v e l y delineate the l i m i t s to which i t w i l l submit in decreasing standards. This w i l l ensure that contingencies with accompanying rationale are developed so that nursing education standards and not unduely jeopardized. Cl e a r l y , nursing practice i s the raison d'etre of the nursing profession. Nursing education is charged with preparing p r a c t i t i o n e r s for the practice of nursing. Educators must be p r o f i c i e n t in the practice of professional nursing, and thus, cannot be separate from nursing practice. Nursing Research Preceptorship programs are extensively used for orientation of novice s t a f f nurses to nursing practice. While many benefits of preceptorship programs for t h i s purpose are noted in the anecdotal l i t e r a t u r e on the subject, the research which has investigated the e f f e c t of preceptorship programs has found c o n f l i c t i n g r e s u l t s . More research i s needed to investigate the e f f e c t of preceptorship programs. It is recommended that this study be replicated with a larger sample siz e and that participants be followed over a longer time frame in order to determine whether changes in role t r a n s i t i o n of novice s t a f f nurses over time can be attributed to the 100 effects of the preceptorship program. In addition, future research could address: (1) Whether preceptorship programs, as opposed to tradit ional orientation programs, have any differences in terms of effects on job satisfaction, 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" rea l i ty and the day-to-day pol i t ics of the bureaucratic organizations in which novice nurses begin practice. (This data would be useful in determining whether this information can be deleted or condensed in orientation programs). (3) Whether differences in novice staff nurse outcomes correlate to level of preceptor competence. (4) Whether there are differences 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 social integration foster positive role transit ion. Clearly preceptorship programs are frequently used in nursing education programs and nursing practice settings. More study is needed to validate whether these programs are truly as effective as they have been declared to be. 102 REFERENCES Ahmadi, K. S., Speedling, E . J . , & Kuhn-Weissman, G. (1987). The newly hired hospital staff nurse's professionalism, satisfaction and alienation. 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Occupational Health Nursing, 32(8), 410-411. 108 Appendix A. 109 Preceptorship Program Schedule Monday 0800-0830 Welcome, Introduction, Meet Instructors 0830-0915 Charting R e s p o n s i b i l i t i e s and Accountability 0915-0930 " L i f t and Transfer Techniques" video 0930-1000 Break 1000-1030 Nursing Personnel P o l i c i e s 1030-1100 "Restraint/Non Restraint" video 1100-1200 Blood Glucose Monitoring 1200-1300 Lunch 1300-1600 C l i n i c a l Area- Complete: Poli c y and Procedure Module,Pharmacy Module, Pre-reading Material, Search and Find and L i f t i n g and Transferring Return Demonstration, Tuesday 0800-1200 1200-1300-1330-1345-1415-1445-1530-1300 1330 1345 1415 1445 1530 1600 Hospital Wide Orientation (by Employee Relations) Lunch Communications Systems Introduction to Competency Based Education Computers in Nursing Break Philosophy Overview of Nursing Div i s i o n Organization Wednesday 0800-0840 Education and Research 0840-0910 Quality Assurance, Standards and Protocals 0910-0930 Break 0930-1000 Pastoral Care 1000-1100 Infection Control 1100-1200 Respiratory Therapy 1200-1300 Lunch 1300-1600 Parenteral Therapy Thursday 0800-1100 Code Blue (General Areas) 1100-1200 Lunch 1200-1600 C l i n i c a l Area OR 0700-1100 C l i n i c a l Area 1100-1200 Lunch 1200-1500 Code Blue (General Areas) Appendix B. I l l Preceptor Development Program Purpose: This half day program is designed to assist participants (registered nurses who wi l l be acting as preceptors) to develop the knowledge, s k i l l s and attitudes necessary to effectively quide a new employee through orientation. Program Objectives: At the end of the program the participant w i l l be able to: 1. Describe the purposes and benefits of a preceptorship program for orientation. 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 orientees. 5. Develop teaching strategies to assist orientees to meet their learning needs and competencies. Give constructive feedback in performance or case study. response to an observed 112 Appendix 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 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 Friday E: 0800 -0830 0830 -0900 0900 -1000 1000 -1100 1100 -1200 1200 -1315 1315 -1400 1400 -1415 1415 -1600 Introduction Pastoral Care Spir i tual Aspects Personnel Services Union Reps: HSA HEU BCNU Coffee Infection Control Fire Safety Disaster Plan Employee Health Services Lunch Nursing Department Philosophy & Objectives Nursing Personnel Information Back Care Program Computerized Medication System I.V. Therapy R.N.A.B.C. Coffee T.P.N. Unit Orientation (Complete seek and find, 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) 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 Wednesday 0800-0815 0830-0845 0845-0915 0915-0945 0945-1000 1000-1045 1045-1200 1200-1300 1300-1315 1315-1415 1430-1600 Thursday 0800-0900 0900-0930 0930-1000 1000-1015 1015-1030 1030-1045 1045-1200 1200-1300 Central Orientation (Welcome from Education Services and Administration, Slide tapes "Welcome to Hospital", "Fundamentals of Back Care", Fire 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 C l i n i c a l Nurse Specialist 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 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 Return Demonstrations: Chest Tubes, Catheterization, Respiratory Therapy 1300-1600 Independent Study: Medicus, Medications, Nursing Department, Pharmaceutical Math Questions Handout, I .V. Therapy and Direct I.V. Medications Fr iday 0800-0900 Demonstration/Practice I .V. Therapy, Direct I .V. Medications 0900-0915 Break 0915-1030 Independent Study: I .V. Therapy, Direct I .V. Medications 1030-1130 Multiple Choice Quiz- Medications, I .V. Therapy, and Direct I .V. Medications 1130-1200 Review Quiz 1200-1230 Lecture/Discussion Charting Legalities 1230-1300 Lunch 1300-1600 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 CPR Basic Level 1 (only i f cert i f icat ion necessary) or Unit Orientation 1300-1400 Transfer Techniques 1400-1530 Mock Arrest (Emergency Cart, Cardiac and Respiratory Arrest Appendix E. 118 Letter of Introduction The University of Bri t i sh Columbia School of Nursing Vancouver, Br i t i sh Columbia Dear Colleague: I am a graduate student in the University of Bri t i sh Columbia School of Nursing. For my thesis, I am conducting a study to examine the effect of orientation programs on the role transition of new graduates in their f irst-t ime 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 just i fy expenditure, i t is important that their effectiveness be evaluated. The purpose of this study is to compare the effectiveness of two types of orientation programs. Your voluntary participation is requested to provide information regarding orientation. This information may be helpful in improving future orientation programs. Each participant wi l l be asked to complete two questionnaires at the start of orientation and again one month later. These include: a self-appraisal of nursing performance using Schwirian's Six Dimension Scale of Nursing Performance and a self-appraisal of role conception using Corwin's Nursing Role Conception Scale. Completion of these scales is estimated to take approximately 15 and 20 minutes respectively. F ina l ly , each participant wi 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 wi l l be kept confidential and they wi l l not be shared with hospital personnel. In order to preserve the identity of participants in the study, each participant in the study wi l l be assigned a code number. Only code numbers, not names of participants, 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 this researcher. A l l data w i l l be maintained in safekeeping by this researcher. The completed study wi l l not disclose the identity of individual participants. 119 Your participation in this study would be appreciated. Participation in this 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 ina l ly , whether or not you participate in this study wi 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 Bri t i sh 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 Bri t i sh 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 hospital: 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 Appendix 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 B E H A V I O R S Instructions; This section contains a list of act iv i t ies in which nurses engage with varying degrees of frequency and sk i l l . For these act iv i t ies that you do perform in your current job, please indicate how well you perform them by using numbers from the fol lowing key: 1 - Not very well 2 - Sat isfactor i ly 3 - Wel l 4 - Very wel l X - Not expected in my current job TC Teach a patient 's family members about the pat ient 's needs. P E Coordinate the plan of nursing care with the medical plan of care. L Give praise and recognit ion for achievement of those under your direct ion. TC Teach preventive health measures to patients and their fami l ies. TC Identify and use community resources in developing a plan of care for a patient and his family. P E Identify and include in nursing care plans anticipated changes in patient 's condit ion. PE Evaluate results of nursing care. IPR Promote the inclusion of the pat ient 's decisions and desires concerning his care. P E Develop a plan of nursing care for a patient. P E Initiate planning and evaluation of nursing care with others. C C Per form technical procedures: e.g., oral suctioning, tracheostomy care, intravenous therapy, catheter care, dressing changes, e tc . TC Adapt teaching methods and materials to the understanding of the part icular audience: e.g., age of patient, educational background, and sensory deprivations. P E Identify and include immediate patient needs in the plan of nursing care. TC Develop innovative methods and materials for teaching patients. 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 care. Accept responsibility for the level of care provided by those under your direction. Perform appropriate measures in emergency situations. Promote the use of interdisciplinary resource persons. Use teaching aids and resource materials in teaching patients and their families. Perform nursing care required by crit ically 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 Communicate facts, ideas, and professional opinions in writ ing to patients and their fami l ies. TC Plan for the integration of patient needs with family needs. C C Functions calmly and competently in emergency situations. L Remain in open to the suggestions of those under your direction and use them when appropriate. IPR Use opportunities for patient teaching when they arise. P E R F O R M A N C E OF P R O F E S S I O N A L D E V E L O P M E N T BEHAVIORS Instructions; Using the fol lowing key, please indicate on the line at the left of each i tem the number that best describes the frequency with which you engage in the following behaviors. 1- Seldom or never 2 - Occasional ly 3 - Frequently 4 - Consistent ly PD Use learning opportunities for on-going personal and professional growth. PD Display sel f -d i rect ion. PD Accept responsibi l i ty for own actions. PD Assume new responsibil i t ies within the l imit of capabi l i t ies. PD Maintain high standards of sel f-performance. PD Demonstrate sel f-conf idence. PD Display a generally posit ive att i tude. PD Demonstrate knowledge of the legal boundaries of nursing. PD Demonstrate knowledge of the ethics of nursing. PD Accept and use construct ive c r i t i c i sm. Key To Subscales: L - Leadership C C - C r i t i c a l Care TC - Teaching/Col laborat ion P E - Planning/Evaluat ion IPR - IPR/Communicat ions PD - Professional Development 126 Appendix H. 127 NURSING R O L E C O N C E P T I O N S C A L E 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. 128 Here is an example: 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 more professional. Then check (V) the first column (STRONGLY A Suppose that, with some exceptions, you disagree that nurses in y< that doctors are more professional. Then check (^ column four (C question B. Be sure you place a check mark {/) after both questions A and B. Bureaucratic Items 1. 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? STRONGLY AGREE AGREE UNDECIDED DISAGREE STRONGLY DISAGREE >uld reg kGREE) 3ur hosp )ISAGR ard doc for que >ital do EE) aftt tors as stion A believe sr 2. 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? 3. 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? 129 4 . 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? STRONGLY AGREE AGREE UNDECIDED DISAGREE STRONGLY DISAGREE 5 . 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. Js this what graduate nurses at your hospital actual ly do when the occasion arises? 6 . A graduate nurse is inf luenced mainly by the opinions of the hospital authorit ies 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 actual ly do consider in forming their opinions? P R O F E S S I O N A L ITEMS 7 . One graduate nurses tr ies to put her standards and ideals about good nursing into pract ice even if hospital rules and procedures prohibit it. 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? 8 . One graduate nurse does not do anything which she is told to do unless she is sat isf ied 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? 130 9. A l l graduate nurses in a hospital are act ive members in professional nursing associations, attending most conferences and meetings of the associat ion. A . Oo you think this should be true of a l l nurses? B. _Is this true of nurses at your hospital? STRONGLY AGREE AGREE UNDECIDED • DISAGREE STRONGLY DISAGREE 10. 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 al l nurses? B. Is this true of nurses at your hospital? 11. 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. Js this what graduate nurses at your hospital actual ly do when the occasion arises? 12. 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. col lege degree. A . Do you think that this is what graduate nurses should bel ieve? B. _ this what graduate nurses at your hospital actual ly do believe? 13. 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 abil i ty to use, judgement about nursing care procedures. A . Dp you think this is what supervisors should regard as important? B. Is this what supervisors at your hospital actual ly do regard as important? 131 14. Some hospitals try to hire only graduate nurses who took their training in col leges and universit ies which are equipped to teach the basic theoret ical knowledge of nursing science. A . Do you think this is the way it should be in nursing? B. Js this the way things are at your hospital? SERVICE ITEMS 15. A t one hospital graduate nurses spend more t ime at bedside nursing than any other nursing task. A . Do you think this is the way it should be in nursing? B. Js this the way things are at your hospital? 16. Head nurses and doctors at one hospital al low the graduate nurse to tel l patients as much about their physical and emotional condit ion 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? 17. A doctor orders a patient to sit up in a wheel chair 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 reatment. A . Do you think this is the way it should be in nursing? B. Is this the way things are at your hospital? 18. Doctors and head nurses at the hospital respect and reward nurses who spend t ime talking with patients in an attempt to understand the host i l i t ies, fear, and doubts which may ef fect the pat ient '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? 132 19. A graduate nurse believes that a patient ought to be referred to a psychologist or a public health nurse and tr ies to convince the doctor of this, even though he is doubtful. A . Do you think this is what a graduate nurse should do? B. Js this what graduate nurses at your hospital actually do when the occasion arises? STRONGLY AGREE AGREE UNDECIDED DISAGREE STRONGLY DISAGREE 20. A t one hospital the nurse's abi l i ty to understand the psychological and social factors in the pat ient 's background is regarded as more important then her knowledge of such other nursing ski l ls as how to give enemas, IVs, or how to chart accurate ly . A . Do you think this is the way it should be in nursing? B. Is this the way things are at your hospital? 21. Some graduate nurses believe that the professional nurses who should be rewarded most highly are the ones who regard nursing as a ca l l ing in which one's religious beliefs can be put into prac t ice . A . Do you think that is is what graduate nurses should bel ieve? B. Js this what graduate nurses at your hospital actually do bel ieve? 22. At some hospitals the graduate nurses who are most successful are the ones who are real ist ic and pract ica l about their jobs, rather than the ones who attempt to live according to ideal ist ic 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? • 

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