The theory of margin as a predictor of success on the National Council Licensure Examination for Registered Nurses

The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is the examination that all graduates of nursing education programs must pass to attain the title of registered nurse. Currently the NCLEX-RN passing rate is at an all-time low (81%) for first-time test takers (NCSBN, 2004); amidst a nationwide shortage of registered nurses (Glabman, 2001). Because of the critical need to supply greater numbers of professional nurses, and the potential accreditation ramifications that low NCLEX-RN passing rates can have on schools of nursing and graduates, this research study tests the effectiveness of a predictor model. This model is based upon the theoretical framework of McClusky's (1959) theory of margin (ToM), with the hope that students found to be at-risk for NCLEX-RN failure can be identified and remediated prior to taking the actual licensure examination. To date no theory based predictor model has been identified that predicts success on the NCLEX-RN. ^ The model was tested using prerequisite course grades, nursing course grades and scores on standardized examinations for the 2003 associate degree nursing graduates at a urban community college (N = 235). Success was determined through the reporting of pass on the NCLEX-RN examination by the Florida Board of Nursing. Point biserial correlations tested model assumptions regarding variable relationships, while logistic regression was used to test the model's predictive power. ^ Correlations among variables were significant and the model accounted for 66% of variance in graduates' success on the NCLEX-RN with 98% prediction accuracy. Although certain prerequisite course grades and nursing course grades were found to be significant to NCLEX-RN success, the overall model was found to be most predictive at the conclusion of the academic program of study. The inclusion of the RN Assessment Examination, taken during the final semester of course work, was the most significant predictor of NCLEX-RN success. Success on the NCLEX-RN allows graduates to work as registered nurses, reflects positively on a school's academic performance record, and supports the appropriateness of the educational program's goals and objectives. The study's findings support potential other uses of McClusky's theory of margin as a predictor of program outcome in other venues of adult education. ^

Evaluation of a six-week professional education curriculum designed to retain registered psychiatric nurses

During the past few years there has been a drastic shortage of registered nurses in the field. The shortage appears to have affected the field of psychiatric mental health nursing most intensely. The psychiatric nursing shortage is a multifaceted problem grounded in decreasing federal funds for advanced clinical training, inadequate undergraduate psychiatric experiences, lack of a well prepared articulate role model, the integrated curriculum and the confusion and blurring associated with the roles and functions of the psychiatric mental health nurse.^ This dissertation will describe the current nursing shortage; the decline in enrollment to nursing programs; the history of psychiatric nursing as a discipline; the shortage of psychiatric mental health nurses; factors contributing to the psychiatric nursing shortage and a plan for a solution to the nursing shortage in psychiatry.^ The paper focuses on an evaluation conducted on an internship curriculum designed to facilitate effective nursing care in the treatment of clients who exhibit emotional problems. The purpose of this study was to attract and retain nurses to employment opportunities in four Hospital Corporation of America (HCA) facilities, using a six week internship program.^ The study will yield an analysis of the effect of combining psychodynamic principles and knowledge with skills in the clinical area. The demands of educational practice have been merged with the discipline of psychiatric nursing in the development of this curriculum. ^

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. ^

Nurses' spiritual well-being: Its influence on attitudes and level of practice in providing spiritual care

The purpose of this study was to examine the relationship between the spiritual well-being of nurses and its influence on their attitudes toward providing spiritual care to patients. Two research instruments and a demographic data form were used for the survey. Using a descriptive design, tbe Spiritual Well-Being Scale, the Health Professional's Spiritual Role Scale, and the demographic data form were administered to 100 registered nurses from a large South Florida teaching hospital. The findings indicated a significantly positive correlation between the overall Spiritual Well-Being Scale and the Health Professional's Spiritual Role Scale (r = 0.52; p =.005). Significant differences were found between correlation of nurses' levels of spiritual well-being and all sociodemographic factors except for the three Age Groups and for religious affiliations. Findings have implications for how nurses should be trained in meeting patients total needs. ^

The role of the health care organization in supporting nurses in the delivery of culturally competent care

This study was designed to explore ways in which health care organizations (HCOs) can support nurses in their delivery of culturally competent care. While cultural competence has become a priority for the federal government as well as the major health professional organizations, its integration into care delivery has not yet been realized. Health professionals cite a lack of educational preparation, time, and organizational resources as barriers. Most experts in the field agree that the cultural and linguistic needs of ethnic minorities pose challenges that individual care providers are unable to manage without the support of the health care organizations within which they practice. While several studies have identified implications for HCOs, there is a paucity of research on their role in this aspect of care delivery. Using a qualitative design with a case study approach, data collection included face-to-face interviews with 23 registered nurses, document analysis, and reports of critical incidents. The site chosen was a large health care system in South Florida that serves a culturally diverse population. Major findings from the study included language barriers, lack of training, difficulty with cultural differences, lack of organizational support, and reliance on culturally diverse staff members. Most nurses thought the ethnic mix was adequate, but rated other supports such as language services, training, and patient education materials as inadequate. Some of the recommendations for organizational performance were to provide the expectations and support for culturally competent care. Implications and recommendations for practice include nurses using trained interpreters instead of relying on coworkers or trying to "wing it", pursuing training, and advocating for organizational supports for culturally competent care. Implications and recommendations for theory included a blended model that combines both models in the conceptual framework. Recommendations for future research were for studies on the impact of language bathers on care delivery, develop and test a quantitative instrument, and to incorporate Gilbert's model into nursing research.

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.

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. ^

Test of a smock system on CPR primary emergency measures and medical errors during simulated emergencies

Rates of survival of victims of sudden cardiac arrest (SCA) using cardio pulmonary resuscitation (CPR) have shown little improvement over the past three decades. Since registered nurses (RNs) comprise the largest group of healthcare providers in U.S. hospitals, it is essential that they are competent in performing the four primary measures (compression, ventilation, medication administration, and defibrillation) of CPR in order to improve survival rates of SCA patients. The purpose of this experimental study was to test a color-coded SMOCK system on: 1) time to implement emergency patient care measures 2) technical skills performance 3) number of medical errors, and 4) team performance during simulated CPR exercises. The study sample was 260 RNs (M 40 years, SD=11.6) with work experience as an RN (M 7.25 years, SD=9.42).Nurses were allocated to a control or intervention arm consisting of 20 groups of 5-8 RNs per arm for a total of 130 RNs in each arm. Nurses in each study arm were given clinical scenarios requiring emergency CPR. Nurses in the intervention group wore different color labeled aprons (smocks) indicating their role assignment (medications, ventilation, compression, defibrillation, etc) on the code team during CPR. Findings indicated that the intervention using color-labeled smocks for pre-assigned roles had a significant effect on the time nurses started compressions (t=3.03, p=0.005), ventilations (t=2.86, p=0.004) and defibrillations (t=2.00, p=.05) when compared to the controls using the standard of care. In performing technical skills, nurses in the intervention groups performed compressions and ventilations significantly better than those in the control groups. The control groups made significantly (t=-2.61, p=0.013) more total errors (7.55 SD 1.54) than the intervention group (5.60, SD 1.90). There were no significant differences in team performance measures between the groups. Study findings indicate use of colored labeled smocks during CPR emergencies resulted in: shorter times to start emergency CPR; reduced errors; more technical skills completed successfully; and no differences in team performance.

Employee perceptions of workplace empowerment in relation to self -reported intent to stay on the job

As the nursing profession faces a shortage of nurses, workplace initiatives focused on retaining employees are critical to the United States healthcare industry (Sochalski, 2002). The purpose of this research was to determine whether self-reported intent to stay on the job was related to perceptions of workplace empowerment using Kanter's (1977) theory of organizational empowerment as a framework. ^ The sample consisted of 206 Florida registered nurses. Four self-report scales and a demographic questionnaire were administered by mail. The Conditions for Work Effectiveness Questionnaire (CWEQ; Chandler, 1987), Job Activity Scale (JAS; Laschinger, Kutzscher, & Sabiston, 1993), Organizational Relationships Scale (ORS; Laschinger, Sabiston, & Kutzscher, 1993) and an intent to stay instrument (Kim, Price, Mueller & Watson, 1996) were used to measure perceived access to empowerment structures, perceived formal power, perceived informal power, and intent to stay, respectively. The data were analyzed using descriptive statistics, correlational analysis, and hierarchical regression. ^ Twenty-eight percent of the variance of intent to stay was explained by perceived access to empowerment structures, perceived formal power, and perceived informal power when holding age, gender, education, overall nursing experience, and number of years on current job constant. Perceived access to empowerment structures (CWEQ total score) was the best predictor of self-reported intent to stay for this sample. Of the four components of perceived access to work empowerment structures, perceived access to opportunity and resources were the best predictors of nurses' intent to stay on the job. ^ This study was the first step in establishing the relationship between Kanter's full model and intent to remain on the job, which is a stepping stone for the development of effective retention strategies based on a workplace empowerment model. This knowledge is particularly important in today's healthcare industry where healthcare administrators and human resource development practitioners are ideally positioned to implement organizational strategies to enhance access to work empowerment structures and potentially reduce turnover and mitigate the effects of nursing shortage. ^

The relationship of aptitude, course grades, and program length, to performance on a standards based test (NCLEX -RN)

The purpose of this study was threefold: first, to investigate variables associated with learning, and performance as measured by the National Council Licensure Examination for Registered Nurses (NCLEX-RN). The second purpose was to validate the predictive value of the Assessment Technologies Institute (ATI) achievement exit exam, and lastly, to provide a model that could be used to predict performance on the NCLEX-RN, with implications for admission and curriculum development. The study was based on school learning theory, which implies that acquisition in school learning is a function of aptitude (pre-admission measures), opportunity to learn, and quality of instruction (program measures). Data utilized were from 298 graduates of an associate degree nursing program in the Southeastern United States. Of the 298 graduates, 142 were Hispanic, 87 were Black, non-Hispanic, 54 White, non-Hispanic, and 15 reported as Others. The graduates took the NCLEX-RN for the first time during the years 2003–2005. This study was a predictive, correlational design that relied upon retrospective data. Point biserial correlations, and chi-square analyses were used to investigate relationships between 19 selected predictor variables and the dichotomous criterion variable, NCLEX-RN. The correlation and chi square findings indicated that men did better on the NCLEX-RN than women; Blacks had the highest failure rates, followed by Hispanics; older students were more likely to pass the exam than younger students; and students who passed the exam started and completed the nursing program with a higher grade point average, than those who failed the exam. Using logistic regression, five statistical models that used variables associated with learning and student performance on the NCLEX-RN were tested with a model adapted from Bloom's (1976) and Carroll's (1963) school learning theories. The derived model included: NCLEX-RNsuccess = f (Nurse Entrance Test and advanced medical-surgical nursing course grade achieved). The model demonstrates that student performance on the NCLEX-RN can be predicted by one pre-admission measure, and a program measure. The Assessment Technologies Institute achievement exit exam (an outcome measure) had no predictive value for student performance on the NCLEX-RN. The model developed accurately predicted 94% of the student's successful performance on the NCLEX-RN.

Hospital discharge planning in the provision of food and nutrition services for older adults post discharge

This descriptive study examined whether discharge planning ensures that food and nutrition services are provided to older adults following hospital discharge. The questionnaire was distributed to discharge planning professionals in 11 South Florida hospitals. Of the 84 respondents (88% response rate), most were female nurse case managers. Almost all reported job barriers including excessive patient loads, too many responsibilities, and limited community services. While physicians, registered nurses, social workers, physical therapists, were deemed "very important" in discharge planning,registered dietitians were not, and almost half consulted them infrequently, if at all. Over 84% said nutrition-related medical conditions/factors, "strongly influenced" discharge planning. Many did not have adequate information about nutrition-related community resources, eg, home delivered meals, food stamps, outpatient registered dietitians. Therewere no universal approaches in meeting the nutrition needs in 6 case scenarios. More communication among community services and hospitals is needed.

Increasing nurse's knowledge of neonatal pain assessment through inservice education program

Recognizing neonatal pain is a challenge for nurses working with newborns due to the complexity of the pain phenomenon. Pain is subjective, and infants lack the ability to communicate, and their pain is difficult to recognize. The purpose of this study is to determine the effectiveness of education on the NICU nurses' ability to assess neonatal pain. With a better understanding of pain theory and the effects of pain on the newborn the nurse will be better able to assess newborns with pain. Designed as a quasi-experimental one-group pretest and posttest study, the data was collected on a convenience sample of 49 registered nurses employed in the neonatal and special care nursery units at a Childrens Hospital in the Miami area. The nurses were surveyed on the assessment of neonatal pain using the General Information and Pain Sensitivity Questionnaire. After the initial survey, the nurses were inserviced on neonatal pain assessment using a one hour inservice education program. One week after the intervention the nurse was asked to complete the questionnaire again. Data analysis involved comparision of pre and post intervention findings using descriptive methods, t test, correlation coefficients, and ANOVA , where applicable. Findings revealed a significant ( p=.006) increase in nurse's knowledge of neonatal pain assessment after completing the educational inservice when comparing the pre-test and post-test results.

Test of a Smock System on CPR Primary Emergency Measures and Medical Errors During Simulated Emergencies

Rates of survival of victims of sudden cardiac arrest (SCA) using cardio pulmonary resuscitation (CPR) have shown little improvement over the past three decades. Since registered nurses (RNs) comprise the largest group of healthcare providers in U.S. hospitals, it is essential that they are competent in performing the four primary measures (compression, ventilation, medication administration, and defibrillation) of CPR in order to improve survival rates of SCA patients. The purpose of this experimental study was to test a color-coded SMOCK system on:1) time to implement emergency patient care measures 2) technical skills performance 3) number of medical errors, and 4) team performance during simulated CPR exercises. The study sample was 260 RNs (M 40 years, SD=11.6) with work experience as an RN (M 7.25 years, SD=9.42).Nurses were allocated to a control or intervention arm consisting of 20 groups of 5-8 RNs per arm for a total of 130 RNs in each arm. Nurses in each study arm were given clinical scenarios requiring emergency CPR. Nurses in the intervention group wore different color labeled aprons (smocks) indicating their role assignment (medications, ventilation, compression, defibrillation, etc) on the code team during CPR. Findings indicated that the intervention using color-labeled smocks for pre-assigned roles had a significant effect on the time nurses started compressions (t=3.03, p=0.005), ventilations (t=2.86, p=0.004) and defibrillations (t=2.00, p=.05) when compared to the controls using the standard of care. In performing technical skills, nurses in the intervention groups performed compressions and ventilations significantly better than those in the control groups. The control groups made significantly (t=-2.61, p=0.013) more total errors (7.55 SD 1.54) than the intervention group (5.60, SD 1.90). There were no significant differences in team performance measures between the groups. Study findings indicate use of colored labeled smocks during CPR emergencies resulted in: shorter times to start emergency CPR; reduced errors; more technical skills completed successfully; and no differences in team performance.