Implications of a theoretical framework on stress and burnout for the development of graduate nursing education curricula

This study had two purposes: (a) to develop a theoretical framework integrating and synthesizing findings of prior research regarding stress and burnout among critical care nurses (CCRNs), and (b) to validate the theoretical framework with an empirical study to assure a theory/research based teaching-learning process for graduate courses preparing nursing clinical specialists and administrators.^ The methods used to test the theoretical framework included: (a) adopting instruments with reported validity, (b) conducting a pilot study, (c) revising instruments using results of the pilot study and following concurrence of a panel of experts, and (d) establishing correlations within predetermined parameters. The reliability of the tool was determined through the use of Cronbach's Alpha Coefficient with a resulting range from.68 to.88 for all measures.^ The findings supported all the research hypotheses. Correlations were established at r =.23 for statistically significant alphas at the.01 level and r =.16 for alphas.05. The conclusions indicated three areas of strong correlation among the theoretical variables: (a) work environment stressor antecedents and specific stressor events were correlated significantly with subjective work stress and burnout; (b) subjective work stress (perceived work related stress) was a function of the work environment stressor antecedents and specific stressor events, and (c) emotional exhaustion, the first phase of burnout, was confirmed to be related to stressor antecedents and specific stressor events. This dimension was found to be a function of the work environment stressor antecedents, modified by the individual characteristics of work and non-work related social support, non-work daily stress, and the number of hours worked per week. The implications of the study for nursing graduate curricula, nursing practice and nursing education were discussed. Recommendations for further research were enumerated. ^

The knowledge and use of critical thinking teaching strategies of faculty in associate degree nursing education programs

The purpose of this study was to determine the knowledge and use of critical thinking teaching strategies by full-time and part-time faculty in Associate Degree Nursing (ADN) programs. ^ Sanders CTI (1992) instrument was adapted for this study and pilot-tested prior to the general administration to ADN faculty in Southeast Florida. This modified instrument, now termed the Burroughs Teaching Strategy Inventory (BTSI), returned reliability estimates (Cronbach alphas of .71, .74, and .82 for the three constructs) comparable to the original instrument. The BTSI was administered to 113 full-time and part-time nursing faculty in three community college nursing programs. The response rate was 92% for full-time faculty (n = 58) and 61% for part-time faculty (n = 55). ^ The majority of participants supported a combined definition of critical thinking in nursing which represented a composite of thinking skills that included reflective thinking, assessing alternative viewpoints, and the use of problem-solving. Full-time and part-time faculty used different teaching strategies. Full-time faculty most often used multiple-choice exams and lecture while part-time faculty most frequently used discussion within their classes. One possible explanation for specific strategy choices and differences might be that full-time faculty taught predominately in theory classes where certain strategies would be more appropriate and part-time faculty taught predominately clinical classes. Both faculty types selected written nursing care plans as the second most effective critical thinking strategy. ^ Faculty identified several strategies as being effective in teaching critical thinking. These strategies included discussion, case studies, higher order questioning, and concept analysis. These however, were not always the strategies that were used in either the classroom or clinical setting. ^ Based on this study, the author recommends that if the profession continues to stress critical thinking as a vital component of practice, nursing faculty should receive education in appropriate critical teaching strategies. Both in-service seminars and workshops could be used to further the knowledge and use of critical thinking strategies by faculty. Qualitative research should be done to determine why nursing faculty use self-selected teaching strategies. ^

The knowledge and use of critical thinking teaching strategies of faculty in associate degree nursing education programs

The purpose of this study was to determine the knowledge and use of critical thinking teaching strategies by full-time and part-time faculty in Associate Degree Nursing (ADN) programs. Sander's CTI (1992) instrument was adapted for this study and pilottested prior to the general administration to ADN faculty in Southeast Florida. This modified instrument, now termed the Burroughs Teaching Strategy Inventory (BTSI), returned reliability estimates (Cronbach alphas of .71, .74, and .82 for the three constructs) comparable to the original instrument. The BTSI was administered to 113 full-time and part-time nursing faculty in three community college nursing programs. The response rate was 92% for full-time faculty (n = 58) and 61 % for part-time faculty (n = 55). The majority of participants supported a combined definition of critical thinking in nursing which represented a composite of thinking skills that included reflective thinking, assessing alternative viewpoints, and the use of problem-solving. Full-time and part-time faculty used different teaching strategies. Fulltime faculty most often used multiple-choice exams and lecture while part-time faculty most frequently used discussion within their classes. One possible explanation for specific strategy choices and differences might be that full-time faculty taught predominately in theory classes where certain strategies would be more appropriate and part-time faculty taught predominately clinical classes. Both faculty types selected written nursing care plans as the second most effective critical thinking strategy. Faculty identified several strategies as being effective in teaching critical thinking. These strategies included discussion, case studies, higher order questioning, and concept analysis. These however, were not always the strategies that were used in either the classroom or clinical setting. Based on this study, the author recommends that if the profession continues to stress critical thinking as a vital component of practice, nursing faculty should receive education in appropriate critical teaching strategies. Both in-service seminars and workshops could be used to further the knowledge and use of critical thinking strategies by faculty. Qualitative research should be done to determine why nursing faculty use self-selected teaching strategies.

Nursing faculty intention to use service learning as pedagogy in higher education

The purpose of this study was to identify the factors that motivate nursing faculty to use service learning. The study was based on the theory of planned behavior (TPB), which implies that the target behavior of intention to use service learning in higher education is influenced by the predictor variables of behavior beliefs (attitude), normative beliefs (peer influence), and control beliefs (confidence and resources). External variables were also considered (years of teaching experience, tenure status, and the type of curriculum). ^ Group interviews and a pilot test were conducted to create the instrument for the study, and Cronbach alpha were calculated for survey item reliability. The participants were full time undergraduate nursing faculty members ( n = 160) in the Southeastern United States who taught in universities with accredited nurse education programs. Demographic data as well as scores on scaled survey responses were used to evaluate the intention of nursing faculty to use service learning in their classes. ^ Pearson product moment correlation coefficient and path analysis were applied to the data. The correlation findings indicated that there were statistically significant relationships between behavior beliefs, normative beliefs, and control beliefs and nursing faculty intention to use service learning. The path analysis also indicated that behavior beliefs and normative beliefs were significant, while control beliefs were not a strong influence on intention to use service learning. Normative beliefs showed the strongest direct influence. The use of a community based curriculum also had a positive influence on intention, and faculty with tenure status were more likely to have positive behavior beliefs (attitude) towards service learning. Finally, as teaching experience increased, positive attitudes towards the intention to use service learning decreased. Seventy-nine percent of the variation in the intention to use service learning was explained by the theory of planned behavior, the type of curriculum, teaching experience, and tenure status. These results will assist nursing administration and faculty to design strategies to facilitate the implementation of service learning pedagogy, as well as a community based curriculum which will help meet the 21st century goals set forth from the American Association of Colleges of Nursing. ^

A developmental education program model for high -risk minority baccalaureate nursing students

The purpose of this study was to define and describe a Developmental Education Program Model for high-risk minority baccalaureate nursing students based upon perceived needs determined by nursing students and nursing faculty. The research examined differences between Black and Non-Black nursing students in level of importance of concerns and issues related to academic, financial, psycho-social and personal areas of student life; faculty perceptions of the differences between Black and Non-Black nursing students in the level of importance of concerns and issues related to academic, financial, psycho-social and personal areas of student life; and the difference between Black and Non-Black nursing faculty perceptions of level of importance of issues and concerns of academic, financial, psycho-social, and personal areas for Black nursing students. In this study two data collection methods were used, questionnaire and interview. The questionnaire was completed by all students and faculty. Black baccalaureate nursing students and nursing faculty were interviewed. The most significant differences were seen in the category of Personal Issues. Student identified concerns and issues related to both academic and health problems. Faculty identified the greatest differences in Academic Issues. The framework for the model which evolved out of the data uses needs from: (1) a whole person perspective (outcome oriented needs); (2) a programmatic perspective (input oriented needs); and (3) learning domain perspective (process oriented needs). ^

Characteristics of effective clinical and theory instructors as perceived by LPN to RN versus generic students in an associate degree nursing program

The purpose of this study was to compare the characteristics of effective clinical and theory instructors as perceived by LPN/RN versus generic students in an associate degree nursing program.^ Data were collected from 508 students during the 1996-7 academic year from three NLN accredited associate degree nursing programs. The researcher developed instrument consisted of three parts: (a) Whitehead Characteristics of Effective Clinical Instructor Rating Scale, (b) Whitehead Characteristics of Effective Theory Instructor Rating Scale, and (c) Demographic Data Sheet. The items were listed under five major categories identified in the review of the literature: (a) interpersonal relationships, (b) personality traits, (c) teaching practices, (d) knowledge and experience, and (e) evaluation procedures. The instrument was administered to LPN/RN students in their first semester and to generic students in the third semester of an associate degree nursing program.^ Data was analyzed using a one factor mutivariate analysis of variance (MANOVA). Further t tests were carried out to explore for possible differences between type of student and by group. Crosstabulations of the demographic data were analyzed.^ There were no significant differences found between the LPN/RN versus generic students on their perceptions of either effective theory or effective clinical instructor characteristics. There were significant differences between groups on several of the individual items. There was no significant interaction between group and ethnicity or group and age on the five major categories for either of the two instruments. There was a significant main effect of ethnicity on several of the individual items.^ The differences between the means and standard deviations on both instruments were small, suggesting that all of the characteristics listed for effective theory and clinical instructors were important to both groups of students. Effective teaching behaviors, as indicated on the survey instruments, should be taught to students in graduate teacher education programs. These behaviors should also be discussed by faculty coordinators supervising adjunct faculty. Nursing educators in associate degree nursing programs should understand theories of adult learning and implement instructional strategies to enhance minority student success. ^

A study of state and trait anxiety and perceived causes of anxiety identified by licensed practical nurses returning to an associate degree nursing program

The purpose of this study was to identify the state and trait anxiety and the perceived causes of anxiety in licensed practical nurses (LPNs) returning to an associate degree nursing program in order to become registered nurses (RNs). The subjects for this study were 98 students enrolled in a transitional LPN/RN associate degree nursing program in two community colleges in the state of Florida. The State-Trait Anxiety Inventory (STAI) developed by Spielberger (1983), was used as the measuring instrument for this study.^ In addition, a Q-sort technique was used to obtain information from the subjects regarding perceived causes of anxiety. Anxiety causes for the Q-sort cards used in the study were developed from the themes identified by a sample of LPN/RN students in a pilot study. The state and trait anxiety levels were obtained using the STAI for college students scoring key and scales. Descriptive statistics were used to determine the state and trait anxiety of the students. Correlational statistics were used to determine if relationships existed between the state and trait anxiety levels and perceived causes of anxiety identified by LPN students returning to an associate degree nursing program.^ The analysis of the Q-sort was performed by computing the means, standard deviations, and frequencies of each cause. The mean trait anxiety level of the students was 57.56, $SD=29.69.$ The mean state anxiety level of the students was 68.21, $SD=25.78.$ Higher percentile scores of trait anxiety were associated with higher ranks of the Q-sort category, "failing out of the program," $\rm r\sb{s}=.27,\ p=.008.$ Implications for future nursing research and application of the findings to nursing education are presented. ^

The relationship between participation in unethical behaviors during the nursing student experience and participation in unethical behaviors as a registered nurse

The effect of unethical behaviors in health care settings is an important issue in the safe care of clients and has been a concern of the nursing profession for some time. The purpose of this study was to examine the relationship between use of unethical behaviors in the nursing student experience and the use of unethical behaviors in the workplace as a registered nurse. In addition, the relationship between the severity of unethical behaviors utilized in the classroom, clinical setting and those in the workplace was examined. To insure greater honesty in self-report, only a limited number of demographic variables were requested from participants.^ During the summer of 1997, a 56 item questionnaire was distributed to registered nurses enrolled in either undergraduate or graduate courses in a public or private institution. The participants were asked to self-report their own use of unethical behaviors as well as their peers use of unethical behaviors. In order to assign a severity score for each item, nursing school faculty were asked to rate severity of unethical behaviors which could be used during the nursing student experience and nursing administrators were asked to rate unethical behaviors which could be used in the workplace.^ A significant positive relationship was found between individuals' use of unethical behaviors during nursing school and those used in the workplace $r=.630.$ A significant positive relationship was found between the severity of unethical behaviors used in the nursing student experience and the severity of unethical behaviors used in the workplace $r=.637.$ No relationship was found between years of practice, type of initial nursing education and whether or not the participant was raised inside or outside the United States and the use of unethical behaviors. ^

A qualitative analysis of the lived experience of nursing staff developers in the process of changing to a new educational model

The purpose of this study was to document and critically analyze the lived experience of selected nursing staff developers in the process of moving toward a new model for hospital nursing education. Eleven respondents were drawn from a nation-wide population of about two hundred individuals involved in nursing staff development. These subjects were responsible for the implementation of the Performance Based Development System (PBDS) in their institutions.^ A purposive, criterion-based sampling technique was used with respondents being selected according to size of hospital, primary responsibility for orchestration of the change, influence over budgetary factors and managerial responsibility for PBDS. Data were gathered by the researcher through both in-person and telephone interviews. A semi-structured interview guide, designed by the researcher was used, and respondents were encouraged to amplify on their recollections as desired. Audiotapes were transcribed and resulting computer files were analyzed using the program "Martin". Answers to interview questions were compiled and reported across cases. The data was then reviewed a second time and interpreted for emerging themes and patterns.^ Two types of verification were used in the study. Internal verification was done through interview transcript review and feedback by respondents. External verification was done through review and feedback on data analysis by readers who were experienced in management of staff development departments.^ All respondents were female, so Gilligan's concept of the "ethic of care" was examined as a decision making strategy. Three levels of caring which influenced decision making were found. They were caring: (a) for the organization, (b) for the employee, and (c) for the patient. The four existentials of the lived experience, relationality, corporeality, temporality and spatiality were also examined to reveal the everydayness of making change. ^

Nursing curriculum: Changing students' knowledge and biases towards older adults

Caring for the older adult is a topic debated and discussed at all levels of today's society. Nurses are expected to educate patients and family members about their medications and care following hospitalization or contact with the health care system. The majority of these patients are elderly. The purpose of the study was to determine if a course on aging would affect the knowledge and biases of nursing students in a Baccalaureate nursing program at a Southeast Florida University. Nursing students (N = 52) were surveyed at the beginning of the semester using Palmore's Facts on Aging Quiz that is structured to determine the knowledge and biases of individuals towards the older adult. Students were surveyed before and after the nursing course that had a didactic and clinical component in the hospital setting. Analysis of the data by Chi square and repeated measure ANOVA supported the hypothesis that a course segment on aging would affect the knowledge level of the nursing students and result in changes of their biases toward the older adult. ^

Differences among undergraduate and graduate nursing students' cultural competency

This study examined differences in cultural competency levels between undergraduate and graduate nursing students (age, ethnicity, gender, language at home, education level, program standing, program track, diversity encounters, and previous diversity training). Participants were 83% women, aged 20 to 62; 50% Hispanic/Latino; with a Bachelor of Science in Nursing (n = 82) and a Master of Science in Nursing (n = 62). Degrees included high school diplomas, associate/diplomas, bachelors' degrees in or out of nursing, and medical doctorate degrees from outside the United States. Students spoke English (n = 82) or Spanish ( n = 54). The study used a cross-sectional design guided by the three-dimensional cultural competency model. The Cultural Competency Assessment (CCA) tool is composed of two subscales: Cultural Awareness and Sensitivity (CAS) and Culturally Competent Behaviors (CCB). Multiple regressions, Pearson's correlations, and ANOVAs determined relationships and differences among undergraduate and graduate students. Findings showed significant differences between undergraduate and graduate nursing students in CAS, p <.016. Students of Hispanic/White/European ethnicity scored higher on the CAS, while White/non-Hispanic students scored lower on the CAS, p < .05. One-way ANOVAs revealed cultural competency differences by program standing (grade-point averages), and by program tracks, between Master of Science in Nursing Advanced Registered Nurse Practitioners and both Traditional Bachelor of Science in Nursing and Registered Nurse-Bachelor of Science in Nursing. Univariate analysis revealed that higher cultural competency was associated with having previous diversity training and participation in diversity training as continuing education. After controlling for all predictors, multiple regression analysis found program level, program standing, and diversity training explained a significant amount of variance in overall cultural competency (p = .027; R2 = .18). Continuing education is crucial in achieving students' cultural competency. Previous diversity training, graduate education, and higher grade-point average were correlated with higher cultural competency levels. However, increased diversity encounters were not associated with higher cultural competency levels.^

The relationship between participation in unethical behaviors during the nursing student experience and participation in unethical behaviors as a registered nurse

The effect of unethical behaviors in health care settings is an important issue in the safe care of clients and has been a concern of the nursing profession for some time. The purpose of this study was to examine the relationship between use of unethical behaviors in the nursing student experience and the use of unethical behaviors in the workplace as a registered nurse. In addition, the relationship between the severity of unethical behaviors utilized in the classroom, clinical setting and those in the workplace was examined. To insure greater honesty in self-report, only a limited umber of demographic variables were requested from participants. During the summer of 1997, a 56 item questionnaire was distributed to registered nurses enrolled in either undergraduate or graduate courses in a public or private institution. The participants were asked to self-report their own use of unethical behaviors as well as their peers use of unethical behaviors. In order to assign a severity score for each item, nursing school faculty were asked to rate severity of unethical behaviors which could be used during the nursing student experience and nursing administrators were asked to rate unethical behaviors which could be used in the workplace. A significant positive relationship was found between individuals' use of unethical behaviors during nursing school and those used in the workplace r = .630. A significant positive relationship was found between the severity of unethical behaviors used in the nursing student experience and the severity of unethical behaviors used in the workplace r = .637. No relationship was found between years of practice, type of initial nursing education and whether or not the participant was raised inside or outside the United States and the use of unethical behaviors.

Differences Among Undergraduate and Graduate Nursing Students’ Cultural Competency

This study examined differences in cultural competency levels between undergraduate and graduate nursing students (age, ethnicity, gender, language at home, education level, program standing, program track, diversity encounters, and previous diversity training). Participants were 83% women, aged 20 to 62; 50% Hispanic/Latino; with a Bachelor of Science in Nursing (n = 82) and a Master of Science in Nursing (n = 62). Degrees included high school diplomas, associate/diplomas, bachelors’ degrees in or out of nursing, and medical doctorate degrees from outside the United States. Students spoke English (n = 82) or Spanish (n = 54). The study used a cross-sectional design guided by the three-dimensional cultural competency model. The Cultural Competency Assessment (CCA) tool is composed of two subscales: Cultural Awareness and Sensitivity (CAS) and Culturally Competent Behaviors (CCB). Multiple regressions, Pearson’s correlations, and ANOVAs determined relationships and differences among undergraduate and graduate students. Findings showed significant differences between undergraduate and graduate nursing students in CAS, p <.016. Students of Hispanic/White/European ethnicity scored higher on the CAS, while White/non-Hispanic students scored lower on the CAS, p < .05. One-way ANOVAs revealed cultural competency differences by program standing (grade-point averages), and by program tracks, between Master of Science in Nursing Advanced Registered Nurse Practitioners and both Traditional Bachelor of Science in Nursing and Registered Nurse-Bachelor of Science in Nursing. Univariate analysis revealed that higher cultural competency was associated with having previous diversity training and participation in diversity training as continuing education. After controlling for all predictors, multiple regression analysis found program level, program standing, and diversity training explained a significant amount of variance in overall cultural competency (p = .027; R2 = .18). Continuing education is crucial in achieving students’ cultural competency. Previous diversity training, graduate education, and higher grade-point average were correlated with higher cultural competency levels. However, increased diversity encounters were not associated with higher cultural competency levels.

Factors that motivate RNs to return to school for the BSN and to remain in school to complete the degree

This exploratory descriptive study examined the factors that influence Registered Nurses (RNs) to return to school to pursue a Baccalaureate of Science in Nursing degree (BSN) and the factors that contribute to the decision to remain in school to complete the degree. Students (N = 226) enrolled in RN-BSN programs in three different universities in southeast Florida participated in the study by completing researcher developed questionnaires. The study group included 140 students who were newly enrolled in an RN-BSN program and 86 students who were preparing to graduate from an RN-BSN program. The instruments used in this study were two researcher developed questionnaires, the Corbett Nursing Educational Motivational Inventory - Form A (CNEMI-A), administered to the newly enrolled students, and the Corbett Nursing Educational Motivational Inventory - Form B (CNEMI-B), administered to the graduating students. The questionnaires included researcher-developed items in addition to items derived from a modified form of the Educational Participation Scale used by other researchers. Demographic data were also collected. Findings indicated that changes in health care, career goals, personal satisfaction, and flexible curriculum patterns are the major reasons why RNs return to school for the BSN. Less significant factors were social support, salary increase, and employer expectations. The factors considered most significant in the decision to remain in school to complete the degree were ranked in the following order: personal achievement, changes in health care, career change/advancement, enrollment options, faculty support, social support, and employer support. Implications for nurse educators related to the changing roles of RNs and the need to continue to assist RNs to adapt to new roles in health care. Recommendations for future research on RN-BSN nursing education included studies to identify the courses considered most useful by RN-BSN students as compared to courses considered repetitive of basic nursing programs. Studies were also recommended to examine the differences between the needs of RNs related to experience as an RN and recency of education. Additional studies were recommended to determine the feasibility of dual-enrollment ADN/BSN programs for last semester ADN students. ^

Laypersons' awareness of the role and function of the nurse practitioner

The purpose of this descriptive study was to document the level of awareness that laypersons have regarding the role and function of the nurse practitioner (NP). An instrument developed for a similar study, conducted in 1994, comparing patients' and physicians' level of knowledge of the role and function of the NP, had a low reliability. Revision of the instrument was required before further use could be justified.^ A pilot study of 25 laypersons was conducted to ensure that the revised tool was reliable prior to conducting a study. Reliability for the pilot sample was 0.84.^ The study results indicated that the majority of the sample (83%), (n = 100) knew that a NP was a registered nurse who was qualified to diagnose and treat minor illnesses. The level of layperson awareness was limited regarding prescriptive privileges, well-woman exams, and the NPs' ability to perform physical exams, and interpret lab results and x-rays. ^