TheFaculty of Medicine, Dentistry and Health Sciences What ...€¦ · Ms Carol Crevacore RN GCTT ....
169
The Faculty of Medicine, Dentistry and Health Sciences What effect, does completing the Enrolled Nursing (EN) Registration Pathway Program and working as a novice EN have on nursing students’ readiness to practice? Western Australia, 2013-2011 Ms Carol Crevacore RN GCTT St. No 20542293 Thesis submitted for part of the degree of Master of Health Professional Education (48 points of the required 72 points) WORD COUNT: 30987
Transcript of TheFaculty of Medicine, Dentistry and Health Sciences What ...€¦ · Ms Carol Crevacore RN GCTT ....
The Faculty of Medicine, Dentistry and Health Sciences
What effect, does completing the Enrolled Nursing (EN) Registration Pathway
Program and working as a novice EN have on nursing students’ readiness to
practice?
Western Australia, 2013-2011
Ms Carol Crevacore RN GCTT
St. No 20542293
Thesis submitted for part of the degree of Master of Health Professional
Education
(48 points of the required 72 points)
WORD COUNT: 30987
DECLARATION
Having completed my course of study and research toward the
degree of Master by research, I hereby submit my thesis for
examination in accordance with the regulations and declare that this
thesis is my own work. This thesis has been completed during the
course of enrolment at the University of Western Australia and has
not been submitted previously to this or any other institution.
Carol Crevacore
i
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ACKNOWLEDGEMENTS
I wish to thank the following people for their support in completing this thesis.
To my two supervisors Associate Professor Diana Jonas-Dwyer and Associate
Professor Pam Nicol.
Diana, words cannot express the gratitude I have for the amazing amount of
support, encouragement and understanding both academically and personally
you have shown me over the past three years. I don’t think my Wednesdays
will ever be quite the same. I will be indebted to you for many years to come.
Pam you were always ready to shine a different light on the subject – even
when you knew it was not what I was looking for, but you knew it was what I
needed. Thank you for sharing your wisdom with me.
To Astrid Davine, thanks for always letting me ask ‘just one more question’
about Teleform. Your calm nature saw me through many frustrating times.
To the nursing students who participated in this research, Thank you.
To my many work colleagues who have shared the journey with me in
particularly Dr Judith Pugh for her assistance in the early days and Dr Gilly
‘Smiff” Smith for her support always.
To my sister Astrid who always supports me in anything and everything I
choose - Thankyou.
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To my Mum, you inspire me and amaze me. During the past year there has
been many mountains for you to climb but you kept encouraging me to continue
to climb this one. Thank you for letting me take over the kitchen table – you can
have it back now. I love you.
To Luca and Siena – it is time to wallpaper the toilet and get the doorstop!!!
Thank you for understanding that I needed to write, write, write, and read, read,
read. You have been with me every step of the way through this journey and
have never complained. I love you ‘more than you do’ and ‘to infinity and
beyond’.
To RN,
Thanks
xx CT xx
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ABSTRACT
In the latter half of the 20th century, registered nurse education moved to
university degree level. At the same time, there has been a reduction in access
for students to clinical experience. In numerous studies, nursing graduates
have reported that they do not feel prepared for practice.
Concurrently, global nursing shortages have resulted in the expectation that the
nursing graduate will be competent and ready to practice in often complex
clinical environments, sometimes described as ‘hitting the ground running’.
With this disparity between perceived abilities and expectations, the importance
of maximising every learning opportunity is paramount.
In 2007, the Western Australian Office of the Chief Nurse developed a pathway
for undergraduate registered nursing (RN) students to become enrolled nurses
at the midway point of their degree to enable them to work, and therefore gain
experience in the clinical practice setting during their education. This pathway
was called the Enrolled Nursing Registration Pathway Program (ENRPP).
There is little published research on the impact of undergraduate registered
nursing students working as enrolled nurses (EN) and their readiness to
practice within the clinical environment.
For the RN students who had completed the ENRPP, this research investigated
the effect of the ENRPP on their perception of their clinical abilities, and
explored their ability to link theory to practice in the clinical environment.
v
The research design for this study was a quasi-experimental, prospective
observational cohort study. Participants were asked to complete a modified
Five Dimension of Nursing Scale questionnaire consisting of 46 questions, two
of which were open-ended. The modified Five Dimension of Nursing Scale
includes the development of interpersonal relationships and communication;
planning and evaluating care; teaching and collaborating with clients; and
identifying and undertaking professional development opportunities and clinical
care activities.
A purposive convenience sample of second and third year enrolled nursing
students were invited to participate in the study. Participants included 39
second year nursing students not enrolled in the ENRPP in 2011 (Group 1), 45
second year nursing students enrolled in the ENRPP in 2011 (Group 2) and, 28
third year nursing students who completed the ENRPP course in 2010 (Group
3) are now working as ENs. A total of 112 nursing students were recruited to
participate in this study.
Descriptive statistics were used to report the findings of the quantitative data.
Thematic analysis was used to identify categories then sub themes and
overarching themes from the answers to the two open ended questions.
Prior to the semester when the ENRPP was to be taught, the quantitative
analyses showed that students who were not enrolled in the ENRPP in 2011
(Group 1) had a statistically significant higher pre-questionnaire perceived
abilities across all domains, except in interpersonal relationships and
communication when compared to students enrolled in the ENRPP in 2011 vi
(Group 2). The third year nursing students did not participate in the pre-
questionnaire as they had completed the ENRPP course in 2010 (Group 3), and
were now working as ENs. In contrast, after the completion of the semester
when the ENRPP was taught, the post-questionnaire quantitative analysis
showed that the No ENRPP group (Group 1) now had statistically significant
lower perceived abilities in four of the five dimensions under study compared to
the ENRPP 2011 group (Group 2). The No ENRPP group (Group 1) also had
significantly lower abilities in all dimensions compared to students who
completed the ENRPP in 2010 (Group 3). The ENRPP 2010 group (Group 3)
had a significantly higher perception of their clinical abilities compared to the
ENRPP 2011 group (Group 2).
The overarching theme identified was ‘Confidence in being a nurse’. Four sub-
themes were identified: (1) increased self-confidence; (2) ready to nurse; (3)
better employment prospects and (4) stress.
This study highlights the value of meaningful employment for all undergraduate
nursing students by providing students with opportunities to increase their
confidence for their future role as an RN.
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TABLE OF CONTENTS
Declaration……………………………………………………………………………. i
Acknowledgements……………………………………...…………………………. iii
Abstract……………………………………………………………………………..…v
Chapter 1. INTRODUCTION ............................................................................. 1
1.1 Background ............................................................................................ 1
1.2 Nursing Titles in Australia ...................................................................... 2
1.3 Clinical Placement hours ....................................................................... 4
1.4 Enrolled Nursing Registration Pathway Program (ENRPP) ................... 4
1.5 Organisation of this thesis. ..................................................................... 6
Chapter 2. LITERATURE REVIEW ................................................................... 9
Introduction ............................................................................................ 9 2.1
Learning Theory ..................................................................................... 9 2.2
2.2.1 Pedagogy ...................................................................................... 10
2.2.2 Andragogy ..................................................................................... 11
Readiness to Practice .......................................................................... 14 2.3
Self Confidence ................................................................................... 17 2.4
Critical thinking .................................................................................... 19 2.5
Clinical Practicum ................................................................................ 22 2.6
Meaningful Employment ...................................................................... 25 2.7
Employment Choices in the undergraduate RN ................................... 26 2.8ix
Externships .......................................................................................... 27 2.9
Significance of the Study to Practice ................................................... 29 2.10
Chapter 3. METHODOLOGY .......................................................................... 31
Introduction .......................................................................................... 31 3.1
Research Questions ............................................................................ 31 3.2
Research Design ................................................................................. 32 3.3
Ethics ................................................................................................... 32 3.4
Participants .......................................................................................... 34 3.5
Instrument ............................................................................................ 35 3.6
The Modified Questionnaire. ................................................................ 37 3.7
Pilot Test .............................................................................................. 38 3.8
Setting ................................................................................................. 40 3.9
Data Collection .................................................................................... 41 3.10
Study Procedure .................................................................................. 42 3.11
Exam Review ....................................................................................... 43 3.12
Data Analysis ....................................................................................... 45 3.13
Quantitative data .................................................................................. 45 3.14
Qualitative data .................................................................................... 46 3.15
Trustworthiness ................................................................................... 50 3.16
Chapter 4. RESULTS ..................................................................................... 53
Introduction .......................................................................................... 53 4.1
Reliability of the Instrument ................................................................. 53 4.2
x
Response Rate .................................................................................... 53 4.3
Demographics ...................................................................................... 55 4.4
4.4.1 Gender .......................................................................................... 55
4.4.2 Age ................................................................................................ 55
4.4.3 Level of Education ......................................................................... 56
4.4.4 Employment History ...................................................................... 58
4.4.5 Year at University .......................................................................... 59
Quantitative Data ................................................................................. 60 4.5
4.5.1 Clinical Care .................................................................................. 60
4.5.2 Teaching and Collaboration .......................................................... 64
4.5.3 Planning and Evaluation ................................................................ 67
4.5.4 Interpersonal Relationships and Communication .......................... 71
4.5.5 Professional Development ............................................................ 75
Qualitative Results ............................................................................... 79 4.6
4.6.1 Confidence in being a nurse .......................................................... 84
4.6.2 Increased Self Confidence ............................................................ 84
4.6.3 Ready to Nurse ............................................................................. 85
4.6.4 Better employment prospects ........................................................ 88
4.6.5 Stress related to the ENRPP ......................................................... 90
Summary ............................................................................................. 90 4.7
Chapter 5. DISCUSSION ................................................................................ 93
Overview ....................................................................................................... 93
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Research Questions addressed ........................................................... 94 5.1
Perceived Confidence ................................................................................... 95
Developing Confidence ................................................................................. 97
Meaningful employment .............................................................................. 100
Readiness to practice .................................................................................. 102
Summary ..................................................................................................... 104
Chapter 6. CONCLUSION AND RECOMMENDATIONS ............................. 107
Recommendations ............................................................................. 107 6.1
Limitations ......................................................................................... 109 6.2
Further research ................................................................................ 109 6.3
Significance of the research .............................................................. 110 6.4
Summary ........................................................................................... 112 6.5
REFERENCES ............................................................................................... 113
APPENDICES ................................................................................................. 121
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INDEX OF FIGURES
Figure 3.1 Timeline showing data collection methods ....................................... 35
Figure 3.2 Thematic Analysis example using Greene et al suggested process 49
Figure 4.1 Interquartile Range Pre Clinical Care............................................... 61
Figure 4.2 Interquartile Range Post Clinical Care ............................................. 63
Figure 4.3 Interquartile Range Pre Teaching and Collaboration ....................... 65
Figure 4.4 Interquartile Range Post Teaching and Collaboration...................... 67
Figure 4.5 Interquartile Range Pre Planning and Evaluation ............................ 68
Figure 4.6 Interquartile Range Post Planning and Evaluation ........................... 70
Figure 4.7 Interquartile Range Pre Interpersonal Relationships and
Communication ................................................................................ 72
Figure 4.8 Interquartile Range Post Interpersonal Relationships and
Communication ................................................................................ 75
Figure 4.9 Interquartile Range Pre Professional Development ......................... 76
Figure 4.10 Interquartile Range Pre Professional Development ....................... 79
Figure 4.11 Overarching theme and four sub themes as identified in this
research. ...................................................................................... 82
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INDEX OF TABLES
Table 3.1 Purposive sample of students who were invited to participate in the
study ................................................................................................ 34
Table 3.2 Research questions and data collection methods ............................. 40
Table 3.3 Group and data collection methods .................................................. 40
Table 4.1 Chronbach Alpha for the modified Five Dimension scale and the
original results of the Six D nursing performance subscale ............. 54
Table 4.2 Response rate for questionnaires by group ...................................... 54
Table 4.3 Gender by group ............................................................................... 55
Table 4.4 Age distribution by group .................................................................. 57
Table 4.5 Level of education by group .............................................................. 58
Table 4.6 Type of current employment by group .............................................. 59
Table 4.7 Year at university .............................................................................. 60
Table 4.8 Pre Clinical Care ............................................................................... 61
Table 4.9 Post Clinical Care ............................................................................. 62
Table 4.10 Pre Teaching and Collaboration ...................................................... 64
Table 4.11 Post Teaching and Collaboration .................................................... 66
Table 4.12 Pre Planning and Evaluation ........................................................... 68
Table 4.13 Post Planning and Evaluation ......................................................... 69
Table 4.14 Pre Interpersonal Relationships and Communication ..................... 71
Table 4.15 Post Interpersonal Relationships and Communication .................... 73
Table 4.16 Pre Professional Development median results ............................... 76
Table 4.17 Post Professional Development ...................................................... 78
Table 4.18 Response rate to Qualitative questions by group ............................ 80
Table 4.19 Theme and sub themes and categories .......................................... 83
xiv
Chapter 1. INTRODUCTION
The focus of this study is to determine the impact of completing the Enrolled
Nursing Registration Pathway Program (ENRPP) at Edith Cowan University
(ECU), Western Australia (WA) and working part time as an enrolled nurse (EN)
on developing nurses’ readiness to practice. The researcher is the coordinator
of the ENRPP and is a lecturer in nurse education. This research stems from
the author’s experience of the ENRPP, anecdotal feedback about the program
and the self-reported impacts on the nursing students.
The questions it aims to answer are:
1. Does the ENRPP facilitate preparation of nursing students to practice as
RN nurses?
2. Do students that complete the ENRPP and work part time as ENs record
higher grades on a clinical scenario presented in their NNT2206 Principles of an
Individual’s Adaption to Altered Health Status exam?
3. Do the students who are working as ENs apply the theories learned in
the unit NNT2206 Principles of an Individuals Adaption to Altered Health Status
in their clinical practice?
1.1 Background
Over the past twenty years the role of the nurse has greatly expanded and there
have been rapid advances in medicine. The move to university level education
for nursing has led to a corresponding reduction in clinical practice hours and
diminished opportunities to bridge the theory to practice gap. Simultaneously,
workforce issues and a lack of suitably qualified nursing staff mean that today’s
nursing graduates need to ‘hit the ground running’.1 1
Therefore, graduating nursing students need to feel ready for practice and
competent to undertake the requirements of the profession.2-6 These demands
highlight the need for nursing students to maximise every learning opportunity
during their undergraduate studies and through any related part-time
employment.
In an attempt to meet current nursing shortages, student nurse externships are
being revisited in the United States of America (USA) and in the National Health
System (NHS) in the United Kingdom (UK). Nurse externships are programmes
that are developed in consultation with the university and the health
organisation whereby nursing students are linked to health care environments.
This allows students to work and experience the clinical environment whilst
undertaking their university studies.7, 8 Within the Australian health care
system, registered nursing (RN) students are often employed as assistants in
nursing (AIN) which benefits the nursing students by exposing them to the
health care setting. However, the innovation of RN students gaining EN
qualifications during their undergraduate studies and working as an EN has not
been studied in Australia.
1.2 Nursing Titles in Australia
Since July 2010 all nurses and midwives are registered under the Health
Practitioner Regulation National Law Act 2009 (National Law) with the National
Nurses and Midwives Registration Board (NMBA). Previously, each state
jurisdiction was responsible for registration and administration of its respective
nurses and midwives.
2
The strategic objective of the National Law is to protect the public by
guaranteeing that registered health practitioners are appropriately educated and
qualified to undertake practice in a proficient and ethical manner.9 The National
Law has “clear restrictions on the use of protected titles. Only people who have
met the requirements of the National Law can use a protected title” such as a
registered nurse (RN) or an enrolled nurse (EN).9
In Australia there are two divisions of nursing:
Division One – registered nurses (RNs) are self-regulating health care
professionals whom since the late 1980’s have completed university
qualifications in the art and science of nursing.10 Their role is to work in
collaboration with the multidisciplinary health care team to provide nursing care
to those in need of their services. Legislation and regulation direct nursing
practice. Registered nurses, as qualified certified professionals, are answerable
and accountable for their own actions and behaviours.10,11
Division Two – enrolled nurses (EN), work under the direction of a RN to afford
patients with basic nursing care. Enrolled nurses working within their scope of
practice are proficient in the practical skills of nursing.10
The scope of practice for the EN includes the identification of both the normal
and abnormal in health assessment, implementation of appropriate nursing care
under the auspice of the RN, monitoring the impact of this implemented care
and communicating effectively with both the RN and the wider multidisciplinary
health care team. Whilst the EN implements this care and collaborates with the
RN in developing a care plan, the responsibility of care plan development lies
with the RN. The EN is at all times accountable for the delegated care they
3
provide. One of the main differences between the scope of nursing practice for
the EN and the RN is that the RN is the delegator of care requirements and the
EN works under the direction and supervision of the RN.12
The student working as an EN has the opportunity to understand the EN role
within the greater health care team. This should help their appreciation of the
EN role when they are working as an RN.
1.3 Clinical Placement hours
The NMBA has set the minimum clinical requirement for a Bachelor of Nursing
curriculum at 800 hours over the duration of a course.13 At ECU where this
study was conducted, the nursing student spends 20 weeks in total (40hours x
20 weeks = 800hrs) in clinical placements.14
1.4 Enrolled Nursing Registration Pathway Program (ENRPP)
This research explores an initiative aimed at assisting the undergraduate RN to
be ready for practice. An overview of the ENRPP at ECU is provided to set the
scene for this study. This program is offered to nursing students at the mid-
point of their undergraduate nursing degree. To be eligible for the course
students must meet three requirements, which are that at time of
commencement of the ENRPP they:
1. have a weighted average mean of 60% or greater in their studies have
completed the first 12 units of study in the undergraduate nursing degree
at ECU have been;
2. be enrolled full time and have already complete all first and second year
nursing units.
4
The ENRPP includes two self-directed learning modules and an acute hospital
clinical rotation.
1. Module One – an assessable online self-directed learning package
reviewing the EN scope of professional practice and legal issues. This
module was developed by the Health Department of Western Australia
(HDWA) and the Office of the Chief Nurse. 15,16
2. Module Two - an intensive 8 week program bridging the gap between
their current knowledge and the Health Training Enrolled Nursing
Package 07 (HLTEN07) national qualification. The students undertake a
written examination in this module.
3. Upon successful completion of this examination the students complete a
two week acute hospital clinical rotation. This clinical rotation assesses
their ability to work as a novice EN based upon the Australian Nursing
and Midwifery Competency Standards for the Enrolled Nurse on a
pass/fail basis.
Successful completion of the two modules and the clinical placement allows the
students to apply for registration as an EN with the NMBA. Once registration is
granted the student can work as an EN.
This program allows students to experience the clinical work environment, to
gain casual meaningful employment and to obtain a relevant Vocational
Education qualification earlier in their course than students who do not complete
this program. In addition, these qualified students are able to provide a short
term contribution to hospital wards which helps towards alleviating the nursing
5
workforce shortage. Anecdotally, both industry and student feedback about the
program has been overwhelmingly positive.15,16
1.5 Organisation of this thesis.
This chapter, Chapter one, introduces the research questions and the
background to the impact of meaningful employment opportunities on the
undergraduate nursing student. A description of the nursing titles used within
the Australia context is provided. Clinical placement hours for the
undergraduate nursing student at Edith Cowan University are listed and the
ENRPP process is explained.
Chapter two explores the current literature in the areas of Learning Theories, in
particular Pedagogy and Andragogy. Readiness to Practice, Self Confidence,
Critical thinking and Clinical Practicum in relation to the undergraduate RN is
discussed. Meaningful Employment, Employment Choices of the
undergraduate RN and Externships are reviewed. Finally, the significance of
this research to practice is presented.
Chapter Three describes the rationale for the research design. Ethical
considerations are discussed. The instrument chosen for this study is
introduced as are the modifications that were made to the instrument. The
setting for this study and the participants are presented. The study procedure
and data analysis are displayed.
6
Chapter Four provides an overview of the results. The researcher reports on the
demographics of the participants in this study and their perceptions of their
abilities in relation to the 5 Dimensions of Nursing as researched in this study.
Firstly, the demographic results are listed. Secondly the quantitative results to
the 5 Dimension of Nursing Scale are presented and finally the qualitative
results to the two open ended questions are displayed.
Chapter Five addresses the aims of this study. Confidence and confidence
development for the undergraduate RN is presented. Meaningful employment
and Readiness to Practice relating to the undergraduate RN is discusses.
Chapter Six presents the practical recommendations for this research. Limiting
factors are stated and areas for future research are discussed. The significance
of this research is outlined.
7
8
Chapter 2. LITERATURE REVIEW
Introduction 2.1
In this chapter firstly the relevant literature about learning theories, in particular
adult learning and the ways students learn are presented. Secondly, studies
relating to beginning nurses’ readiness to practice and the factors that
contribute readiness including, readiness to practice, clinical practicum and
critical thinking are outlined. The research into the importance of clinical
practicums for undergraduate nursing students and the employment choices of
undergraduate nurses and externships are explained. The chapter concludes
with the identification of gaps in the literature and the significance of the current
research to practice.
Learning Theory 2.2
Learning theories are described extensively in education literature. These can
provide an understanding of how learners learn. There are many different
theories with little agreement on the number of learning theories and how they
should be categorised for discussion.17 (p.18)18
According to Knowles adults learn differently to children.17(p.2) Pedagogy is a
term used to describe the art and science of teaching children whereas,
Andragogy is the art and science of teaching adults.17(p.2) Each of the two
learning theories is described individually and assumptions associated with
each of these are contrasted.
9
2.2.1 Pedagogy
Pedagogy comes from the Greek work ‘paidagogus’ where ‘paid’ means child
and ‘agog’ means to lead.17(p.36) So its meaning is focussed around leading a
child. This learning theory has been traced back to Stone Age times when
parents passed on to their children the ways and means of survival.19 The
education system became more organised in the Greek and Roman periods,
with an organised form of education beginning in the 7th century. It was during
this time that the origins of pedagogy were formed.17(p.36)
The main purpose for the development of schools in the 7th century was for the
education of young men as priests.17(p.36)20 The pedagogical model was founded
on the following assumptions:
1. The learner was dependent upon the teacher, based on the assumption
that the learner did not know what their learning needs were.
2. Learning needed to be subject focussed, thus the curricula was subject
based requiring reading, writing and arithmetic.
3. The motivation for learning was extrinsic and thus rewards were required
for achievement.
4. The prior experience of the learner was irrelevant and not
considered.17(p.62)
The growth of schools in the 18th and 19th century saw the ready adoption of
these principles as it was the only real existing model of teaching at the time.20
Pedagogy is a model that allows teachers to decide the what, where, when and
how of learning.17(p.62)20
10
2.2.2 Andragogy
Andragogy emerged in the 1880’s when Alexander Kapp introduced the term
andragogy. 21 Andragogy lay dormant for the next 50 years till Eduard C.
Lindeman began to write about this learning theory.22 Lindeman described this
learning theory as one where adults learn in order to solve problems, become
aware of situations and review the circumstances that they are experiencing.22
The adult learner identifies a situation which is problematic and applies the
learned material from their lived experiences to aid in the understanding of the
problem being faced. 17(p.40)20 The role of the teacher in this form of learning
therefore, is not as a ‘sage on the stage’ but rather that of a facilitator for
learning in a problem based environment.20 In this environment the teacher
considers both their own and the students real life experiences to facilitate
learning.20
In the 1950’s Malcolm Knowles, amongst others expanded on Lindeman’s
work.20 He popularised the term andragogy. Andragogy is based on six
assumptions of adult learning identified by Knowles.17(p.64).
1. The need to know: The adult learner needs to understand why they are
learning something in before undertaking the task.17(p.64)23(p.55)
2. Self-concept: As individuals develop their self-concept shifts from being
‘a dependent personality’ to that of being ‘self-directed’. These learners
need to understand the importance and relevance of the learning prior to
undertaking it. 17(p.64) 23(p.55) Adult learners have a desire to be, and to
be treated by others as self-directed. They resent situations where they
are told what to learn and how they will learn. 17(p.66) 23(p.56)
11
3. Experience: As individuals mature they build up a wealth of experience
that can be converted into an escalating resource for future learning.23
The teacher in this environment implements strategies that will allow for
experiential learning with 17(p.66)23(p.56) the use of simulation, problem
based learning and group discussion.
4. Readiness to learn. As people develop, their ‘readiness to learn’ orients
towards social role development. .17(p.66)23(p.56)23 The learner needs to
see value in the topic in order to be ready to learn. This value may be
due to the application of the learning to real life situations.20
5. Orientation to learning. As a person matures, their need for applying new
knowledge becomes immediate. This is a shift from delayed application
of knowledge.20,23 The learning is life, problem or task centred in
andragogy versus subject centred in pedagogy. 17(p.66)23(p.56) The
teacher’s role in orienting a learner is to present the required skills and
knowledge in the context of real life situations.20
6. Motivation to learn: As a person matures the motivation to learn is
intrinsically driven versus extrinsic motivation.17(p.68)23(p.56) That does not
mean that the learner is not motivated by extrinsic drivers, rather the
main motivation is internal pressure, and the desire to achieve.20 Tough
in 1979 with the Adult Learner’s Project described the investment an
adult learner has with their learning – the learner will identify the benefits
that the learning will provide versus the consequences of not having that
learning. Thus, Tough argues that the first task of the teacher is to help
the learner identify what it is they want to learn. 24(p.73)
12
Whilst the differences between andragogy and pedagogy have been outlined,
they are not mutually exclusive. The principles of pedagogy are focused on the
dependent learner that learns ‘subject matter’, who is extrinsically motivated
and does not take into account the learners prior experiences. Pedagogy would
continue to treat the person as dependent whereas, in andragogy they will
gradually cut the ties of the learning experience thereby facilitating self-direction
and autonomy.20 However, andragogy does and should contain many aspects
of pedagogy. Andragogy acceptors believe that there is a time and place for
the principles of pedagogy in the learning environment, for example, when a
learner has no prior experience in a situation and is dependent on the teacher
(such as learning cardio pulmonary resuscitation). This theory is of particular
relevance to this ENRPP as students are adult learners.
Zyemov describes the main goal of education in the 1980’s as being more than
the acquisition of knowledge. It includes the skills to adapt to change in both the
natural and social environments as well as instilling in the learning the
importance of lifelong learning.25
For a novice nurse to be ‘ready’ for nursing practice, immense amounts of time
and energy need to be expended to learn the knowledge, skills and attributes
required. The ENRPP is a program that helps develop the skills and attributes
that Zyemov discusses and scaffolds for lifelong learning.25 Additionally, there
are various factors that influence continued learning, most commonly, an
identified gap in the knowledge of the learner, job related motives such as
promotional opportunities, employer demands and personal interest.26
13
In keeping the principles of adult learning theory, students undertaking the
ENRPP have the opportunity to determine their own learning needs, to continue
to build their resource base, and to apply what they have learnt to the clinical
situation to be able to meet their immediate needs. These students have
already exhibited intrinsic drivers by enrolling in a program that requires
additional work to their immediate studies.
Readiness to Practice 2.3
The Australian and Midwifery Council describes the RN on entry to practice as
being competent in the provision of assessing, planning, implementing and
evaluating holistic evidence based nursing care to all demographics in society.
In addition, the RN must learn to lead in the coordination of nursing and health
care in many different clinical environments and continue to learn and develop
throughout the course of his or her career.27
The ability to coordinate nursing and health care is often referred to in the
literature as ‘readiness to practice’. Debates relating to “practice readiness” or
“job readiness” of the novice nurse are referred to in this research as “readiness
to practice” and have been discussed globally since the move to university-
based education in the late 1970’s.4,28-31 Wolff et al attempted to define
‘readiness to practice’ in 2006 after identifying this was ill defined in the
literature. . The research was completed in Canada where nurses were
recruited from the education sector, current clinicians and from the regulating
bodies in British Columbia, Canada. One hundred and fifty nurses participated
in this research. Four main themes emerged from Wolff et al.’s focus group
14
research.32 The focus groups involved novice nurses, educators, regulation
authorities and industry and focussed on the meanings of readiness.
For these stakeholders, readiness is:
1. Having a generalist foundation and some job specific capabilities;
2. Providing safe client care;
3. Keeping up with current realities and future possibilities;
4. Possessing a balance of doing knowing and thinking.32
Limits surrounding this research are that it is from only one province in Canada
and not a global study.
The reality is however, that many graduating RN students doubt their ‘readiness
to practice’. 33,34 A qualitative exploratory study completed in 2005 of 105 newly
qualified and experienced nurses in the United Kingdom identified three main
areas of concern. These were nursing students:
1. do not feel ready to practice at the point of registration,
2. felt that they have knowledge about specific areas of nursing where the
student had completed an assessment on a given topic rather than a
general base of nursing knowledge, and,
3. were concerned that they lack the specialist, technical and management
skills required to start nursing.
A limitation of this study is that focus groups can influence responses made by
the participants due to the interactions that occur between the group and a wide
range of experiences within the groups.34 This study supports the statement
that many graduating RN students do not feel ready to nurse upon graduation.
15
An Australian study also supports the notion that nursing students due to
decreased self-confidence do not feel ready to nurse. Helsop, McIntyre and
Ives in 1997-1998 investigated via a descriptive survey of 105 ‘Undergraduate
student nurses’ expectations and their self-reported preparedness for the
graduate year role.’ The students in this study voiced apprehension about
meeting workplace expectations related to their self-reported lack of clinical
experience.33 Follow up studies to assess how their reported expectations
matched reality would be beneficial for this study.33
Supporting the idea that nursing students need to master many areas of both
skill acquisition and (author’s emphasis) psychological preparedness a
qualitative study by Crookes et al. used focus groups to explore the
components of professional confidence as perceived by diploma-prepared
registered nurses enrolled in a problem-based baccalaureate degree program in
Canada.35 This study found that students need a range of skills to be acquired
in order to feeling ‘ready to practice’ which include ‘becoming informed’, ‘finding
ones voice’, ‘knowing’ and ‘doing’. The descriptive nature of the findings, small
sample size, and uniqueness of the educational program are limitations in terms
of the transferability of this research35
The range of studies show’s that apprehension concerning the new graduates
readiness to practice continues, regardless of noteworthy developments in the
undergraduate nursing curricula.32
16
Self Confidence 2.4
In the literature, two terms, “self-efficacy” and “self-confidence” are used
somewhat interchangeably. In this thesis, the term “self-confidence” will be
adopted.
Crookes et al. found that students’ defined self-confidence as sound
progression through four distinct stages: feeling, knowing, doing and
reflecting.35 The attainment of confidence is a gradual, incremental process that
occurs throughout their studies.34,36 Although achievement of confidence differs
between students, they share many stressors that affect their self confidence in
the clinical setting including lack of experience, poor interpersonal skills with
both the nursing and wider multidisciplinary team and inadequate
communication skills. Whether students' perceptions are shared by others is of
little significance to their feelings of confidence. In addition to the students’
definition of self-confidence, many authors have attempted to define self-
confidence through research and theory development.35
Bandura’s self-efficacy theory describes self-confidence as the belief an
individual has about their ability to perform required activities.37(p.37) A strong
level of self-confidence encourages accomplishment and this impacts directly
on personal wellbeing in a variety of ways, including reduced stress levels and
lowers risk for depressive disorders.37(p.74) Individuals with high self confidence
levels approach tasks believing that they can achieve, they also set high goals
and recover from setbacks more readily.37(p.84) According to Bandura, self-
confidence can be achieved in four main ways - mastery of experiences,
17
vicarious experience through mentors and models, social persuasions and
physiological factors.38(p.2,3)
Mastery experiences results from performing the behaviour to a desired level.
According to Bandura this is the most important factor in increasing self-
confidence.37(p.80)39 The clinical practicum and the simulation ward provide
opportunities for mastering skills. If a nursing student is successful in
completing an action, their belief that they can repeat the action and/or improve
on ir means that their self-efficacy may increase. According to Barta and Stacy,
repetitive unsuccessful attempts at an action or a task may lead to a decrease
in self-confidence.39 However, occasional failure can reorient thinking and
motivate practice to allow a practitioner to identify what is needed to achieve
their goal. 38,39,40
Bandura also says that vicarious experience is fostered by exposing individuals
to others of similar capabilities who have successfully performed the behaviour.
37(p.88)41 The role of mentoring and preceptorship on clinical placements as well
as university based learning is based on vicarious experience.
Social persuasion is a strategy used to persuade people through verbal and
non-verbal communication that they have the skill to adequately perform a
particular behaviour.38 The range of encouragement to the learner can be as
simple as a smile or a nod of the head or more comprehensive, such as a
prepared feedback session following set criteria. 37 (p.101,102)41
Emotional states can influence self-efficacy, for example anxiety, fatigue and
depression can diminish one’s self efficacy.37(p.320) Anxiety may inhibit one’s
18
ability to successfully complete an activity. Individuals rely on physiological
feedback to judge their capabilities.37(p.320) Therefore, according to Bandura a
nursing student needs to be able to identify physiologically if they are ready to
undertake an activity.
Nursing students who experience the clinical environment in their work life will
have additional opportunities to develop their self-confidence. They have more
opportunity to model their behaviours, identify mentors and receive positive
reinforcement from a variety of people, including doctors, nurses, patients and
family members. The increase in their self-confidence via meaningful work
opportunities may allow them to transition into clinical practicum more readily
and focus on achieving the required skill sets.
Critical thinking 2.5
Critical thinking underpins professional practice.42 There is no widely accepted
definition of critical thinking. However a vast array of definitions have been
written and often subsumes other crucial modes of thought, including, but not
limited to, clinical reasoning, creative thinking, reflective processes and
evaluative thinking. 42(p.2) A four year study in 2000 using the Delphi technique
invited 135 nurse experts of which 86 agreed to participate in an attempt to
explore the meaning of critical thinking in nursing. The research group arrived
at the following consensus statement about critical thinking in nursing:
Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. Critical thinkers in
19
nursing practice the cognitive skills of analysing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge.43(p.357)
Arriving at a consensus for critical thinking regarding critical thinking gives
nursing researchers a base for further research and discussion. Whilst the
study was international it did not include nurse experts from all countries
including Australia and had a large proportion of experts from the USA.
Student nursed develop critical thinking abilities as they progress through their
course and experience new and challenging situations.44 Development of these
‘habits of mind’ as identified in the consensus statement outlined above occur in
a variety of formats. A study published in 1997 in Ohio, USA, using a
qualitative case study methodology approach describes seven students’ critical
thinking from their own perspective. Source of information included reflective
journal writing, interviews and laboratory observations by the researcher. This
study identified four major themes from the data including: ‘development of the
profession self-perspective, development of a caring perspective, development
of a perfectionist perspective and development of a caring perspective. In
addition, the importance of meaningful dialogue within a supportive clinical
environment is important in encouraging the growth of the students’ critical
thinking and reflective abilities. Limitations of this study include the small
sample size and the use of only first year nursing students. The inclusion of
second and third year nursing students in this study would have allowed the
identification of how the student perceives their critical thinking abilities to be
reviewed.45
20
To attend to the needs of particular situations, both novice and expert nurses
need to assimilate knowledge from their own practice, theoretical learning and
grounded science.46 With the application of critical thinking to both procedural
and interpersonal characteristics nurses can facilitate appropriate responses to
different situations.46 Graduate nurses need to respond appropriately to
unpredictable situations to resolve potentially life threatening situations in a way
that is focused, organised and where appropriate, innovative.
Fero et al. in 2004–2006 conducted a post hoc retrospective analysis of 2144
newly graduated and newly hired nurses’ Performance Based Development
System Assessment (PBDS) assessment data in a USA university-affiliated
healthcare system. The nurses completed the PBDS assessment which
consists of 10 videotaped vignettes that depict change in patient status. Nurses’
results were recorded as meeting or not meeting expectations as identified in
the PBDS classification system. The study found that 25% of new graduates in
their study were did not meet expectations and were unable to make
appropriate decisions in a critical situation.47
Similarly, a study published in 2007 from Michigan, USA, found that mixed and
multiple clinical experiences, support from teaching staff which includes clinical
preceptors, and debriefing and sharing experiences with peers were essential
for the development of critical thinking in the transition from student nurse to
beginning practitioner. This research was conducted using a descriptive,
longitudinal, phenomenological study approach that used semi-structured
interviews to study the meaning of making clinical nursing judgments. The
21
participants were interviewed three times over a nine month period to ascertain
understanding as to how graduates learned to critically think. The limitations of
this study as suggested by the researcher are ‘situational contaminants such as
the quality of the interviewer’s interaction with the subjects’. The sample size is
not mentioned in this research however the use of comparable questions with a
larger population of new graduate nurses should corroborate the findings of this
research about how new graduate nurses learn to critically think.48
Critical thinking involves a variety of skills and attributes which develop over
time. Both qualitative and quantitative research has found that nursing students
and new graduates lack critical thinking abilities.
Clinical Practicum 2.6
Clinical practicums are defined a professional practice placement undertaken
within a workplace setting by allied health, medical, nursing and midwifery
students.49 Clinical practicums are of paramount importance to successful
healthcare teaching and learning as clinical environments afford students
opportunities to assimilate and apply competencies and behaviours acquired in
the classroom into actual performance.3,50,51 The clinical practicum enables
students to advance their clinical skills, link theory to practice, apply and
develop problem-solving skills and to improve their interpersonal skills.5,52,53
Moreover, the students become familiar with the formal and informal norms,
protocols and expectations of the nursing profession and the health care
system.5,52,53 There is extensive research regarding the importance of clinical
practicums for the nursing student.
22
A study published in 2000 reported the findings of 49 undergraduate nursing
students studying at a university in Sydney Australia. The research design
adopted was a ‘Story telling’ approach about the students experience on clinical
practicum.50 The students identified that clinical practicum was where they
were able to develop clinical skills and apply theory to the practice of nursing.
In addition to these important skills, the clinical practicum experience provides
essential opportunities for socialisation into the discipline.50 Further research
adopting a nationwide perspective would identify similarities between nursing
students across Australia.
In line with the findings above a study published in 2000 reports on practicum
experiences of nursing students and teaching students at a Queensland
university in Australia. A grounded theory approach identified three broad
themes across the disciplines which included three key outcomes of the field
experience common to all students in this study were the opportunity to be
socialised into the role of teacher or nurse, the self-confidence to perform the
role effectively, and the belief of making a difference in the lives of their
students or patients.52 Whilst there were many positive reports in this study the
undergraduate RN students commented that they still feel ‘’ill prepared” for the
real world of nursing.52
The importance of socialisation to the nursing role identified is also identified in
a study by Chang and Hancock. They reported in 2003 on the stressors
confronting the 173 graduate nurses in Australia. The questionnaire used in
this study examined sources of role stress and changes in role stress 2–3
23
months after employment, and 11–12 months later. The authors found that the
initial transition from student nurse to nurse was associated with feelings of both
role ambiguity and overload, and role ambiguity the most important factor at this
time of the developing nurse, and role overload the most important factor 10
months later. 6 Clinical practicums may allow the student to begin to develop
the socialisation skills necessary for the future.
Clinical practicum opportunities may encourage critical thinking and may equip
them with the necessary skills to respond appropriately to the many challenges
that may be encountered as a registered nurse.6
Whilst the importance of clinical placements cannot be underestimated it is
essential that the clinical environment is a quality learning environment. A
commonly cited definition of the clinical learning environment is that is is “an
interactive network of forces influencing student learning outcomes in the
clinical setting”.54 Universities and more often the clinical environments that
are available dictate the amount and range of experience available to the
student.55 The increasing numbers of nursing and allied health students limits
the number and type of clinical placements available.56 Therefore, the skills
acquired by student nurses in the clinical practicum may be limited due to the
location of the placement and the acuity of the patients. 21,33,57,58
Whilst there is mounting evidence that undergraduate nursing programs
achieve their aims, and that graduate registered nurses are adequately
prepared for beginning practice,5,6,52,53 many students remain concerned about
the transition to the clinical environment.6,59 A study by Cope, Cuthbertson and
Stoddart in Scotland in 2000 analysed the experience of 30 final year nursing
24
students in relation to clinical placements and theory –practice gaps. The
research reported the transitioning nurse feels vulnerable when commencing in
a new clinical environment. The small number of participants in this study does
not allow for application to other institutions or clinical practicum
environments.53
Clinical practicums are essential for the developing the skills that nursing
students need to nurse, however in some cases nursing students still feel the
need for more clinical experience.
Meaningful Employment 2.7
In the literature, meaningful employment is often linked to people with
disabilities,60-63 and more recently with the quest that one undergoes to find
meaning in their own life.64 The Merriam-Webster online dictionary defines
meaningful as “full of meaning; significant” 7and employment as “the state of
being employed”.65
For most students, employment is essential whilst undertaking university
studies for financial reasons.66 Finding meaningful employment whilst
completing undergraduate studies can be highly motivating and beneficial to
one’s educational experience; however, opportunities are limited and can be
highly competitive. The majority of nursing students seeking work in health will
work in the aged care environment, which many see, as a means to an end
rather than a career choice.67 Work opportunities in the acute care setting allow
students to experience more variety of work environments. This may help them
25
better prepare for the clinical practicum experience and to identify long term
career choices.
Employment Choices in the undergraduate RN 2.8
The ‘Final report of a national survey of student in public universities in Australia
in 2006’ states that little is known of the employment choices of undergraduate
students in Australia.68 What is known about employment choices is that in
general the work undertaken by the undergraduate students is not structured or
linked to their intended graduate career. 66 Approximately 70% of full-time
students in Australia work on average 14 hours per week during the semester
with one in six reporting they work in excess of 20 hours. 66 Many students are
just attempting to ‘survive’ rather than enhance their learning or career
prospects. 66 The relationship, if any, between employment choices of the
undergraduate nursing students and transition experiences to the RN role
appears to be an area that has not been extensively studied. This deficit in
knowledge is not unique to Australia but is mirrored in countries with similar
nursing education histories, such as, the United Kingdom.69
Worldwide, many nursing students seek employment in health related industries
working as patient care assistants, nursing assistants and the like.65,70,71 It is
important to ascertain if the experience in university study related part time
employment is at all beneficial besides the obvious financial gain. A
prospective, quantitative survey design was used to collect data from a regional
university in Australia over a 2-year period from 2001 to 2002. A total of 267
nursing students were included in the study. Findings from this study showed
working greater than 16 hours per week had a negative effect on the academic
26
performance of nursing students. More importantly, this study shows that
nursing-related employment is not advantageous to students' academic
performance, even for a nursing practice-based subject.62
Another study published in 2013 research the impact of the of student nurses
working part time as a health care assistants in Northern Ireland. Thirty-two
students took part in four focus groups and 13 took part in individual interviews.
Findings revealed that 27 (60%) of students were in paid nursing related
employment. This was reported to be advantageous by most participants with
regards to increasing self-confidence and skills, and exposure to the clinical
setting. However, it was also perceived by a small number of participants as
being detrimental to subsequent learning resulting in role confusion, influencing
placement behaviour, and preferences for future nursing practice. Students who
did not work in any employment believed this placed them at a disadvantage in
relation to their learning and the socialisation with clinical placement.72
Whilst there is some discussion within the literature of the relationship between
skill acquisition during nursing studies and transition into the work place, there
is no solid research on this subject.71,73 This link between employment choice
and outcomes in early career choices with a focus on the ‘work ready’ graduate
warrants investigation.
Externships 2.9
Externships are popular amongst universities and collaborating hospitals in the
United States of America (USA). These hospitals have developed programmes
27
that allow the students to experience the clinical environment as paid
employees which supplements the clinical exposure of undergraduate nurses.
According to Mang, Nursing externships help the students to transition to the
clinical environment more readily upon graduation.74,7 It has been argued that
externships better prepare nursing students for the transition to the workplace,
in that the student are more work ready and are able to ‘hit the ground running’,
due to the increased clinical experience and associated socialisation in to the
work place.75,76 As well as being a means of gaining valuable clinical experience
externship programs are designed to assist the student nurses to develop more
self confidence in the clinical setting. The benefits of externship programs
include developing the students’ ability in leadership, team work and
communication with the wider health care team.77
A study undertaken in the USA and published in 1997 investigated the effect of
internships on undergraduate nursing students. This study surveyed 33
students in a pre test–post test design. Analysis of data showed greater
autonomy especially in older students and participants reported increased self
confidence.78 Externships do not currently exist widely within the Australian
context. Instead, Australian nursing students either work in unrelated
employment or as Assistants in Nursing (AIN).69 Formal programs such as
nursing externships are lacking in Australia, with only a few hospitals
developing meaningful employment opportunities such as AIN programs.69,79
Research as to the value of nursing externships is limited to qualitative studies
or to journal entries or descriptions of experiences by students and program
evaluations.78 In-depth studies of students’ experiences of externship programs
28
in Australia or their experiences of transitioning to the clinical practicum in their
subsequent programs of study are missing.
Significance of the Study to Practice 2.10
Across Australia there are approximately 30 schools of nursing offering
undergraduate nursing degrees that utilise various approaches to the training
and development of registered nurses.80 Although the effectiveness of
university programs has been demonstrated,5,6,52,53 debate continues as to
whether recently graduated nurses enter the profession with the essential skills
and attributes that are necessary to practice proficiently as registered nurses36
including employing appropriate clinical decision making.33,34
A well-documented stressor for student and novice nurses is the ‘theory to
practice’ gap. It relates to challenges in applying theoretical understandings
achieved at university to clinical practice in the ‘real world’, that is, at the
bedside.81 The National Nursing and Nursing Education Taskforce Scopes of
Practice identified in 2005 that the “prevailing culture of nursing is evident in the
disillusionment of new graduate nurses who having been prepared to practice in
one way are then acculturated into a more restrictive way of practicing when
they enter the workforce”. 82(p.35)
The researcher who has worked as a lecturer in nursing for eight years
repeatedly hears from nursing students their concerns about their ability to
succeed in the clinical practicum. They comment that they feel underprepared
29
for the experience ahead. They are concerned that they will not be accepted or
valued as a team member and that they feel ‘unwanted’ on clinical placement.
There is a large body of research on the preparation of the undergraduate
nursing student and readiness for practice in the clinical environment.4,6,21,33,57,58
Several issues facing students when undertaking the clinical practicum have
been identified and outlined in section 2.6 of this thesis. These include an
increased number of nursing students and a steady reduction in clinical
placements, as well as limited exposure to a variety of clinical environments. A
gap exists within the current literature relating to research that investigates the
impact of working within the clinical environment in a part-time capacity on
students’ preparedness for the clinical placement and the application of
theoretical knowledge.
This study will explore ‘readiness to practice’ in the clinical environment for
undergraduate students and the effect that meaningful employment
opportunities have on readiness.
In this Chapter the literature on learning theories, pedagogy and andragogy
were presented. The literature relating to student nurses perception of their
readiness to practice as well as self-confidence, critical thinking and clinical
practicums were discussed. Current understanding of nursing externships,
employment options of the undergraduate nursing student and meaningful
employment were also presented.
30
Chapter 3. METHODOLOGY
Introduction 3.1
This chapter is divided into various sections. Firstly, the research questions are
presented. Next, the research design, research instrument, setting and
demographics of the participants are outlined. The research methods used to
collect data for the pilot test and the main study are provided. The procedures
used to administer the questionnaire and to review the exam question are
outlined. The methods used for data analysis are described and are followed
by sections in trustworthiness and ethics.
Research Questions 3.2
The following research questions guided data collection of the impact of the
ENRPP on the nursing students’ readiness to practice.
1. Does the ENRPP facilitate preparation of nursing students to practice as
RN nurses?
2. Do students that complete the ENRPP and work part time as ENs record
higher grades on a clinical scenario presented in their NNT2206
Principles of an Individual’s Adaption to Altered Health Status exam?
3. Do the students who are working as ENs apply the theories learned in
NNT2206 Principles of an Individuals Adaption to Altered Health Status
at university to their clinical environments?
31
Research Design 3.3
The research design used in this study was a Quasi experimental, prospective
observational cohort study as suggested by Elliott and Thompson.83 It was not
possible to randomly assign nursing students to the study groups as entry into
the ENRPP was voluntary in nature.84 The Nurses and Midwives Board of
Western Australia (now NMBA) specified the criteria for entry into the ENRPP
course. Edith Cowan University develop their ENRPP following these criteria.
This allowed the researcher to identify an existing group that could be
compared with students who had not participated in the ENRPP.
Data was collected through a questionnaire that was administered twice, once
at the beginning of the ENRPP and also at the end of the ENRPP. In addition to
this, a section of an second year nursing unit of study exam paper which
contained critical thinking short answer questions were reviewed.
Ethics 3.4
A proposal was approved by The UWA Human Research Ethics Committee and
to ECU’s, Human Research Ethics Committee (HREC RA/4/1/4901). Formal
approval was obtained from the Head of School of Nursing and Midwifery at
ECU prior to data collection. In accordance with the National Statement on
Ethical Conduct in Human Research participants were informed that their
participation was voluntary and that they could withdraw from the study at any
time without penalty.
In recognition of the NHMRC (2007) (National Health and Medical Research
Council) guidelines, the researcher acknowledged that the research participants 32
represented a vulnerable group, as the researcher also taught students within
the school of nursing at ECU.
To help address any potential concerns the participants may have had the
researcher advised them in writing that any refusal to participate in the study
would bear no impact upon their learning environment or assessment activities.
Also, all data collected would be de-identified and allocated a unique code.
Student numbers would initially be used for matching purposes only. Each
individual participant would be provided with a unique numeric code. This list
would be compiled and kept by a third party lecturer in the event a student
misplaced their allocated code. All data was de-identified by this third party.
These actions were taken to ensure the confidentiality and anonymity of the
participants in the study.
During the course of the study, transcripts and digital data were stored securely
in a locked filing cabinet at the researcher’s office. At the conclusion of the
study, in accordance with NHMRC regulatory guidelines, the researcher will
permanently delete all materials from the hard drive of the computer used to
store and analyse the data. Electronic materials will be stored on a compact
disc and securely stored with hard copies of the research materials for the five-
year period as prescribed by the NHMRC. At the conclusion of the mandatory
storage period, the materials will be destroyed.
33
Participants 3.5
A purposive convenience sample of 147 second and third year enrolled nursing
students were invited to participate in the study. Purposeful sampling is when
the researcher selects the most appropriate sample in order to answer the
research question.85 Students comprised of three groups, 57 second year
nursing students who were not enrolled in the ENRPP in 2011 (Group 1), 50
second year nursing students enrolled in the ENRPP in 2011 (Group 2), as well
as 40, third year nursing students previously enrolled in the ENRPP course in
2010 (Group 3) and who were now working as an EN’s.
Table 3.1 Purposive sample of students who were invited to participate in the study
Group Description N=147
1 Year 2 Semester 2 NO ENRPP 57
2
Year 2 Semester 2 undertaking ENRPP in
2011 50
3
Year 3 Stage 2, completed ENRPP in
October 2010 and working as EN currently 40
Students who had either completed the ENRPP and were not working as an EN
in 2011 on a part time basis or worked as an EN and had completed their EN
qualification either as a hospital based graduate or at a Vocational Education
and Training facility were excluded from the study.
34
The study was conducted in 2011 between August and December. This is
displayed in Figure 3.1.
Figure 3.1 Timeline showing data collection methods
Cormack acknowledges that the research approach adopted by a researcher
will depend on several factors, including the variables to be investigated, the
aim of the research and the state of existing knowledge in an area.86 Given that
the researcher wished to evaluate the impact of the ENRPP on nursing students
in a variety of ways including the student experience, questionnaire scores and
specific exam question scores, mixed methods of data collection were chosen.
Instrument 3.6
The research instrument identified as being most relevant to the current study
was the Six Dimension Scale of Nursing Performance, a 52 item questionnaire
with 5 point Likert scale answers, one being strongly disagree and 5 being
strongly agree that was developed in 1977 by Schwirian et al.87
35
According to Schwirian, this nursing performance measurement scale was
developed to be:
• applicable to both acute and sub-acute settings and also to be;
• consistent with best current practice;
• applied to nurses and completing or having completed their studies in the
past one to two years;
• usable by nurses to self-appraise and also by supervisors to assess
performance;
• comprised of behaviours that are observable by the nurse and
supervisor;
• comprised of items that can be interpreted consistently without further
discussion with the participant.87
The tool was initially developed by Schwirian through the identification of 52
nurse behaviours. Whilst the original tool has six dimensions to it, the items in
the sixth dimension focus around delegation is not in the scope of novice ENs
working in the Western Australian Health Service. Contact was made with
Schwirian who gave permission for the tool to be adapted and used in the
current study. (Pat Schwirian, e-mail communication, 5th June 2011)
Modification of the instrument occurred by the researcher to include only 5
dimensions incorporating 47 behaviours. Another modification was made to
introduce more contemporary wording for several items (Section 3.8 Pilot Test)
For example
Original wording -
‘Use mechanical devices: eg., oral suctioning, tracheostomy care, intravenous
therapy, catheter care, dressing changes’
36
was adapted to
‘Use mechanical devices: e.g., suction machine, cardiac monitor, Dynamap,
ECG.’
Besides the identified Professional Development Behaviours, the behaviours
were placed in the identical order as the original Six Dimensions of Nursing
scale for use in a pilot nursing questionnaire.87
The Modified Questionnaire. 3.7
The modified questionnaire consists of three separate parts.
The first, Part A (Appendix A, Section A) collects demographic information
including participants’ age, gender, stage of education in the undergraduate RN
Bachelor degree, completion of ENRPP, employment status as an EN,
employment other than working as an EN.
The second, Part B (Appendix A, Section B) has a quantitative rating scale to
determine student nurses’ confidence to perform various aspects of nursing
care and to interact with the wider health care team. These are grouped under
five domains of practice.
1. Clinical Care (7 items)
2. Teaching and Collaboration (11 items)
3. Planning and Evaluation (7 items)
4. Interpersonal Relationships/Communication (12 items)
5. Professional Development (10 items)
37
The third section is Part C, which is comprised of two open-ended questions to
elicit more detailed information about student nurses’ experiences upon
entering the clinical practicum setting and their perceived readiness for the
practicum. These questions ensured that students’ experiences were captured
(Appendix A, Section C). The questions are:
1. What can we do better to improve the undergraduate nursing course to
‘ready you for practice?’
2. If you have completed the ENRPP, has this program ‘readied you for
practice’? If so please explain.
Although the participants were asked the two open ended questions the
students who had not completed the ENRPP (Group 1) were advised not to
answer the second question as it was not relevant to them having not
completed the ENRPP.
Pilot Test 3.8
Pilot tests are completed to highlight any uncertainties or misinterpretations that
the participants may have about the instrument or methods used.88(p.324) In July
2011, the modified Five Dimension of Nursing Scale was pilot tested along with
questions about its validity and clarity (Appendix B). In order to ensure the
confidentiality of the participants the pilot was conducted by a colleague of the
researcher.
Five third year nursing students were randomly selected from a third year
nursing class and asked to participate in the pilot study. After a verbal
explanation and the provision of a written information sheet detailing the
research project were given to the students, written consent was obtained from
38
the students to take part in the study. The students were then invited to
complete the pilot questionnaire. Students were advised that the purpose of
completing the pilot questionnaire and the validity questionnaire was to discover
whether there were any problems with the instrument itself. Students were
made aware that their responses would not be included in the results of the
main study. They were also informed that by participating in the pilot test they
would be precluded from participating in the main study in order to avoid and
potential bias that could be caused by respondents completing a questionnaire
that they had previously seen. Students were asked to complete the
questionnaires and to place them in a box at the front of the room.
All of the five students who were approached to take part in the pilot of the
questionnaire agreed to participate. By conducting the pilot the researcher
established that the items within the modified Five Dimension of Nursing Scale
were comprehensible, non-ambiguous and pertinent. A 100% agreement rate
was obtained from the pilot and therefore no changes were made. The data
from the pilot questionnaires were not interpreted. Content validity was checked
by three experts in the field, two nursing academics and one clinical supervisor
of the nursing group under investigation. No changes were made to the
questionnaire.
Following the piloting of the modified 5 Dimension of Nursing Scale, students
undertaking the ENRPP course were invited to complete their perceived level of
readiness to practice prior to, and, at the end of their course. The data
collection and its relevance to each research question are shown in Table 3.2.
39
Table 3.3 shows the various study groups and various data collected from them.
Table 3.2 Research questions and data collection methods
Question 1 Pre and post questionnaire
Question 2
Review of examination papers and
critical thinking questions
Question 3 Pre and post questionnaires
Table 3.3 Group and data collection methods
Group
Pre
test
Post
test
ENRPP
Working
as EN
Examination
Results
No ENRPP
(Group 1)
X X X 0 0
ENRPP 2011
(Group 2)
X X X X 0
ENRPP 2010
(Group 3)
0 X X X X
Setting 3.9
The study was carried out at ECU where approximately 1500 undergraduate
nursing students were enrolled across six semesters in the three-year pre-
registration program. The undergraduate group was selected as it was one the
universities that introduced the ENRPP in 2006. Of the three universities
participating in the program it had the largest number of students enrolled into
40
the ENRPP. The students from the other two universities were not included in
the study.
Data Collection 3.10
A suitable approach to investigate the impact of the ENRPP on undergraduate
nursing students is by questionnaire. Questionnaire are commonly used to
assess research variables.89(p.196) According to Elliott and Schneider,
questionnaires should be written in a clear concise manner; addressing one
variable at a time; in grammatically correct and appropriate language for the
intended audience and is a useful format for obtaining information about a
subject’s awareness of an experience.89(p.196) Furthermore, they suggest that
data obtained by this method can be compared to that obtained through
interview; however, the responses tend to have less depth.90 89(p.196)
Conversely, as questions are consistent, there is a greater chance of gathering
more reliable data and that the findings can be generalised to a larger
population. Questionnaires can ascertain specifics in relation to the participants
understanding of actions and events, and their beliefs, attitudes and
opinions.89(p.196) Questionnaires also allow the efficient collection of a large
volume of data in a timely manner.89(p.197)
Questionnaires, like interviews can be both quantitative and qualitative in
nature. Whitehead,89(p.196) explains that open-ended questions can be used to
elicit rich personal data which then can be analysed through content analysis.
Quantitative questions, on the other hand, are designed with a fixed format that
do not allow respondents to describe personal experiences or understanding,
however the results can be analysed using statistical methods.89(p.196-198) With
41
these two facts in mind both open and closed questions that can be described
both qualitatively and quantitatively were chosen to be included in this
questionnaire.
Study Procedure 3.11
Figure 3.1 shows a timeline of sequence of the data collection, including the
questionnaire distribution to each of the three groups and the review of the
exam questions. The questionnaires were distributed to students as follows:
1. No ENRPP (Group 1) - at the beginning of the NMS 3201;
Pathophysiology and Pharmacology tutorial week 2 Semester 2, 2011.
2. For students in the ENRPP 2011 (Group 2) group at the commencement
of the second ENRPP tutorial, week 2 Semester 2, 2011;
3. Mailed to the students who had completed the ENRPP in 2010 (Group
3) at the commencement of week 2 Semester 2, 2011.
The following six items were outlined to the students in groups one and two:
1. The aims and purpose of the study;
2. Written documentation surrounding data collection and analysis.
(Appendix C - Information for Participants);
3. The independent nature of this study, in that participation was voluntary
and that students had the opportunity to withdraw from the study at any
time without penalty;
4. All data collected would to be given a numeric code to protect individuals’
identities and to maintain their anonymity;
5. Choosing to participate or not would not impact on their results or their
study options at the university;
42
6. The research documents in hard copy or electronic format would be kept
securely in a locked filing cabinet at the researchers’ office. At the
conclusion of the study in accordance with the NHMRC regulatory
guidelines, the researcher will permanently delete all materials from the
hard drive of the computer used to store and analyse the data. Following
the mandatory five year storage period the materials will be destroyed;
7. The written Consent form (Appendix D).
Exam Review 3.12
The nursing students’ application of theory to a clinical scenario was
investigated by reviewing their results of a clinical scenario from the exam paper
for a second semester, 2nd year nursing unit.
The clinical scenario and the expected responses are described individually and
are presented below.
The Scenario
Vincent Diesel, a 22 year old male sustained a stable fracture of C6 after falling
four metres from a roof while he was working as a roof tiler.
a) - Describe the immediate nursing and medical management he needs.
(10 marks)
Expected Response – (1 mark per item)
(DR) ABC, immobilise, Log roll,
Hard collar / sand bags,
Spinal board. TPR, BP SpO2 - ? cardiac monitor
43
NGT due to ileus
IDC due to loss of bladder tone
Methylprednisolone
IV fluids and O2 therapy due to spinal shock
Temp control
?? adrenaline and atropine
Explain reassure
b) - It is now 12 weeks since Vincent sustained his accident. He has been at
the rehabilitation hospital for eight weeks and during the daytime he is ventilator
independent. You have been assigned to care for him on the morning shift. He
complains to you of a severe headache and you noticed he has facial flushing.
You suspect Autonomic Dysreflexia.
Describe the nursing and medical interventions he needs. (10 marks)
Expected Response (marks as stated in () )
If supine, sit up, loosen constrictive clothing / devices, (1 mark)
Check bladder, if not catheterised, do so – if already has one, check for free
flow or irrigate. (2 marks)
Check for faecal impaction – if present, may need gentle manual (2 marks)
If BP above 150ish, give antihypertensive eg. nifipidine, nitroglycerin,
hydalazine or GTN (2 marks)
Check BP and pulse – after interventions recheck BP etc...(1 mark)
Analgesia for headache (1 mark)
Reassure (1 mark)
44
Data Analysis 3.13
Various types of data analysis were applied. IBMs SPSS is a comprehensive
statistical package that is able to undertake complex data manipulation and
analysis with simple instruction.91 The IBM Statistical Package for the Social
Sciences (SPSS) was utilised to compute all statistical tests in this research.
Descriptive statistics were performed to describe the demographic
characteristics of the students. Chronbach’s Alpha was computed to analyse
the internal consistency of scale items in the questionnaire. Chronbach’s alpha
tests the internal consistency of Likert-scale questionnaires. 92(p.219) In Likert-
scale questionnaires each item is compared simultaneously with all other
items.92(p.219) The results of the Chronbach’s alpha are presented in Section 4.2
In order to ascertain the effect size of any statistical difference between the
results Cohen’s criteria was implemented.93
Quantitative data 3.14
Quantitative research has its roots in 19th Century when philosopher Auguste
Comte developed the concept and saw the scientific method as replacing
metaphysics.94,95 According to van Inwagen Metaphysics is difficult to define96
however, he defined it as being a branch of philosophy that tries to explain the
basic workings of the world by finding answers to the following questions ‘what
is there?’ and ’what is it like?’.96
According to Smith people who believe in the scientific approach believe that
‘reality and truth’ are independent to people and the context of the situation.94
Quantitative research is based on measurement and statistics in tightly
controlled environments.97(p.107) Quantitative research allows for connections to
45
be made between observation, experiment and quantifiable concepts. 97(p.107)
Quantifiable concepts are those concepts that can be measured and converted
into a number which tends to add a higher degree of reliability to the research.
97(p.107) The scientific or empirical design of a study is objective and when
performed correctly can be highly replicable when undertaken by second
parties. 97(p.107) In order to gain descriptive data associated with students’
perceptions of their readiness to practice for statistical comparison of the groups
quantitative data collection was chosen as an appropriate method.98
The data was treated as nonparametric as the participants were not randomly
drawn from a normally distributed population, rather they are a convenience
sample of nursing students in one university.99
Mann Whitney – U tests were performed on the pre questionnaire modified Five
Dimension of nursing scale responses for the No ENRPP group (Group 1) and
the ENRPP 2011 group (Group 2) to compare the mean rankings of the two
samples. Kruskall-Wallis tests were performed on the post questionnaire
responses for all groups to determine differences between groups.
Qualitative data 3.15
Qualitative research allows researchers to explore ‘personal experiences,
interpretations and constructs from the perspective of the research
participant’.100(p.106) Whitehead suggests that the understanding of situations
and events can be explored through the participants ‘beliefs, meanings, values
and experiences.92(p.107)
46
To gather students’ perceptions about their readiness to practice as a RN two
open ended questions were incorporated to part C of the questionnaire in order
to provide the researcher with a more in-depth understanding of the
participant’s beliefs surrounding their readiness for the clinical practicum
experience and the preparation for particular clinical tasks whilst completing
their university study. The inclusion of these questions helped the researcher to
understand the meanings and processes associated with this phenomenon that
could not be reduced to a numerical result.101
Thematic analysis has been described by Stemler as a ‘systematic, replicable
technique for compressing many words of text into fewer content categories
based on explicit rules of coding’.102 It is a method that is often favoured by
researchers to analyse qualitative questions.103 In the current study, thematic
analysis was applied to the responses from section C of the questionnaire. This
allowed for the synthesis of meaning to occur. Coding of the data follows a
number of steps. All participants’ comments were entered into a spread sheet.
Level I analysis involved the identification of key words and phrases to be
identified from the answers to the questions which were then entered into a
second column on the spread sheet.
Level II analysis of data involved the expansion of the key words and phrases
identified in level I into categories. Leinenger,103 describes the period of
thematic analysis as the bringing together of meaningless fragments to create
meaning.
47
Level III analysis involved the reduction of the categories in some cases into a
broader category.
Level IV analysis involves the categories being expanded into major themes.
Combining and categorisation of data facilitates the materialisation of connected
patterns, commonly referred to as themes.103 The themes identified at this point
in the current study are reported later in the results chapter.
An example of this is analysis is reflected in Figure 3.2.
To ensure that the qualitative data has been coded correctly a second coder,
coded all qualitative responses for the ENRPP 2010 group (Group 3). Cho
explains that there in excess of 30 different statistical measures of inter-rater
reliability.104 There are only a few measures that are widely used, with little
consensus in the literature of the single best measure.104 The ‘percent method’
is a widely used index.104 It is calculated by the number of coding decisions that
are in agreement out of all coding decisions made by a pair of coders.104 The
percent method is used in this research to review inter-rater reliability.
48
Figure 3.2 Thematic A
nalysis example using G
reene et al suggested process
49
In the current study, the use of mixed methods of data collection and analysis
allowed the researcher to gather, examine, assimilate and link the
commonalities between the results. Students’ perceived levels of readiness to
practice, prior to, and post completion of the ENRPP course were collected.
One academic examination question in a chosen nursing unit of study was
reviewed in an effort to ascertain the impact of the program on students’
understanding of theoretical concepts within a unit of study.
Trustworthiness 3.16
According to Graneheim and Lundman the trustworthiness of the research is
impacted by the activity of the researcher.105 To guarantee accurateness and
trustworthiness of the modified instrument and the data collected the
questionnaire was pilot tested. During the post-data collection period, the
accuracy of the quantitative data was promoted through the inspection and
cleaning of data sets. The trustworthiness of qualitative data was preserved by
the researcher undertaking self-reflection, the creation of audit trails (Appendix
E) and confirmation of data interpretation with a third party. According to
Graneheim and Lundman, these activities contribute towards the overall
trustworthiness of the study.105 In addition to these items peer debriefing was
undertaken to enhance trustworthiness.
Reflective practices were undertaken by the researcher throughout the data
analysis. According to Moon this process encourages safeguarding of the truth
in the research process.106 For example, during this research no interviews
were conducted therefore, the qualitative data collected was only in the words
the participants chose to write in response to the questions. The researcher did
50
not have an opportunity to clarify meaning with the participants, nor did she
have any non-verbal cues to help in understanding their meaning. The use of a
journal through the data analysis phase of research allowed the researcher to
write thoughts and feelings associated with the struggle of not being able to ask
further questions. Below is a quote from the researcher’s reflective journal
highlighting how at times it was difficult to remain objective in the analysis
process.
‘I wanted to ask for clarification to some of the written responses. I wanted to ask why and how their confidence had developed. When they don’t explain what has actually improved relating to their confidence I find it frustrating as I want to link their ‘improvement’ to findings of others.’(Researcher)
This journaling allowed an outlet for the researcher to focus on just what was
written rather than on reading anything more into the data. Reflective practices
as outlined by Moon encouraged the researcher to be aware of her own impact,
biases and beliefs on the research process and how this could impact the
outcomes of the research.106
A critical analysis of interpretations occurred as a result of peer debriefing
throughout the analysis of the open ended questions, as categories and themes
were developed. 107(p.150)
As suggested by Annells an audit trail was maintained by following the stages of
qualitative data analysis from initial coding, interpretation and thematic
development and interpretation.107(p.149) An example of which can be seen in
Appendix E.
51
In this chapter the research questions and research design were discussed.
The rationale for the use of the research instrument and mixed method data
collection were presented. Ethical considerations were stated. The use of
SPSS analysis of the quantitative data, and, Mann Whitney-U and Kruskall
Wallis tests to the qualitative data was described. Reflective processes
undertaken by the research to ensure trustworthiness were stated
52
Chapter 4. RESULTS
Introduction 4.1
In this chapter the results of the data analysis are presented. In the first section,
the response rate of the questionnaire is provided followed by the demographic
information from Part A of the modified Five Dimension of Nursing Scale. Next,
the results of Part B of the questionnaire which relate to the participants’
confidence are presented. In the final section, the findings relating to the two
qualitative questions in the questionnaire about the participants experiences in
the undergraduate nursing degree and suggested improvements are presented.
Reliability of the Instrument 4.2
Chronbach’s Alpha as mentioned in Section 3.13 was measured to determine
the reliability of the instrument. The Chronbach’s Alpha results for the modified
Five Dimension scale are shown in Table 4.1 as well as the original results of
the Chronbach’s alpha from Schwirians original 1978 study. All sections of the
Modified 5 D Scale had a Chronbach’s Alpha of greater than >.80. Pallant
suggests internal consistency is achieved with a Chronbach’s Alpha of >.70.108
(p.97)
Response Rate 4.3
One hundred and forty-seven questionnaires were distributed to students. A
total of 112 completed questionnaires were returned. This represents a
response rate of 76%. The breakdown of responses by group is also provided
in Table 4.2
53
Table 4.1 Chronbach’s Alpha for the modified Five Dimension scale and the original results of the Six D nursing performance subscale
Subscale
Six D
self-appraisal
(1978)
Modified 5 D
self-appraisal
(pre-questionnaire)
Modified 5 D self-
appraisal (post-
questionnaire)
Leadership .901 N/A
N/A
Clinical Care .919 .814 .804
Teaching/collaboration .926 .935 .920
Planning/evaluation .936 .934 .928
Inter-professional
communication .959 .884 .919
Professional
Development .978 .856 .883
Table 4.2 Response rate for questionnaires by group
Group
Number of
questionnaires
distributed
Number of
questionnaires
returned
Response
rate
%
NO ENRPP (Group 1) 50 39 78%
ENRPP 2011 (Group 2) 57 45 78%
ENRPP 2010 (Group 3) 40 28 70%
Total 147 112
54
Demographics 4.4
The demographic data includes the gender, age, education level, current
employment and current year of study at ECU by group.
4.4.1 Gender
Of the participants in this study 90% were female and 10% were male.
Australian census data from 2006 shows that 91% of the nursing workforce are
women.109 In 2006, the demographic data for nursing students at ECU where
this study took place was similar (89% female and 11% male) to the Australian
Bureau of Statistics (ABS) results. The 2007 Australian Health Workforce data
for registered nursing students shows 87% (21534) are female and 13% (3137)
are male.110 Therefore, the sample used in this study was similar to the wider
nursing profession as represented in Table 4.3. The groups were
representative of the gender distribution in nursing.
Table 4.3 Gender by group
Group Male Female n=112 (%)
No ENRPP (Group 1) 3(6%) 36(92%) 39(100%)
ENRPP 2011 (Group 2) 4(9%) 41(91%) 45(100%)
ENRPP 2010 (Group 3) 4(14%) 24(86%) 28(100%)
TOTAL 11(10%) 100(90%)
4.4.2 Age
While the average age of the participants in the current study was consistent
across the three groups there was a difference in the age group distribution 55
between groups. In all groups the age grouping 18-22 had the greatest percent
of students. In both the ENRPP 2011 & 2010 (Groups 2 & 3), 4 percent of
participants were aged 33-37 is, whereas in the No ENRPP (Group 1) group
only 1% of participants were in this age range. The ENRPP 2010 (Group 3)
group had 2% of participants aged in the 43-47 age group compared with no
participants in this age group in the other groups. Comparing the three groups,
those who had undertaken the ENRPP in 2010 (Group 3) and 2011 (Group 2)
were more similar in age ranges than the group who had not undertaken the
ENRPP (Group 3). The average age of all participants was 20.5 years of age
(Table 4.4)
4.4.3 Level of Education
Students come to their university studies with a variety of educational
backgrounds. Table 4.5 shows the different levels of education across the three
groups. More than 50% of students in each group had achieved a year 12 level
of education. The main difference between the three groups was in attainment
of undergraduate degree qualifications. The ENRPP 2010 group (Group 3) had
5% of participants with a degree whereas only 1% of the ENRPP 2011 (Group
2) held degrees. Three percent of participants in the No ENRPP group (Group
1) held a degree.
56
Table 4.4 Age distribution by group
Group Age Grouping n=112 %
No ENRPP
(Group 1)
18-22 21 19
23-27 4 4
28-32 7 6
33-37 1 1
38-42 1 1
Total 34 30
Missing 5 4
ENRPP 2011
(Group 2)
18-22 21 19
23-27 5 4
28-32 3 3
33-37 4 4
38-42 5 4
Total 38 34
Missing 6 2
ENRPP 2010
(Group 3)
18-22 12 11
23-27 4 4
28-32 1 1
33-37 4 4
38-42 1 1
43-47 2 2
Total 24 22
Missing 4 4
57
Table 4.5 Level of education by group
Group Level of Education n=112 %
No ENRPP
(Group 1)
Year 10
Year 12
TAFE Certificate
TAFE Diploma
Undergraduate Degree
Total 39 35
4
23
1
7
4
39
4
21
1
6
3
35
ENRPP 2011
(Group 2)
Year 10
Year 12
7
29
6
26
TAFE Certificate 8 7
Undergraduate Degree 1 1
Total 45 40
ENRPP 2010
(Group 3)
Year 10
Year 12
1
15
1
13
TAFE Certificate 6 5
TAFE Diploma 1 1
Undergraduate Degree 5 5
Total 28 25
4.4.4 Employment History
Many students work in a variety of roles to support their university studies.
Both groups No ENRPP (Group 1) and ENRPP 2011 (Group 2) had a higher
level of participants – 55% and 62% respectively - working in unrelated
employment as compared to the 2010 ENRPP (Group 3) where 15% were
working in unrelated employment. Eighty-two percent of the ENRPP 2010
(Group 3) were working as enrolled nurses. The spread of types of employment
58
between the other two groups, No ENRPP (Group 1) and ENRPP 2011 (Group
2), was consistent. Table 4.6 shows the variety of employment held by
participants in this study.
Table 4.6 Type of current employment by group
Group Employment type n=112 %
No ENRPP (Group 1)
Working in Unrelated Employment 21 55 Working as a Patient Care Assistant 4 10 Working as an Assistant in Nursing 3 7 Working as a Carer 11 28 Total 39 100
ENRPP 2011 (Group 2)
Working in Unrelated Employment 28 62 Working as a Patient Care Assistant 4 9 Working as an Assistant in Nursing 4 9 Working as a Carer 9 20 Total 45 100
ENRPP 2010 (Group 3)
Working in Unrelated Employment 4 15 Working as an EN 23 82 Working as an Assistant in Nursing 1 3 Total 28 100
4.4.5 Year at University
The undergraduate Nursing degree at ECU takes students 3 years full time to
complete. The ENRPP is offered to nursing students in the second year of their
university studies.
Table 4.7 depicts the students’ current level of university study by groups. Both
groups NO ENRPP (Group 1) and ENRPP 2011 (Group 2) were second year
nursing students. 59
Table 4.7 Year at university
Group Year of Study n=112
No ENRPP (Group 1) Undergraduate RN student 2nd year 39
ENRPP 2011 (Group 2) Undergraduate RN student 2nd year 45
ENRPP 2010 (Group 3) Undergraduate RN student 3rd year 28
Quantitative Data 4.5
The following five sections present the results of the questionnaire for each
dimension of nursing.
4.5.1 Clinical Care
Pre Questionnaire
A Mann-Whitney U test was completed to review the impact of the ENRPP on
participant’s perceived pre intervention ‘Clinical Care’ abilities. The results
revealed statistically significant differences in the perceived Clinical Care
abilities of the No ENRPP (Group 1), (Md = 15, n = 39) and the ENRPP 2011
(Group 2), (Md = 9, n = 45) U =.581, z = -2.662, p <.001 and r=0.42. The effect
size was r = 0.42 which according to Cohen’s criteria is a medium effect.93
These results are shown in Table 4.8.
The IQR for the No ENRPP (Group 1) and the ENRPP 2011 (Group 2) groups
are 7, this is shown in shown in Figure 4.1.
60
Table 4.8 Pre Clinical Care
Group (n = 84) Median IQR pValue
No ENRPP (n=39) (Group 1) 15 7 *0.001
ENRPP2011 (n=45) (Group 2) 9 7 *p=statistically significant
p = <0.001*
Figure 4.1 Interquartile Range Pre Clinical Care
Post Questionnaire
A Kruskal-Wallis H test was undertaken to ascertain whether there were any
perceived differences in ‘Clinical Care’ abilities across the three groups. The
test identified a statistically significant difference across the three groups (NO
ENRPP (Group 1), n = 39: ENRPP 2011 (Group 2), n = 45: and ENRPP 2010
(Group 3), n = 28, x2 (2, n = 112) = 21.264, p = .000. The highest median score
was recorded by the ENRPP 2010 (Group 3) (Md = 21), the ENRPP 2011
61
(Group 2) recorded a median score of (Md = 19) and No ENRPP (Group 3)
median score was (Md = 16). These results are presented in Table 4.9. The
IQR for NO ENRPP (Group 1) and ENRPP 2010 (Group 3) is 5, for the ENRPP
2011 (Group 2) the IQR is, 6. The IQR is displayed in Figure 4.2
Table 4.9 Post Clinical Care
Group (n = 84) Median IQR pValue
No ENRPP (n=39) (Group 1) 16 5 *0.009
ENRPP2011 (n=45 (Group 2) 19 6
Group (n = 67) Median IQR pValue
No ENRPP (n=39) (Group 1) 16 5 *0.000
ENRPP2010 (n=28) (Group 3) 21 6
Group (n = 76) Median IQR pValue
ENRPP2011 (n=45) (Group 2) 19 5 *0.011
ENRPP2010 (n=28) (Group 3) 21 6 *p=statistically significant
62
No ENRPP and ENRPP 2011 p= <0.009* No ENRPP and ENRPP 2010 p= <0.000* ENRPP 2011 and ENRPP 2010 p= <0.011*
Figure 4.2 Interquartile Range Post Clinical Care
A Mann-Whitney U test was completed to identify if there were differences
between the three groups in relation to their perceived ‘Clinical Care’ abilities.
The result revealed significant differences between all groups.
No ENRPP (Group 1) (Md = 16, n = 39) and ENRPP 2011 (Group 2) (Md = 19,
n = 45) U = 585, z = -2.627, p = .009 and r=0.29. The effect size was r = 0.29
which according to Cohen’s criteria is small.93
The No ENRPP (Group 1) (Md = 16, n = 39) and the ENRPP 2010 (Group 3)
(Md = 21, n = 28) U = 198, z = -4.436, p = .000 and r= 0.54. The effect size
was r = 0.54 which according to Cohen’s93 criteria is a large effect.
63
ENRPP 2011 (Group 2) (Md = 19, n = 45) and ENRPP 2010 (Group 3) (Md =
21, n = 28) U = 406, z = -2.553, p= .011 and r = 0.30. This is also a small effect
according to Cohen.93
4.5.2 Teaching and Collaboration
Pre Questionnaire
To review the impact of the ENRPP on participant’s perceived pre intervention
‘a Teaching and Collaboration” ability, a Mann-Whitney U test was completed.
The results revealed a significant difference in the perceived Teaching and
Collaboration ability of the No ENRPP (Group 1) (Md = 28, n = 39) and the
ENRPP 2011 (Group 2) (Md = 21, n = 45) U = 581, z = -2.662, p = .008, r = .29.
According to Cohen the effect size is large.93 These results are shown in Table
4.10 The IQR for No ENRPP (Group 1) group is 6 and ENRPP 2011 (Group
2)is 12, this is shown in shown in Figure 4.3.
Table 4.10 Pre Teaching and Collaboration
Group (n = 84) Median IQR pValue
No ENRPP (n=39) (Group 1) 28 6 *0.008
ENRPP2011 (n=45) (Group 2) 21 12
*p=statistically significant
64
p=<0.008*
Figure 4.3 Interquartile Range Pre Teaching and Collaboration
Post Questionnaire
A Kruskal-Wallis H test identified a statistically significant difference in
perceived ‘Teaching and Collaboration’ abilities across the three groups. The
test results across the three groups were No ENRPP (Group 1), n = 39: ENRPP
2011 (Group 2), n = 45: ENRPP 2010 (Group 3), n = 28, x2 (2, n = 112) =
24.387, p = .000. The ENRPP 2010 group (Group 3) and ENRPP 2011 group
both recorded a high median score (Md = 33) compared to No ENRPP (Group
1) median score (Md = 28). These results are illustrated in Table 4.11. The
IQR for the No ENRPP (Group 1) is 7, for ENRPP 2011 (Group 2), 5, and for
ENRPP 2010 (Group 3) it is 6. The IQR is displayed in Figure 4.4
65
Table 4.11 Post Teaching and Collaboration
Group (n = 84) Median IQR pValue
No ENRPP (n=39 (Group 1)) 16 7 *0.000
ENRPP2011 (n=45) (Group 2) 19 5
Group (n = 67) Median IQR pValue
No ENRPP (n=39) (Group 1) 16 7 *0.000
ENRPP2010 (n=28) (Group 3) 21 6
Group (n = 76) Median IQR pValue
ENRPP2011 (n=45) (Group 2) 19 5 0.837
ENRPP2010 (n=28) (Group 3) 21 6
*p=statistically significant
To identify any differences between the groups, Mann-Whitney U tests were
completed.
No ENRPP (Group 1) (Md = 28, n = 39) and ENRPP 2011 (Group 12 (Md = 33,
n = 45) U = 377.5, z = -4.498, p = .000 and r=0.49. This effect size according to
Cohen’s93 criteria is large.
No ENRPP (Group 1) (Md = 28, n = 39) and ENRPP 2010 (Group 3) (Md = 33,
n = 28) U = 241, z = -3.888, p = .000 and r= 0.47. The effect size of r = 0.47 is
large according to Cohen’s93 criteria. No significant difference was revealed
between the ENRPP 2011 (Group 2) (Md = 33, n = 45) and the ENRPP 2010
(Group 3) (Md = 33, n = 28) U = 612, z = -.206, p= 0.837 and r = 0.02.
66
No ENRPP and ENRPP 2011 p= <0.000* No ENRPP and ENRPP 2010 p= <0.000* ENRPP 2011 and ENRPP 2010 p= <0.837
Figure 4.4 Interquartile Range Post Teaching and Collaboration
4.5.3 Planning and Evaluation
Pre Questionnaire
The Mann–Whitney U test results for the “Planning and Evaluation” dimension
of nursing revealed that there was no significant difference between the two
groups of participants. The No ENRPP (Group 1) (Md = 19, n = 39) and the
ENRPP 2011 (Group 2) (Md = 17, n = 45) U = 745.5, z = -1.190, p = .234, r =0
.12. These results are presented in Table 4.12. The IQR for No ENRPP (Group
1) ENRPP 2011 (Group 2) was 5 and 6 respectively. The IQR is displayed in
Figure 4.5
67
Table 4.12 Pre Planning and Evaluation
Group (n = 84) Median IQR pValue
No ENRPP (n=39) (Group 1) 19 5 0.234
ENRPP2011 (n=45) (Group 2) 17 6
*p=statistically significant
p=<0.234
Figure 4.5 Interquartile Range Pre Planning and Evaluation
Post Questionnaire
A significant perceived difference in ‘Planning and Evaluating’ abilities across
the three groups was identified through a Kruskal-Wallis H test, (No ENRPP
(Group 1), n = 39: ENRPP 2011 (Group 2), n = 45: ENRPP 2010 (Group 3), n =
28; x2 (2, n = 112) = 23.753, p = .000. The ENRPP 2010 (Group 3) recorded
the highest median score (Md = 24), the ENRPP 2011 (Group 2) recorded a
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median score of (Md = 21) and the No ENRPP (Group 1) median score was
(Md = 19). These results are displayed in Table 4.13. The IQR for the no
ENRPP (Group 1)was 5, for ENRPP 2010 (Group 3), 6 and the ENRPP 2010
(Group 3) 5. These results are shown in Figure 4.6.
Table 4.13 Post Planning and Evaluation
Group (n = 84) Median IQR pValue
No ENRPP (n=39) (Group 1) 19 5 *0.000
ENRPP2011 (n=45) (Group 2) 21 6
Group (n = 67) Median IQR pValue
No ENRPP (n=39) (Group 1) 19 5 *0.53
ENRPP2010 (n=28) (Group 3) 24 5
Group (n = 76) Median IQR pValue
ENRPP2011 (n=45) (Group 2) 21 6 0.175
ENRPP2010 (n=28) (Group 3) 24 5
*p=statistically significant
69
No ENRPP and ENRPP 2011 p= <0.000* No ENRPP and ENRPP 2010 p= <0.53* ENRPP 2011 and ENRPP 2010 p= <0.175
Figure 4.6 Interquartile Range Post Planning and Evaluation
Mann-Whitney U tests were completed to identify any significant differences
between the groups.
The No ENRPP (Group 1) (Md = 19, n = 39) and the ENRPP 2011 (Group 2)
(Md = 21, n = 45) U = 465.5, z = -3.739, p = .000 and r=0.41. According to
Cohen93 this is a large effect size.
The No ENRPP (Group 1) (Md = 19, n = 39) and ENRPP 2010 (Group 3) (Md =
24, n = 28) U = 200, z = -4.419, p = .000 and r= 0.53. According to Cohen’s93
criteria this is a large effect size.
The ENRPP 2011 (Group 2) (Md = 21, n = 45) and the ENRPP 2010 (Group 3)
(Md = 24, n = 28) U = 500, z = -1.496, p= .135 and r = 0.175. There is no
significant difference between these two groups.
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4.5.4 Interpersonal Relationships and Communication
Pre Questionnaire
To identify any differences between the pre-intervention perceived abilities
relating to ‘Interpersonal Relationships and Communication’ a Mann –Whitney
U test was conducted. There was no significant difference between the groups
(Table 4.14). The results were – No ENRPP (Group 1) (Md = 35, n = 39) and
ENRPP 2011 (Group 2) (Md = 35, n = 45) U = 871.50, z = -0.054, p = .957, r
=0.0006. The IQR for both groups No ENRPP (Group 1)and ENRPP 2011
(Group 2) was 6. The IQR is displayed in Figure 4.7
Table 4.14 Pre Interpersonal Relationships and Communication
Group (n = 84) Median IQR pValue
No ENRPP(n=39) (Group 1) 35 6 0.957
ENRPP2011 (n=45) (Group 2) 35 6
*p=statistically significant
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p= <0.957
Figure 4.7 Interquartile Range Pre Interpersonal Relationships and Communication
Post Questionnaire
The Kruskal-Wallis H test identified a statistically significant perceived
difference in ‘Interpersonal Relationships and Communication’ abilities across
the three groups (No ENRPP (Group 1), n = 39: ENRPP 2011 (Group 2), n =
45: ENRPP 2010 (Group 3), n = 28; x2 (2, n = 112) = 16.585, p = .000. The
ENRPP 2010 (Group 3) recorded the highest median score (Md = 43), the
ENRPP 2011 (Group 2) recorded a median score of (Md = 39) whereas the No
ENRPP (Group 1) median score was (Md = 36). These results are presented in
Table 4.14 The No ENRPP (Group 1) and the ENRPP 2010 (Group 3) both had
an IQR of 8 , 8,whereas the ENRPP 2011 (Group 3) recorded and IQR of 9.
The IQR is displayed in Figure 4.8
72
No ENRPP and ENRPP 2011 p= <0.001* No ENRPP and ENRPP 2010 p= <0.000* ENRPP 2011 and ENRPP 2010 p= <0.221*
Figure 4.8 Post Interpersonal Relationships and Communication
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Table 4.15 Post Interpersonal Relationships and Communication
Group (n = 84) Median IQR pValue
No ENRPP (n=39) (Group 1) 36 8 *0.001
ENRPP2011 (n=45) (Group 2) 39 9
Group (n = 67) Median IQR pValue
No ENRPP (n=39) (Group 1) 36 8 *0.000
ENRPP2010 (n=28) (Group 3) 43 8
Group (n = 76) Median IQR pValue
ENRPP2011 (n=45) (Group 2) 39 9 0.221
ENRPP2010 (n=28) (Group 3) 43 8
*p=statistically significant
Mann-Whitney U tests were undertaken to identify any differences between the
groups.
The No ENRPP (Group 1) (Md = 36, n = 39) and ENRPP 2011 (Group 2) (Md =
39, n = 45) U = 521.5, z = -3.210, p = .001 and r=0.35. According to Cohen93
this is a medium effect size.
The No ENRPP (Group 1) (Md = 36, n = 39) and ENRPP 2010 (Group 3) (Md =
43, n = 28) U = 262.5, z = -3.617, p = .00 and r= 0.44. According to Cohen93
this is a medium/large effect.
The ENRPP 2011 (Group 2) (Md = 39, n = 45) and ENRPP 2010 (Group 3) (Md
= 43, n = 28) U =523, z = -1.225, p= .221 and r = 0.14. There were no
significant differences between these two groups.
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No ENRPP and ENRPP 2011 p= <0.001* No ENRPP and ENRPP 2010 p= <0.000* ENRPP 2011 and ENRPP 2010 p= <0.221*
Figure 4.8 Interquartile Range Post Interpersonal Relationships and Communication
4.5.5 Professional Development
Pre Questionnaire
No significant differences were found between the two groups perceived pre
intervention ‘Professional Development’ abilities by a Mann-Whitney U test.
The No ENRPP (Group 1) (Md = 30, n = 39) and the ENRPP 2011 (Group 2)
(Md = 28, n = 45) U = 728.5, z = -1.343, p = .179, r = 0.146. These results are
shown in Table 4.156. The IQR for No ENRPP (Group 1) and ENRPP 2011
(Group 3) was 4 and 5 respectively. The IQR is displayed in Figure 4.9.
75
Table 4.156 Pre Professional Development median results
Group (n = 84) Median IQR pValue
No ENRPP(n=39) (Group 1) 30 4 0.179
ENRPP2011 (n=45) (Group 2) 28 5
*p=statistically significant
p= <0.179*
Figure 4.9 Interquartile Range Pre Professional Development
Post Questionnaire
Kruskal-Wallis H test was completed to identify whether there were any
differences amongst the three groups’ perceived abilities in ‘Professional
Development’. A statistically significant difference was found in the No ENRPP
(Group 1), n = 39: ENRPP 2011 (Group 2), n = 45: ENRPP 2010 (Group 3) n =
28; x2 (2, n = 112) = 10.337, p = .003. The ENRPP 2010 (Group 3) recorded
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the highest median score (Md = 37), the ENRPP 2011 (Group 2) recorded a
median score of (Md = 33) and the No ENRPP (Group 1) groups’ median score
was (Md = 31). These results are shown in Table 4.16.
The No ENRPP (Group 1) recorded an IQR of 7, ENRPP 2011 (Group 2)
recorded an IQR of 9 and the ENRPP (Group 1) group recorded an IQR of 6.
The IQR is displayed in Figure 4.10
Mann-Whitney U tests were undertaken to identify any significant differences
between the groups relating to Professional Development. The No ENRPP
(Group 1) (Md = 31, n = 39) and the ENRPP 2011 (Group 2) (Md = 33, n = 45)
U = 639.5, z = -2.152, p = 0.031 and r=0.36. There was no significant
difference between these groups.
The No ENRPP (Group 1) (Md = 31, n = 39) and ENRPP 2010 (Group 3) group
(Md = 33, n = 28) U = 294, z = -3.214, p = .001 and r= 0.39. According to
Cohen’s93 criteria this is a medium effect size.
The ENRPP 2011 (Group 2) (Md = 33, n = 45) and the ENRPP 2010 (Group 3)
(Md = 37, n = 28) U =543, z = -0.992, p= .321 and r = 0.12. There was no
significant difference between these two groups.
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Table 4.16 Post Professional Development
Group (n = 84) Median IQR pValue
No ENRPP (n=39) 31 7 0.031
ENRPP2011 (n=45) 33 9
Group (n = 67) Median IQR pValue
No ENRPP (n=39) 31 7 *0.001
ENRPP2010 (n=28) 37 6
Group (n = 76) Median IQR pValue
ENRPP2011 (n=45) 33 9 0.321
ENRPP2010 (n=28) 37 6
*p=statistically significant
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No ENRPP and ENRPP 2011 p= <0.031 No ENRPP and ENRPP 2010 p= <0.001* ENRPP 2011 and ENRPP 2010 p= <0.321
Figure 4.10 Interquartile Range Pre Professional Development
Qualitative Results 4.6
Participant responses to the two open ended questions in the modified Five
Dimension of Nursing Scale are now presented sequentially.
Question 1.
What can we do better to improve the undergraduate nursing degree at
Edith Cowan University?
There were 89 responses in total for question A. Seventy four percent (n = 39)
of No ENRPP (Group 1) responded to question 1. Of the 45 participants in the 79
ENRPP 2011 (Group 2), 73% (n=45) responded to question one and 27
participants of the 28 participants in the ENRPP2010 (Group 3), (96%)
responded. The response rate is represented in Table 4.17. The first question
was asked with a view to improving the nursing course at ECU. The main three
improvements by the students were increase clinical placement time, increase
the time they spend in simulation time and provide for more hands on learning.
These suggestions have been passed on to relevant staff at ECU.
Table 4.17 Response rate to Qualitative questions by group
Question 2.
How has the ENRPP impacted on your undergraduate nursing studies at
ECU in relation to clinical practicum and theoretical learning?
Students who had not completed the ENRPP (Group 1) were advised not to
answer the second question as it was not relevant. Of the 45 participants in the
ENRPP 2011 (Group 2), 93% (n=45) responded to question 2 and 93% of the
Question Group n= %
1 No ENRPP (Group 1) 39 74
ENRPP 2011 (Group 2) 45 73
ENRPP 2010 (Group 3) 29 96
2 ENRPP 2011 (Group 2) 45 93
ENRPP 2010 (Group 3) 29 93
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ENRPP 2010 (Group 3) responded to question 2. The response rate is
represented in Table 4.17.
Inter rater reliability as mentioned in Section 3.15 was computed to determine
the reliability of the coding for the second question. The ‘percent method’ was
used and the result for inter-rater reliability was 84%.
An overarching theme identified through the responses was ‘Confidence in
being a nurse’
Four sub-themes were also identified by the researcher.
1. Increased self confidence
2. Ready to nurse
3. Better employment prospects
4. Stress related to the ENRPP
Some responses fitted into more than one theme. The theme and sub themes
are illustrated through quotes from the participants. Where quotes are provided
the participants are identified by a numerical code e.g. P111.
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Table 4.18 Theme and sub themes and categories
*Note % rounded
Theme
n=215 Sub theme n=214 % Category n= %
Confidence in being a nurse
Increased Self confidence 41 19 Self confidence 41 19
Ready to Nurse 127 59
More time to practice being a nurse 26 12 Understanding learning in the ward and in the classroom 26 12 Improve basic nursing skills 26 12 Enhanced Undergraduate experience 15 7 Improved time management 14 7 Understanding of job role 11 6 Understanding of wounds 5 2 Change of emotional state 4 2
Better Employment Prospects 41 19 Meaningful employment 25 12
Opportunities for the future 16 7
Stress related to the ENRPP 5 2
Stress related to the ENRPP 5 2
TOTAL 214 99 214 100
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4.6.1 Confidence in being a nurse
This overarching theme encompassed many facets of nursing. Participants
stated that they had improved their self-confidence and felt better prepared to
work as a nurse as a result of completing the ENRPP. They expressed a feeling
of confidence in being able to take on the role of the nurse as they understand it
to be, whilst they may still be apprehensive they are confident that they are
ready to nurse.
4.6.2 Increased Self Confidence
The first sub theme is ‘Increased Self Confidence’. Of the 215 comments 41
(19%) were related directly to confidence. Many of these responses related to a
feeling of being more confident. In some instances the comments related to
multiple areas of nursing, and nursing studies, and were placed in more than
one category. For example:
‘…..confidence with medication administration, wound care, and time
management skills’ (P333)
Whereas, some responses were related to individual situations
-‘…For in relation to a clinical practicum I feel more confident’ (P313)
It has allowed me to expand my practice experience in the clinical
area and helped prepare me for working in the health sector as an RN. (P331)
An amazing opportunity which I have no doubt will prepare me be an efficient and skilful RN when I graduate.(P230)
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4.6.3 Ready to Nurse
The sub theme “Ready to Nurse” incorporates each of the seven sub
categories. The sub themes and categories identified attributes that students
felt were important for a student nurse to have in order to begin nursing. Six of
the categories led to students feeling better prepared which contributed to their
being ready to nurse. Whereas, the one category ‘Understanding the role of the
nurse’ resulted in the students having a greater understanding of the job role
which contributed to them feeling ready to nurse.
‘Ready to Nurse’ categories are presented in the order of the most common
response in Table 4.18.
All graduates wanted to feel that they are prepared for their future career.57,58
Comments from the participants showed they appreciated the opportunity to
spend more time in the clinical environment practising nursing skills. They felt
this had increased their ability to undertake these skills and become better
prepared for the job role. The following comments illustrate this.
Time to practice being a nurse was also discussed by the students as shown in
the following comment.
Twelve percent of the comments related to ‘Understanding learning in the ward
and the classroom’. The majority of comments in this category showed that the
students thought that the program had improved their application of theoretical
‘…gives me a chance to further develop nursing skills.’ (P240)
‘… Even just a simple thing like check the skin integrity for the pressure ulcer.’ (P226)
‘…By being able to work as an EN I am getting valuable clinical experience that will help me find my feet quicker as a registered nurse.’ (P 306).
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knowledge to the clinical situation. However, one participant did not agree.
Participant 249 commented
Most participants expressed that the opportunity to link real life situations to
theoretical learning had enhanced their learning experience. The following
comments highlight this.
Comments from the students’ show that the impact of the ENRPP was not
limited to just meaningful employment but also to a feeling that it enhanced the
overall experience of the students at the university. They also showed the
students who completed the ENRPP thought they had had extra opportunities
to learn compared to other nursing students who had not completed the
ENRPP.
The students commented on how their experience of undertaking the ENRPP
impacted on their ability to handle their work load. For example, ‘Time
management’ was improved as explained in the following comments.
‘…The theoretical classes would be more beneficial if they reviewed skills more and assessment tools. As they are now I found them interesting but not very
useful.’ (P249)
‘.…given me more confidence with my approach to practical use of the theoretical knowledge I have gained.’ (P206)
‘‘…I've put theory into practice and understand the theoretical learning more..’(P255)
‘…I have experiences other students won't get until they are working.’ (P307)
‘…the ENRPP has made my prac experiences much more enjoyable and worthwhile - I don’t spend so much time practicing the basics and I spend more time researching cases specific to the area to determine why/how their plans of
care are created/maintained.’ (P302)
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In the category ‘Understanding of the job role’ the students highlighted that they
were able to identify with the role of the nurse after having worked in the role
themselves, either in the additional practicum or that they have completed the
ENRPP that they can gain more meaningful employment. This is demonstrated
by the following comments.
Several students felt that they were now ready to work as a nurse are a result of
completing the ENRPP as expressed in the following comments.
‘…. I now feel confident in time management, taking on a full patient load and providing high quality care which I previously didn’t feel very confident in.’(P214)
‘I feel it has greatly improved my time management skills and my ability to
independently initiate nursing care for patients.’(P239)
‘…gives me a chance to further develop nursing skills.’ (P240)
‘…Instead of trying to get particular skills signed off during a prac the ENRPP I concentrated on the holistic care of a patient load. This experience of carrying a patient load more closely resembles what a nurse would experience post -
graduation.’(P242)
‘…The practical also has made me ready to practice hands on, on the ward. This transition has really made me prepare for my RN training much more
practically and to think critically in everything that I do to a patient. I appreciate this training and now have a good focus on what to do as a nurse.’(P232)
‘…it has allowed me to expand my practice experience in the clinical
area and helped prepare me for working in the health sector as an RN.’(P331)
‘…When I graduate I will be work ready and have the confidence to start work as an RN.’ (P303)
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A few students identified that their previous emotional situation had changed
due to the ENRPP experience in that they had diminished feelings of fear.
Another area of the ENRPP that the participants commented about was the
completion of the wound management modules n=5 (2%). The participants felt
that their ‘Understanding of wounds’ was enhanced. The participants also felt
that at the present point of their undergraduate studies wound management had
not been covered as extensively as it had in the ENRPP as evidenced by the
following two comments.
4.6.4 Better employment prospects
The sub theme of better employment opportunities included two categories;
meaningful employment and opportunities for the future. Participants identified
career opportunities for ‘Meaningful employment’ in 12% of responses as
demonstrated in
‘….It has taken away from me the fears I had regarding nursing. I feel that I’m
now able and ready to work as a registered nurse because of the ENRPP. I
wish every nursing student could get a chance to do the ENRPP.’ (P324)
‘…won’t be screaming on the inside when I do prac and given an opportunity.’(P204)
‘I also found the wound care components very beneficial as this is something not covered greatly in the undergraduate nursing degree.’ (P218)
‘…I feel that the wound care package in the ENRPP has been amazing help.’(P313)
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The students commented on the importance of having a job within the health
care environment and said it was integral to their learning. This meaningful
employment facilitated the practice of theoretical principles, skills and
knowledge. Comments included:
In addition to meaningful employment for the undergraduate period, 7% of the
participants identified the ENRPP as having had an impact on their
‘Opportunities for the future’. Participants mentioned that the ENRPP course
had equipped them with a feeling of being better prepared than their peers for
the transition to the world of full time employment. For example, two comments
clearly show the students identified another benefit of the program as being the
link with industry.
One participant acknowledged he/she felt that although the ENRPP had
enhanced her confidence taking part in other clinical practicum she did not feel
ready to find employment as an EN as a result.
‘…I find my theoretical learning easier to understand as I am constantly learning the practical side of most of it at work.’ (P337)
‘…It has enabled me to work within the industry as a nurse.’ (P333)
‘…Overall, it has opened doors for me with employers and raised my self- esteem.’ (P333)
‘The ENRPP has largely impacted upon my future career. I hoped to study midwifery at ECU after completing my undergraduate Nursing degree. I was
told that without an RN graduate program behind me I did not stand much chance of being considered by birthing hospitals. Thanks to the ENRPP, I am
currently being considered by three birthing hospitals for a student midwife position due to my experience working as an EN.’ (P312)
‘…It did help to give me more confidence in my other practicum; however, I felt very rushed and didn't feel I have the knowledge or experience to go out with
using the qualification.’ (P315)
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4.6.5 Stress related to the ENRPP
Whilst the ENRPP was identified by the participants as having many benefits, it
also created additional workloads both during and following the course which
caused stress as reported in 2% of the responses in Table 4.18. The course
required participants to attend extra face to face classes and to take on an
additional two weeks practicum. For some students the meaningful
employment opportunities that followed the ENRPP were welcomed but also
caused them stress.
Summary 4.7
In this chapter the results from the data analysis were presented. The
demographic data were representative of both the wider nursing demographic in
Australia and the university demographic for nursing at ECU. There are more
women involved in nursing education at this university compared to men. The
average age of the students in this study was 20.5 years. The students in this
study came with a range of previous education experiences. The main
difference between the groups in this study was their previous undergraduate
qualifications. The majority of the participants were in their second year of
nursing studies at the university. The quantitative results for each of the five
domains of the modified Five Dimensions of Nursing Scale were presented
‘It has put pressure on my other studies but I think it has been worth it. From extra prac and taking on a patient load I feel far more comfortable and confident
with my skills.’ (P254)
‘It was an extra stress and created even more 'time poverty' but I'm sure that it will be worth it when I get a job as an EN.’ (P251)
‘Stage six studies and working as an EN have however Increase the stress levels.’ (P317)
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including the pre and post questionnaire results. An overarching theme was
identified from the analysis of the open ended questions which is confidence to
nurse. In addition to this, four sub themes were identified; 1) Increased self-
confidence, 2) Ready to nurse, 3) Better employment prospects and 4) Stress
related to the ENRPP were outlines and illustrated through the participants
quotes.
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Chapter 5. DISCUSSION
Overview
The Australian Government Productivity Commission has stated that the need
to have confident, competent nursing graduates who are able to transition
effectively and efficiently into the work environment is of paramount importance
to the nursing workforce.1 The move to university based nursing qualifications
brought with it recognition of nursing as a profession rather than a vocation.
This recognition however came at certain costs, namely a reduction in
opportunities to prepare for transition to work. These reduced opportunities
include less clinical contact hours, networking opportunities and practicing of
essential communication skills which nurses were previously able to acquire
during the traditional vocational apprenticeship.34,111
In the current study the impact of the ENRPP on the perceived clinical abilities
of undergraduate RN nurses were examined against those of students who did
not undertake the ENRPP. In this study, students who completed the ENRPP
in 2011 (Group 2) showed a statistical difference in 4 of the 5 domains studied
compared to those students who had not complete the ENRPP (Group 1). The
findings suggest nurses who participated in the ENRPP (Groups 2 & 3)
perceived an improvement in their clinical abilities due to meaningful paid
employment which allowed them to further develop their clinical abilities during
clinical rotations associated with their university studies.
93
The cost of reaccreditation of this course had made its ongoing implementation
prohibitive. Edith Cowan University is currently exploring alternative pathways
for the ENRPP to continue, albeit in a modified format.
In this chapter, the research questions raised in Chapter One of this thesis are
answered and the main issues discussed.
Research Questions addressed 5.1
1. Does the ENRPP facilitate preparation of nursing students to practice
as RN nurses?
The findings of this research support the notion that working as an enrolled
nurse helps RN students to consolidate various skills. Students who
participated in this study and completed the ENRPP in 2011 (Group 2) reported
higher confidence levels in their perceived nursing ability in 4 of the 5 domains
studied compared to those students who did not undertake the program.
Students who completed the ENRPP in 2010 (Group 3) and had been working
as a EN for a year reported higher levels in their perceived confidence in all five
domains studied compared to those students who did not complete the ENRPP
(Group 1).
2. Do students that complete the ENRPP and work part time as ENs do
better on the clinical scenario in their unit of study titled “NNT2206
Principles of an Individual’s Adaption to Altered Health Status”?
This research was not able to recruit sufficient participants who were willing to
have their exam papers reviewed which meant the question could not be
answered
94
3. Do the students who are working as ENs apply the theories learned
in the unit of study titled “NNT2206 Principles of an Individuals
Adaption to Altered Health Status” to their clinical environments?
The thematic analysis of the qualitative results from this research suggest that
students who are working as ENs have the opportunity to more readily apply the
theoretical knowledge learnt in the unit of study titled “NNT 2206 Principles of
an Individuals Adaption to Altered Health Status” during their employment. The
qualitative responses support this finding. The quantitative results also show
the students who participated in this program were more confident in the
delivery, planning and the evaluation of clinical care. Moreover, they were more
confident in teaching clients and collaborating with and developing interpersonal
relationships with the wider multidisciplinary team compared to nursing students
who did not participate in the ENRPP (Group 1).
Perceived Confidence
Nursing students regularly report that they lack confidence in the clinical
environment and that they are concerned about their ability to meet some of the
requirements of clinical practicum objectives. 33, 112,111,113, The students in the
current study reported various degrees of confidence levels at differing points in
time. The students who did not complete the ENRPP (Group 1) were initially
more confident in the dimensions of Clinical Care and Teaching and
Collaboration compared to the students who had completed the program.
However, in the post questionnaire results, the students who did not complete
the ENRPP (Group 1) were less confident in all dimensions, with the exception
of professional development (where the groups were equal), than the students
95
who had completed the program. Moreover, the students who had completed
the program and were now working as EN’s had further increases in their
confidence in clinical skills when compared to the students who had only
recently completed the program.
There are several possible reasons why the latter may have been the case.
According to Meechan some nursing students are more aware of what they are
responsible for and who they are accountable to, which results in some
students being more readily able to recognise their own limitations.114 This
disparity in perceived confidence was also found in the current study. An earlier
UK study reported similar findings that graduate nurses who entered work
environments with a degree qualification rated themselves lower in nursing
abilities than those entering with diploma qualifications.115
Students who enrolled in the ENRPP (Groups 2 & 3) identified their perceived
gap in knowledge and skills and anticipated that the ENRPP would address this.
These differing levels of confidence between the students may be attributed to
the perception of feeling ready to nurse until the reality of immersion in clinical
practice when they can better identify their capabilities. That is, some students
may not be able to identify their abilities until they are actually exposed to the
work environment.
Students who participated in the ENRPP (Groups 2 & 3) and who were
therefore exposed to the clinical environment were more likely to be able to
understand their limitations and therefore may have felt less confident prior to
undertaking the ENRPP. Many people exhibit confidence with an unknown
96
situation, for example a study by Kruger and Dunning reported that the medical
students in their study who were in the lower quartiles for academic results were
unable to identify less of what they did not know compared to medical students
in higher quartiles.116
Developing Confidence
The hospital environment is highly technical and has a unique culture.117 118
People outside the culture, and this includes novice nursing students, can only
imagine what a nurse should be, based on their lived experience as a patient or
a visitor to the hospital, and what they observe through media such as television
programs and news stories. 119,120 Students coming into an undergraduate
nursing program have preconceptions about what it means to be a nurse which
may be incongruent with the actual role; and when commencing clinical
placements, may feel unprepared to work within the hospital culture.121 The
findings of the current study support these findings. Some students described
reduced anxiety levels following their completion of the ENRPP and said that
they felt ready to become a registered nurse.
Clinical placements are important as they afford students the opportunity to
undertake guided practice and improve their skills, to transfer theoretical
knowledge into practical skills and to network within the clinical setting.3,36,50,51
Some students believed that the nurses on the wards were expecting them to
be highly knowledgeable nurses and able to integrate into the team as an
effective nurse.34 By believing this the students place unnecessary pressure
upon themselves which has been found to contribute to decreased self-
confidence.34
97
How does the student RN develop confidence?
Confidence starts to develop in student RNs through successful learning and
supported practice. 122,123 Supported learning environments can provide the
scaffolding needed for achievement. These ‘scaffolded’ environments allow
tasks to be broken down into achievable chunks that can be mastered in part
and then sequenced together for the final act. Practice and repetition of the
task, and further practice in clinical situations,37 p.87) allows students to develop
confidence in their own abilities.42 Students within the current study reported
that the ENRPP allowed them to apply theory to practice. The students who
completed the ENRPP (Groups 2 & 3), and who had been working as an EN for
a year, reported higher levels of confidence post questionnaire in all domains
under study. The recently completed ENRPP students reported higher
confidence levels in all dimensions except professional development when
compared to the students who did not undertake the program. The completion
of the ENRPP allowed students to register as an EN and to work in meaningful
employment that in turn afforded them the opportunity to practice skills and
knowledge they had previously learnt or were concurrently learning at
university.
When does the student RN develop confidence?
Through time and authentic practice, student nurses develop
confidence.42,55,113,124 Many studies have found that students want more clinical
time to practice the skills learnt in the classroom.34,111 Crookes et al. undertook
a qualitative study using focus groups to explore the professional confidence as
perceived by diploma-prepared RN’s enrolled in a student-centred, problem
solving-based RN degree program. These students identified the need for more
98
clinical time to cement their learning.38 Another study completed in the USA in
2010 analysed one year nursing alumni surveys which provided the basis for
developing evidence-based curricular strategies to better prepare nursing
graduates for their transition into practice. In total 480 surveys from a five year
period were reviewed. The sixty-seven percent of the respondents reported the
need for more clinical time in the undergraduate course.111 The current study
revealed that confidence was improved over time, with exposure to the clinical
setting and increased practice at clinical skills. The findings of Casey et al.
where five students volunteered to work as assistants in nursing reported that it
assisted in their readiness to practice as a RN.113 This is supported by the
findings in the current study.
The qualitative comments of the current study showed that, in addition to clinical
practice, students would like both more simulation teaching and more clinical
skills workshop opportunities. Other studies have also found students would like
more opportunity for skills practice in the simulated environment. 80,121,125 One
aspect of skill learning is regular practice. Students lose skill competencies
after about 4-6 months depending upon the complexity of the skill and whether
or not relearning is taking place by opportunities to practice during that period.
126,127 Repeated authentic clinical practice with opportunities for feedback and
improvement can help build sound clinical skills. Skills need to be practiced in
order for them to be retained. Studies surrounding medical skill retention, such
as CPR, have found that skill level usually decreases over a period of three to
six months unless participants are given the opportunity to practice. 126,127 In the
context of the current study student nurses can experience up to six months
99
between clinical placements due to the summer break. This can hinder
successful retention and development of skills.
The qualitative comments from the students who did not undertake the ENRPP
(Group 1 )mainly focused on the need for more practice time. Whereas, the
students who completed the ENRPP (Groups 2 & 3) commented about
increased confidence, feelings of authenticity in their role and the benefits of
access to more clinical practice.
Meaningful employment
For the readers convenient the definition of meaningful employment provided on
p.25 is repeated. Meaningful employment is employment that is full or meaning
or is significant. Meaningful employment provides opportunities for nursing
students to practice skills that they are currently learning. Meaningful
employment enhances ones perception of self.55 The main areas where
‘meaningful employment’ opportunities exist for nursing students are within
tertiary hospitals and aged care settings.55
Aged care offers the opportunity for many important basic nursing skills to be
practised; however, the skills are often less technical than the skills required in
tertiary hospital settings.128 Students working in aged care environments do not
have the opportunity to continue developing skills that are needed for other
practice contexts.
Several research studies have shown that whilst the aged care environment can
help student nurses consolidate an array of skills, it can also have a negative
100
effect on nursing students who may turn away from nursing or from geriatrics as
a specialty as a result.67,129 The reasons for this are varied. The lack of acuity
in aged care and the lack of respect for aged care as a specialty compared to
the acute care setting are among the reasons.129
In the current study, working as an EN in the tertiary environment alone allowed
students to develop skills in more areas of their nursing practice.
Many students who were involved in the ENRPP commented that they felt part
of both the nursing team and the wider multidisciplinary health team. Feeling
part of, or belonging to a team, has been shown to increase confidence in
nursing.55,76 Student nurses often report that they do not feel part of the team
and that qualified staff do not allow them to be fully responsible for an allocated
patient load,7,55,130 resulting in less opportunity for some skills such as time
management to be fully developed. The ENRPP students (Groups 2 & 3) were
responsible for the patient loads allocated to them during their meaningful
employment. Over time, their time management and planning skills were able
to develop as a result of this responsibility. The findings of the current study
support other researchers’ conclusions’ that have identified students working as
assistants in nursing and externships are provided with more opportunities to
practice skills.55,130-132 Staff on the ward organised and allowed the nursing
students who were working as part of the ward staff, opportunities that they
would not normally offer to a student on a nursing placement.55,76,130
Students can feel extreme pressure about assessment tasks. Having the
opportunity to practise nursing skills without the pressure of being assessed
101
was also felt to have been a benefit of completing the ENRPP. When at work,
the nursing students have access to experienced staff that can guide and
facilitate the development of their skills.
Participants in the ENRPP also identified that the potential to obtain future
employment opportunities were a benefit of this program. Despite the shortage
of skilled nurses in Western Australia, graduate nurse programs are extremely
competitive and in short supply. Having the opportunity to build meaningful
relationships with the health care team that they are working with and being
able to demonstrate their skills to the team, who have the capability to offer
them employment upon graduation were also seen as favourable outcomes of
the program.
Readiness to practice
Being ready to practice a career is a highly desired quality for all university
graduates, including nurses. Wolff et al. found that there were four common
themes of readiness to practice nursing in their study. These were:
1. Having a generalist foundation and some job specific capabilities;
2. Providing safe client care;
3. Keeping up with the current realities and future possibilities, and
4. Possessing a balance of doing, knowing and thinking.32(p.6)
Graduate nursing programs were introduced to facilitate newly graduated
nurses into the culture and needs of a specific workplace, and to aspects of
their professional role in it. Inadequate staffing due to current workforce issues
has put pressure on support for graduate nursing programs and supervisory
staff leading to less than ideal support and increased work pressures for new
102
graduates. In addition, new nursing graduates often have unrealistic
expectations about their ability to complete all tasks efficiently and competently
as soon as they start their graduate program. 33 Graduating students want to be
ready for practice and to contribute meaningfully to the health care team
however, this takes time and practice to achieve.33
The ENRPP students (Groups 2 & 3) have been able to consolidate their basic
nursing skills whilst being employed as ENs compared to students who wait a
long period of time for the opportunity to practice and apply this same learning.
The opportunity to interact with all facets of the health care environment whilst
undertaking part time work allowed the ENRPP students (Groups 2 & 3) to feel
more ready to practice as RNs. The students have had the time to work in the
role of the nurse. By being an EN themselves they are interacting and working
alongside the RN, through this they are observing the RN job role and
responsibilities, thus developing a greater understanding and appreciation for
the role. In addition to this, they may be able to transition more easily to an RN
position as they have taken multiple smaller steps towards becoming an RN
compared to students who have not worked as an ENs.
The role of both the RN and the EN includes teaching patients and their families
about health. Like clinical practice and skill acquisition this dimension of
nursing practice is allowed to develop in the ENRPP through ongoing
interactions with clients and their families. The students working as ENs have
the opportunity to watch other clinicians educate clients and learn from these
experiences. The participants of the ENRPP (Groups 2 & 3) reported a higher
degree of confidence in the dimension of Teaching and Collaboration.
103
The opportunity to work as an enrolled nurse has allowed nursing students to
actively contribute to the team and to experience opportunities which enable
them to be more ‘ready to practice’ that are not always provided to nursing
students.
Summary
In this chapter, a discussion surrounding the quantitative and qualitative results
was presented. Nursing students are concerned with their level of
preparedness for entering into the clinical nursing environment. When nursing
training moved from the hospital based training to the tertiary based Bachelor of
Nursing degrees there was a corresponding reduction in the number of clinical
hours offered to students. The ENRPP program has been identified in this
research as an innovative way to provide meaningful employment opportunities
to nursing students which can in turn increase the exposure of students to the
clinical environment. Students who completed the ENRPP in 2011 (Group 2)
reported increased levels of self-confidence associated with four of the five
domains of nursing studied. Students, who had completed the program in 2010
and had been working as EN for a year, reported higher levels of confidence in
all five domains under study. The ENRPP allowed students to work in
employment that afforded them the opportunity to practice the skills and
knowledge they had learnt or were concurrently learning at university.
The small number of students who consented to allow access to their exam
papers resulted in the researcher being unable to establish whether this
program increased performance in the written clinical scenario exam questions
in the unit of study. However, many students reported that they were more 104
readily able to apply theory to practice than they had been prior to the
completion of the ENRPP.
105
106
Chapter 6. CONCLUSION AND RECOMMENDATIONS
This section presents the recommendations from this research. Following this,
the limitations of the study are explored and areas for future research
suggested. Areas for further research are discussed. The suggestions made in
this section will hopefully provide improved opportunities for undergraduate
nursing students to obtain meaningful employment opportunities which will
enhance their learning and ultimately improve patient care.
Recommendations 6.1
This research study has highlighted some areas that could be used to improve
the undergraduate RN experience in WA. Four recommendations are made.
Recommendation One – Increase clinical exposure opportunities for all nursing
students.
Whilst the pressure for clinical placements is high it is imperative that nursing
students are equipped with skills and knowledge for transition into the working
environment. Clinical practice is essential for all nursing students. Having the
opportunity to practice clinical skills between clinical rotations can enhance
retention of the skills, and may improve the confidence of the nursing students.
Recommendation Two – Re-establish the Enrolled Nursing Registration
Pathway Program.
It is unfortunate that the National Nurses Registration Board in Australia is not
supporting the re-accreditation of this program. It has become financially
prohibitive for all institutions that were offering this program to their
107
undergraduate nursing students. This has resulted in the abolition of the
program at ECU. Further discussion with the Nurses Board exploring
alternative avenues for re-accreditation of the ENRPP is needed.
Recommendation Three – Provide more meaningful employment opportunities
to undergraduate nursing students.
Meaningful employment pathways and enhanced work opportunities for
undergraduate nursing students need to be further explored. Undergraduate
nursing students can work in a variety of roles within the health care setting. In
addition to the EN role, student nurses could also work as Acute Care
Assistants in Nursing. Building meaningful partnerships with industry to develop
innovative nursing opportunities for undergraduate nurses such as Acute Care
Assistants is required. Through meaningful employment the students will have
the opportunity to improve and practice their clinical skills, apply theory to
practice, and network within the clinical team which may ultimately lead to
enhancing skills of the graduate nurses. This will benefit not only the students
but also the clinical environment and ultimately the patients they care for.
Recommendation Four – Increase the use of simulation within the teaching
environment.
Students within the current study suggested that they would like more
opportunities to access simulation teaching and learning environments.
Increasing the amount of simulation within the nursing curriculum is the final
recommendation in this study. Simulation may facilitate ease of learning for
hands on learners thereby increasing student confidence with new situations.
108
Further research in conjunction with these recommendations may help to
improve the confidence levels of the undergraduate nursing student.
Limitations 6.2
This study has several limitations which are outlined below:
1. The research was conducted at one university and as such cannot be
generalised to undergraduate nursing students as a whole.
2. There was no evaluation of the nursing skills of the participants in this
research by a third party assessor.
3. The voluntary nature of the study may result in self-selection bias.
4. The staff working with the EN’s who had completed the ENRPP were not
consulted in relation to the EN’s abilities.
5. The students who enrolled in the ENRPP did so voluntarily and therefore
may have identified a need for further growth and development.
6. The participants in this study may have anticipated what the researcher
wanted to hear and responded accordingly. However the researcher
included both open and closed questions in the questionnaire to counter
this.
7. Due to limited time, interviews and focus groups were not included in this
study. However qualitative comments were collected through the
questionnaire.
Further research 6.3
This research has provided knowledge about perceived confidence as related
by student nurses at ECU in Western Australia. It does not explain why
students in the ENRPP initially identified their confidence as lower than the
109
students who did not take part in the ENRPP. The lack of understanding
student nurses perceived their confidence highlights opportunities for further
research and raises the following questions:
• Why did these the ENRPP students feel they needed to take on more
clinical experience than the tertiary system was offering?
• Was it because they wished to work in employment that was meaningful
to their future profession and their current studies?
• Was it because they had exposure (lived experience) to the hospital
environment prior to taking on their studies, either as a patient or visitor?
• Or were these students just more anxious compared the group that did
not participate in the ENRPP?
Formal review of the ENs who had completed the ENRPP clinical skills could be
explored to ascertain any difference between self-reporting and third party
identification.
Further qualitative data could be collected such as interviews or focus groups to
ascertain a deeper understanding of the experience of students, as well as staff
in the workplace.
Significance of the research 6.4
The findings of this research are significant for three reasons.
First of all, for ECU, where this study was completed, the findings will offer
supporting evidence to re-establish this program within its School of Nursing.
Alternatively they could be used to explore alternative pathways for
110
undergraduate nursing students to attain meaningful employment opportunities
whilst completing their nursing qualification.
Secondly, the results of this study may also be beneficial to other universities
that teach nursing, if they are looking for alternative ways to add value to their
existing undergraduate nursing degrees. The results demonstrate that a
program can add benefit to nursing students’ experiences, financially, as well as
within their nursing studies.
Thirdly, hospitals that are looking to support initiatives for meaningful
employment, such as the ENRPP, for the undergraduate nursing student and to
reduce the impact of the nursing shortage could partner with a local university to
commence a similar program. By doing so, they would be able to potentially
support and develop their future work force. Furthermore, they would also be
able to offer well educated support staff to their registered nursing work force.
The findings in this study indicate that students who undertake meaningful
employment opportunities, such as the ENRPP, are more confident whilst on
their clinical rotations, are able to link theoretical knowledge to the clinical
environment and feel as though they belong to the clinical team. These findings
have all been found to increase their perception of self. Student nurses may
also find this research useful as it clearly describes the student voice in relation
to improved self-confidence and meaningful employment opportunities due to
this program. Nursing students who are struggling with attaining confidence
and who are searching for opportunities to improve their confidence may also
find this research helpful.
111
Summary 6.5
In this chapter four recommendations were made. These focused on themes
related to increased clinical exposure, the re-establishment of the ENRPP,
increased clinical practicums and exploring ways to provide more opportunities
for meaningful employment for the undergraduate nursing students. Several
limitations of the study were outlined which were followed by suggestions for
further research into the confidence levels of student nurses. The Chapter
closes with a section on the significance of the research to other nursing
educators.
.
112
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129. Abbey J, Abbey B, Bridges P, Elder R, Lemcke P, Liddle J, et al. Clinical placements in residential aged care facilities: the impact on nursing students' perception of aged care and the effect on career plans. Aust J Adv Nurs [Internet]. 2006 [cited 2012 Oct 2]; 23(4): Available from: http://ezproxy.ecu.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009209908&site=ehost-live&scope=site.
130. Rush KL, Peel K, McCracken B. Empowered learning on the inside: an externship experience. Nurs Educ Perspect. 2004;25(6):284-291. Available from: Cinahl
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APPENDICES
Appendix A Modified 5 Dimensions of Nursing Scale
Appendix B Pilot Study Modified 5 Dimensions of Nursing Scale
Appendix C Participant information sheet
Appendix D Consent form
Appendix E Snapshot of thematic analysis
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APPENDIX A
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PRE / POST TEST QUESTIONAIRRE – Dear Participant, Please follow the instructions below when completing this questionnaire. Upon completion place in the box located at the front of the lecture hall. Section A Demographic Details: These questions relate to information about YOU 1. Gender: Male Female Other 2. Age as of 30th June 2011______________________yrs Level of experience 3. 2nd year Student 3rd year student Cross more than one box if appropriate Enrolled Nurse who has completed their qualification at ECU in the ENRPP in 2010 RN student completing the ENRPP in 2011 Enrolled Nurse on a conversion program Level of Education 4. Please select the highest level of education you have completed Year 10 Year 12 TAFE Certificate TAFE Diploma Undergraduate Degree Postgraduate Qualification Please State: Other, please specify: Employment History Working in unrelated employment – not working in the health environment in any form Working as an EN Working as a: Patient Care Assistant Assistant in Nursing Carer
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SECTION B
Instructions: The following is a list of activities in which nurses engage with varying degrees of frequency and skill.
Please circle the response that best relates to your present ability to perform the activities listed. The key is as follows
Abbreviation Description SD Strongly Disagree D Disagree N Neutral A Agree SA Strongly Agree
Please answer them as how they relate to you at this point in time I am able to
Clinical Care 1. Perform technical procedures: e.g. oral suctioning, tracheostomy care, IV therapy, catheter care,
dressing changes. SD D N A SA 2. Use mechanical devices: e.g., suction machine, cardiac monitor, dynamap, ECG SD D N A SA 3. Give emotional support to family of dying patient SD D N A SA 4. Perform appropriate measures in emergency situations SD D N A SA 5. Perform nursing care required by higher dependency patients. SD D N A SA 6. Recognise and meet the emotional needs of a dying patient SD D N A SA 7. Function calmly and competently in emergency situations. SD D N A SA Teaching and Collaboration 8. Teach a patient's family members about the patient's needs. SD D N A SA 9. Teach preventive health measure to patients and their families. SD D N A SA 10. Identity and use community resources in developing a plan of care for a patient and his/her family.
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SD D N A SA 11. Adapt teaching methods and materials to the understanding of the particular audience: e.g., age of
patient, educational background and sensory deprivation. SD D N A SA 12. Develop innovative methods and materials for teaching patients. SD D N A SA 13. Promote the use of interdisciplinary resource persons. SD D N A SA 14. Use teaching aids in teaching patients and their families. SD D N A SA 15. Encourage the family to participate in the care of the patient. SD D N A SA 16. Identify and use resources within the health care agency in developing a plan of care for a patient
and his/her family. SD D N A SA 17. Pass on facts, ideas, and professional opinions in writing (such as information sheets) to patients
and their families. SD D N A SA 18. Plan for the integration of patient needs with family needs. SD D N A SA Planning and Evaluation 19. Coordinate the plan of nursing care with the medical plan of care. SD D N A SA 20. Evaluate Nursing care with OTHERS. SD D N A SA 21. Evaluate results of nursing care. SD D N A SA 22. Develop a plan of nursing care for a patient. SD D N A SA 23. Initiate planning and evaluation of nursing care with OTHERS. SD D N A SA 24. Identify and include immediate patient needs in the plan of nursing care. SD D N A SA 25. Contribute to the plan of nursing care for a patient.
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SD D N A SA Interpersonal Relationships/ Communication 26. Promote the inclusion of patient's decision and desires concerning his/her care. SD D N A SA 27. Communicate a feeling of acceptance of each patient’s welfare. SD D N A SA 28. Seek assistance when necessary. SD D N A SA 29. Contribute to productive working relationships with other health team members. SD D N A SA 30. Help a patient meet his/her emotional needs. SD D N A SA 31. Use opportunities for patient teaching when they arise. SD D N A SA 32. Help a patient communicate with others. SD D N A SA 33. Verbally communicate facts, ideas, and feelings to other health care team members. SD D N A SA 34. Promote the patients' rights to privacy. SD D N A SA 35. Contribute to an atmosphere of mutual trust, acceptance, and respect among other health team
members. SD D N A SA 36. Explain nursing procedures to a patient prior to performing them. SD D N A SA 37 Use nursing procedures as opportunities for interaction with patients. SD D N A SA Professional Development 38. Use learning opportunities for ongoing personal and professional growth. SD D N A SA 39. Display self-direction. SD D N A SA
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40. Accept responsibility for own actions SD D N A SA 41. Assume new responsibilities within the limits of capabilities. SD D N A SA 42. Maintain high standards of performance SD D N A SA 43. Demonstrate self-confidence. SD D N A SA 44. Display a generally positive attitude. SD D N A SA 45. Demonstrate knowledge of the legal boundaries of nursing. SD D N A SA 46. Demonstrate knowledge in the ethics of nursing. SD D N A SA 47. Accept and use constructive criticism. SD D N A SA SECTION C Please answer the following question in the space provided – all students 1.What can we do better to improve the undergraduate nursing degree at Edith Cowan University? _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
If you have or are completing the ENRPP at ECU then please answer the following question. 2. How has the ENRPP impacted on your undergraduate nursing studies as ECU in relation to clinical
practicum and theoretical learning? _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Adapted from the Six D Scale of Nursing Performance Scale, 1978. Used with kind permission of Author – PM Schwirian
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APPENDIX B
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PILOT STUDY Dear Participant, In order to ascertain if there are any problems with the following research questionnaire you have been invited to complete it. At the end of the questionnaire there is an area to complete in relation to the wording and format of the research questionnaire. By completing this section we will be able to make the necessary changes and improvements following your feedback. Please follow the instructions below when completing this questionnaire. Upon completion place in the box located at the front of the lecture hall. SECTION B
Instructions: The following is a list of activities in which nurses engage with varying degrees of frequency and skill.
Please circle the response that best relates to your present ability to perform the activities listed. The key is as follows
Abbreviation Description SD Strongly Disagree D Disagree N Neutral A Agree SA Strongly Agree
Please answer them as how they relate to you at this point in time I am able to
Clinical Care 1. Perform technical procedures: e.g. oral suctioning, tracheostomy care, IV therapy, catheter care,
dressing changes. SD D N A SA 2. Use mechanical devices: e.g., suction machine, cardiac monitor, dynamap, ECG SD D N A SA 3. Give emotional support to family of dying patient SD D N A SA 4. Perform appropriate measures in emergency situations SD D N A SA 5. Perform nursing care required by higher dependency patients. SD D N A SA 6. Recognise and meet the emotional needs of a dying patient SD D N A SA 7. Function calmly and competently in emergency situations.
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SD D N A SA Teaching and Collaboration 8. Teach a patient's family members about the patient's needs. SD D N A SA 9. Teach preventive health measure to patients and their families. SD D N A SA 10. Identity and use community resources in developing a plan of care for a patient and his/her family. SD D N A SA 11. Adapt teaching methods and materials to the understanding of the particular audience: e.g., age of
patient, educational background and sensory deprivation. SD D N A SA 12. Develop innovative methods and materials for teaching patients. SD D N A SA 13. Promote the use of interdisciplinary resource persons. SD D N A SA 14. Use teaching aids in teaching patients and their families. SD D N A SA 15. Encourage the family to participate in the care of the patient. SD D N A SA 16. Identify and use resources within the health care agency in developing a plan of care for a patient
and his/her family. SD D N A SA 17. Pass on facts, ideas, and professional opinions in writing (such as information sheets) to patients
and their families. SD D N A SA 18. Plan for the integration of patient needs with family needs. SD D N A SA Planning and Evaluation 19. Coordinate the plan of nursing care with the medical plan of care. SD D N A SA 20. Evaluate Nursing care with OTHERS. SD D N A SA 21. Evaluate results of nursing care.
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SD D N A SA 22. Develop a plan of nursing care for a patient. SD D N A SA 23. Initiate planning and evaluation of nursing care with OTHERS. SD D N A SA 24. Identify and include immediate patient needs in the plan of nursing care. SD D N A SA 25. Contribute to the plan of nursing care for a patient. SD D N A SA Interpersonal Relationships/ Communication 26. Promote the inclusion of patient's decision and desires concerning his/her care. SD D N A SA 27. Communicate a feeling of acceptance of each patient’s welfare. SD D N A SA 28. Seek assistance when necessary. SD D N A SA 29. Contribute to productive working relationships with other health team members. SD D N A SA 30. Help a patient meet his/her emotional needs. SD D N A SA 31. Use opportunities for patient teaching when they arise. SD D N A SA 32. Help a patient communicate with others. SD D N A SA 33. Verbally communicate facts, ideas, and feelings to other health care team members. SD D N A SA 34. Promote the patients' rights to privacy. SD D N A SA 35. Contribute to an atmosphere of mutual trust, acceptance, and respect among other health team
members. SD D N A SA 36. Explain nursing procedures to a patient prior to performing them.
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SD D N A SA 37 Use nursing procedures as opportunities for interaction with patients. SD D N A SA Professional Development 38. Use learning opportunities for ongoing personal and professional growth. SD D N A SA 39. Display self-direction. SD D N A SA 40. Accept responsibility for own actions SD D N A SA 41. Assume new responsibilities within the limits of capabilities. SD D N A SA 42. Maintain high standards of performance SD D N A SA 43. Demonstrate self-confidence. SD D N A SA 44. Display a generally positive attitude. SD D N A SA 45. Demonstrate knowledge of the legal boundaries of nursing. SD D N A SA 46. Demonstrate knowledge in the ethics of nursing. SD D N A SA 47. Accept and use constructive criticism. SD D N A SA SECTION C Please answer the following question in the space provided – all students
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1.What can we do better to improve the undergraduate nursing degree at Edith Cowan University? _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
If you have or are completing the ENRPP at ECU then please answer the following question. 2. How has the ENRPP impacted on your undergraduate nursing studies as ECU in relation to clinical
practicum and theoretical learning? _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Adapted from the Six D Scale of Nursing Performance Scale, 1978. Used with kind permission of Author – PM Schwirian
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PILOT STUDY QUESTIONS Please complete the following questions in relation to the pilot research paper.
1. Is there any wording on the questionnaire that is ambiguous or needs attention?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
2. In relation to the pilot study please make any further comments that you wish.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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APPENDIX C
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PARTICIPANT INFORMATION SHEET Students
You are being invited to take part in a study that is aimed at investigating the effect of the Enrolled Nursing Registration Pathway Program and working as a novice Enrolled Nurse have on readiness to practice in clinical practicum. Before you give consent it is important you are aware of what your participation will involve, so please read and consider the following information carefully. Please ask if there is anything that is not clear or if you would like more information. Should you choose to participate please keep this information sheet and duplicate copy of the consent form for your records; the remaining consent form will be retained for our records. Title of the Research Nursing Students and Meaningful Employment Background and Aims of the Research This research aims to investigate the impact, if any, the Enrolled Nursing Registration Pathway Program (ENRPP) completed at a university in Western Australia and working part time as an EN, has on the developing nurses’ readiness to practice. The research is being undertaken by the coordinator of the ENRPP who is also a lecturer in nurse education. This research stems from the authors experience of the ENRPP and anecdotal feedback surrounding the course and impact on the student. Participants Student nurses completing the Bachelor of Nursing Program at Edith Cowan University. What it means to you If you decide to participate in this research you will be asked to
1. Complete a pre and post questionnaire depending upon your year of study 2. Allow access to your exam papers in the unit NNT2206 Principles of the Individual’s
Adaption to Altered Health Status, for review of your response to critical thinking questions as identified in the exam paper
Please note to allow data matching a staff member not involved in the research will provide a unique code for each student, which will be recorded on each piece of data, The researchers will not be able to identify individuals except by this code. Your participation is voluntary and you have a right to not participate without any impact on your grades or relationship with teaching staff. Refusal to take part will involve no penalty or loss of benefits to which you are otherwise entitled. What happens if I change my mind? You are free at any time to withdraw consent to further participation in this study, without prejudice in any way. You do not need to give a reason or justification for such a decision, and if you wish your data can be excluded from the study at that time. Data, Ethics and Confidentiality All data will be de-identified and kept confidential. Data access will be restricted to the research investigators – Carol Crevacore, Diana Jonas Dwyer and Pam Nicol. It is anticipated that data from this study may be presented at conferences and meetings, and published in an appropriate journal. Participants will not be identifiable except by codewhen data is presented.
Education Centre, Faculty of Medicine, Dentistry and Health Sciences M515, 35 Stirling Highway, CRAWLEY,WA 6009
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Contact If you have any questions about this study, now or at any time during your participation, please contact the Chief Investigator, Associate Professor Diana Jonas-Dwyer via email: [email protected] or telephoneon 6488 6895. Carol Crevacore is a postgraduate student at UWA and this study forms part of her Master of Health Professional Education.
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APPENDIX D
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CONSENT FORM (2nd yr PARTICIPANT COPY)
I …………………................................................................ (the participant) have read the information provided and any questions I have asked have been answered to my satisfaction. I agree to participate in this activity, realising that I may withdraw at any time without reason and without prejudice.
I understand that all identifiable (attributable) information that I provide is treated as strictly confidential and will not be released by the investigator in any form that may identify me. The only exception to this principle of confidentiality is if documents are required by law.
I have been advised as to what data is being collected, the purpose for collecting the data, and what will be done with the data upon completion of the research.
I agree that research data gathered for the study may be published provided my name or other identifying information is not used.
I consent to participation in the following sections of the research study (please tick all that apply)
1. Pre and Post test
2. Review of written examinations section of the NNT 2206 Principles of the Individual’s Adaption to Altered Health Status
_____________________________ __________________ Participant Date
Contact
If you have any questions about this study, now or at any time during your participation, please contact either Carol Crevacore via email: [email protected] or telephone: 63043496 or the Chief Investigator, Associate Professor Diana Jonas-Dwyer on 6488 6895. Ms Carol Crevacore is a postgraduate student at the UWA and this study forms part of her Master of Health Professional Education.
"Approval to conduct this research has been provided by The University of Western Australia, in accordance with its ethics review and approval procedures. Any person considering participation in this research project, or agreeing to participate, may raise any questions or issues with the researchers at any time. In addition, any person not satisfied with the response of researchers may raise ethics issues or concerns, and may make any complaints about this research project by contacting the Human Research Ethics Office at The University of Western Australia on (08) 6488 3703 or by emailing to [email protected] All research participants are entitled to retain a copy of any Participant Information For and/or Participant Consent Form relating to this research project."
Education Centre, Faculty of Medicine, Dentistry and Health Sciences M515, 35 Stirling Highway, CRAWLEY,WA 6009
144
CONSENT FORM (2nd yr - UWA COPY)
I …………………................................................................ (the participant) have read the information provided and any questions I have asked have been answered to my satisfaction. I agree to participate in this activity, realising that I may withdraw at any time without reason and without prejudice.
I understand that all identifiable (attributable) information that I provide is treated as strictly confidential and will not be released by the investigator in any form that may identify me. The only exception to this principle of confidentiality is if documents are required by law.
I have been advised as to what data is being collected, the purpose for collecting the data, and what will be done with the data upon completion of the research.
I agree that research data gathered for the study may be published provided my name or other identifying information is not used.
I consent to participation in the following sections of the research study (please tick all that apply)
1. Pre and Post test
2. Review of written examinations section of the NNT 2206 Principles of the Individual’s Adaption to Altered Health Status
______________ __________________ Participant Date
Contact
If you have any questions about this study, now or at any time during your participation, please contact either Carol Crevacore via email: [email protected] or telephone: 63043496 or the Chief Investigator, Associate Professor Diana Jonas-Dwyer on 6488 6895. Ms Carol Crevacore is a postgraduate student at the UWA and this study forms part of her Master of Health Professional Education.
"Approval to conduct this research has been provided by The University of Western Australia, in accordance with its ethics review and approval procedures. Any person considering participation in this research project, or agreeing to participate, may raise any questions or issues with the researchers at any time.
In addition, any person not satisfied with the response of researchers may raise ethics issues or concerns, and may make any complaints about this research project by contacting the Human Research Ethics Office at The University of Western Australia on (08) 6488 3703 or by emailing to [email protected]
All research participants are entitled to retain a copy of any Participant Information For and/or Participant Consent Form relating to this research project."
Education Centre, Faculty of Medicine, Dentistry and Health Sciences M515, 35 Stirling Highway, CRAWLEY,WA 6009
145
CONSENT FORM (3rd YEAR - PARTICIPANT COPY)
I …………………................................................................ (the participant) have read the information provided and any questions I have asked have been answered to my satisfaction. I agree to participate in this activity, realising that I may withdraw at any time without reason and without prejudice.
I understand that all identifiable (attributable) information that I provide is treated as strictly confidential and will not be released by the investigator in any form that may identify me. The only exception to this principle of confidentiality is if documents are required by law.
I have been advised as to what data is being collected, the purpose for collecting the data, and what will be done with the data upon completion of the research.
I agree that research data gathered for the study may be published provided my name or other identifying information is not used.
I consent to participation in the following sections of the research study (please tick all that apply)
1. Post survey
2. Review of written examination section of the NNT2206 Principles of the Individual’s Adaption to Altered Health Status.
_____________________________ __________________ Participant Date
Contact
If you have any questions about this study, now or at any time during your participation, please contact either Carol Crevacore via email: [email protected] or telephone: 63043496 or the Chief Investigator, Associate Professor Diana Jonas-Dwyer on 6488 6895. Ms Carol Crevacore is a postgraduate student at the UWA and this study forms part of her Master of Health Professional Education.
"Approval to conduct this research has been provided by The University of Western Australia, in accordance with its ethics review and approval procedures. Any person considering participation in this research project, or agreeing to participate, may raise any questions or issues with the researchers at any time.
In addition, any person not satisfied with the response of researchers may raise ethics issues or concerns, and may make any complaints about this research project by contacting the Human Research Ethics Office at The University of Western Australia on (08) 6488 3703 or by emailing to [email protected]
All research participants are entitled to retain a copy of any Participant Information For and/or Participant Consent Form relating to this research project."
146
CONSENT FORM (3rd YEAR - UWA COPY)
I …………………................................................................ (the participant) have read the information provided and any questions I have asked have been answered to my satisfaction. I agree to participate in this activity, realising that I may withdraw at any time without reason and without prejudice.
I understand that all identifiable (attributable) information that I provide is treated as strictly confidential and will not be released by the investigator in any form that may identify me. The only exception to this principle of confidentiality is if documents are required by law.
I have been advised as to what data is being collected, the purpose for collecting the data, and what will be done with the data upon completion of the research.
I agree that research data gathered for the study may be published provided my name or other identifying information is not used.
I consent to participation in the following sections of the research study (please tick all that apply)
1. Post survey
2. Review of written examination section of the NNT2206 Principles of the Individual’s Adaption to Altered Health Status.
______________ __________________ Participant Date
Contact
If you have any questions about this study, now or at any time during your participation, please contact either Carol Crevacore via email: [email protected] or telephone: 63043496 or the Chief Investigator, Associate Professor Diana Jonas-Dwyer on 6488 6895. Ms Carol Crevacore is a postgraduate student at the UWA and this study forms part of her Master of Health Professional Education.
"Approval to conduct this research has been provided by The University of Western Australia, in accordance with its ethics review and approval procedures. Any person considering participation in this research project, or agreeing to participate, may raise any questions or issues with the researchers at any time.
In addition, any person not satisfied with the response of researchers may raise ethics issues or concerns, and may make any complaints about this research project by contacting the Human Research Ethics Office at The University of Western Australia on (08) 6488 3703 or by emailing to [email protected]
All research participants are entitled to retain a copy of any Participant Information For and/or Participant Consent Form relating to this research project.
147
148
APPENDIX E
149
Snapshot of Thematic Analysis.
208
1 Being able to manage a four patient load has been invaluable. I feel so much more confident. I have learnt just about everything about pre-post op care in Surgical nursing which was my clinical area. I am so glad I decided to do it. I actually feel like a nurse now.
Improved time management
Confidence
Understand learning
More time to prac being a nurse
150
209
1 I have thoroughly enjoyed the program. It has given me more confidence for my future nursing.
Enhanced UG experience
Confidence
213
1 It has helped me gain experience and to be able to practice the theory I am learning at uni.
More time to prac being a nurse
Understand learning
151
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